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Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care Lori Newman - RHR Annie Portela - MPS Nathalie Broutet - RHR Global Health Histories Seminar Geneva April 27, 2011

Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

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Page 1: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Mobilising Communities to Eliminate Congenital Syphilis and Strengthen

Antenatal CareLori Newman - RHR

Annie Portela - MPS

Nathalie Broutet - RHR

Global Health Histories Seminar

Geneva

April 27, 2011

Page 2: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Overview

• WHO framework to empower individuals, families, and communities (IFC) for maternal and newborn health (MNH)– Example of implementation

• How we are applying community mobilization principles to elimination of congenital syphilis– Examples of implementation

Page 3: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

•2003 concept paper based on a review of programme experiences

• Objectives

• To contribute to the empowerment of individuals, families and communities to increase control over and improve MNH

• To increase access and utilization of quality services

WHO framework to empower individuals, families, and communities for MNH

Available at: http://whqlibdoc.who.int/hq/2010/WHO_MPS_09.04_eng.pdf

Page 4: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

WHO framework to empower individuals, families, and communities for MNH

•Build healthy public policy•Create supportive environments•Strengthen community action•Develop personal skills•Reorient health services

Health Promotion

Page 5: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Main Points1. Important interventions integrated into MNH strategies can build

capacity of women, families and communities to better care for themselves and increase access and use of services

2. To achieve people-centred care and address broader determinants, need participatory approach with other health programmes, local authorities, women, and communities

3. Service delivery team and the community need certain competencies to do this

4. Need to evaluate contribution of interventions and participatory approach and document processes and lessons learned

5. WHO and others have developed tools and guides, but there are gaps

Page 6: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

1. Priority areas for interventionsDeveloping CAPACITIES

to stay healthy, make healthy decisions,

and respond to emergencies

Increasing AWARENESS

of the rights, needs and potential

problems

Strengthening LINKAGES

for social support and within the health system

Improving QUALITY

of care, health services, and interactions

o Self-care/care in the household

o Care-seeking behaviour

o Birth and emergency preparedness

o Human and reproductive rights

o Role of men and other influentials

o Community involvement in surveillance and maternal- perinatal death audits

o Community financing and transport schemes

o Maternity waiting homes

o Roles of traditional birth attendants within the health delivery system

o Community involvement in the quality of care

o Companion of choice during childbirth

o Interpersonal and intercultural competencies of health-care providers

Page 7: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

2. Process of implementation

Province and National Levels:

Phase 3:

Joint planning process

Phase 1:

IFC Preparation

Phase 2:

Participatory Community Assessment

(PCA)

Phase 4:

Participatory implementation

Phase 5:

Participatory evaluation

Awareness-raising Skills-building Resource Mobilization

Local Level:

Initial activities

Ongoingactivities

Scale-up activities

Page 8: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

3. Building competencies

• Strengthen skills and attitudes– Within the health services– Within the community

• Resource person• Skilled birth attendant

– Interpersonal and intercultural skills– Community mobilization– Advocacy

• Community– Self care– Care seeking behaviour– Birth and emergency preparedness

Page 9: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

4. Monitoring and evaluation of interventions and participatory approach

9

• Has it contributed to improvements in MNH outcomes?• Has change occurred?

• Favorable public policy for MNH• Improved coordination between levels• Community and intersectoral participation• Strengthened human resources for health

• Have priority areas of action been implemented?• Developed CAPACITIES• Increased AWARENESS• Strengthened LINKAGES• Improved QUALITY

Page 10: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

5. WHO tools and supporting materials

• IFC Framework• IFC Implementation Tool Kit

– Start-up – Orientation Package for Health

Programme Managers– Participatory Assessment Tool

and Training Guide – Guide to Develop Final Plan,

including M&E• Handbook for Counselling and

Communication in MNH• Pregnancy, Childbirth,

Postpartum, and Newborn Care

• Standards of Care• Midwifery Education Modules• WHO Recommended Interventions

for MNH• Community-based Strategies for

Breastfeeding Promotion• Community-based Distribution of

Contraceptives

Page 11: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

5. Existing gaps

• Tools to strengthen community capacity for participation

• Strengthen evidence base of the individual interventions (in progress)

• More & better documentation of country experiences (in progress)

Page 12: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

The El Salvador experience

El Salvador sought to reduce maternal and neonatal mortality through

• Empowering women, their partners, families and communities to improve monitoring and self-care of their health

• Strengthening links between community actors and health service providers

• Raising awareness on the needs and rights of pregnant women

• Increasing the demand for and quality of health services

What did they achieve?• Increased number of women

attending ANC from 78% to 93%• Increased institutional births from

84% to 90%• Communities voice criticisms and

demand better health care • Health units have dedicated space

for maternal health: better quality of care for pregnant women and reduced waiting times

• Specialized personnel in rural areas: gynecologists available for 4 hours, three days a week

• Scaled up 60 municipalities and national policy on social participation

Page 13: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

How are we applying these principles to elimination of

congenital syphilis?

Logo for Mongolia's Rapid Syphilis Testing Initiative

Page 14: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

– Approximately 2 million pregnant women infected with syphilis per year

– Over 80% of infected women unidentified, untreated, or treated after 1st trimester

– 69% of infected pregnant women will have an adverse outcome of pregnancy (congenital syphilis)

• 25% stillbirths• 11% neonatal deaths• 13% preterm or low birth-weight infants• 20% infants with clinical infection*

Congenital syphilis is common and severe

Need to increase IFC awareness of adverse outcomes of syphilis

in pregnancy!

*Source: Kamb et al, Obstetrics and Gynecology International, 2010.

Page 15: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Syphilis seropositivity among women attending ANC reported for 2008 & 2009

Madagascar 7.70%

Chad 7.30%

Mozambique 6.93%

Ghana 6.15%

CAR 5.88%

PNG 5.78%

Kiribati 5.61%

Grenada 5.25%

Fiji 5.15%

Zambia 5.10%

*Source: HIV Universal Access reporting data, WHO.

Page 16: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Congenital syphilis is preventable and treatable

Congenital syphilis is preventable and treatable

– Inexpensive test less than US $1.00• Traditional tests require laboratory• Rapid tests do not require laboratory

– Treatment• Widely available• Penicillin (one dose) = US $0.50

– Screening all pregnant women is cost- effective even in low-prevalence settings

– Treatment given early in pregnancy is more likely to avoid bad outcomes – should test at first ANC visit!

*Source: The global elimination of congenital syphilis: rationale and strategy. WHO, 2007.

Page 17: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Reported proportion of ANC attendees tested for syphilis in African countries in 2008*

0%10%20%30%40%50%60%70%80%90%

100%

Guinea

-Biss

auBuru

ndi

Ethiopia

MaliMad

agasc

arZim

babwe

Guinea

United

Rep

ublic

of Tan

zania

Centra

l Afric

an R

epub

licMoz

ambiq

ueRwan

daCôte

d'Ivo

ireCom

oros

Sao To

me and

Prin

cipe

Namibi

aCap

e Verd

eGab

onSey

chell

es

*Source: WHO, HIV Universal Access reporting system, unpublished data, 2009.

Page 18: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Why does CS persist despite an effective intervention?

Page 19: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Stillbirths: what difference can we make and at what cost?*

"Screening pregnant women for syphilis and treating them — recommended almost everywhere, but overlooked in many places —

would prevent 136,000 stillbirths. "The Washington Post, Wed, April 13, 2011

*Bhutta, Yakoob, Lawn Rizvi, Friberg, Weissman, Buchmann, Goldenberg, for The Lancet Stillbirths Series steering committee. The Lancet, April 13, 2011.

Page 20: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

WHO Global Elimination of Congenital Syphilis Initiative

• Objective– To eliminate congenital syphilis (ECS) as a public health problem

• Targets by 2015– Screen >90% of first ANC attendees for syphilis– Treat >90% of syphilis-seropositive ANC attendees

• The four pillars of ECS

Available at: http://whqlibdoc.who.int/publications/2007/9789241595858_eng.pdf

I. Ensure sustained political commitment and advocacy

Example: raise awareness of adverse outcomes of syphilis

in pregnancy

II. Increase access to, and quality of, maternal and newborn health services

Example: strengthen linkages with PMTCT of HIV

to improve MCH services

III. Screen all pregnant women and treat all positives

Example: improve quality of antenatal care

IV. Surveillance, monitoring and evaluation systems

Example: develop capacity of traditional and skilled birth attendants to report stillbirths and CS

Page 21: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Congenital Syphilis Elimination helps to reach goals

Millennium Development Goals– 3: Building capacity for self-care empowers women– 4: Prevention of congenital syphilis reduces neonatal

mortality– 5: Early antenatal care and fewer spontaneous

abortions and stillbirths improve maternal health– 6: Women with syphilis are at greater risk of acquiring

and transmitting HIV

Secretary General's Global Strategy for Women's and Children's Health

– Ensure universal access for women and children to a comprehensive, integrated package of essential interventions and services

Page 22: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Congenital Syphilis Elimination

ECS

HIV (PMTCT)Reproductive

Health

MNCH

Demonstrates the importance of linkages

STI

A generation free of HIV and syphilis?

Conceptual Framework for the Elimination of

Pediatric HIV and Congenital Syphilis in the Asia Pacific, 2011-

2015

USG Global Health

Initiative

Page 23: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Building capacity and awareness

Men in Brazil

Partners in Argentina

October 16, 2011Communities in Mongolia

Source: Mongolia, Brazil, and Argentina ministries of health.

Page 24: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Improving the quality of antenatal care in Peru

*RST = Rapid Syphilis TestSource: Patty Garcia, Universidade Caeyetana Heredia, Lima, Peru.

*

Page 25: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Strengthening linkages: the Cambodia Linked Response

Source: National Centre for HIV/AIDS Dermatology and STD (NCHADS), Ministry of Health Cambodia

Page 26: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Evaluating the Cambodia Linked Response

Kirivong and Prey Veng Districts

-Syphilis screening integrated in early 2009-Increased HIV and syphilis testing coverage-Increased ANC 1st visit, delivery, and family planning coverage

Source: National Centre for HIV/AIDS Dermatology and STD (NCHADS), Ministry of Health Cambodia andDelvaux T et al. Linked Response for prevention, care, and treatment of HIV/AIDS, STIs, and reproductive health issues: Results after 18 months of implementation in 5 operational districts in Cambodia. JAIDS, published ahead of print.

3% 6% 8% 7%11%

55%

79%74%

85%85%80%88%90%

85%

70%68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2007 2008 2009

Per quarter and year

Per

cent

ages

HIV testing coverage Syphilis testing

HIV/syphilis testing coverage

Page 27: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Summary thoughts on community mobilization to strengthen ANC and ECS• Working with individuals, families, and

communities can contribute to congenital syphilis elimination

• WHO has developed a range of tools to support countries

• Role for more systematic efforts to mobilize community as part of comprehensive MNH package

Page 28: Mobilising Communities to Eliminate Congenital Syphilis and … · Mobilising Communities to Eliminate Congenital Syphilis and Strengthen Antenatal Care. Lori Newman - RHR. Annie

Contact informationDr. Lori Newman – [email protected]

More information available at: www.who.int/reproductivehealth/topics/rtis/syphilis/en/index.html

Working together to eliminate congenital syphilis!