Global Newborn Health Conference

Opportunities and Challenges 15 April 2013

Dr N R Dlamini

Causes of Neonatal Mortality in South Africa

Similar to other countries: 1. Birth Asphyxia - leading cause of death especially in birth weight >2.5kgs. 2. Infection - 3rd largest cause of neonatal death in all weight categories but highest in the 1000g to 2000g weight category. 3. Prematurity

Trends in Health Outcome Indicators

INDICATOR BASELINE PROGRESS 2009 2010 2011 MATERNAL AND CHILD MORTALITY (OUTPUT 2) INDICATOR BASELINE PROGRESS 2009 2010 2011 Under-5 Mortality Rate (U5MR) per 1 000 live-births Infant Mortality Rate (IMR) per 1 000 live-births Neonatal Mortality Rate (<28 days) per 1 000 live-births INDICATOR 56 40 14 53 37 13 42 30 14 TARGET 2014

2008

2009
333

2010
No data yet
WHO (300/100,000)

Maternal Mortality Ratio 310 (MMR) per 100,000 live-births

TARGET 2014 (HDACC) 50 (10% reduction) 36 (10% reduction) 12 (10% reduction) TARGET 2014 270 (reverse increasing trend and achieve 10% reduction)
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Source: Medical Research Council, Rapid Mortality Surveillance Report 2011

OPPORTUNITIES

Technical & Expert Support

The Minister of Health appointed 3 advisory technical committees - obstetricians & gynaecologists, midwives, paediatricians: 1. National Committee on Confidential Enquiries into Maternal Deaths. 1996 2. National Perinatal Mortality and Morbidity Committee 2008. 3. Committee on Mortality and Morbidity in Children. 2007 Conduct audits & produce triennial reports. Information generated from their reports is used in policy formulation. Investigate incidents & produce recommendations for minister.

NHI (National Health Insurance)

Aim: to attain universal health coverage. Shift SA from a hospicentric curative health care system to one with a preventative and health promotion focus. Principles: social solidarity, equity & fairness.

NHI (National Health Insurance)

Policy objective: to ensure that everyone has access to appropriate, efficient and quality health services. Will require significant overhaul of existing service delivery structures, administrative & management systems. Intention is to phase-in the NHI over 14 years.

Re-engineering of Primary Health Care

This is the core of the NHI. Consists of three streams: 1. District Clinical Specialist Teams (district obstetrician, paediatrician, anaesthetist, family physician, advanced midwife, PHC nurse, paediatric nurse). A team for each of the 52 districts in SA. 2. Municipal Ward - Based PHC teams (community health workers.) 3. Integrated School Health Programme.

CARMMA in South Africa (Campaign for the Accelerated Reduction of Maternal & Child Mortality in Africa) under the auspices of the African Union. Aim: To accelerate the reduction of maternal and child morbidity and mortality through accelerated implementation of evidence-based interventions essential to improve maternal health and child survival.

CARMMA priorities
Contraception Early booking and improving the quality of antenatal care Prevention of Mother-to-child-transmission of HIV Dedicated Obstetric ambulances Establishment of Maternity Waiting Homes Training in ESMOE Essential Steps in the Management of Obstetric Emergencies & EOST (Emergency Simulation Training). Skilled birth attendants including additional midwives
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CARMMA priorities contd.....

Improving new born care and treatment of sick children, including provision of Kangaroo Mother Care. Strengthen coverage of the Expanded Programme on Immunisation. Lactating mothers lodges. Intensification of coverage of lifelong ART to mothers with CD4<350 (for their own health).

HHAPI-NESS. Road map for healthy babies in South Africa

NEONATAL SURVIVAL STRATEGY

Summary of the Key Recommendations. HHAPI-NeSS

Improve the Health System for mothers and babies. Improve the knowledge and skills of Health Care Providers in maternal and neonatal care. Reduce deaths due to Asphyxia Reduce deaths due to Prematurity Reduce deaths due to Infection NeSS = Newborn Survival Strategy

5 Hs reduction of maternal mortality

Reduce deaths due to HIV/AIDS Reduce deaths due to Haemorrhage Reduce deaths due to Hypertension Improve Health worker training and Health system strengthening

HHAPI

5 Hs

IMPROVE NEONATAL HEALTH OUTCOMES AND MATERNAL HEALTH OUTCOMES

NEONATAL SURVIVAL STRATEGY: KEY INTERVENTIONS TO REDUCE MORTALITY

KEY CAUSE INTERVENTIONS OF MORTALITY Health Contraception, including for post miscarriage and system postpartum, integration with HCT, chronic diseases, school health services. for mothers 24 hour access to functioning emergency obstetric and neonatal care including clear referrals routes. and Maternity waiting homes, Kangaroo Care sites in all babies:

hospitals Hospital CEOs to ensure that there is no rotation of nursing staff providing neonatal care Knowled Train all health care workers providing maternity and ge and neonatal care in the ESMOE programme.
skills of Train health care workers who deal with pregnant women in health HCT & initiation of ART. Train all health care workers in care correct management of intrapartum care (use of the providers

Partogram, 3rd stage of labour)

Deaths due to asphyxia: A birth attendant skilled in neonatal resuscitation can reduce deaths to hypoxia by up to 40%.

Every woman in labour must be monitored appropriately by a skilled birth attendant All birth attendants must be skilled in at least bag and mask ventilation of the neonate The partogram must be used to monitor labour according to prescribed norms All complicated and obstructed labours must have access to Caesarean Section

Deaths due to prematurity: The use and application of nasal CPAP at a district hospital can reduce mortality of this group by up to 40%.

Corticosteroids must be given where possible to every woman in preterm labour Antibiotics must be given to every woman with prolonged rupture of membranes All hospitals (especially district hospitals) must have staff skilled in the use of nasal CPAP All mothers of premature infants must have easy access to Kangaroo Mother Care

Deaths Strict adherence to basic hygiene in labour wards and nurseries. Hand washing. Alcohol due to sprays, soap, clean water and paper towels infection must be available in all nurseries as essential consumables. Case management of neonatal sepsis, meningitis and pneumonia. As breast milk provides the best nutrition and protection for the preterm baby, districts should provide breast milk (not preterm formulae) to preterm babies by the establishment of human milk banks. Infection dashboard introduced in all neonatal nurseries to reduce infections by heightening awareness and surveillance of infection rates.

Prevention of Mother to Child Transmission of HIV (PMTCT)

Improvements in PMTCT is the single most important reason for declining child mortality rates in SA. SA has an elimination strategy; eMTCT MTCT transmission rate among HIV-exposed infants at six weeks: 2008: 8.0% 2010: 3.5% 2011: 2.7%

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PMTCT
New guidelines ie fixed dose combination (FDC) triple therapy of Tenofovir, Emtricitabine & Efavirenz implemented in April 2013 to further reduce MTCT to < 1%. Regardless of CD4 count; ARVs for all pregnant HIV positive women & those breast feeding for the duration of B/F. Lifelong ART if CD4<350.

Priority Newborn Interventions

Prevention of HIV infection through effective PMTCT Resuscitation of newborns and provision of quality care Promotion of early and exclusive breastfeeding Post-natal visit within six days, which includes newborn care and supporting mothers to practice exclusive breastfeeding. Contraception.
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KEY STEPS FOR OPERATIONALIZING HHAPI-NeSS. Start with the worst performing districts and expand.

Establish teams and focal persons

Assess Situation (bottleneck analysis)

Develop costed evidence based plan & training plan tailored to context

Implement Plan

Conduct Ongoing Monitoring to track progress

Conduct Regular Reviews

Document Best Practices and lessons learned. Benchmarking

Key challenges
Community education & demand for services. Access to care Essential Equipment Quality care Training of Health Care Providers Monitoring and evaluation

THANK YOU