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Community-based Interventions for Newborns in Ethiopia (COMBINE)

Global Newborn Conference April 16, 2013 By: Dr. Abeba Bekele

Outline

Neonatal survival in Ethiopia COMBINE


Objectives Interventions Lessons /results Opportunities Challenges

Newborn survival and MDG 4 in Ethiopia


Neonatal mortality rate (UN) Under 5 mortality rate (UN) Under 5 mortality rate (DHS) Neonatal mortality rate (DHS) MDG 4 Target

300

Mortality per 1000 live births

200

100

88

66

37
0 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010* 2015

1- 59 month mortality rate reducing each year at 5.5% Source: U5MR (UN): www.childinfo.org NMR (UN):year Oestergaard et al 2011 PLoS Neonatal mortality rate/ www.childmortality.org reducingand each only by 2.4% updated for 2011 data , Sept 2012
Data sources: Updated from Opportunities for Africas Newborns with UN data from www.childmortality.org. * 2010 year contains 2008 data

81,700 neonatal deaths, 33% of all under-five deaths

Estimated Causes of Neonatal Deaths in Ethiopia


81,700 Deaths Annually
Congenital, 6% Diarrhoea, 1% Other, 4%

Intrapartum related, 28%

Severe infection, 24%

3 causes account for 89% of all newborn deaths

Preterm birth complications, 37%

Source: Liu L. et al. 2012. Global, regional, and national causes of child mortality in 20002010: an updated systematic analysis. The Lancet. doi:10.1016/S0140-6736(12)60560-1.)

Service coverage trends


60 50 49 38 34 29 27 28 2000 2005 2011 10 6 6 6 2 0 Contraceptive Antenatal Care Deliveries by Postnatal Care Prevalence Skilled Birth Rate Attendant Exclusive Breast Feeding 5 7 52

40
30 20 10

15

Delivery by skilled attendants and PNC remained very low

Community Based Interventions for Newborns in Ethiopia

COMBINE

Objectives

To measure impact on newborn mortality of:


Strengthened Health Extension Program (HEP) to implement newborn care as per the existing policy Newborn sepsis management with antibiotics by Health Extension Workers (HEWs)

What is the Health Extension Program


The key health care delivery platform at the PHC level Two HEWs and a health post per 5000 population, supported by community Health Development Army (HDA) HEWs provide basic promotive, preventive and selected high impact curative interventions (ICCM)

Health Post

Health Extension Workers

COMBINE Key interventions

COMBINE helped to strengthen the implementation of the HEP for maternal and newborn care
Improved the HEWs ability to capture & manage cases of severe neonatal infections at community level

HEP strengthening under COMBINE


Tightening link between HEWs and the fCHP/DTL Training HEW & fCHP/DTL to identify sick young infants Supportive supervision and mentoring Ensure availability of supplies Improve documentation and use of data

HEP strengthening under COMBINE:


Pregnancy Home Visit Package

Counselling on benefits 2 visits by fCHP/DTL of focused ANC As soon as identified Recognition of danger 8th month of the signs pregnancy Birth plan Essential newborn care 1 visit by HEW Notification of HEW ASAP after delivery

HEP strengthening under COMBINE:


Postnatal Home Visit Package 2 visits by HEW in 1st week
Day 1, Day 4

3 visits by fCHP /DTL in 1st week


Day 1, 3, 7 1 extra visit for LBW and sick newborns 1 visit on 29th day

Counselling and support for ENC Assess newborn & mother for danger signs Referral for illness Sepsis management of newborn if referral not accepted (intervention arm)

Community management of newborn sepsis under COMBINE


Based on identification of danger signs, and when referral is not possible
Provision of injectable gentamycin by HEWs for 7 days And oral amoxacillin by the mother for 7 days

Very low birth weight: administer pre-referral dose and refer

How? A model for community-based newborn sepsis management The 4 Cs


Contact: All newborns have early contact with HEWs
and/or 1:5 network leaders;

Capture: All cases of severe infections in newborns are


identified by 1:5 network leaders/ HEWs or families;

Care: Sick newborns are provided care, and antibiotic


treatment if appropriate, as soon as possible after diagnosis;

Completion: Newborns diagnosed with severe infection


complete a full seven-day course of antibiotics by HEWs

Capturing sick newborns is part of MNH continuum of care through HEW


Early contact with all newborns: postnatal home visits Immediate notification of labour/ births Identification and registration of pregnant mothers
Counselling and support for ENC Assess newborn & mother for danger signs Manage (treat or refer) for suspected illness Promote facility delivery Assist delivery Support ENC
Counselling on benefits of ANC Recognition of Danger Signs Birth Plan ENC Notification of HEW ASAP after delivery

Summary of routine data

Deliveries Identified and PNC Visits Within Two or Three Days


Proportion of deliveries identified by fCHPs/DTL Proportion of PNC visits within two days by fCHPs/DTL or HEWs Proportion of PNC visits within three days by fCHPs/DTL or HEWs
100

90 80
70 60 50

40 30
20 10 0

Q1

Q2
2009

Q3

Q4

Q1

Q2
2010

Q3

Q4

Q1

Q2
2011

Q3

Q4

Q1

Q2
2012

Q3

Q4

PNC Visits In the First Week


90 80 70 60 50 40

78.3 74.6

79.2 76.7

79.5 77.3

80.778.5

33.4
30 20 10 0 1st day In 2 days

36.1

36.5

37.1

In 3 days

In 7 days

fCHP/DTL or HEW

fCHP/DTL

HEW

What is Working?

Over 85% of expected pregnancies identified & visited

High level of pregnancy Over 70% of expected deliveries identification, notification of got early PNC delivery and conduct of early home visit postnatal home visits 50% of expected Good proportion of neonatal PSBI cases id and sepsis cases identified and treated treated High levels of treatment Over 90% of completion at Health Posts those started on
antibiotics completed

What is Working?
High motivation of HEWs to provide the services
Family referral of sick neonates indicating improved awareness of neonatal danger signs

Male involvement in changing some norms through community and religious leaders.

Challenges:
Demand side Entrenched cultural practices preventing families from taking newborns out of the home early in life Poor awareness of newborn illness & its seriousness; value /belief of modern health care for newborn illness Supply side Access related barriers Human resources Logistics and supplies

Opportunities for scale up:


Community platform - HEP and ICCM can add communitybased management of newborn sepsis
Facility strengthening - The PHCU will strengthen the health system at community level, essential for effective referral and care

Demand Home visits and counseling by HEW and HDA network leaders contribute to improve care seeking
An integral part of the continuum of care Community management of neonatal sepsis has a potential to save many newborn lives in the Ethiopian context

Thank you!
Collaborators:
Save the Children MOH UNICEF JSI Research & Training Institute Bill and Melinda Gates Foundation LSHTM JHU EPS WHO