Testing new program indicators in the Dominican Republic

Goldy Mazia, MD, MPH Newborn Technical Advisor MCHIP Coordinator - LAC Neonatal Alliance Global Newborn Health Conference Johannesburg, South Africa April 16th, 2013

Presentation Outline

Relevant background on newborn programs in the DR Measuring indicators for newborn infections, KMC, and HBB/ENC at birth Challenges Lessons learned

MCHIP Newborn Health Work in the DR

Started with BASICS in 2007; DR Mission support since Collaboration for scale-up with bilateral (Abt Associates) Maternal and Child Centers of Excellence Project (8 of 9 health regions) Program will finish in December 2013 The DR pioneered USAID/MCHIP funded KMC and HBB in LAC Transfer to MOH and partners:

HBB currently is national program 4 KMC centers; advocacy for uptake from MOH QI of management of newborn sepsis on scale-up by continues with Centers of Excellence Project
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Measuring KMC Indicators

Program started in 2009; one regional hospital trained in KMC Foundation in Bogota (became national training center) 3 additional hospitals trained locally SNL KMC indicators adapted and measured from start MCHIP creating automated data base (to generate indicators and graphs)-will be available for countries for adaptation
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Current Data Collection Tool (KMC-A)

Date File Mother of first numb Mother name age visit er Address Phone

Type of delivery (1=vaginal Name of Birth Date of Place of Sex ; 2=Cbaby birth birth weight section; 3=multiple ) Gest ation al age

First visit

Feeding KMC Com (1=exclu Chron Corre positi plicati Weight Weig sive ons gain since ologic cted on ht breastfee age age (yes/ (desc discharge dintg; no) ribe) 2=other)

Selected current indicators results

Date KMC started Trained by # newborns in KMC

HOSPITAL

Proportion of eligible newborns in the KMC program

90% 4 (0.8 %)

# and proportion of deaths in KMC babies

Proportion of babies abandoning KMC F/U

HSVP *

May 2009

KMC Foundation Bogota 478

2.5%

MSLM
HSVP February 2013 40

January 2012

HSVP

427

38%

5 (1.1%)

10%

Morillo King
April 4th 2013 HSVP

N/A

0%

Musa

N/A

N/A

KMC and Neonatal Mortality in Training Center in the DR (HSVP)

50
44 42.1

46

45

40
30

35

30

25

24.5

20

NMR per 1,000 live births

15

10

5 2008 2009 2010

7

0 2011 2012

Reduction in mortality of premature/LBW babies since KMC implementation (HSVP)

90% 78% 67% 64% 61%

Proportion of newborn deaths in prematures/LBW

100 90 80 70 60 50 40 30 20 10 0 2008 2009 2010

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2011

2012

National implementation of Helping Babies Breathe (HBB) in the DR

Initiated in June of 2010 (global launch in WDC); training of 4 national master trainers Translated materials into Spanish, adaptation of pictures for LAC 7 national master trainers, 30 facilitators, 300 providers in 10 Centers of Excellence (collaboration with USAID bilateral) in 8 of 9 regions; continuing Equipment for service provision in process of distribution by bilateral (indicator) Collecting GDA indicators (plus ENC at birth); using added register for delivery room (~ to MCHIP Malawi example); developing automatized database
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HBB/ENC Data Collection Tool (snapshot )

Breathed after resuscitation Temperature maintenance: 1. Yes 2. No Cord cutting: Eye prophylaxis: 1. Yes 2. No 1. Dried immediately and put in skin-toskin contact 2. Dried and wrapped 3. Dried and put under warmer 4. None 1. Sterile instrument 2. Non sterile instrument BF first hour: 1. Yes 2. No

Cried/breathed at birth

Resuscitation golden minute:

1. Yes 2. No

1. None 2. Aspiration and stimulation 4. Bag and mask ventilation 5. Advanced resuscitation

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Some illustrative examples (Jan-Mar 2013)

HOSPITAL

TOTAL # BABIES

# (%) OF BABIES NOT CRYING OR BREATHING AT BIRTH # (%) BABIES RESUSCITATED WITH BAG AND MASK VENTILATION WARMTH MAINTENANCE EYE PROPHYLAXIS

STERILE INSTRUM TO CUT CORD

BF IN FIRST HOUR

MUSA

213

15 (7%) 43 (2.3%) 10 (0.5%) 99%

8 (4%)

100%

94%

100%

73%

MSLM

1,851

89.1%

100%

21.2%

HSVP

157

18 11.4%

0%*

100%

100%

100%

82%

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Quality improvement of newborn sepsis management at the facility level in the DR

Part of regional strategy since 2007 (virtual sessions for exchanges); currently 10 centers involved. One championed and is mentoring others What indicators to use?

Proportion of observed staff complying with correct technique and recommended times for hand washing for newborn care Proportion of observed deliveries applying elements of clean/sterile delivery (clean hands, sterile linen, sterile instrument for cord cutting, clean spaces, etc.) Proportion of admissions to the nursery due to suspected nosocomial infection (based on CDC definition)
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Some achievements

Admissions for suspected hospital-acquired infection - One regional hospital 3 year follow-up Dominican Republic

Percentage

50 40 30 20 10 0

7 ug ct ec 08 pr n go ct ec 09 br n ug ct ec 10 eb ar 0 ' A O D ' A Ju A O D ' A Ju A O D ' F M b n b n Ju Ja Fe Fe

Month
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Challenges

Incorporation of new neonatal indicators; mainly new and still being tested Technical staff not used to data collection and analysis, perceiving as addition of unnecessary work Need for periodic quality control of data collection Frequent rotation of staff requires frequent trainings in data collection and analysis Complexity of data collection tools

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Lessons learned

Advocacy and frequent sharing of results to central level authorities: MOH invited MCHIP to recommend newborn indicators for inclusion into HMIS Results measurement and sharing stimulate staff to comply with changes and measure routinely Friendly competition among centers User-friendly tools- Automatize where possible Pioneering stimulates commitment
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Siyabonga - Thanks

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