dlamini: reaching every newborn - opportunities and challenges

7/28/2019 Dlamini: Reaching Every Newborn - Opportunities and Challenges

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Global Newborn Health

Conference

Opportunities and Challenges

15 April 2013Dr N R Dlamini


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Causes of Neonatal Mortality in South

Africa

Similar to other countries:

1. Birth Asphyxia - leading cause of death

especially in birth weight >2.5kgs.

2. Infection - 3rd largest cause of neonatal death

in all weight categories but highest in the

1000g to 2000g weight category.

3. Prematurity


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Trends in Health Outcome Indicators

INDICATOR BASELINE PROGRESS TARGET20142009 2010 2011MATERNAL AND CHILD MORTALITY (OUTPUT 2)INDICATOR BASELINE PROGRESS TARGET

2009 2010 2011 2014

(HDACC)

Under-5 Mortality Rate

(U5MR) per 1 000 live-births

56 53 42 50 (10%

reduction)

Infant Mortality Rate (IMR)

per 1 000 live-births

40 37 30 36 (10%

reduction)

Neonatal Mortality Rate (


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OPPORTUNITIES


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Technical & Expert Support

The Minister of Health appointed 3 advisory technicalcommittees - obstetricians & gynaecologists, midwives,paediatricians:

1. National Committee on Confidential Enquiries into

Maternal Deaths. 19962. National Perinatal Mortality and Morbidity Committee2008.

3. Committee on Mortality and Morbidity in Children. 2007

Conduct audits & produce triennial reports. Information

generated from their reports is used in policy formulation. Investigate incidents & produce recommendations for

minister.


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NHI (National Health Insurance)

Aim: to attain universal healthcoverage.

Shift SA from a hospicentric curativehealth care system to one with apreventative and health promotionfocus.

Principles: social solidarity, equity &fairness.


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NHI (National Health Insurance)

Policy objective: to ensure that everyone

has access to appropriate, efficient and

quality health services. Will require significant overhaul of

existing service delivery structures,

administrative & management systems. Intention is to phase-in the NHI over 14

years.


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Re-engineering of Primary Health Care

This is the core of the NHI.

Consists of three streams:

1. District Clinical Specialist Teams (district -

obstetrician, paediatrician, anaesthetist, familyphysician, advanced midwife, PHC nurse,paediatric nurse). A team for each of the 52districts in SA.

2. Municipal Ward - Based PHC teams (communityhealth workers.)

3. Integrated School Health Programme.


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CARMMA in South Africa (Campaign for theAccelerated Reduction of Maternal & ChildMortality in Africa) under the auspices of the

African Union.Aim:

To accelerate the reduction of maternal and childmorbidity and mortality through accelerated

implementation of evidence-based interventionsessential to improve maternal health and childsurvival.


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CARMMA priorities

Contraception

Early booking and improving the quality of antenatalcare

Prevention of Mother-to-child-transmission of HIV Dedicated Obstetric ambulances

Establishment of Maternity Waiting Homes

Training in ESMOEEssential Steps in the

Management of Obstetric Emergencies & EOST(Emergency Simulation Training).

Skilled birth attendants including additional midwives

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CARMMA priorities contd.....

Improving new born care and treatment of

sick children, including provision of Kangaroo

Mother Care.

Strengthen coverage of the Expanded

Programme on Immunisation.

Lactating mothers lodges.

Intensification of coverage of lifelong ART to

mothers with CD4


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NEONATAL SURVIVAL STRATEGY

HHAPI-NESS. Road map for healthy babies in South Africa


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Summary of the Key

Recommendations. HHAPI-NeSS

Improve the Health System for mothers and

babies.

Improve the knowledge and skills ofHealth

Care Providers in maternal and neonatal care.

Reduce deaths due to Asphyxia

Reduce deaths due to Prematurity

Reduce deaths due to Infection

NeSS = Newborn Survival Strategy


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5 Hs reduction of maternal

mortality

Reduce deaths due to HIV/AIDS

Reduce deaths due to Haemorrhage Reduce deaths due to Hypertension

Improve Health worker training and

Health system strengthening


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HHAPI 5 Hs

IMPROVE NEONATAL HEALTH

OUTCOMES AND MATERNAL

HEALTH OUTCOMES


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KEY CAUSE

OF

MORTALITY

INTERVENTIONS

Health

system

for

mothers

and

babies:

Contraception, including for post miscarriage and

postpartum, integration with HCT, chronic diseases, school

health services.

24 hour access to functioning emergency obstetric and

neonatal care including clear referrals routes. Maternity waiting homes, Kangaroo Care sites in all

hospitals

Hospital CEOs to ensure that there is no rotation of nursing

staff providing neonatal care

Knowledge and

skills of

health

care

providers

Train all health care workers providing maternity andneonatal care in the ESMOE programme.

Train health care workers who deal with pregnant women in

HCT & initiation of ART. Train all health care workers in

correct management of intrapartum care (use of the

Partogram, 3rd stage of labour)

NEONATAL SURVIVAL STRATEGY: KEY INTERVENTIONS TO REDUCE MORTALITY

D th d t Every woman in labour must be monitored appropriately


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Deaths due to

asphyxia:

A birth attendant

skilled in neonatal

resuscitation can

reduce deaths to

hypoxia by up to

40%.

Every woman in labour must be monitored appropriately

by a skilled birth attendant

All birth attendants must be skilled in at least bag and

mask ventilation of the neonate

The partogram must be used to monitor labour according

to prescribed norms

All complicated and obstructed labours must have

access to Caesarean Section

Deaths due to

prematurity:

The use and

application of nasal

CPAP at a districthospital can

reduce mortality of

this group by up to

40%.

Corticosteroids must be given where possible to every

woman in preterm labour

Antibiotics must be given to every woman with prolonged

rupture of membranes

All hospitals (especially district hospitals) must havestaff skilled in the use of nasal CPAP

All mothers of premature infants must have easy access

to Kangaroo Mother Care


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Deaths

due to

infection

Strict adherence to basic hygiene in labour

wards and nurseries. Hand washing. Alcohol

sprays, soap, clean water and paper towelsmust be available in all nurseries as essential

consumables.

Case management of neonatal sepsis,

meningitis and pneumonia. As breast milk provides the best nutrition and

protection for the preterm baby, districts should

provide breast milk (not preterm formulae) to

preterm babies by the establishment of humanmilk banks.

Infection dashboard introduced in all neonatal

nurseries to reduce infections by heightening

awareness and surveillance of infection rates.


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Prevention of Mother to Child

Transmission of HIV (PMTCT)

Improvements in PMTCT is the single most

important reason for declining child mortality

rates in SA.

SA has an elimination strategy; eMTCT

MTCT transmission rate among HIV-exposed

infants at six weeks:

2008: 8.0%

2010: 3.5%

2011: 2.7% 19


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PMTCT

New guidelines ie fixed dose combination

(FDC) triple therapy of Tenofovir, Emtricitabine

& Efavirenz implemented in April 2013 to

further reduce MTCT to < 1%.

Regardless of CD4 count; ARVs for all

pregnant HIV positive women & those

breast feeding for the duration of B/F.

Lifelong ART if CD4


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Priority Newborn Interventions

Prevention of HIV infection through effectivePMTCT

Resuscitation of newborns and provision of

quality care Promotion of early and exclusive breastfeeding

Post-natal visit within six days, which includesnewborn care and supporting mothers to practiceexclusive breastfeeding.

Contraception.

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Establish

teamsand focal

persons

Assess

Situation(bottleneck

analysis)

Developcosted

evidence

basedplan &

training

plan

tailored

to context

Imple-ment

Plan

Conduct

OngoingMonitoring

to track

progress

ConductRegular

Reviews

Document

Best Practicesand lessonslearned.

Benchmarking

KEY STEPS FOR OPERATIONALIZING

HHAPI-NeSS. Start with the worst

performing districts and expand.


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Key challenges

Community education & demand

for services.

Access to care

Essential Equipment

Quality care Training of Health Care Providers

Monitoring and evaluation


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THANK YOU

dlamini: reaching every newborn - opportunities and challenges

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