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Facility-Based Maternal & Newborn Care in Facilities within the Household-toHospital Continuum of Care (HHCC)

Steve Wall Save the Children Global Newborn Health Conference Johannesburg April 15, 2013


I. Global shift in care seeking toward facilities I. Quality of facility-based MNH care I. Linkages to community/household care

135 million live births per year

High income countries ~11 million births

Middle income countries ~34 million births

One in 4 newborns is African

2035 ~50 million births at home

One in 3 will be African

~40 million facility births

Institutional delivery varies greatly by region

Percentage of births delivered in a health facility, 20072012

Source: SOWC 2013, UNICEF global databases 2012, from MICS, DHS and other nationally representative sources. Note: Global estimates are based on a subset of 110 countries, covering 82% of births in the developing world. Regional estimates represent data from countries covering at least 50% of regional births. Data coverage was insufficient to calculate the regional average for CEE/CIS.

Increasing coverage of skilled attendance

100 90 80 70 Coverage (%) 60 50

Around the year 2000 Around the year 2010

71 59

30 20 10 0 Bangladesh
12 27




18 11





Source: Newborn survival decade of change analysis: Health Policy and Planning. 27(Suppl. 3) papers 3 to 7

Changes in skilled birth attendance for Malawi, 1990-2010


80 70 Coverage (%) 60 50 40 30 20 10 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 55


Increased by 16% over the last 5 years

Multiple approaches both supply and demand > 30% increase in numbers of nurse/midwives
Source: Malawi DHS 1992, 2000, 2004, preliminary 2010. Malawi MICS 2006

Increasing facility deliveries

State in India % Institutional Deliveries

Bihar Chattisgarh Jharkhand Madhya Pradesh

47.7 34.9 37.6 76.1

Rajasthan Uttar Pradesh Uttarkhand

70.2 45.6 50.5

Source: Indian Annual Health Survey, 2011.

Contributing factors to this rapid increase

Incentives for CHWs and families

Service availability, including appropriate drugs and tools

Changing community and practices

Not all facilities are created equal

Babies born in facilities with trained staff and equipment for neonatal resuscitation

% of all babies born at facilities

90% 80%

% of all babies born by staff trained in neonatal resuscitation




% of all babies born in facilities with equipment for newborn respiratory support




47% 41%




40% Missed Opportunities Quality Gap in Facilities Only 1 of 5 babies born in 22% hospitals have 19% access to 17% Neonatal Resuscitation 12% 8% 7%


15% 10% 2% 6% 8% 8%








Original data source: National Service Provision Assessment Surveys, years ranging 2002-2006 Source: Wall S et al, IJGO 2009

Facility Birth quality MN care . . . unless there is Respectful care Skilled staff 24/7 Functional equipment Essential medicines in stock Newborn routine and emergency care signal functions with B/EmOC Standard protocols used Quality control in place
Data Action Measurement

Newborns need basic care, and special care for complictions

Basic newborn care - Hygiene, warmth, immediate/exlusive breastfeeding, cord care Intrapartum complications:
Prevention: Quality obstetric care and labor monitoring Treatment: Stimulation/resuscitation, if not breathing

Prematurity/low birth weight:

Prevention of complications: Steroids to mother during premature labor Management: Kangaroo Mother Care

Prevention: clean delivery, cord care, handwashing, breastfeeding; chlorhexidine Detection and treatment: antibiotics (including at health centers/posts)

New opportunities for facility-based NB care

Neonatal resuscitation in peripheral facilities Helping Babies Breathe (and similar programs)

Antenatal corticosteroids identification of PTL and1st dose ACS at peripheral facility, referral
KMC provide space, support to mothers/families Chlorhexidine ? high mortality settings, poor hygiene, early discharge Safe birth checklist ? Increase newborn health components Treatment of routine sepsis/pneumonia at health centers/posts (pending evidence from simplified antibiotic trials (2013-14)

Safe birth checklist

Ending harmful facility practices

- Oxytocin augmentation of labor (without monitoring) risk of uterine rupture, intrapartum stillbirth, birth asphyxia
- Routine suctioning of all newborns potential to depress breathing and heart rate needlessly; use only when necessary, as indicated - Routine or frequent separation of mothers and newborns immediately after birth (all too common with newborn corner, stabilization units, etc)

- Elective c-section prior to 39 weeks major contributor to high preterm rates, increased newborn morbidity and mortality

Community referral systems
Community awareness and leadership Birth/emergency preparedness, Transport Community funds Trained CHWs to accompany mothers/newborns

Primary to referral facilities

Pre-referral care and referral protocols Ambulance services Mobile technologies hotline High quality emergency care 24/7 at referral facility.

Facility linkages to community/home

Many/most mothers & newborns are discharged (or leave facility) within hours of delivery
Need to ensure pre-discharge examination of mother & baby (including breastfeeding); counseling to mother re: home care practices, danger signs; contact CHW for home visit Need to ensure early postnatal home visits (ie, within 1- 2 days) by trained health worker - check on mother and baby, refer for danger signs, counsel on home care practices

Missed opportunities: Post-discharge counseling

Integrated Family Health Initiative (Bihar, India). Facility Assessment Direct Observation: Baseline 2012

Missed opportunities: Post-discharge counseling

Integrated Family Health Initiative (Bihar, India). Facility Assessment Direct Observation: Baseline 2012

Simple approaches to improve MNH in HHCC

Pre-discharge checklist
Breastfeeding assessment Assess mother & baby Provide counseling (eg, danger signs)

SMS to link facility discharge to early CHW home visit

Postnatal home visit checklist

M health tools

Monitoring facility based care

Need impact/outcome indicators of quality of facility-based MNH care

Possible new indicator: neonatal death in fist day + fresh stillbirths

Improve routine monitoring

Process indicators (esp for newborn care signal functions) Capacities to collect and use data for decision making

Expanding death audits: maternal, newborn, fresh stillbirths

We can make it happen: High coverage, high quality, and high demand for facility-based maternal-newborn care

Changing expectations
(From the SNL evaluation team visit to Nysamba Hospital, Uganda)
SNL supported training of midwives, nurses, clinical officers, and physicians in management of labor & delivery and essential newborn care.

Facility staff reflection re neonatal resuscitation:

Now we are not afraid of handling this tiny human being. Previously we used not to audit those deaths, but would just say, Sorry, sorry without establishing the cause of the problem. No one was responsible or accountable. Now we expect the woman who comes to deliver to go away with a live baby.

Much to do
- Together we can make it happen. - Thanks