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An Action Plan To End Preventable Deaths
#EveryNewborn
EVERY NEWBORN
Metrics Improvement Plan
Webinar 11 March 2015
www.everynewborn.org #EveryNewborn
ENAP Metrics Webinar Agenda
1. Overview core indicators and improvement Joy Lawn, LSHTM
2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO
• Other UN groups and NBITWG
Agbessi Amouzou, UNICEF
• INDEPTH network
Peter Waiswa, Makerere University, Uganda
3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF
4. Questions and discussion
5. Closing and how to get more information
www.lancet.com/series/everynewborn #EveryNewborn
Every Newborn Series
5 papers
6 comments
55 authors from 18+ countries
60+ partner organisations
Every Newborn Action Plan
Based on the evidence from the Series
Co-led by UNICEF & WHO,
Consultation >60 country governments
>80 organisations, >1000 individuals
World Health Assembly 2014 resolution
Launched June 2014
Now to action in many countries…
Main funders: Bill & Melinda Gates Foundation, USAID, Children’s Investment Fund Foundation
@joylawn
www.everynewborn.org #EveryNewborn
Three main streams of activities are ensuring the
action plan leads to real change in countries:
1. Country implementation: identifying and
responding to technical support needs,
supporting translation of evidence into action,
including Every Mother Every Newborn quality
improvement initiative.
2. Data and metrics: improving and
institutionalizing metrics to track coverage and
impact based on the goals and targets of the
ENAP and five strategic objectives.
3. Advocacy: strengthening maternal and
newborn health advocacy efforts globally and in
countries, building a movement for change.
Every Newborn action now:
Research as cross cutting
www.everynewborn.org #EveryNewborn
CO CHAIRS WHO: Matthews Mathai
LSHTM: Joy Lawn
COORDINATION GROUP
(to link to existing metrics
work, and institutionalize)
UNICEF: Agbessi Amouzou, Holly Newby
UNFPA: Sennen Hounton
SNL/NBITWG: Lara Vaz
CIFF: Suzanne Fournier
Gates: John Grove
USAID: Allisyn Moran
MHTF: linked via by ENAP management team
TASK TEAMS Task teams with initial focus on specific newborn care interventions linked
with existing initiatives especially UNCoLSC and others
ACADEMIC PARTNERS
to promote leadership
especially Africa & Asia
Three countries with EMEN project sites (Ghana, Tanzania, Bangladesh)
Two networks:
1. Mortality focus: led by INDEPTH Maternal and Newborn Group
(Peter Waiswa et al)
2. Beyond Survival /follow up of at risk newborns: led by
All India Institute of Medical Sciences (Ashok Deorari et al)
Also welcoming inputs from other institutions, partners and countries
WIDER INTEREST
GROUP
wide and inclusive
>50 at ENAP metrics improvement planning meeting by WHO Dec 2014
>100 people drawn from wider metrics community including Newborn
Indicators Technical Working Group
ENAP Metrics work and who is involved
www.everynewborn.org #EveryNewborn
Three tracks of work linked with ENAP metrics - overview
• Indicators for impact, coverage, process of maternal & newborn care • Initial focus on the 4 + 1 treatment interventions
• KMC (led by KMC acceleration group) • Resuscitation (UNCoLSC, USAID, SNL Bangladesh, WHO, HBB etc) • Antenatal Corticosteroids (WHO and UNCoLSC TRT etc) • Sepsis case mx (WHO, UNCoLSC etc) • CHX cord cleansing (UNCoLSC, SNL etc)
• Priority research to improve the metrics for use
Technical mapping & planning of indicators, tools & work in progress
1
Institutionalise
in national collection platforms and in global metrics architecture, with accountability
2
Leadership development to improve & use the data for action
3
• Birth and perinatal death certificates, coverage & quality • Develop and test Minimum Perinatal Dataset • Perinatal Mortality audit tool, linked to Maternal Mortality audit • Inputs to facility HMIS, Health Facility Assessments such as SARA, and to household surveys
• Testing in countries also linked to EMEN work • Southern institutions as centres of excellence • Integrated technical oversight especially with maternal health • User friendly formats eg score cards, links to accountability and parent voices (eg partnerships with E4A and WRA)
www.lancet.com/series/everynewborn #EveryNewborn
ENDING
PREVENTABLE CHILD
AND MATERNAL DEATHS
@joylawn
www.lancet.com/series/everynewborn #EveryNewborn
Lancet GH Sept 2013 : The Lancet Global Health 2013; 1:e176-e177 (DOI:10.1016/S2214-109X(13)70059-7)
Ending preventable maternal deaths Maternal mortality target also included in Every Newborn Action Plan
Global average MMR of 70 per 100,000 with different targets for different countries
Also need clear target for sexual and reproductive health (MDG 5 b)
www.lancet.com/series/everynewborn #EveryNewborn
Ending preventable child and newborn deaths Mortality targets in Every Newborn Action Plan and A Promise Renewed
Source: Lancet Every Newborn series, paper 2
From 2.8 to 0.8 million neonatal deaths ~100 countries have already met the target – focus on equity gaps
About 29 countries will have to more than double their rates of progress
Every Newborn target by 2030:
National NMR of 12 or less
www.lancet.com/series/everynewborn #EveryNewborn
Source: Lancet Every Newborn series, paper 2
From 2.6 to 1.1 million stillbirths Aligned with NMR target but more ambitious change needed
Stillbirths still NOT MENTIONED in any SDG document… few weeks left to change this – please sign the petition on Everynewborn.org
Also ending preventable stillbirths
Every Newborn target by 2030:
National SBR of 12 or less
www.lancet.com/series/everynewborn #EveryNewborn
5 things to do differently
Integrated Plans
Integrated service delivery, continuum of
care, coordination
Implementation & Innovation
Address health system bottlenecks, Every Mother Every Newborn initiative
Indicators & metrics Targets in post 2015
Measurement of progress and impact
Intentional leadership
development
Especially in countries with highest burden
AMBITIOUS MEASUREMENT
CHANGE IS CRITICAL TO EVERY
STEP Eg for HIV/AIDS, malaria and EPI
Investment for impact
Governance, community participation, partner
alignment
www.lancet.com/series/everynewborn #EveryNewborn
Core indicators selection during ENAP development
Step 1: Developed matrix of relevant indicators Organised according to ENAP Framework from impact (mortality) down to inputs including financial (>120 rows in the Excel!)
Step 2: Graded each indicator as follows: Direct relevance to the 5 ENAP objectives and focus (from A to C)
Current availability of the data (from 1 to 3)
Step 3: Ranked indicators By A to C, with A being closest match to ENAP focus. By 1 to 3 where 1 is most currently available
Ref: Every Newborn: From evidence to action to deliver a healthy start for the next generation. Mason et al for the Lancet Every Newborn Study Group. Lancet 2014.
Ambition to count what matters Indicators prioritised by importance (category A)
Urgent work to improve the input data, specific milestones in ENAP for this
www.lancet.com/series/everynewborn #EveryNewborn
Every Newborn action plan included core indicators Core ENAP Indicators Additional Indicators
Impact
1. Maternal Mortality Ratio
2. Stillbirth Rate Intrapartum Stillbirth Rate
3. Neonatal Mortality Rate Low birth weight rate
Preterm birth rate
Small for gestational age
Neonatal morbidity rates
Disability after neonatal conditions
Coverage:
Care for all
mothers and
newborns
4. Skilled attendant at birth
5. Early postnatal care for mothers and babies
6. Essential newborn care (tracer of immediate
breastfeeding)
Coverage:
Complications &
extra care
7. Antenatal corticosteroid use Caesarean section rate
8. Newborn resuscitation
9. Kangaroo mother care, feeding support
Chlorhexidine cord cleansing 10. Treatment of neonatal sepsis
Counting Birth registration Death registration, cause of death
ENAP service
delivery packages
(process)
Every Mother Every Newborn quality initiative
Care of small and sick newborn
Shaded = not currently routinely tracked.
Bold = indicator requiring additional evaluation for consistent measurement
Ref: Every Newborn: From evidence to action to deliver a healthy start for the next generation. Mason et al for the Lancet Every Newborn Study Group. Lancet 2014.
www.everynewborn.org #EveryNewborn
ENAP Milestones by 2020
• Count births and deaths in CVRS (women, newborns and stillbirths)
• Minimum perinatal dataset & perinatal mortality audit being widely used in countries
• ENAP core indicators to be defined , incorporated in national metrics platforms and widely used
Improving, institutionalising & using ENAP metrics for action
x World Health
Assembly
May/June 2014
Dec 2014 Meeting To scope
ENAP Metrics improvement plan
June 2015 - May 2018 Testing indicators and
tools in limited number of countries
June 2018 - May 2020 Wide use in many countries CVRS, facility HMIS, surveys
linked to health systems scale up
2020
Jan- May 2015 Refining and consulting on
metrics plan & ENAP monitoring FW
www.everynewborn.org #EveryNewborn
Every Newborn action plan core indicators Core ENAP Indicators
Impact
1. Maternal Mortality Ratio
2. Stillbirth Rate
3. Neonatal Mortality Rate
Coverage:
Care for all mothers and
newborns
4. Skilled attendant at birth
5. Early postnatal care for mothers and babies
6. Essential newborn care (tracer of immediate breastfeeding)
Coverage:
Complications & extra care
7. Antenatal corticosteroid use
8. Newborn resuscitation
9. Kangaroo mother care, feeding support
10. Treatment of neonatal sepsis
Chlorhexidine cord cleansing
C-Section rate
Counting Birth registration
ENAP service delivery
packages (process)
Every Mother Every Newborn quality initiative
Care of small and sick newborn
Shaded = not currently routinely tracked.
Bold = indicator requiring additional evaluation for consistent measurement
Ref: Every Newborn: From evidence to action to deliver a healthy start for the next generation. Mason et al for the Lancet Every Newborn Study Group. Lancet 2014.
Excel sheet has details of definitions and testing questions Please send questions or ideas to Harriet Rees-Forman [email protected]
Task Teams
working.
Significant
progress
New work needed on
content of care – critical to
link with maternal metrics
communities
Definitions clear – but need
better tools, improved
quantity and quality of data
www.everynewborn.org #EveryNewborn
Civil Registration and Vital Statistics • Birth certificates (improved weight, possibly gestational age)
• Perinatal Death certificates and ICD codes (linked to new WHO ICD-perinatal mortality classification)
Facility and HMIS • Perinatal mortality audit (linked to maternal audit)
• Minimum perinatal dataset
• DHIS2 and other HMIS collation for highly prioritised data points
• Health facility assessment tools (treatment indicators, process)
Population based surveillance and surveys (DHS/MICS) • Mortality capture including recall, misclassification of stillbirth/neonatal death and
pregnancy vs live birth
• Verbal autopsy for stillbirths and neonatal deaths
• Social autopsy
• Birth weight, birth size and gestational age
Measurement tools to be improved/developed and linked
Core perinatal dataset
•Eg as per data on ICD perinatal death certificate
Facility based
•Eg South Africa
•PPIP
More complex facility setting
•Eg Vermont Oxford neonatal network
Research studies
•Potentially with biodata
www.everynewborn.org #EveryNewborn
Mortality data etc
Population-based pregnancy surveillance of births, stillbirths, neonatal deaths.
Opportunities to advance validation of pregnancy history modules, verbal autopsy, improved LBW assessment etc.
Networks to ensure testing and use in many contexts
“Beyond newborn survival” data
With UNICEF and others partners in India and beyond
INDEPTH Maternal & Newborn Interest Group 20+ sites in Africa and Asia
Follow up at risk newborns by varying levels of health care
Opportunities to validate and test feasibility of follow up, screening for disability, ROP and models to improve care
www.everynewborn.org #EveryNewborn
Building on 3 countries working on quality initiatives including “Every Mother Every Newborn”
Ghana Tanzania Bangladesh
Validation and feasibility testing for facility-based coverage data Also tools such as audit, min perinatal dataset, simplified gest age assessment etc
Also opportunities to test similar questions in other countries and with other organisations.
Coordinated approach will yield the fastest collective progress
www.lancet.com/series/everynewborn #EveryNewborn
21
ENAP Metrics Webinar Agenda
1. Overview core indicators and improvement Joy Lawn, LSHTM
2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO
• Other UN groups and NBTWIG
Agbessi Amouzou, UNICEF
• INDEPTH network
Peter Waiswa, Makerere University, Uganda
3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF
4. Questions and discussion
5. Closing and how to get more information
www.everynewborn.org #EveryNewborn
Linking metrics for maternal & newborn health WHO & partners are considering forming a Maternal Newborn Measurement Expert Reference Group (MNH MERG) Why?
• Convergence of efforts to end preventable mortality –
maternal, newborn, child
• Opportunities through harmonisation – effectiveness,,
more coordinated support for countries, more efficiency
• Greater potential for synergies in metrics innovations,
especially for tracking content and quality as well as
coverage
• Less chance of falling through the gaps – eg stillbirths
• Important common lessons learned eg on mortality audit
scale up and linking this to change
Who?
• WHO and partners will convene, learning from lessons
learned in other MERGs. May be time limited. Needs to
link to clear technical outputs
www.everynewborn.org #EveryNewborn
ENAP Metrics Webinar Agenda
1. Overview core indicators and improvement Joy Lawn, LSHTM
2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO
• Other UN groups and NBTWIG
Agbessi Amouzou, UNICEF
• INDEPTH network
Peter Waiswa, Makerere University, Uganda
3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF
4. Questions and discussion
5. Closing and how to get more information
www.everynewborn.org #EveryNewborn
Linking ENAP metrics improvement with other ongoing work by the UN and (many!) others
A Promise Renewed report 2014 had focus on newborns Links to many current work-streams including with H4 eg on
EmOC indicators
Countdown to 2015 linked to ENAP and the metrics work is linked in all the 4 CD technical working groups
Hopkins (JHU) grant on Improving Coverage Measurement testing specific indicators including for essential newborn care
Secretariat of NBITWG is with Saving Newborn Lives. Meets twice a year. Linked with ENAP by many organisations and individuals
Coverage Task teams for various treatment indicators (eg resuscitation, antenatal corticosteroids, Chlorhexidine etc) directly link with and build on the relevant UNCoLSC teams
www.everynewborn.org #EveryNewborn
ENAP Metrics Webinar Agenda
1. Overview core indicators and improvement Joy Lawn, LSHTM
2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO
• Other UN groups and NBTWIG
Agbessi Amouzou, UNICEF
• INDEPTH network
Peter Waiswa, Makerere University, Uganda
3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF
4. Questions and discussion
5. Closing and how to get more information
www.everynewborn.org #EveryNewborn
INDEPTH Maternal & Newborn Interest Group Leader: Dr Peter Waiswa Makerere University
Unique opportunity to
test and improve population-based
metrics especially for stillbirths and
neonatal deaths, LBW and preterm
birth, with mhealth
innovations
AND capacity-building
www.everynewborn.org #EveryNewborn
ENAP Metrics Webinar Agenda
1. Overview core indicators and improvement Joy Lawn, LSHTM
2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO
• Other UN groups and NBTWIG
Agbessi Amouzou, UNICEF
• INDEPTH network
Peter Waiswa, Makerere University, Uganda
3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF
4. Questions and discussion
5. Closing and how to get more information
www.everynewborn.org #EveryNewborn
WHO ENAP Metrics meeting December 2014 Who? >60 technical experts from Africa, Asia, North and
South America and Europe including UN, academics, clinicians, programme experts, DHS, MICS, SARA , SPA, DHIS, CVRS & many others
What? Two days of hard work! Emphasis on harmonisation
with related metrics work eg WHO QoC metrics,100 core indicator list
Results? Advances for core indicators and accelerating
improvement (ENAP metrics Improvement Plan). WHO Meeting Report in process
“Prioritization is key as ambitious timeline for collecting data at-scale!”
Selected quotes....
“Important to remember essential newborn care in our metrics’’
“Measurement of care for small and sick newborns is a total GAP! Could be tackled like EmOC core competencies”
“Treatment indicators “stink” and the worst part is the denominator!”
www.lancet.com/series/everynewborn #EveryNewborn
Advocacy now for post 2015 targets • Neonatal and maternal mortality expected in SDGs but not
yet clear if universal or relative (%) targets
• Stillbirth counting still absent from SDGs! Sign petition at
EveryNewborn.org!
• Join ENAP advocacy - Anita Sharma, Lori McDougall & E4A.
• Post-2015 health measurement discussion (18th March 8.15-
10.00 ET – after this call!)
Improve and use the data in countries • Some metrics ready for wider scale use now
• ENAP for technical advances and linked tools
Intentional capacity development • To improve, use and further improve the data
Action now
3
1
2
@joylawn
www.lancet.com/series/everynewborn #EveryNewborn
Which indicators to use now for what and
more detail on ENAP metrics definitions • Review excel, welcome to send questions or ideas to
Harriet Rees-Forman [email protected] (on behalf of Matthews Mathai & Joy Lawn)
• Discussion opportunities at Newborn indicators Technical
Working Group in DC next week (18th) if you will be there
• Upcoming WHO ENAP meeting report and BMC paper
Metrics Improvement Plan • Ideas for improvement or other inputs please contact
Harriet Rees-Forman
More technical information 1
2
@joylawn
We have the potential to transform survival and health for EVERY newborn
EVERY mother including for the world’s poorest families –
Acting on the plan depends on better data