Helping Babies Breathe Program in Tanzania

Georgina Msemo (MD, Mmed Paed) Global Newborn Health Conference South Africa, 16th April 2013

Background Country Context

Population size 44.9 million (census 2012) Under five: 7.74 mill Infant: 1.65 mill Women of child bearing age 10.4 mill Live births:1.8mill Tanzania is divided administratively into: 30 regions (25 Mainland; 5 Zanzibar) 142 LGAs ( Local government authorities)

Maternal, Newborn and Child Health

Country commitments /targets MDG 5- reduce maternal mortality rate to 193/100,000 live births by 2015 MDG 4- reduce U5 mortality to 54/ 1000 live births MKUKUTA and Election Manifesto reduce maternal mortality rate to 264/100,000 live births and U5MR to 79/1000 by 2010

Background- Country situation

Situation in 2004/5 DHS 2004/5 showed no improvement in reduction of maternal and neonatal mortality 24% Reduction in under-five mortality and 31% reduction in infant mortality (1999-2004)

National DHS 2004/5 showed child survival gains

180 162

160
145

141

140

136

-24% 147
112

Mortality (nq0)

120 100 80 60 40 20 91 92 87 99

Under-five

-31%
68

Infant
54.3

32

37.9
40.4

Neonatal MDG Target

32

1990

1992

1996

1999

2004

2009

2015

Source: URT Measure DHS

An improvement of 24% in under 5 mortality represents 39,200 fewer child deaths per year in Tanzania

Country effort to attain MDG 4

1. Continue with child health interventions at scale:
IMCI (used research for advocacy to scale up) - Case management
Quality of Care at Hospital level

Immunization (through campaign and outreach, now GAVI HSS opportunity to scale up ) Vitamin A supplementation Malaria interventions
Long Lasting Insecticide Treated Nets (LLINs), Access to Malaria Treatment

Management of Diarrhoea (ORS/Zinc)

Country effort to attain MDG 4

2. Strengthen Newborn care by dealing with major killers of neonates mainly:
Infections-28% Premature complications-27% Birth asphyxia- 26%

Efforts to strengthen newborn care

Newborn health desk office established in the Ministry of Health-Newborn programming Adaptation/Review IMCI guidelines at all levels to include the newborn in the first week of life-Neonatal Infections Establishment of Kangaroo mother care services- Low birth weight babies Newborn Resuscitation program-Reducing birth asphyxia related mortality

Birth Asphyxia on "Tanzania's HBB program."

HBB-Background
49% of women and their babies do not receive skilled care during birth (DHS 2010) The first day at birth especially the first hour is critical for a newborn survival Proper monitoring of labour, appropriate newborns resuscitation are interventions to reduce newborn deaths

HBB-Background
Limited resuscitation skills and knowledge among service providers. The number of skilled providers present at delivery was <50 % Incidence of Birth asphyxia remained unchanged for >15 years

HBB-Background
High level Political commitment: His Excellency President Jakaya Kikwete
Statement made in Sept 2007 during 62nd session UN General Assembly- countries are the MDG timeline while targets set are not there yet In 2008 during the Launch of MNCH Roadmap 2008-2015 and Deliver now Campaign for women and children and He wanted to have scaled interventions that are proved to work rather than pilots

HBB-Background
MOHSW submitted proposal to the Global Implementation Taskforce of Helping Babies Breathe - American Academy of Pediatrics (AAP) in April 2009 with request for financial support for HBB program in Tanzania The goal was to achieve universal newborn resuscitation coverage of skilled birth attendants.

Components of HBB
The program has: An intervention component (training) A research component The Primary Goal- to reduce Birth Asphyxia related mortality by 50% A Secondary Goal- to reduce stillbirth deaths by 25%.

Intervention component
Educational material developed by the AAP (later translated into Swahili), Neonatalie model and resuscitation equipment were used
Cascade model approach to train health providers throughout the country

Cascade training approach

40 145
Zonal /Regional District Trainers Service providers Service providers District trainers

Master Trainers Zonal /Regional District Trainers Zonal /Regional Zonal /Regional

1332
10,000+

Service providers

Service Provider

Continuing cascade training and refresher training

Trained providers and trainers: Continue to provide on job training to other service providers Refresher training in the facilities where they are working.

National data acquisition and reporting

Each facility reports all births and their outcome using existing reporting format. Weekly notification reporting of all newborn death. Data compile at health facility on monthly basis. Districts /Region compile both a quarterly report and annual report. Central level receive bi-annually reports from regions using existing reporting system.

Status of training to date

Master trainers 40 trained in September/October 2009 (WHO support) Zonal trainers 126 trained in October-December 2009 (WHO support) District trainers 592 trained in December 2009December 2012 (UNICEF support) Service providers 1987 trained up to December support from some CCHPs (UN JP2 and Laerdal Foundation support)

Research components
Research sites were 8 ( Eastern Zone -3 and collaborating institutions; Northern zone -3; Lake zone -2) A data collection form with core elements and desired elements was used

Program monitoring
Data committee reviews and assesses the status of implementation Steering committee ensures the running of the program

Summary of Neonatal Deaths, Stillbirth Rates and Perinatal Deaths

Variable Pre HBB Post HBB Number/Total Number (rate/1000)
107/7969 (13.4) 155/8124(19.0) 552/77369 (7.1) 1131/78500 (14.4)

Risk Reduction (95% CI)

0.53( 0.43-0.65)* 0.76(0.64-0.90) **

Neonatal Deaths 24h Stillbirths

Perinatal Deaths

262/8124(32.2)

1683/ 78500(21.6)

0.67(0.59-0.76)*

* p < 0.0001, ** p=0.001.

Results Conclusion
HBB implementation is associated with: HBB implementation was associated with a significant reduction in both early neonatal deaths within 24 hours and rates of FSB HBB uses a basic intervention approach readily applicable at all deliveries.

These findings should serve as a call to action for other resourcelimited countries striving to meet Millennium Development Goal
Published in the February 2013 edition Journal of the American Academy of Pediatrics

Challenges for the current HBB program

Inadequate supportive supervision to the sites Inadequate funds to roll-out cascade trainings Inadequate skilled providers Ensuring availability and maintenance of equipment

Scale up plan
Used research findings to acquire CIFF support- three year program (2012-2015) Scale up neonatal resuscitation training to remaining service providers Improve facility readiness by providing resuscitation equipment and training materials Establish mentorship program for MNCH

Sustainability Plan
HBB program fully owned by the Ministry Steps have been taken to ensure newborn resuscitation training takes hold in all areas of the medical system. The HBB curriculum is being introduced into the preservice midwifery curriculum
Midwifery instructors from more than half of the nursing schools have already been trained in HBB to be able to train the next generation of service providers.

Districts have already begun to budget for HBB training and supervision in their annual budgets National clinical mentoring system to be developed.

Acknowledgements
Global Task Force on Resuscitation Tore Laerdal and the Laerdal Foundation American Academy of Paediatrics UN Agency UNICEF and WHO Children Investment Foundation Fund SNL/SC- Newborn health programming initiatives Jeff Pearlman- Weil cornel University

Asanteni Sana