Community-Based Services within the Continuum of Newborn Care: Choices & Challenges

Newborn 2013 Johannesburg 15 April 2013

The Body of Evidence: Community-Based Newborn Care

Study Design

Home visits

Home Treatment of illness

Community mobilization

Mortality reduction

SEARCH India

1 intervention & 1 control Before-after Cluster randomized trial Cluster randomized trial Pilot (4 vs. 4 clusters) Cluster randomized

62% 50% 34% 50% 20% 30%

ANKUR India
Projahnmo Bdesh Shivgarh India Hala Pakistan Makwanpur Nepal

Home Visits for the Newborn WHO-UNICEF Joint Statement, 2009

Key recommendation: Home visits for newborn care days one and three after birth, and if possible, a third visit on day seven
Promote early and exclusive breastfeeding Help keep the newborn warm Promote hygienic umbilical cord and skin care Help the family to recognize signs of illness and promote prompt care-seeking Promote birth registration and timely vaccination Identify and newborns who are low-birth-weight, have illness and those born to an HIV-infected mother and provide or refer for additional health care Counsel the mother about her own health.
3

NATIONAL NEONATAL HEALTH STRATEGY AND GUIDELINES FOR BANGLADESH

Approved in March 2009

What has been achieved in Bangladesh with newborn care?

Facility Delivery Has Increased But Not Home Delivery By Skilled Attendants
Facility-Private/NGO Facility-Public Home (Skilled) 18% 13% 3% 6% 4% 32% 28% 13% 17%

8%
10% 7% 12% 3%

3% 2007
BDHS

4%

2004
BDHS

2010
BMMS

2011
BDHS

Increases in skilled attendance at deliveries has been entirely due to increases in facility deliveries, particularly in private facilities

Facility Delivery and Postnatal Care of the Newborn

Facility Delivery PNC - Newborn
19% 15% 12% 9% 29% 30% 23% 23%

2004
BDHS

2007
BDHS

2010
BMMS

2011
BDHS

Almost all of the increase in postnatal care can be explained by increases in facility deliveries

Essential Newborn Care Practices

82%84% 59%

2007
51% 33%

2011

45%

47% 43%

6%

2%

0% 2%

Cord cut with Nothing Applied Dried within 5 Wrapped within Boiled to Cord mins of birth 5 mins of birth Instrument

Initiated BF within 1 hr

All practices

Source: Bangladesh Demographic and Health Surveys, 2007, 2011

Density of ENC trained Community Health Worker (per

10,000 population)
The national average - 5 per 10,000. Chittagong division has the fewest ENC trained CHWs per 10,000 Rangpur, with 16 ENC trained workers per 10,000 has the most. Around 67,000 community health workers are trained on ENC 51,000 concentrated in Dhaka and Rangpur Divisions. Only 38% of all CHWs trained in ENC.

Save the Children

However,

less than 6% home-born

newborns in Bangladesh received PNC within 2 days of birth from a CHW or medically trained provider
BMMS 2010
In the MNCS special programme area (GoB/UNICEF), covering 7 of 64 districts in Bangladesh, trained community volunteers (MNCS Promoters) were able to make a home visit to 45% of home births within 2 days of delivery

A continuum of care is needed:

Across pre-pregnancy, pregnancy, labour and delivery, and newborn periods, and
Across service levels

Continuum of care under controlled conditions: Projahnmo, Sylhet

At least one antenatal check up from a trained provider Iron and folate supplements At least two tetanus-toxoid immunisations Clean cord-cutting instrument used 48% 43% 40% 39% 46% 4% 45% 72% 84%

Baseline Endline

95%
78% 81%

First bath delayed until at least the third day

Breastfeeding initiated within 1 h

12

BUT: Only 19% of Pregnant Mothers and Newborns Receive all Care in the real world

Source: Bangladesh Maternal Mortality Survey, 2010

Managing Neonatal Infections

No national data on treatment coverage of neonatal infections Who can manage neonatal infections that occur in the community:
CHWs? Community Clinics? Union-level Health Facilities?

Must improve and sustain the quality of care at referral facilities (particularly UHCs)
Most of these facilities do not NOW have the capacity to provide effective care to sick newborns Some initiatives have been started but we need to move rapidly to scale

Background

3.5 Innovative approaches for Neonatal Care Community-based operations research or feasibility studies to improve management of neonatal infections, compliance of KMC at home, low birth weight management, birth asphyxia management at community level

Operations Research to improve communitybased management of neonatal infections

Primary objective: To assess the quality and coverage of different approaches of community case management of neonatal sepsis A cluster-randomized design adopted, nested in the GoB-UNICEF MNCS programme Time: July 2011 December 2012

Operations Research- Neonatal Sepsis

4 upazilas (sub-districts) in 3 districts: 385,707 population, 75,621 households

10 intervention unions ~40,000 HH MNCS service package Plus Neonatal case management*
Total Live births: 7,055 (estimated)

10 comparison unions ~40,000 HH

MNCS service package

Total Live births: 7,140 (estimated)

*Community-based providers -Government HW (HA, FWA) -MNCS Promoter -Village doctor

Operations Research- Neonatal Sepsis Intervention implementation

Training of service providers Programme management through existing government systems with some support from the MNCS NGO and ICDDR,B:
Supply and logistics Supervision and monitoring

Operations Research- Neonatal Sepsis Intervention details (Jul 2011Dec 2012)

Gov HW Number of trained providers 79 26 39 MNCS-P 213 72 85 Vill Doc 200 20 38 Total 492 118 162

Number of trained providers reporting cases

Number of cases reported and confirmed (tracked)

Total Live births: 7,055 (estimated)

Operations Research- Neonatal Sepsis Intervention details (Jul 2011Dec 2012)

Gov HW Total cases tracked Locally Managed - Given an injection Referred: - Referred to hospitals - Referred to Com. Clinics 39 16 25% 23 87% 0% MNCS-P 85 17 44% 68 71% 6% Vill Doc 38 26 39% 12 92% 0% Total 162 59 37% 103 77% 4%

- Referred to vill. doctors

Compliance with referral

0%
52%

18%
53%

0%
67%

12%
54%

Operations Research- Neonatal Sepsis Rolling Household Survey

A sample of about 2,000 households under 3monthly surveillance in each of the 10 intervention and 10 comparison unions (a total of 40,557 HHs under surveillance)
All pregnancy outcomes identified and interviewed for intervention coverage and care-seeking practices

Operations Research- Neonatal Sepsis Rolling Household Survey

Care-seeking (%) for possible newborn infections
Intervention (range) Comparison (range)

Sought care for possible newborn sepsis

Primary or higher referral hospitals Local health facilities Private/NGO facilities Doctors Homeopaths Informal providers (village doctor)/drug store Other (paramedic, herbal, spiritual)

83 (76-92)

87 (80-95)

6 (3-11)
7 (0-18) 2 (0-4) 10 (2-18)

6 (3-8)
5 (1-15) 3 (1-9) 17 (6-29)

25 (19-32)
39 (30-49) 5 (1-14)

25 (16-32)
39 (37-42) 4 (2-8)

Case Management of Neonatal Infections in Bangladesh

Choices to be made

Community vs. Facility Based Strategies and the Role of CHWs

PANCHAGARH LALMONIRHAT THAKURGAON NILPHAMARI KURIGRAM DINAJPUR RANGPUR GAIBANDHA

INDIA
SHERPUR

* JOYPURHAT

In weak health system and high mortality areas, community-based strategies more appropriate may be as interim measures
SYLHET

Use of referral facilities for sick newborn care

46 55 51

NAOGAON BOGRA NAWABGANJ

JAMALPUR

SUNAMGANJ NETRAKONA MYMENSINGH

14

20

12

16

RAJSHAHI NATORE SIRAJGANJ TANGAIL

MAULVIBAZAR KISHOREGANJHABIGANJ

INDIA
KUSHTIA MEHERPUR CHUADANGA

PABNA

GAZIPUR NARSINGDI BRAHAMANBARIA

MANIKGANJ DHAKA NARAYANGANJ RAJBARI

Sylhet
*
KHAGRACHHARI

INDIA
FARIDPUR MUNSHIGANJ COMILLA CHANDPUR SHARIATPUR MADARIPUR FENI BARISAL LAKSHMIPUR NOAKHALI RANGAMATI

JHENAIDAH MAGURA

25
INDIA

JESSORE

NARAIL GOPALGANJ

Use of referral facilities for sick newborn care

KHULNABAGERHAT JHALOKATI SATKHIRA PIROJPUR BHOLA PATUAKHALI

CHITTAGONG

BARGUNA

*
BANDARBAN

Mirzapur

Bay of Bengal
COX'S BAZAR

In the presence of strong health facilities, CHWs can serve as health promotion workers

MYANMAR

Population density of Mega Countries with more than 100 million (2008)
1200
Population Density (/ sq.km.)

Bangladesh
1000 800 600

Population density in Bangladesh is 3 to 40 times higher than other mega countries

Japan
400 200

Pakistan

Indonesia USA China

800 1000

India

0 Nigeria 0

200

400

600

1200

1400

Mexico

Russia

Brazil Population (millions)

Access to health facilities

% of ever-married women of age 13-49 with a live birth in previous 3 years able to reach health facility in less than 1 hour 88% 71%
2001 2010

91% 69% 74%

75%

56%

20%

Public facility (UHC, MCWC, GoB-Hosp)

Upazila Health Complex (UHC)

Private facility

Either public or private facility

Source: Bangladesh Maternal Mortality Surveys, 2001 & 2010

Case Management of Neonatal Infections in Bangladesh

Choices to be made
Going to scale with home-based care and services have been difficult and gains in coverage has been mixed Bangladesh needs its own model of community based care, taking into account:
Population density and increased access to health services The influence health service strength and quality on utilization Increasing investments in closer-to home functional health facilities, e.g., community clinics (per 6,000 pop) and upgraded union facilities Increasing investments in establishing advanced care services in referral facilities

Case Management of Neonatal Infections in Bangladesh

Choices to be made
Bangladesh needs its own model of community based care: Greater reliance on strategically located and accessible, linked health facilities
with appropriate management, quality assurance and referral support enhanced ability to ensure continuum of care through packaged services, including advanced care

Community health workers a more specific and time-limited role for

changing community norms in terms of maternal/newborn care practices, with an emphasis on educating and empowering families/communities with skills, information and the ability to make the right choices, and Helping communities to more closely and effectively link to health services

Designing and implementing special programmes for hard-to-reach areas