el arifeen: community-based services within the continuum of newborn care - choices & challenges

7/28/2019 El Arifeen: Community-Based Services Within the Continuum of Newborn Care - Choices & Challenges

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Community-Based Serviceswithin the Continuum of

Newborn Care:

Choices & Challenges

Newborn 2013

Johannesburg15 April 2013


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The Body of Evidence:

Community-Based Newborn Care

Mortalityreduction

Communitymobilization

Home Treatmentof illness

Homevisits

DesignStudy

62%1 intervention &1 control

SEARCH

India

50%Before-afterANKURIndia

34%Clusterrandomized trial

Projahnmo

Bdesh

50%

Cluster

randomized trial

Shivgarh

India

20%Pilot (4 vs. 4clusters)

Hala

Pakistan

30%Clusterrandomized

MakwanpurNepal


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Home Visits for the Newborn

WHO-UNICEF Joint Statement, 2009

3

Promote early and exclusive breastfeeding Help keep the newborn warm

Promote hygienicumbilical cord and skin care

Help the family to recognize signs of illness and

promote prompt care-seeking

Promote birth registration and timely vaccination Identify and newborns who are low-birth-weight,

have illness and those born to an HIV-infected

mother and provide or refer for additional health

care

Counsel the mother about her own health.

Key recommendation:

Home visits for newborn care days one and

three after birth, and if possible, a third

visit on day seven


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4

NATIONAL

NEONATAL

HEALTHSTRATEGY AND

GUIDELINES FOR

BANGLADESH

Approved in

March 2009


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What has been achieved inBangladesh with newborn care?


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Facility Delivery Has Increased But Not

Home Delivery By Skilled Attendants

Increases in skilled attendance at deliveries has been entirely due

to increases in facility deliveries, particularly in private facilities

4% 3% 4% 3%

6% 7%10% 12%

3%8%

13%17%

13%

18%

28%

32%

2004 2007 2010 2011

Facility-Private/NGO

Facility-Public

Home (Skilled)

BMMS BDHSBDHSBDHS


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Almost all of the increase in postnatal care can be explained by

increases in facility deliveries

9%

15%

23%

29%

12%

19%

23%

30%

2004 2007 2010 2011

Facility Delivery

PNC - Newborn

BMMS BDHSBDHSBDHS

Facility Delivery and Postnatal Care of

the Newborn


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Essential Newborn Care Practices

82%

45%

6%2%

43%

0%

84%

59%

51%

33%

47%

2%

Cord cut withBoiled

Instrument

Nothing Appliedto Cord

Dried within 5mins of birth

Wrapped within5 mins of birth

Initiated BFwithin 1 hr

All practices

2007 2011

Source: Bangladesh Demographic and Health Surveys, 2007, 2011


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The national average - 5 per 10,000. Chittagong division has the fewest ENC

trained CHWs per 10,000

Rangpur, with 16 ENC trained workers

per 10,000 has the most.

Around 67,000 community health

workers are trained on ENC

51,000 concentrated in Dhaka and

Rangpur Divisions.

Only 38% of all CHWs trained inENC.

Density of ENC trained Community Health Worker (per

10,000 population)

Save the Children


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However,

less than 6%home-bornnewborns in Bangladesh received

PNC within 2 days of birth from aCHW or medically trained provider

BMMS 2010

In the MNCS special programme area (GoB/UNICEF),

covering 7 of 64 districts in Bangladesh, trained community

volunteers (MNCS Promoters) were able to make a home

visit to 45% of home births within 2 days of delivery


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A continuum of care is needed:

Across pre-pregnancy, pregnancy,

labour and delivery, and newbornperiods, and

Across service levels


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12

Continuum of care under controlled

conditions: Projahnmo, Sylhet

48%

43%

40%

46%

4%

45%

72%

84%

39%

95%

78%

81%

At least one antenatal check up from

a trained provider

Iron and folate supplements

At least two tetanus-toxoidimmunisations

Clean cord-cutting instrument used

First bath delayed until at least thethird day

Breastfeeding initiated within 1 h

Baseline

Endline


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BUT: Only 19% of Pregnant Mothers and

Newborns Receive all Care in the real world

Source: Bangladesh Maternal Mortality Survey, 2010


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Managing Neonatal Infections

No national data on treatment coverage of neonatal

infections

Who can manage neonatal infections that occur in

the community: CHWs? Community Clinics? Union-level Health Facilities?

Must improve and sustain the quality of care at

referral facilities (particularly UHCs)

Most of these facilities do not NOW have the capacity to

provide effective care to sick newborns

Some initiatives have been started but we need to move

rapidly to scale


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Background

3.5 Innovative approaches for Neonatal Care

Community-based operations research or feasibility studies to improve management of neonatal

infections, compliance of KMC at home, low birth weight management, birth asphyxia

management at community level


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Operations Research to improve community-

based management of neonatal infections

Primary objective: To assess the quality and coverage of differentapproaches of community case management of neonatal sepsis

A cluster-randomized design adopted, nested in the GoB-UNICEF

MNCS programme

Time: July 2011 December 2012


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Operations Research- Neonatal Sepsis

10 intervention unions

~40,000 HH

10 comparison unions

~40,000 HH

4 upazilas (sub-districts) in 3 districts: 385,707 population, 75,621 households

*Community-based providers

-Government HW (HA, FWA)

-MNCS Promoter

-Village doctor

MNCS service packagePlus

Neonatal case management*

MNCS service package

Total Live births:

7,055 (estimated)

Total Live births:

7,140 (estimated)


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Intervention implementation

Training of service providers

Programme management through existing

government systems with some support from

the MNCS NGO and ICDDR,B:

Supply and logistics

Supervision and monitoring


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Intervention details (Jul 2011Dec 2012)

Gov HW MNCS-P Vill Doc Total

Number of trained

providers79 213 200 492

Number of trainedproviders reporting cases

26 72 20 118

Number of cases reported

and confirmed (tracked)39 85 38 162

Total Live births: 7,055 (estimated)


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Gov HW MNCS-P Vill Doc Total

Total cases tracked 39 85 38 162

Locally Managed 16 17 26 59

- Given an injection 25% 44% 39% 37%

Referred: 23 68 12 103

- Referred to hospitals 87% 71% 92% 77%- Referred to Com. Clinics 0% 6% 0% 4%

- Referred to vill. doctors 0% 18% 0% 12%

Compliance with referral 52% 53% 67% 54%


Intervention details (Jul 2011Dec 2012)


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Rolling Household Survey

A sample of about 2,000 households under 3-

monthly surveillance in each of the 10 intervention

and 10 comparison unions (a total of 40,557 HHs

under surveillance)

All pregnancy outcomes identified and interviewed

for intervention coverage and care-seeking practices


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Intervention (range) Comparison (range)

Sought care for possible newborn sepsis 83 (76-92) 87 (80-95)

Primary or higher referral hospitals 6 (3-11) 6 (3-8)

Local health facilities 7 (0-18) 5 (1-15)

Private/NGO facilities 2 (0-4) 3 (1-9)

Doctors 10 (2-18) 17 (6-29)

Homeopaths 25 (19-32) 25 (16-32)

Informal providers (village doctor)/drug store 39 (30-49) 39 (37-42)

Other (paramedic, herbal, spiritual) 5 (1-14) 4 (2-8)


Rolling Household Survey

Care-seeking (%) for possible newborn infections


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Case Management of Neonatal

Infections in Bangladesh

Choices to be made


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Community vs. Facility Based

Strategies and the Role of CHWs

714

20

1216

SylhetINDIA

INDIA

INDIA

Bay of Bengal

MYANMAR

INDIA

*

*

*

RANGAMATI

SYLHET

TANGAIL

BOGRA

BANDARBAN

KHULNA

PABNA

COMILLA

DINAJPUR

NAOGAON

MYMENSINGH

SUNAMGANJ

CHITTAGONG

JESSORE

SATKHIRA

HABIGANJRAJSHAHI

RANGPUR

NETRAKONA

NATORESIRAJGANJ

DHAKA

BAGERHAT

KURIGRAM

BHOLA

FARIDPUR

NOAKHALI

FENI

KUSHTIA

JAMALPUR

MAULVIBAZAR

GAZIPUR

GAIBANDHA

KISHOREGANJ

JHENAIDAH

KHAGRACHHARI

COX'S BAZAR

CHANDPUR

NILPHAMARI

NAWABGANJ

SHERPUR

NARAIL

RAJBARI

THAKURGAON

GOPALGANJ

MAGURA

MANIKGANJ

BARISAL

BRAHAMANBARIANARSINGDI

PANCHAGARH

SHARIATPURMADARIPUR

LAKSHMIPUR

CHUADANGA

LALMONIRHAT

JOYPURHAT

MUNSHIGANJ

PATUAKHALI

MEHERPUR

PIROJPUR

BARGUNA

NARAYANGANJ

JHALOKATI

INDIA

INDIA

INDIA

Bay of Bengal

MYANMAR

INDIA

*

*

*

RANGAMATI

SYLHET

TANGAIL

BOGRA

BANDARBAN

KHULNA

PABNA

COMILLA

DINAJPUR

NAOGAON

MYMENSINGH

SUNAMGANJ

CHITTAGONG

JESSORE

SATKHIRA

HABIGANJRAJSHAHI

RANGPUR

NETRAKONA

NATORESIRAJGANJ

DHAKA

BAGERHAT

KURIGRAM

BHOLA

FARIDPUR

NOAKHALI

FENI

KUSHTIA

JAMALPUR

MAULVIBAZAR

GAZIPUR

GAIBANDHA

KISHOREGANJ

JHENAIDAH

KHAGRACHHARI

COX'S BAZAR

CHANDPUR

NILPHAMARI

NAWABGANJ

SHERPUR

NARAIL

RAJBARI

THAKURGAON

GOPALGANJ

MAGURA

MANIKGANJ

BARISAL

BRAHAMANBARIANARSINGDI

PANCHAGARH

SHARIATPURMADARIPUR

LAKSHMIPUR

CHUADANGA

LALMONIRHAT

JOYPURHAT

MUNSHIGANJ

PATUAKHALI

MEHERPUR

PIROJPUR

BARGUNA

NARAYANGANJ

JHALOKATI

25

46

5551

Mirzapur

Use of referral facilitiesfor sick newborn care

In weak health system and highmortality areas, community-based

strategies more appropriate may be

as interim measures

Use of referral facilities

for sick newborn care

In the presence of strong health facilities,

CHWs can serve as health promotion workers


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Population density of Mega Countries with more than

100 million (2008)

0

200

400

600

800

1000

1200

0 200 400 600 800 1000 1200 1400

Population (millions)

PopulationDens

ity(/sq.km.) Bangladesh

Japan

Pakistan

Nigeria

Indonesia

Mexico Russia Brazil

USA China

India

Population density in

Bangladesh is 3 to 40

times higher than

other mega countries


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Access to health facilities

71%

56%

20%

74%

88%

75%69%

91%

Public facility (UHC,

MCWC, GoB-Hosp)

Upazila Health

Complex (UHC)

Private facility Either public or

private facility

2001 2010

% of ever-married women of age 13-49 with a live birth in previous 3 years

able to reach health facility in less than 1 hour

Source: Bangladesh Maternal Mortality Surveys, 2001 & 2010


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Going to scale with home-based care and services have been

difficult and gains in coverage has been mixed

Bangladesh needs its own model of community based care,

taking into account:

Population density and increased access to health services

The influence health service strength and quality on utilization

Increasing investments in closer-to home functional health facilities, e.g.,

community clinics (per 6,000 pop) and upgraded union facilities

Increasing investments in establishing advanced care services in referral

facilities

Choices to be made


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Bangladesh needs its own model of community based care:

Greater reliance on strategically located and accessible, linked health

facilities

with appropriate management, quality assurance and referral support

enhanced ability to ensure continuum of care through packaged services,

including advanced care

Community health workers a more specific and time-limited role for

changing community norms in terms of maternal/newborn care practices,

with an emphasis on educating and empowering families/communitieswith skills, information and the ability to make the right choices, and

Helping communities to more closely and effectively link to health

services

Designing and implementing special programmes for hard-to-reach

areas

Choices to be made


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el arifeen: community-based services within the continuum of newborn care - choices & challenges

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