Newborn survival lessons from the Western Pacific region – two stories from our knowledge hub work

Chris Morgan

•  Places with the highest maternal and newborn mortality generally have the worst access to services, and higher rates of home-birth.

•  Most deaths of mothers and many deaths of babies occur on or near the day of birth,

•  WHO and national strategies recommend childbirth care in a health facility, but this takes time to scale up –  PNG Maternal Task Force

plans “60% of all pregnant women having skilled attendant at delivery by 2015 and 80% by 2020”

Like Nepal

or PNG, or Lao PDR or….

The problem in certain settings in our region

Provoked one stream of knowledge collation

•  There are forms of community-based care at childbirth, that could be delivered by trained lay health workers or community-based staff

•  Some are interim measures to meet the immediate crisis in maternal deaths.

•  Could maybe reduce maternal and newborn deaths by 30% or more.

•  However, they must be introduced in a carefully measured fashion, using a systems approach, to monitor for impact and unforeseen consequences.

Established packages for newborn care (warmth, hygiene, EBF), clean delivery kits;

Community mobilisation, facilitated referral;

Oxytocics from trained workers or self-administered; Antibiotics from trained workers (lay or paid); and ? pre-filled injection devices for vaccination or oxytocics.

Recognising the many other determinants, such as

family planning, girls’ education and nutrition etc

Site analyses

Collaboration with World Vision for an “evidence-based policy-advocacy’ study

•  … on the potential of “Family and Community Care” that is: care by family and community members, rather than by health professionals” –  Eg by “trained lay health workers” – aka VHVs

•  We did a –  Comprehensive literature review of

international publications to find interventions or packages delivered by FCC

–  Determined a simple cost-effectiveness rating and excluded any that were not good value for money

–  Researched their current or past application on PNG through publication and contacting experts

An interventions and service delivery analysis of Family and Community Care for maternal and child survival in PNG -

What we concluded

•  In places where the maternal and newborn mortality rates are still relatively high…

•  FCC interventions could avert deaths: –  Up to one third of maternal

deaths –  Up to two thirds of newborn

deaths –  Up to half of child deaths

•  PNG already has a variety of experiences with nearly all interventions researched

Two ways to view family and community care, provided by VHVs, in PNG

•  A complement to the current investment in re-building the health infrastructure, training more health workers (including midwives) and strengthening systems –  FCC can help engage communities in a stronger HSS

process •  A stop-gap for get some high impact interventions to

mothers and children, while the health system is being rebuilt –  Might require innovative approaches and some risk-benefit

analysis

What came next

Another story – unique to East Asia and the Western Pacific

•  Most of the operational research demonstrating the efficacy of community-based newborn care has come from South Asia

•  Meanwhile, in East Asia and the Pacific, it has been immunization programs that focused on the first 24 hours after birth –  The critical period during which vaccination against

hepatitis B can interrupt perinatal transmission of hepatitis B (the form most likely to lead to chronic liver disease and death)

•  Scale-up of this has been a major push for the WHO WPRO

Rationale for early post-natal care and vaccination visits in homes - in Angoram District, East Sepik Province (our study site)

•  Coverage of HepB birth dose is low: –  National: 16% 2005 survey), 25% (2008 NHIS) –  East Sepik: 27% Prov, 18% Angoram (2008 NHIS)

•  Proportions of childbirth occurring in health facilities had not increased for 10 years - between 30 and 40% –  But our partner, Save International PNG, has a good

network of village health volunteers •  Maternal and newborn mortality is high and postnatal

care underutilised •  Indonesia has supported hepatitis B vaccine in Uniject,

–  makes injection by LHWs feasible

THE STUDY: A small feasibility trial of expanded health services, in a “difficult” but characteristic location

•  To answer the questions: –  Can postnatal care be expanded for home births? –  Can birth-dose vaccination reach home births? –  Can combining the two result in synergy rather

than fragmentation or competition? •  Providing

–  birth-dose vaccination for hepatitis B vaccination (HBV) using UnijectTM in a real-world setting, including out-of-cold chain usage

–  Integrated with early post-natal visits for home births in a remote district

•  Provision by –  Trained lay Village Health Volunteers (VHV), –  Nursing Officers (NOs) and Community

Health Workers (CHWs)

MINIMAL POSTNATAL PACKAGE for community or aid-post level •  Hepatitis B vaccine

–  within 24 hours of birth, w UnijectTM •  Essential information:

–  breast-feeding and nutrition for the mother and baby

–  warmth and hygiene (inc. cord care) –  signs of infection in mother/baby,

how to prevent and respond •  Additional information and care

–  weighing the baby and information on care of low-birth weight babies, especially for temperature control

–  routine postnatal care for mother and baby, including further routine immunisations

–  family planning •  Vitamin A for the mother

Trainers Manual

IEC brochure draft

Both translated into Tok Pisin

IMPLEMENTATION

•  Training of staff and VHVs: –  13 rural health staff (NOs & CHWs) –  212 VHVs (175 female)

•  Provision of services in four health centre catchments: –  UnijectTM HBV procurement and distribution via govt systems –  Services to more than 364 mothers

•  Monitoring and supervision by a locally based project officer

–  birth and postnatal visit record form, designed for use by VHVs –  calendar to ensure vaccine out of the cold chain < 30 days

•  Evaluation –  using project databases - 2 for triangulation –  two visits with structured questionnaires for qualitative data

gathering - involved National Dept of Health and WHO

Extract from the VHV birth and postnatal care record form

EVALUATION - POSITIVE OUTCOMES

•  Coverage with birth-dose increased –  83% overall (cf district average 24%) –  74% (homebirths), 93% (health centre)

•  Use of VHVs extended coverage: –  ~ 10 VHVs for every paid staff member

•  VHVs vaccinated safely, using Uniject •  Out-of-cold chain management of HBV

feasible and appropriate, vaccine vial monitors used appropriately

•  Active VHVs credited the level of support provided by Save and Burnet

•  Most of postnatal package provided most of the time (but Vit A only 62%)

•  Having a vaccine role motivated greater attendance at birth for VHVs

•  Good community acceptance

VHV Unitha Longhi providing birth-dose vaccination w UnijectTM

EVALUATION - SURPRISES

•  Births in health centres increased –  often a VHV accompanied and

attended the birth in the health facility, with staff on stand-by

•  UnijectTM use in health centres –  contributed to increased coverage there as well as

at community level –  staff found it far easier the multi-dose vial

•  Considerable new information regarding birth outcomes and care-seeking behaviour –  very high rates of obstetric complications and

death persist –  our program could only really influence newborn

outcomes and possibly puerperal sepsis

Global extensions •  2009 WHO Position Paper adopted the policy led by

WPRO –  “In all regions of the world, all infants should receive the

first dose of hepatitis B vaccine as soon as possible (<24 hours) after birth. This should be followed by two or three doses to complete the series.”

–  Adopted as part of the World Health Assembly’s resolution on the control of viral hepatitis in 2010

–  New global hepatitis program established at WHO in 2011

•  Implications for other regions –  African and South Asian settings with high home birth rates

that have not yet introduced birth dose vaccination –  Can vaccination leverage better maternal/newborn care or

will it be a burden on over-stretched systems?

WCH Knowledge Hub supported WHO expansion efforts •  WHO global consultation on birth-dose held in Melbourne, Dec 2010

•  Systematic review of global practices to provide birth-dose vaccination –  A chance to ensure that

integration with postnatal care for newborn and maternal survival was highlighted

Issues for newborns: -  timing of home visit -  preventive care only, or therapeutic as well -  integration with maternal and immunisation programs

Issues for mothers: -  risk encouraging home births or distracting from facility care -  misoprostol - treatment or prevention; vs oxytocin, timing -  unknowns around puerperal sepsis in the community

Issues for both: -  introduce in concert with health system strengthening -  comprehensive PHC still offers best health system environment

To finish: Some critical service delivery questions for us

The value of kangaroo care

Morgan and Rongong. Use of Kangaroo Nursing Method in Western Nepal; J Nepal Med Assoc, Jul-Sep 1997 (36): 320 - 323

Thank you

A short history of baby care •  BC 2000

–  “Just carry it next to your skin. Breastfeed it whenever it is hungry.”

•  AD1660 –  “Breastfeeding is undignified. Hand it over to a wet-

nurse.” •  AD 1850

–  “Wet-nurses are low class and have an undesirable influence on the child. Get a good experienced nanny to bottle feed it cow’s milk, and wean it on to a cup as soon as possible.”

•  AD 1930 –  "Cow’s milk is unsuitable for babies. It must be

bottle fed on a special infant formula.” •  AD 1950

–  “Bottle feeding at all hours is bad for the baby. Follow a strict routine, let it sleep in its own room and ignore it when it cries at other times.”

•  AD 2000 –  “Bottle feeding is unsuitable, a strict time-table is

nonsense, babies don’t like being alone, and crying is stressful. Just carry it next to your skin. Breastfeed it whenever it is hungry.”

(Joan Norton, 2001)