Framework for newborn health continuum of care package

Bernadette Daelmans,

Coordinator Policy, Planning and Programmes
Department of Maternal, Newborn, Child and Adolescent Health (MCA)

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The continuum of care

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Essential interventions

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Essential interventions
Before pregnancy
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During pregnancy
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Prevention of too early, unwanted, or rapid successive pregnancies
Adequate nutrition, including iron and folic acid supplementation, and treatment of anaemia Immunization (rubella, HepB, TT) Prevention of HIV and STIs Prevention and treatment of substance use Smoking cessation Protection from harmful exposures and from interpersonal violence
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Tetanus toxoid immunization
Birth and emergency planning Detection and management of problems complicating pregnancy Detection and treatment of syphilis Intermittent preventive therapy for malaria* Information and counseling on self-care Sleeping under an insecticide treated bednet Prevention of mother to child transmission of HIV* (PMTCT)

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Essential interventions
During child birth
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In the newborn period
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Monitoring of progress of labour, maternal and foetal wellbeing with partograph
Social support (companion) during birth Immediate newborn care (resuscitation if required, thermal care, hygienic cord care, skin-to-skin contact, early initiation of BF) Emergency obstetric and newborn care for complications Antibiotics for pre-term premature rupture of membranes (pPROM) Antenatal corticosteroids for preterm labour PMTCT
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Exclusive breastfeeding
Thermal care Hygienic cord care

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Prompt care-seeking for illness
Extra care for low-birth-weight babies, including kangaroo mother care Immunization Management of newborn illness PMTCT

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Packages of care
Clinical
TREATMENT FOR PREGNANCY COMPLICATIONS

ESSENTIAL LABOUR AND CHILDBIRTH CARE

MANAGEMENT OF NEWBORN PROBLEMS

IMMEDIATE NEWBORN CARE

REPRODUCTIVE CARE

Outpatient

ANTENATAL CARE

POSTNATAL CARE

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MANAGEMENT OF NEWBORN PROBLEMS

PREPREGNANCY CARE
HOME VISITS DURING PREGNANCY SAFER HOME BIRTH

Family/ community

CARING FOR THE NEWBORN AT HOME

EARLY POSTNATAL HOME VISIT

MANAGEMENT OF NEWBORN PROBLEMS

Intersectoral: improved housing, water and sanitation, and nutrition; education and empowerment

6 Pre-pregnancy

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Pregnancy

Childbirth

Newborn/postnatal 

The time AROUND childbirth:
A window of opportunity for impact
Labour and childbirth care  Labour monitoring  Childbirth care Obstruction/Fetal distress: CS, vacuum PT labour: corticosteroids, antibiotics for PPROM

Essential newborn care Not breathing at Birth: drying, skin-to-skin birth: Resuscitation  First week: early/excl. BF, Preterm birth: Kangaroo warmth, cord care, hygiene Mother Care, BF support, Suspected sepsis: immediate treatment of Early antibiotic suspected infection treatment
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Ending preventable newborn deaths

REPRODUCTIVE CARE

TREATMENT FOR PREGNANCY COMPLICATIONS

Labour and childbirth care   Labour monitoring Childbirth care Obstruction/Fetal distress: CS, vacuum PT labour: corticosteroids, antibiotics for PPROM

Essential newborn care

PRECONCEPTION CARE

CARE DURING PREGNANCY

 Not breathing at birth: Resuscitation 

Birth: drying, skin-to-skin First week: early/excl. BF, warmth, cord care, hygiene

Suspected sepsis: Early antibiotic treatment

Preterm/LBW: Kangaroo Mother Care, BF support, immediate treatment of suspected infection

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Quality of care: a barrier to progress
 Quality of care has been recognized as a neglected issue in the international health agenda.  Global data show that quality of care provided in referral facilities is often poor.  Poor quality of care leads to significant morbidity and mortality.  Existence of a quality gap is a most likely contributor to slow progress towards MDG 4 and 5.
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Improving quality of care
practice guidelines, structural standards, training standards motivation, professional development, incentives, accreditation, etc.

assessment and indicators

champions, MoHs, local authorities, professional association, NGOs & international agencies.
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Evidence based newborn guidelines (2009 – 13)
 Care of the newborn immediately after birth  Newborn resuscitation  Newborn immunization  Postnatal care  Care of the preterm and low birth weight baby  Management of neonatal sepsis  Management of neonatal seizures  Management of neonatal jaundice  Management of necrotizing enterocolitis  Care of the HIV-exposed newborn
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http://www.who.int/maternal_child_adolescent/documents/en 

Monitoring quality
WHO Safe Childbirth Checklist
contains 29 items addressing:  the major causes of maternal death - haemorrhage, infection, obstructed labour and hypertensive disorders  intrapartum-related stillbirths inadequate intrapartum care  neonatal deaths - birth asphyxia, infection and complications related to prematurity
http://www.who.int/patientsafety/implementation/checklists/childbirth/en/index.html

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Context matters: Health workforce

WHO Global Health Workforce Statistics. Countdown countries affected by a severe health workforce shortage | 13 in 2012, by UNICEF region. al Health Workforce Statistics. 

Midwifery: the dual gap
 Quantity  Not enough midwives, 38 countries have severe shortages  Quality  Many existing facilities are poorly equipped, with inadequate staffing levels  Competencies of staff may be insufficient  Motivation and respect are compromised
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A call for bold steps
 Governments:
– Recognize midwifery and engage midwives at national policy decisions – Include midwifery in costed MNH plans, and align human resources for health plans. – Invest in active monitoring of the practising midwifery/MNH workforce.

 Regulatory bodies
– Educational standards and practice competencies. – License and relicense midwives.

 By schools and training institutions
– Improve and maintain competencies in midwifery and transformative education. – Support development of midwifery leadership

 By professional associations
– Establish solid governance, strengthen administrative capacity and improve financial management

 By partners:
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– Support programmes to scale up midwifery services enabling country commitments to the Global Strategy 

Community health workers: a critical link
Pregnancy visits to promote: • • • Antenatal care Birth with skilled birth attendant Newborn care at birth: immediate drying and skin-to-skin contact, early initiation of breastfeeding, clean cord care Early and exclusive breastfeeding

Postnatal visits to support: •

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Keeping the newborn warm, hygienic cord care
Extra care for LBW babies Timely recognition of danger signs

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Uptake of family planning 

Adolescence: a time for investment
 Preventing early pregnancy
– – – – – – Prevent early marriage Prevent early pregnancy Increase use of contraception Combat coerced sex Reduce unsafe abortions Increase access to skilled care

 Reaching out before conception
– Provide folic acid supplementation – Reduce harmful behaviors (tobacco, alcohol) – Pay attention to mental health

 Providing extra care for mother and baby
– During pregnancy and childbirth – In the postnatal period
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Conducive policies are essential

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Surveillance to save lives
Surveillance

QoC improvement

Vital registration

Response action Review deaths

Identify deaths

Report deaths

Response
QoC 19 | measurement MMR tracking 

Life-saving commodities: a new impetus
13 life-saving commodities 10 recommendations
  Shaping global markets Shaping local delivery markets

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Putting in place innovative financing
Strengthening quality Making regulation more efficient Increasing supply and awareness Increasing demand and utilization Reaching the poorest women and children Improving performance and accountability Prioritizing and funding product innovation

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Closing the equity gap
Coverage

| Barros AJD et al., Equity in maternal, newborn and child health interventions in Countdown to 2015: Source: 21
a retrospective review of survey data from 54 countries. Lancet 2012; 379: 1225-33. 

Bringing it all together

Country leadership & Implementation
Key advocacy events and catalytic initiatives in support of Every Woman Every Child Born too soon A Promise Renewed Decade of Vaccines Global action plans: nutrition, pneumonia & diarrhea, newborn Innovations working group Commission on Live-saving Commodities Family Planning Summit

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CoIA

Independent Expert Review Group Visit www.everywomaneverychild.org 

The continuum in action
This young mother lives in an area covered by a home-based newborn care program
 HOME: She and her family were visited by a CHW during pregnancy, who encouraged ANC and early care-seeking for danger signs

 HOSPITAL: When the mother went into premature labour, her husband urged her to go to the hospital, and she delivered a LBW infant weighting 1.5 kg

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 HOME: When discharged from the hospital on day 5, the CHW visited to assist with feeding, ensuring warmth and screen for danger signs 

Thank you

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