Download - Chris Morgan, Burnet Institute
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Newborn survival lessons from the Western Pacific region – two stories from our knowledge hub work
Chris Morgan
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• Places with the highest maternal and newborn mortality generally have the worst access to services, and higher rates of home-birth.
• Most deaths of mothers and many deaths of babies occur on or near the day of birth,
• WHO and national strategies recommend childbirth care in a health facility, but this takes time to scale up – PNG Maternal Task Force
plans “60% of all pregnant women having skilled attendant at delivery by 2015 and 80% by 2020”
Like Nepal
or PNG, or Lao PDR or….
The problem in certain settings in our region
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Provoked one stream of knowledge collation
• There are forms of community-based care at childbirth, that could be delivered by trained lay health workers or community-based staff
• Some are interim measures to meet the immediate crisis in maternal deaths.
• Could maybe reduce maternal and newborn deaths by 30% or more.
• However, they must be introduced in a carefully measured fashion, using a systems approach, to monitor for impact and unforeseen consequences.
Established packages for newborn care (warmth, hygiene, EBF), clean delivery kits;
Community mobilisation, facilitated referral;
Oxytocics from trained workers or self-administered; Antibiotics from trained workers (lay or paid); and ? pre-filled injection devices for vaccination or oxytocics.
Recognising the many other determinants, such as
family planning, girls’ education and nutrition etc
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Site analyses
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Collaboration with World Vision for an “evidence-based policy-advocacy’ study
• … on the potential of “Family and Community Care” that is: care by family and community members, rather than by health professionals” – Eg by “trained lay health workers” – aka VHVs
• We did a – Comprehensive literature review of
international publications to find interventions or packages delivered by FCC
– Determined a simple cost-effectiveness rating and excluded any that were not good value for money
– Researched their current or past application on PNG through publication and contacting experts
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An interventions and service delivery analysis of Family and Community Care for maternal and child survival in PNG -
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What we concluded
• In places where the maternal and newborn mortality rates are still relatively high…
• FCC interventions could avert deaths: – Up to one third of maternal
deaths – Up to two thirds of newborn
deaths – Up to half of child deaths
• PNG already has a variety of experiences with nearly all interventions researched
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Two ways to view family and community care, provided by VHVs, in PNG
• A complement to the current investment in re-building the health infrastructure, training more health workers (including midwives) and strengthening systems – FCC can help engage communities in a stronger HSS
process • A stop-gap for get some high impact interventions to
mothers and children, while the health system is being rebuilt – Might require innovative approaches and some risk-benefit
analysis
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What came next
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Another story – unique to East Asia and the Western Pacific
• Most of the operational research demonstrating the efficacy of community-based newborn care has come from South Asia
• Meanwhile, in East Asia and the Pacific, it has been immunization programs that focused on the first 24 hours after birth – The critical period during which vaccination against
hepatitis B can interrupt perinatal transmission of hepatitis B (the form most likely to lead to chronic liver disease and death)
• Scale-up of this has been a major push for the WHO WPRO
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Rationale for early post-natal care and vaccination visits in homes - in Angoram District, East Sepik Province (our study site)
• Coverage of HepB birth dose is low: – National: 16% 2005 survey), 25% (2008 NHIS) – East Sepik: 27% Prov, 18% Angoram (2008 NHIS)
• Proportions of childbirth occurring in health facilities had not increased for 10 years - between 30 and 40% – But our partner, Save International PNG, has a good
network of village health volunteers • Maternal and newborn mortality is high and postnatal
care underutilised • Indonesia has supported hepatitis B vaccine in Uniject,
– makes injection by LHWs feasible
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THE STUDY: A small feasibility trial of expanded health services, in a “difficult” but characteristic location
• To answer the questions: – Can postnatal care be expanded for home births? – Can birth-dose vaccination reach home births? – Can combining the two result in synergy rather
than fragmentation or competition? • Providing
– birth-dose vaccination for hepatitis B vaccination (HBV) using UnijectTM in a real-world setting, including out-of-cold chain usage
– Integrated with early post-natal visits for home births in a remote district
• Provision by – Trained lay Village Health Volunteers (VHV), – Nursing Officers (NOs) and Community
Health Workers (CHWs)
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MINIMAL POSTNATAL PACKAGE for community or aid-post level • Hepatitis B vaccine
– within 24 hours of birth, w UnijectTM • Essential information:
– breast-feeding and nutrition for the mother and baby
– warmth and hygiene (inc. cord care) – signs of infection in mother/baby,
how to prevent and respond • Additional information and care
– weighing the baby and information on care of low-birth weight babies, especially for temperature control
– routine postnatal care for mother and baby, including further routine immunisations
– family planning • Vitamin A for the mother
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Trainers Manual
IEC brochure draft
Both translated into Tok Pisin
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IMPLEMENTATION
• Training of staff and VHVs: – 13 rural health staff (NOs & CHWs) – 212 VHVs (175 female)
• Provision of services in four health centre catchments: – UnijectTM HBV procurement and distribution via govt systems – Services to more than 364 mothers
• Monitoring and supervision by a locally based project officer
– birth and postnatal visit record form, designed for use by VHVs – calendar to ensure vaccine out of the cold chain < 30 days
• Evaluation – using project databases - 2 for triangulation – two visits with structured questionnaires for qualitative data
gathering - involved National Dept of Health and WHO
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Extract from the VHV birth and postnatal care record form
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EVALUATION - POSITIVE OUTCOMES
• Coverage with birth-dose increased – 83% overall (cf district average 24%) – 74% (homebirths), 93% (health centre)
• Use of VHVs extended coverage: – ~ 10 VHVs for every paid staff member
• VHVs vaccinated safely, using Uniject • Out-of-cold chain management of HBV
feasible and appropriate, vaccine vial monitors used appropriately
• Active VHVs credited the level of support provided by Save and Burnet
• Most of postnatal package provided most of the time (but Vit A only 62%)
• Having a vaccine role motivated greater attendance at birth for VHVs
• Good community acceptance
VHV Unitha Longhi providing birth-dose vaccination w UnijectTM
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EVALUATION - SURPRISES
• Births in health centres increased – often a VHV accompanied and
attended the birth in the health facility, with staff on stand-by
• UnijectTM use in health centres – contributed to increased coverage there as well as
at community level – staff found it far easier the multi-dose vial
• Considerable new information regarding birth outcomes and care-seeking behaviour – very high rates of obstetric complications and
death persist – our program could only really influence newborn
outcomes and possibly puerperal sepsis
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Global extensions • 2009 WHO Position Paper adopted the policy led by
WPRO – “In all regions of the world, all infants should receive the
first dose of hepatitis B vaccine as soon as possible (<24 hours) after birth. This should be followed by two or three doses to complete the series.”
– Adopted as part of the World Health Assembly’s resolution on the control of viral hepatitis in 2010
– New global hepatitis program established at WHO in 2011
• Implications for other regions – African and South Asian settings with high home birth rates
that have not yet introduced birth dose vaccination – Can vaccination leverage better maternal/newborn care or
will it be a burden on over-stretched systems?
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WCH Knowledge Hub supported WHO expansion efforts • WHO global consultation on birth-dose held in Melbourne, Dec 2010
• Systematic review of global practices to provide birth-dose vaccination – A chance to ensure that
integration with postnatal care for newborn and maternal survival was highlighted
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Issues for newborns: - timing of home visit - preventive care only, or therapeutic as well - integration with maternal and immunisation programs
Issues for mothers: - risk encouraging home births or distracting from facility care - misoprostol - treatment or prevention; vs oxytocin, timing - unknowns around puerperal sepsis in the community
Issues for both: - introduce in concert with health system strengthening - comprehensive PHC still offers best health system environment
To finish: Some critical service delivery questions for us
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The value of kangaroo care
Morgan and Rongong. Use of Kangaroo Nursing Method in Western Nepal; J Nepal Med Assoc, Jul-Sep 1997 (36): 320 - 323
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Thank you
A short history of baby care • BC 2000
– “Just carry it next to your skin. Breastfeed it whenever it is hungry.”
• AD1660 – “Breastfeeding is undignified. Hand it over to a wet-
nurse.” • AD 1850
– “Wet-nurses are low class and have an undesirable influence on the child. Get a good experienced nanny to bottle feed it cow’s milk, and wean it on to a cup as soon as possible.”
• AD 1930 – "Cow’s milk is unsuitable for babies. It must be
bottle fed on a special infant formula.” • AD 1950
– “Bottle feeding at all hours is bad for the baby. Follow a strict routine, let it sleep in its own room and ignore it when it cries at other times.”
• AD 2000 – “Bottle feeding is unsuitable, a strict time-table is
nonsense, babies don’t like being alone, and crying is stressful. Just carry it next to your skin. Breastfeed it whenever it is hungry.”
(Joan Norton, 2001)