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Facility-based Newborn care Country Successes and Challenges

17th April 2013

Dr. Jesca Nsungwa

Ass. Commissioner, Child Health Ministry of Health

Implementation arrangements

Progress Successes Challenges Way forward

Uganda at a glance
Total Population MMR U5MR NMR Number of Newborn Deaths Number of Stillbirths Proportion of U5 deaths that are newborns NB Deaths due to prematurity Stillbirths as a proportion of deaths 32,000,000 438/100 000 LBs 90/1000 LBs 27/1000 LBs 39,000 38,000 41% 16,090 26%

Sources: UDHS 2011

STATUS : Trends in Mortality 1995-2011

152 158 137


89 76



54 29 27





Neonatal Mortality

Infant Mortality

Under five Mortality

Causes of newborn deaths

Sources: UDHS 2011, Mbonye et al 2012

3 causes account for 90% of all newborn deaths

Implementation Arrangements - Process

1. 2. Policy Framework for Implementation Newborn Health Service Standards
Facility level Community level (Village health Teams)


Quality Improvement Approach mentoring, coaching, learning sessions between different facilities


Linking Health facility and Village Health Teams

Policy Implementation Framework

Health Sector Strategic and Investment Plan 2010/11-2014/15 (1) Roadmap to Reduction of Maternal and newborn Mortality (1) Child Survival Strategy
Newborn Health Implementation Framework
Newborn Health Service Standards

Integrated Community Case Management (includes newborn postnatal home visits)

Newborn Service standards

Include the most relevant parameters and service practices that need to be in place for ensuring quality newborn health services. Grouped into seven sections standards for 1. 2. 3. 4. Infrastructure and equipment Management systems Infection prevention Information, Education and Communication 5. 6. 7. Clinical Services Client services Village Health Teams

Percent among facilities offering delivery service (N=261) with items available in delivery room

Example of page in the standards handbook

How to verify
STANDARD Health facility has infrastructure to cater for both high risk and normal babies OPERATIONAL DEFINITION Resuscitation space Nursery space KMC beds MEANS OF VERIFICATION Physical check for their presence

Implementation Steps
1. Joint health facility Audit using service standards district and national team (assessment teams, and tools) 2. On site mentoring of health workers (master trainers, mentoring diaries etc) 3. Uganda adapted Helping Babies Breathe PLUS Curriculum (PLUS action plan, flip chart, Hand book, OSCE etc) 4. Quality Improvement Collaborative (Team in facilities, best practice identification, select indicators to show practice etc) 5. Facility death audits and response


New born R esuscitation
PLUS = Essential New born Care

Flip Chart

American Academy of Pediatrics

American Academy of Pediatrics

Learners Handbook

Three Action Plan - Infection - Preterm - Normal baby


Present and demonstrate

The cord can present life threatening complications if not properly observed and cared for. Demonstrate how to clean the cord stump Wash hands before touching the stump Wash with clean water only and put nothing on the stump Keep cord stump dry and uncovered Do not apply anything on the cord stump

Practice with Action Plan

Ask the learners to practice Cleaning the cord Make sure the cord is clean and dry Follow the Action Plan: Ask a learners to point out The action step advise on cord care

Apply nothing on the cord Baby powder and herbs should be applied to facilitate cord drying Umbilical redness is normal A cord should dry and fall off within a few days

Check yourself

Group discussion

Demonstrate signs and treatment of umbilical infection Reddening around umbilicus or pus draining from cord Treat infection with cleaning cord and gentian violet Treat local umbilical infection three times a day Background and educational advice: Obsep

1. Experience with serious umbilical cord infection or tetanus? 1.Local practices around cutting, tying, and treating the cord? 2.Availability treatment for cord infection?

Common cord problems are bleeding from the cord and infections. Infections of the cord in a newborn and can spread to the whole body causing disease and death. Thus it is important to prevent cord infections by practicing good care for the cord. It is important to teach the mother how to observe the cord stump for any bleeding on the first day and to prevent cord infection: Wash your hands with water and soap before caring for the cord, Use saline water for cleaning the cord if it is soiled, do not apply anything such as herbs, animal dung and other treatments on the cord, and do bandage the cord, cover it with a loose piece of clean cloth The mothers should be taught the signs of cord infection. She should seek medical care if any redness around the umbilicus or pus draining from the cord is observed


Mother Child Health Passport

Implementation arrangements Successes Challenges Way forward

Coverage of facility interventions/packages

Helping Babies Breathe Plus (HBB Plus) Maternal and Perinatal Death Reviews (MPDR) HBB Plus and ICCM HBB Plus and MPDR Integrated Community Case Management

1. Zonal/regional master trainers and mentors formed to support MOH and district roll out working with national newborn steering committee 2. HBB training adapted to cover essential newborn care (HBB Plus) for mentoring better counseling and treatment skills 3. Service standards useful for district planning and dialogue for health systems strengthening + benchmarks for quality improvement 4. Common understanding how to roll out facility newborn care 5. Not only on building health worker skills - institutionalize quality improvement activities many months after training through regular coaching, learning sessions 6. Newborn indicator manual addendum of health sector indicator manual

Results from a maternal and newborn improvement collaborative in Uganda

Partograph use for monitoring labor (45 facilities)
80 70 Percent 60 50 40 30 20 10 0 # of deliveries at a facility in which a partograph was used Jan 265 Feb 382 Mar 635 Apr May Jun Jul Aug Sep Oct Nov Dec
sensitized staff on partograph use IC methodology introduced Data reported in 1st learning session Data reported in 2nd learning session

reminders to use a partograph for every mother in labor

966 1159 1270 1264 1779 2122 2149 2110 2335

Total # of women who delivered at the 2980 2664 2863 2743 2980 2793 2875 2827 3213 2979 2864 3094 facility % of mothers in labor monitored with partograph % of mothers who developed prolonged/obstructed labor 9 4.7 14 3.5 22 3.0 35 2.9 39 3.6 45 2.9 44 3.0 63 3.6 66 3.2 72 2.9 74 2.8 75 3.9

New born babies that received ENC package (45 facilities)

80 Percent 60 40 20 0 Newborns that received ENC package Total live births at facility
IC methodology introduced 1st learning session 2nd learning session Introduced a checklist for ENC services

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 650 679 817 1118 1445 1540 1761 2342 2683 2751 2541 2636 2745 2668 2766 3070 3235 3290 3401 3405 3740 3688 3345 3528 25 30 36 45 47 52 69 72 75 76 75

% new born babies that received 24 ENC package

Overview implementation arrangements Progress so far Successes Challenges Way forward

Model for Improving facility NBC

Improvement in HW Skills

Strengthening Health Facility

Clinical Management Skills

Link with Village Health Teams

Facility Support


Mentoring Teams Tools Monitoring

VHT PNC visits Mentoring Scaling Up

Standards Assessment Checklist Death Audit HF collaborative

Health system challenges availability of medicine e.g. corticosteroids, antibiotic use at lower levels Capacity building H/Worker shortage, turnover or transfer constrain mentoring Training materials especially procurement dummies Lack of equipment desirable to have all equipment and commodities soon after training Procurement procedures e.g. competitive bidding Penguin suction bulbs Lack of data for planning and decision making Data driven process to solve problems and source support Routine HIS not able to report on QI processes, little information on premature births Poor staff reporting e.g. more macerated compared to fresh still births Weak birth death registration

Low utilisation of facility services combined communication activities needed Health facility delivery currently 57% Post natal care attendance 29% Poor referral systems Coordinating available resources - it is important to map who is doing what, where and resources Piecemeal implementation of the core inputs Lesser investment in community mobilization Human Resource staffing, housing, poor salaries, training specific cadres Tapping other vehicles for NBC implementation PMTCT, Malaria etc. Public private facility engagement Focus and awareness on newborn good negative public reaction, media, politicization and criminalization of maternal and newborn deaths. Need to have more inclusive implementation

Implementation arrangements Progress so far Successes Challenges Way forward

Way Forward
Nationwide health worker mentoring Re-equipping all health facilities (MNH) Advocacy on newborn survival and rights Pre-service training Institutionalize further death auditing and problem identification, response Improve data systems for decision making Emphasis on preterm births and deaths Resource mobilization and better tracking/ synergies with other interventions