Ensuring Newborns with Infections get Prompt Treatment: Nepals Experience

Dr. Shyam Raj Upreti Director Child Health Division MOHP May 2012

Nepal in context

Population: TFR CPR CMR NMR SBA

26.6 million with 1/3 of the population living below the poverty line 2.6 43.2% 54/1000 (down 64% since 1991) 33 / 1000 36%

MMR

281 / 100,000 (DHS 2006)

Health Care Delivery System

50-100 villages (VDCs) Population of 5,000-10,000 per village Sub Health Post OR Health Post OR Primary Health Care Center

75 districts

Health Care Delivery System Community level

50-100 villages (VDCs) 9 wards (hamlets) Population 500-2000 per ward

50-200 households 52000 Female Community Health Volunteers

75 districts

Key Newborn Indicator Progress

Child Mortality in Nepal (DHS)

200 160 120 80 40 0 1991 1996 2001 U5MR 2006 IMR NMR 2011 2015 -MDG
153

118 102 79 64 48 46 50 39 33 46 33 61 54 54 34 15 91

Causes of Newborn Deaths

65 % of births take place at home 35% of deliveries occur in health facilities
Others 10% Congenital Anomaly 8% Preterm/L BW 6% Birth Asphyxia 15%

Injury 19%

36% of deliveries were assisted by skilled birth attendants

Harmful practices for cord care and essential newborn care Misconception that newborn care required better technology and specialized HR

Severe Infections 42%

Source:NDHS 2006

Infection is the major cause of Neonatal Deaths

Continuum of Care Maternal and Neonatal Health

120 100
82 82.9 68.3 70 63.2 59.3 56 45 36 29.4 22.7 18.7 10.9 17.7 9.1 9.4 17.6 14.3 35 25 20.7 9.3 33.0 35.4 35 31.1 53.0 96 93.2

percentage

80 60 40 20 0
50 45.3

4 ANCs

2 TTs

Ir o n d ur ing p r eg nancy*

D eliver y b y SB A * *

Inst it ut io nal D eliver y

C lean Ho me D eliver y Kit

D elayed B at hing af t er 2 4 hr s

PN C V isit *

Exclusive B f up t o 6 mo nt hs

B f wit hin 1 hr

BCG

NDHS 2001

NDHS 2006

NDHS 2011

Evidence Generation Management of Newborn infection Pilot to scale up

Morang Innovative Neonatal Intervention (MINI) pilot

Evidence Generation: MINI pilot

Based on evidence from successful implementation of CB-IMCI program at scale MINI pilot tested whether the most peripheral health volunteers and health workers could successfully identify, treat and manage neonatal infections

MINI Program

All births - FCHV visits within 24 Hrs

Sick Neonates Assessed

Takes birth weight

FCHV classifies LBI

FCHV classifies PSBI

If low birth weight Counsel on ENC Four F/U Visits

FCHV Treats as per guidelines

FCHV gives 5 days Cotrim Calls VHW/MCHW Also does 3rd day F/U

3rd day F/U by FCHV

VHW/MCHW tx with Gentamicin for 7 days

Key Finding from MINI

Indicators
Total Live Births recorded Total deaths Episodes of Possible Severe Bacterial Infection (PSBI) % of PSBI episodes receiving Cotrimoxazole-P % of PSBI episodes receiving Gentamicin

Results for final year (May 2008-April 2009)

50,618 776 3,614 (7%) 98% 86%

% of PSBI episodes completing full 7 doses of Gentamicin

94%

Conclusions from MINI

1. Community-based management of neonatal sepsis is feasible and effective through existing government health system 2. Female Community Volunteers (FCHVs) can follow an algorithm for classification of sick neonates, initiate treatment, and facilitate referral

3. Community health workers (VHWs/MCHWs/HWs) can provide gentamycin injection, with high treatment completion rates and these likely contributes to reduction of neonatal deaths
Community Based Newborn Care Program (CB-NCP) developed based on lessons learnt from MINI

Community Based Newborn Care Program CB-NCP

An Innovation being piloted by the Government of Nepal

Components of Community Based Newborn Care Seven key components:

1. Behavior Change and Communication 2. Promotion of institutional deliveries & clean delivery practices in case of home deliveries 3. Prevention and management of hypothermia 4. Recognition and management of birth asphyxia 5. Postnatal care 6. Care of low birth weight babies 7. Community based management of possible severe bacterial infection

Behavior Change and Communication using the Birth Preparedness Package

BPP counseling

Promotion of health facility delivery

HF delivery

Management of LBW
KMC for VLBW newborn

Postnatal Visit with Counseling on Danger Signs

Identification and Management of Neonatal Infection

Family or FCHV identifies danger sign during PNC

FCHV Assesses for Possible Severe Bacterial Infection

No PSBI

PSBI

Counsels on ENC & FU PNC visits conducted

FCHV initiates Cotrim & refers to HW for Inj. Gentamicin

HW provides in x 7 days Baby recovers / referred / dead

Monitoring & Evaluation System

Monitoring framework developed for CBNCP Monitoring data collected and reported through the existing reporting system but not yet included in the HMIS only for pilot period When scaled up to all districts selected indicators will be included in the HMIS.

100

Pregnant women registered with FCHVs in CB-NCP FY 2010/2011

As percentage of Expected Pregnant Women 78 65 59 70

60

40

27

35

Key Finding from CBNCP districts

47 44 24

20

0 Bardiya Dang Sunsari Doti Kavre Morang Chitwan Palpa Dhankuta Parsa

71

80

Essential Newborn Care Practices

As percentage of home deliveries that happened in FCHVs presence
100
90 80 70 60 50 40 30 73 73 95 95 100 100 100 100 95 95 100 100 100 100

90 90 81 81

85 85

20
10 0

Sunsari

Doti

Dhankuta

Bardiya

Palpa

Kavre

Morang

Skin to Skin contact between mother and newborn after birth Breastfeeding within an hour of birth

Chitwan

Parsa

Dang

% of all births

100 90 80 70 60 50 40 30 20 10 0

Bardiya Dang Sunsari Doti Kavre

97 99 95 97 94 96 86 95 97

97 99

3rd day

Morang
Chitwan Palpa Dhankuta Parsa
71 76

95

7th day
94 98 93 97 95 95

Percentage of all births receiving home visits by FCHVs on days 3, 7 of birth

Percentage of possible severe bacterial infection among babies 0-59 days

14.0%
12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.7% 0.0% Bardiya Dang Sunsari Doti Kavre Morang Chitwon Palpa Dhankuta Parsa 11.7%

2.9% 2.2% 0.8%

2.9%

2.4% 0.6% 0.5%

2.3%

Gentamycin Treatment and Compliance for 7 doses

100 99 97 99

96

89

89

92 49
84

100 90 80 70 60 50 30

81

96

79

20
10 0

32

40

73

96

Treated by Gentamycin

Compliance of Gentamycin

Delivery Practices, Bardiya District Nepal, 2008 and 2010

Baseline and endline HH surveys CB-NCP implementation
100
90
81 93 96

80

75
66 64

Per centage of m other s

70
60 50

65

40 30
20
19

34

30

10 0 Deliver y at hom e Deliver y at HF Deliver y by SBA PNC 48h - m o PNC 48h - NN

2008

2010

Some initial conclusions

FCHVs have been able to reach more than 50% of the expected pregnant women in 5 of the pilot districts and less than 50 % in the remaining 5 districts. Essential new born practices satisfactory FCHVs are capturing PSBI cases, but performance varies across districts (11 to 0.5%) Compliance for Gentamycin treatment is satisfactory in most districts

What have been the key enabling factors?

Creation of Enabling Environment

Policy Environment Approval of policy for under five children pneumonia treatment by Female Community Health Volunteers 1995 Approval of policy for management of neonatal Infection by Female Community Health Volunteers under Community Based Newborn Care Program 2007 Injection Gentamycin included in National Essential Drug List 2007 Coordinated support by partners: USAID & NFHP II, UNICEF, CARE, Plan, Health Right, One Heart, Save the Children

Way Forward
Assessment of the Community Based Newborn Care Program Modification of package based on assessment findings Integration with IMCI & Safe Motherhood program Incorporation of newer tested interventions Chlorhexidine Strengthening of facility based newborn care National level scale up Focus on unreached population

Thank You!