NATIONAL NEWBORN CARE

KEY FINDINGS

AND

RECOMMENDATIONS

Child Priorities Meeting

December 2014

N R Rhoda

Neonatal Care Improvement Advisor, NDOH - RMCH (DFID)

This presentation is provided on the South African Child Health Priorities Website as presented at the 5th Child Health Priorities Conference except

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content of the presentation.

OUTLINE

• KEY FINDINGS

• RECOMMENDATIONS

• POST MDG Dec 2015 • WAY FORWARD

2

3

THE MATERNAL – FETAL - NEONATAL CONTINUUM

HOW TO REDUCE PERINATAL DEATHS • STRATEGIC MATERNAL NEONATAL HEALTH ACTIONS

1. High priority in government policies

2. Cost effective clinical interventions

3. Functional health system (access/skilled care)

4. Continuum of care

5. Community involvement

Neonatal Survival 3, Systematic scaling up of neonatal care in countries, Lancet , March 2005

• Integrate

– Data sets

– National ministerial reports

– Existing programmes within MCWH

– Global initiatives – CARMMA, ENAP

• Decentralize care

– Drainage areas

– Facility plans

– Continuum of care

– Community

INTEGRATE MATERNAL + NEWBORN HEALTH

•Continuum of care

•Healthy pregnancy = healthy newborn

•Provide Road map •“guideline for improving maternal and neonatal care” Dec 2012

•Integrate NCCEMD and NAPEMMCO recommendations •5 H’s + HHAPI-NeSS

INCLUDED IN (E)NAPs

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ADDRESSING THE CONTINUUM OF CARE MATERNAL - CHILD CROSS CUTTING INTERVENTIONSENTIONS

• Family Planning

• BANC

• Maternity Waiting Homes

• Emergency services (dedicated ambulances)

• Child PIP - late neonatal deaths

• WBOTS

• ISHP

Continuum of care Kate Kerber et al, Lancet, Oct 2007

Data Information

ACTIONABLE

KNOWLEDGE CHANGE Analysis Interpretat

ion Decision

Evidence

Collect

Co

llate

NBC LEADERS NAPEMMCO nCIA (RMCH)

MCWH PROV PAEDS

DCST

NHIRD

THE USE OF DATA AND INFO FOR CHANGE

BURDEN OF DISEASE API = 5237 DEATHS 5237 DEATHS

cENNd number 1000g+ Calc DHIS per year

SA CHC DH RH PT NC

Congenital abnormalities

738 17 254 206 114 147

ASPHYXIA 2711 86 1355 757 289 224

PREMATURITY 1946 36 979 587 162 182

INFECTION 580 24 152 188 109 107

Miscellaneous 371 20 177 103 42 29

Trauma 56 3 27 16 9 1

Unknown cause of death

162 11 79 32 18 22

Total 6563 196 3023 1889 743 712

}

BURDEN OF DISEASE

Saving Babies, 9th report, R Pattison, N R Rhoda, 2014

INTEGRATE “HHAPI-NeSS”INTERVENTIONS RECOMMENDATIO

N

INTERVENTIONS

Reduce deaths

due to Asphyxia

1. Ensure that labour is monitored appropriately by a skilled

birth attendant (ESMOE )

2. Ensure all birth attendants are skilled at a minimum in

neonatal bag and mask ventilation (HBB+ESMOE)

3. Ensure that the partogram is used to monitor labour and

the fetus and mother are monitored according to the

prescribed norms ensuring proper data interpretation.

Reduce death

due to

Prematurity

1. Ensure that corticosteroids are given to every women in

preterm labour

2. Ensure antibiotics are given with preterm premature

rupture of membranes

3. Ensure the appropriate hospitals are skilled in the used of

nasal CPAP

4. Ensure that all mothers of immature infants have easy

access to KMC

Reduce deaths

due to Infection

1. Promote breastfeeding (especially exclusive breastfeeding)

2. Ensure strict adherence to basic hygiene in labour wards

and nurseries

3. Ensure presumptive antibiotic therapy for at risk newborns

is available

4. Ensure clean cord care with chlorhexidine

5. Ensure case management of neonatal sepsis, meningitis

and pneumonia

INCLUDES ALL 4 LIFE SAVING NEWBORN HEALTH COMMODITIES –Sept 2012

MANAGEMENT OF SMALL AND SICK

PLANNED PREGNANCY Family planning

ANTENATAL CARE BANC, PMTCT

ROUTINE NEWBORN CARE KMC, breastfeeding, cord care

Postnatal care

H A H P I

ESSENTIAL NEWBORN CARE

INTRAPARTUM CARE Partogram MATERNITY UNIT

HC WORKERS

NURSERY UNIT HC WORKERS

HBB

CPAP

HIGH IMPACT FACTORS

HHAPI-NeSS recommendations

NCCEMD recommendations

NBC TRAINING

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 death due to Prematurity

• Reduce deaths due to Infection

Implement interventions for each of the recommendation forms the basis of the newborn survival strategy (NeSS).

NB**The HHAPI-NeSS road map includes the

5 Hs for maternal health.

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3 top causes of neonatal

deaths

SUGGESTIONS TO CHANGE APPROACH

• Models of care • NB *”No one size fits all!!”

• Use of analytical model List • Financial plan • % reduction in deaths

REF:PRICELESS REPORT

• Recommendations written in action style • Who facilitates • Who advocates • What is timeline and deadline

INTEGRATION OF MATERNAL CONDITIONS ASSOCIATED WITH STILLBIRTHS, EARLY NEONATAL DEATHS AND MATERNAL DEATHS

0

10

20

30

40

50

60

70

Coin Unant MD NPRI HT APH/Pl Ut rupt. Cord AF Abn

Lab.

PPH

unsp.

PRS

unsp.

Emb Early

preg.

Unk Normal

%

Maternal death Stillbirth ENND

Labour related

Saving Babies report, 2010

65% ASPHYXIA

15% STILLBIRTHS

INTRAPARTUM CARE

Essential Mother and Baby Care (EMoBaC) Lives saved/year

Lives

saved/year

Dimensions of Facility

Care Obstetric Mother Baby New born Baby

General requirements for health facility

Service availability 24/7

Skilled providers in sufficient numbers

Referral service to higher-level care, communication

tools

Reliable electricity and water supply, heating in cold

climates, clean toilets

A. Routine care (for all mothers and babies)

HIV screening and treatment 638 PMTCT

TB Screening and treatment 329 Thermal protection 169

Monitoring and management of labour using

partograph 762 1315 Immediate and exclusive breastfeeding 720

Infection prevention measures (hand-washing, gloves) 67 65 Infection prevention including hygienic cord care 395

Active management of third stage of labour (AMTSL) 15 (PMTCT if HIV-positive mother) B. Basic emergency care (for mothers and babies with complications)

Parenteral antibiotics for maternal infection 15 Antibiotics for preterm or prolonged PROM to

prevent infection 229

Parenteral magnesium sulphate for (pre-) eclampsia 62 Corticosteroids in preterm labour 1671

Parenteral oxytocic drugs for haemorrhage Resuscitation with bag and mask of non-

breathing baby 481

Manual removal of placenta for retained placenta KMC for premature/very small babies 1324 Removal of retained products of conception 31 Alternative feeding if baby unable to breastfeed

Assisted vaginal delivery Injectable antibiotics for neonatal sepsis 994

ARV treatment

C. Comprehensive emergency care (functions in addition to Basic)

Surgery (e.g. C-section) including anaesthesia Intravenous fluids

Blood transfusion Safe administration of oxygen

Total lives saved 1919 1380 5983

Total lives saved/year (mother and baby) 9282

M&E: SIGNAL FUNCTIONS - Gabrysch et al, 2012

KEY FINDINDS

KEY FINDINGS FOR 2ND TRIENNIAL REPORT (2010-13)

• The neonatal mortality rate for calendar year 2013 has stayed the same

• Highest neonatal death rates is in the weight category 1000g – 1999g

• Reduction in the data gap between DHIS and PPIP has improved

PPIP with quality of care assessments:

good Mpumalanga, N West, Free State, W Cape,

moderate Limpopo and Northern Cape

poor Eastern Cape, Gauteng and KwaZulu-Natal.

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Data:

Causes of neonatal deaths:

• There is no change in the top three causes Asphyxia, Prematurity and Infections of neonatal deaths

• Unexplained stillbirth is the largest category of macerated stillbirths across all levels of care

• Intrapartum birth asphyxia is the most common category in fresh stillbirths in CHCs and district hospitals.

• Almost 50% of these deaths were thought to be probably preventable; the common problems being with fetal monitoring, use of the partogram and the second stage of labour.

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At district level • District hospitals have the most deaths, most births and highest

mortality rates and perinatal care indices.

• Small but noticeable improvement in all indicators for districts hospitals when this saving babies report is compared to the 2010-11 Saving Babies report.

• On average one district hospital will deliver: • If 2000 deliveries / year then

• a live born baby between 1000g and 1999g once every 5 days • 12% (one in eight will be an early neonatal death).

• If 500 deliveries / year then: • they will deliver a live born between 1000g and 1999g every 20 days • two will die per year

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PERINATAL CARE INDICATORS / LOC 2010-2011 COMPARED TO 2012-2013

2010- 2011 2012-2013 2010- 2011 2012-2013 2010- 2011 2012-2013 2010- 2011 2012-2013 2010- 2011 2012-2013

Community Health

Centre District Hospital Regional Hospital Provincial Tertiary National Central

PNMR 9.57 9.8 33.43 30.5 39.50 42.7 51.04 55.3 63.30 64.2

PNMR 1000g+

6.88 7.3 27.17 24.3 28.35 30.7 36.16 38.7 41.19 41.0

SBR 8.11 8.4 22.03 20.2 27.57 30.2 33.26 39.2 42.87 42.9

SBR 1000g+ 5.89 6.2 18.18 16.4 20.39 22.6 24.70 28.8 28.49 27.9

ENNDR 1.47 1.4 11.21 10.5 12.26 13.0 18.39 16.7 21.34 22.3

ENNDR 1000g+

0.99 1.1 9.16 8.0 8.12 8.2 11.75 10.2 13.07 13.5

Saving Babies report – 2012-2013, R.Pattison, N R Rhoda (2014)

Avoidable causes

• Administrative associated causes- • Inadequate facilities were the most common avoidable

factor in spontaneous preterm labour • Deaths due to immaturity were thought to be probably

preventable if better neonatal facilities were available

• Patient associated • In almost one in five deaths which were unexplained

stillbirths the patient was reported as not responding to poor fetal movements

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Avoidable causes

• Medical personnel associated: • Health care provider issues were relatively rarely reported,

but are significant in their nature.

• Unprofessional behaviour was found by doctors not responding to calls and lack of training also featured.

• In almost a third of babies dying due to complications of hypertension, hypertension was detected but NOT acted upon.

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2010 2011 2012 2013 One year

% reduction

Eastern Cape 15.2 16.4 18.4 16.4 10.9

Free State 16 16 12.9 14.7 - 17.1

Gauteng 11.2 13.2 11.9 11.7 1.7

KZN 10.7 10.2 10.4 11.9 - 13.5

Limpopo* 11.6 12.4 13.1 13 - 0.8

Mpumalanga 10.6 9.7 10.9 9.7 11.0

North West 13.7 13.7 12.2 11.2 9.8

Northern Cape* 13.1 13.2 14.7 13.6 7.5

Western Cape 5.8 5.6 7.1 6 15.5

South Africa 11.2 12.1 12.2 11.9 2.5

PROVINCIAL % REDUCTION IN NMR 2012 VS 2013 PER PROVINCE DHIS

Source : DHIS extracted June 2014

EG: PROVINCIAL DATA TEMPLATE

RECOMMENDATIONS

2014 KEY RECOMMENDATIONS 1. ENABLING ENVIRONMENT (STRUCTURES).

NBC leadership at all levels of care

• National – Establish a Neonatal directorate within NDOH

• Provincial – appoint the Provincial paediatric specialist (only 3/9 provinces appointed)

• District – increase uptake of the DCST Paediatrician (only 20/52 districts appointed)

Figure: NBC leadership across the LOC

MINIMUM REQUIREMENT TO EFFECT CHANGE

2014 KEY RECOMMENDATIONS

2. RESOURCES

2.1 Financial: Ring fence money for neonatal care (2012 recommendation)

2.2. Human:

2.2.1 Minimum requirements=Prov Paed + 50% Paed DCST

2.2.2 Appointment of a provincial data co-ordinator

3. CO-ORDINATED PLAN

3.1 National neonatal implementation and monitoring plan

3.2 Standardised Provincial plans

3.3 Strategic District plans -

3.4 Facility plans

2014 KEY RECOMMENDATIONS 4. TRAINING

4.1 Prioritise national roll out of newborn interventions in all districts

4.1.1.Reducing Asphyxia - increase coverage of HBB to 50% by March 2015.

4.1.2.Reducing Premature birth – “preterm package”: • Tocolytics to all mothers in Preterm labour

• Antenatal steroid use at PHC, CHC and DH especially

• CPAP implementation

• MSSN training in districts

4.1. 3 Reducing Infection prioritise hand washing

5. MONITORING AND EVALUATION

5.1 Standardised Provincial template across the country aligned with global Every Newborn Action Plan newborn care indicators

5.2 Neonatal Signal Functions should be incorporated into the DHPs

HHAPI-NeSS

3 Building Blocks

Knowledgeable and skilled health care providers

Appropriately resourced health care facilities (including equipment and human resources)

Rapid inter-facility emergency transport system

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How

Care: Commitment to quality

Coverage

Nasal CPAP

Contraception

Community involvement

5 C’s HHAPI-NeSS interventions

What

Reduce deaths due to Asphyxia

Reduce deaths due to Prematurity

Reduce deaths due to Infection

PACKAGED

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HOW WHO

Care: Commitment to quality

- DCSTs to improve clinical governance, clinical supervision, response to local audit findings, and leadership functions

- HCP to make themselves available for training and to participate in drills

- Managers to ensure emergency drills performed regularly

Coverage - District managers to ensure all effective interventions are implemented in neonatal , especially for the poorest section of the population

- EMS to ensure transport home to institution and between institutions

Nasal CPAP - CEOs and district managers rationalise resources to ensure skills and facilities available 24/7

- HCP have skills to perform nasal CPAP + safe administration of oxygen

Contraception - All HCP to motivate people to prevent unwanted pregnancies

- Managers to ensure various modalities are always available - WBOTs to identify women requiring contraception, and refer

Community involvement - Health facility management to engage with community health committees

- WBOTs convey the essential maternity and baby care messages to all pregnant and postnatal women

PACKAGED: 5 C’s

AIM

Post MDG

2035 global ENAP targets SBR<10

NMR<10

PNDSR PERINATAL DEATH SURVEILLANCE RESPONSE – AU conference, 2012

“EVERY FETUS COUNTS -20 000”

“EVERY NEWBORN COUNTS -12 000”

STILL BIRTHS (DHIS 2013: +20 000 deaths)

• Current interventions with impact

• ESMOE - • HBB - 10% reduction in fresh still births

Develop a National plan to reduce SBs (NAPEMMCO + NCCEMD)

WAY FORWARD 2015+

ACKNOWLEDGEMENTS

RMCH colleagues

NDOH - NHIRD/DHIS

NDOH - child directorate

NDOH - maternal directorate

PPIP – MRC Pretoria

Partners • ELMA

• UNICEF

• WHO

• PATH

• Limpopo University

• Save the Children

NAPEMMCO MEMBERS

• N R Rhoda (chair)

• N. Mzolo (KZN)

• M. Patrick (KZN –child PIP)

• T. Maphosa (MPU)

• N. Shipalana (LP)

• R. Pattison (secretariate)

• P. Cooper (GAU)

• S. Velaphi (GAU)

• OI. Adejayan (NW)

• A. Jassen (NC)

• M. Nazo (EC)

• H. Steinberg (FS)

• I. Els (WC)

• D. Bradshaw (MRC)

THANK YOU