Early Essential Newborn Care Action Plan for Mongolia ... · PDF fileEarly Essential Newborn...

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Early Essential Newborn Care Action

Plan for Mongolia, 2014-2020

MOH

DRAFT March4, 2014

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1. Introduction Background: Newborn Health in Mongolia Reducing newborn deaths is critical to reducing under-five child mortality in Mongolia. Although under five mortality has fallen 74% since 1990 (to 28 per 1000 live births in 2012), newborn mortality has fallen

at a slower rate (falling from 25 to 10 per 1000 live births between 1990 and 2012). Newborn deaths

now represent 37% of all under-5 child deaths. The risk newborn of death tends to be higher among poor, rural and disadvantaged groups who are less likely to have access to quality care. As a consequence,

progress in reducing newborn mortality is uneven within the country. More needs to be done to accelerate

the reduction in newborn mortality, with an emphasis on reaching those at highest risk.

The most important causes of newborn mortality are complications of preterm birth, asphyxia, and

infection (Figure 1). Seventy five percent of newborn deaths occur in the first 3 days of life, with the

majority of these occurring in the first 24 hours after birth. For this reason essential interventions need to be delivered to the mother and baby during delivery and in the first few hours and days after delivery. A

high proportion of women deliver with a skilled birth attendant and at health facilities(99% in 2010) –

however available data suggest that the quality of early newborn care needs improvement.

FIGURE 1: CAUSES OF NEWBORN DEATHS, MONGOLIA, 2012

Newborn deaths in Mongolia Are mostly preventable

Have declined at a slower rate than deaths in older children

Represent 37% of children who died before their fifth birthday

Are concentrated in the first 3 days of life, especially the first 24 hours

Must be lowered to further reduce child mortality and reach MDG4

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Figure 2: Trends in Under-5 and Newborn Deaths, Mongolia, 1990-2011

23%25%

36%

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140

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Source: IGME (1990, 2000, 2012)

What is early essential newborn care? Early essential newborncare (EENC) is a package of interventions delivered to the mother and newborn

between delivery and the first 3 days after birth. Interventions included in the package are low cost have

been demonstrated to be effective in preventing newborn deaths from the most common causes (Figure 3 and Annex 1). EENC interventions are delivered during delivery (at the onset of contractions), the

immediate post-delivery period (1-2 hours) and in the postnatal period (1-2 hours to 3 days after

delivery). There are three principal components to the EENC package:

The First Embrace - for all mothers and newborns. Interventions include immediate and thorough drying;

immediate skin-to-skin contact; appropriately timed cord clamping; and non-separation of mother and

newborn forearly exclusive breastfeeding.

Prevention and management of prematurity – for preterm and low birth weight babies (5-7% of all

newborns). Interventions include preventing unnecessary inductions and caesarian sections; antibiotics

for premature pre-labor rupture of membranes; antenatal steroids; tocolytics when indicated; and the Kangaroo Mother Care approach.

Care for Sick Newborns – for babies with birth asphyxia, neonatal sepsis and complications of delivery (10-15% of all newborns). Interventions include management of asphyxia using bag and mask

ventilation; identification of babies at high risk, and management of sepsis and other common problems.

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Figure 3: Priority Interventions of Early Essential Newborn Care (EENC)1

How is EENC delivered? EENC is an integral part of comprehensive labor, birth and newborn care. It is not a new or separate program. Rather, it requires that existing services are strengthened to improve the quality of care

provided, by improving health systems. It also requires that outdated, harmful or ineffective practices are

stopped. Existing packages that incorporate key EENC interventions include skilled delivery care, Emergency Obstetric and Newborn Care (EmONC), Integrated Management of Newborn and Childhood

Illness (IMNCI), and postnatal care (PNC). Improving delivery of EENC may require action in a number

of systems areas, including policies,planning and coordination, human resources, essential commodities,

service delivery and quality of care.In addition, improving EENC home care and care seeking practices requires that key EENC approaches and messages are incorporated into community-based programs.

What progress has been made in newborn healthin Mongolia? The proportion of women delivering with a skilled birth attendant and at a health facility is very high in

Mongolia (99% in 2010). A high proportion of babies also receive important interventions in the early post-natal period, including weighing (98%) and early breastfeeding within an hour of birth (72%)

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Limited data are available on the quality of thermal and cord care around delivery or on early postnatal

care – however a facility survey of the quality of EmONC in 2009 showed that facility care often does not

1WHO/WPRO, UNICEF. Action Plan Towards Healthy Newborns in the Western Pacific Region (2014-2020). April, 2013.

Manila: WHO/WPRO. 2National Statistics Office, UNICEF, 2011. Multiple Indicator Cluster Survey 2010: Summary Report, Ulaan Bataar, Mongolia

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meet quality standards3. The MOH in Mongolia has developed a Health Sector Master Plan 2006-2015

which includes a focus on maternal, child and newborn health and on building high quality sustainable systems which reach underserved and disadvantaged populations. In line with the Health Sector Strategic

Master Plan, a Maternal and Newborn Health Strategy (2011-2015), Child Survival Strategy (2011-2015),

and Fourth National Reproductive Health Programme (2012-2016) were developed and endorsed. These

strategies include a number of EENC interventions including a focus on newborn resuscitation and essential newborn care.Several other policies which support newborn health have been put in place,

including authorizing first-level health staff to provide newborn resuscitation, updating IMCI to include

management of the sick newborn and developing infection control guidelines for delivery rooms. Care for mothers and newborns is provided free of charge for all mothers and newborns. A maternal and child

handbook has been developed which is kept in the home and used to track all essential contacts for

mothers and babies; and a maternal and child surveillance system has been established to regularly collect data and track progress. It is recognized that gaps remain, particularly in the area of quality of care, and

that there is now a need to develop a clear plan for future action

Key newborn policies and guidelines endorsed or adopted by the MongoliaMOH, 2005 - 2014

Maternal and Newborn Health Strategy (2011-2015);

Child Survival Strategy (2011-2015);

Fourth National Reproductive Health Programme (2012-2016);

Convention on the Rights of the Child Ratified, with regular reporting;

Health workers at first level facilities authorized to provide newborn resuscitation;

Action Plan Towards Healthy Newborns in the Western Pacific Region (2014-2020)45endorsed (2013);

IMCI adapted to include management of the sick newborn;

Infection control guidelines in hospitals and health facilities providing deliveries;

Maternal and newborn surveillance system - National Center for Maternal and Child Health (2011);

Ministerial decree on Essential Newborn Care (ENC) – ENC incorporated into pre-service training curriculae (2006);

Maternal and child handbook for use by all mothers and children (2012)

How was the plan developed? The plan was developed in consultation with MOH and other stakeholders at a review and planning

meeting in February 20146. The planning meeting brought together MOH participants from national and

sub-national levels as well as development partners. The proceedings included presentations, plenary discussions and group work. A systematic process was used to review policies and health systems needed

to support EENC. Strengths and gaps were identified and findings used to identify activities needed. A

draft Action Plan for EENC was developed. The draft plan was subsequently reviewed by MOH staff and development partners and further edits and modification made. A one day meeting was convened to

review the final draft and finalize inputs in June, 2014.

3Mongolian Federation of Obstetrics and Gynecology, Wellspring NGO, 2009. Current Status of EmONC in Mongolia: Needs

Assessment of EmOC and ENC facilities in Ulaan Baatar and Western Region. Ulaan Baatar, Mongolia. 4 WHO/WPRO, UNICEF. Action Plan Towards Healthy Newborns in the Western Pacific Region (2014-2020). April, 2013. Manila: WHO/WPRO. 5 WHO/WPRO. CONSULTATION ON THE DRAFT REGIONAL ACTION PLAN FOR HEALTHY

NEWBORNS IN THE WESTERN PACIFIC 2014–2018. Manila Philippines, March 18-20, 2013. April 15, 2013. Manila: WHO/WPRO. 6 MOH, WHO, UNICEF. Mongolia Early Essential Newborn Care Planning Workshop: Ulaan Baatar 24-27, February 2014. Ulaan Baatar, Mongolia.

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What is the purpose of the plan?

This plan outlines activities to improve implementation of EENC for a six year period between 2014 and

2020. Itbuilds on existing policies and systems and experience from current program activities conducted by both the MOH and development partners. The plan has three key objectives as follows:

To address the most important policy and systems gaps needed to improve early essential newborn

care;

To ensure clarity on the roles and responsibilitiesof stakeholders– so that all stakeholders are working

towards common goals and objectives; and

To secure commitment from stakeholders – to ensure that human, financial and material resources are

made available and shared so that key activities are conducted.

It is recognized that the plan may need to be modified as more data become available and as experience is

gained with implementation on the ground. For this reason, the Action Plan will be supplemented with annual detailed implementation plans that allow changes to be made as needed. At the end of the plan

cycle (2020), progress with implementation will be reviewed and a new action plan developed based on

available data and field experience.

How is the plan organized? The plan is organized into four sections

EENC scale-up approach Early implementation hospitals

Process to be used

Mechanism for providing oversight and support

Strategic objectives, objectives and activities

1. Ensure consistent adoption of Early Essential Newborn Care;

2. Improve political and social support to ensure an enabling environment for Early Essential Newborn Care;

3. Ensure availability, access, and use of skilled birth attendants and essential maternal and newborn commodities in a safe environment;

4. Engage and mobilize families and communities to increase demand; and

5. Improve the quality and availability of perinatal information.

Monitoring and evaluation Impact indicators

Coverage indicators

Implementation indicators Cost Estimates Organized by strategic objective, activity and year

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2. Approach to EENC Scale-up EENC scale-up will begin in the nationalMCH hospital and one Aimag Hospital. Once hospital-based

implementation in these sites is functional,hospital teams will support implementation the remaining

Aimag and district hospitals and maternity homes. Aimag hospitals will be responsible for introducing EENC to Soum clinics. Although building facility capacity is the initial focus of scale-up activities –

efforts to improve household and community practices by through advocacy and health promotion and

behaviour change will be ongoing. The scale-up approach is summarized in Figure 4. Hospital teams are trained in the EENC approach at hospitals. Following training, hospital teams begin supporting hospital

staff to change practices, and track progress with data. Regular support visits are provided by EENC

facilitatorsto help solve problems and ensure that implementation is working. Annual programme implementation reviews are conducted to review progress and take action to address gaps and problems.

Figure 4: EINC Scale-up Strategy – 2014 – 2020

Document review

MNCH

surveys rvesurvsurveysacility surveys

MICS

Inputs 2-3 day EENC coaching workshop materials adapted and translated Guidelines on facility EENC process adapted and translated Workshops conducted EENC facilitators support hospital teams (frequency to be determined) EENC Technical Working Group oversees training, support visits to hospitals, and tracking with data EENC monitoring tools and methods developed and translated Implementation review visits conducted (annually)

Introduction into health facilities Central Hospital (1) – 2014

Aimag Hospitals (21) – 2014/2015 District Hospitals (2), Maternity homes (3) – 2015

Soum Clinics (300) – 2016-2020

Brief hospital staff on EENC introduction

Form hospital teams to support EENC

Train hospital teams using 2-3 day EENC coaching workshop (TOT)

Select and train EENC facilitators to support implementation in hospitals and lower levels

Hospital Teams Begin Process of Introducing EENC in their hospital and provide support to lower level

facilities

Identify EENC coordinators (OBS and PEDS)

Conduct weekly meetings

Work through process of identifying gaps and taking action to address gaps

Collect simple data to track progress

Regular support by EENC facilitators

Annual Programme Implementation Review

Hospital visits by teams from MCH center and EENC facilitators use structured approach to review progress with EENC , identify gaps and barriers and take action to address problems

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3. Strategic Actions, Objectives and Activities, 2014 – 2016

Vision: A healthy start for every newborn.

Mission: To strengthen the health system and to cultivate an enabling environment where skilled

providers of newborn care value and practice Early Essential Newborn Care (EENC) at every birth.

Goal: To ensure that newborns do not die from preventable causes by providing universal access to high

quality Early Essential Newborn Care.

Target 1: At least 80% of facilities where births take place are implementing EENC by 2020.

Target 2: At least 80% of skilled birth attendants practice EENC at all deliveries by 2020.

Target 3a*: National neonatal mortality rate (NMR) 5 per 1000 live births or less by 2020. Target 3b*: Sub-national** NMR 5 per 1000 live births or less by 2020.

Five Strategic Actions support consistent adoption of Early Essential Newborn Care

1. Ensure consistent adoption of Early Essential Newborn Care;

2. Improve political and social support to ensure an enabling environment for Early Essential Newborn Care;

3. Ensure availability, access, and use of skilled birth attendants and essential maternal and newborn

commodities in a safe environment;

4. Engage and mobilize families and communities to increase demand; and

5. Improve the quality and availability of perinatal information.

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Strategic Action 1: Ensure consistent adoption and implementation of Early Essential

Newborn Care

Operational Objective 1.1: To ensure Early Essential Newborn Care has been incorporated into

national and sub-national health agendas, plans, budgets and financing mechanisms.

Activity Responsible and timing

1. Complete EENC Action Plan: 2014 - 2020

a. Complete draft EENC Action plan based on EENC planning meeting

input

b. Cost planned activities –in consultation with stakeholders and

planning staff

c. Review by the EENC steering committee

d. Review with other stakeholders – individual review and health partners meeting

e. Finalization – and final approval/adoption by the MOH

WHO/J Murray/Dr. Soyol (step a and b–

March, 2013)

MOH,EENC TWG, WHO, UNICEF,

UNFPA other DPs (Steps b-e -

April2014– June 2014)

2. Improve coordination and management of EENC implementation

a. Form national EENC TWG – to oversee planning, implementation,

stakeholder coordination, advocacy and communication for EENC.

Develop terms of reference and convene regular meetings (monthly

in the first year).

b. Allocate a full-time staff person to support EENC and newborn

health in the MOH.

c. Engage obstetric, pediatric, MW societymembers as resource persons

to support EENC at Aimag and Soum levels - after central

implementation.

MOH/ WHO (a – March - May-

December 2014; b – 2014/2015).

Dr. Soyol, EENC TWG, pediatric

obstetric societies, WHO, UNICEF, UNFPA (c) - 2014 – ongoing

3. Develop EENC scale-up approach and begin team-based scale-up in

hospitals – 1 central hospital, 3 maternity homes, 21 Aimag hospitals and regional diagnostic and treatment centers + 2 district

hospitals; Soum clinics

a. Adapt2 day EENC coaching workshop materials/approach (including

revision of data collection forms for weekly meetings)

b. Adapt/translate EENC facility team approach with accompanying

guidelines

c. Form hospital core teams (beginning at the MCH center)

d. TOT – hospital core team and EENC facilitators

e. Core teams begin staff training in hospital, regular meetings and

facility-process to support EENC introduction

f. Facilitators provide regular support, follow-up, supervision g. EENC TWG meets regularly to oversee EENC scale-up , track

progress and oversee weekly and then semi-monthly hospital visits

to support facility implementation.

h. Support repeat hospital team training in Aimag hospitals, maternity

homes and district hospitals; then Soumclinics.

EENC TWG, H SobelJ. Murray, WHO,

UNICEF (steps a – d –May - December 2014– MCH central hospital and 1 Aimag

hospital: 2015– maternity homes, Aimag

hospitals, district hospitals; 2016 –

onwards –Soum clinics).

EENC TWG regular meetings and

oversight (e – July 2014 – Ongoing to

2020).

EENC facilitators support national,

Aimag and Soum implementation – 2015

-2020.

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4. Make financial resources available to support EENC

a. Advocate for financial protection of mothers and children (free or highly subsidized care) to ensure that key MNCH services are

provided free of charge and that high risk populations are reached.

Address key issues: Local governors provide resources for

transportation costs for returning home after delivery; migrant

families coverage not always protected by social protection.

b. Develop mechanisms for ensuring financing of EENC activities on

the ground – by advocating for central budgets to include EENC,

developing costed annual implementation plans and encouraging

better coordination and support from development partners through

the EENC TWG. Investigate the allocation of resources from local

government – for improved delivery services - medicines, supplies and infrastructure

MOH, EENC TWG, WHO, UNICEF,

UNFPA, other development

partners,Aimag health department -

advocacy at Aimag Governors office,

local government.

5. Strengthen implementation of EmONC in implementation hospitals

a. Ensure that hospital teams use most recent BeMONC and

CeMONC guidelines that include updated EENC interventions.

b. Ensure that measures of EmONC quality are included in EENC

implementation process – and actions taken to address gaps.

Review quality of EmONC in EINC implementation review (7)

c. Advocate to include resources to support EmONC training in

annual EENC plans

MOH, EENC TWG, MCH center, WHO,

UNFPA (December 2014 – ongoing)

6. Support implementation of IMNCI (management of the sick

newborn) - LINK with ONGOING MOH IMNCI PLAN AND

BUDGET

a. Develop approach for training and supporting IMNCI facilitators to

support training and follow-up at all levels – review management of

sick newborn component to ensure that it is being taught effectively

b. Develop approach to strengthening IMNCI follow-up after training

visits

MOH MNCH, EENC TWG, WHO (June-December 2014)

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7. Conduct programme implementation review of new EENC scale-up

hospitals annually (develop indicators, methods and conduct site

visits) – use findings to adjust implementation methods or content.

Dr. Soyol, EENC TWG, WHO/J

Murray/Sobel – develop approach and

tools (December, 2014), conduct field

visits (mid-2015, repeated annually to

2020)

Operational Objective 1.2: To ensure Early Essential Newborn Care has been incorporated into

clinical protocols, quality improvement cycles and accreditation mechanisms Activity Responsible and timing

8. Incorporate Early Essential Newborn Care interventions into

clinical guidelines

a. Adapt and translate clinical pocket guide for intra partum and

newborn care, format, print and distribute.

b. Review EENC training content of existing clinical standards

and guidelines– Skilled delivery care, EmONC, resuscitation,

prematurity/LBW, ANC/PNC, ENC, IMNCI, FP. Decide which are

needed – remove unnecessary guidelines or revise existing

guidelines to be consistent with EENC.

c. Review MBFHI guidelines/standards and incorporate EENC guidelines

MOH, EENC TWG, WHO, UNICEF (a

– May - December 2014)

Dr. Soyol, MCH Center, EENC TWG, local training consultant, Training

institutions*, WHO, UNICEF, pediatric

association, obstetrics association ,

midwife association, (b-cDecember: 2014

– December 2015)

9. Integrate up-to-date EENC guidelines/interventions into existing pre-service curriculae

a. Review current curriculae – nursing, midwifery, medicine – identify

gaps and address gaps (IMNCI, EmONC, EENC). Link with

UNFPA review and revision of undergraduate medicine and

midwifery curriculae; and ADB review and revision of post-graduate

training. Ensure that training methods include better practical

training – and hands-on methods.

b. Develop EENC education/training materials for use by trainers in

pre-service schools – DVD, technical references, powerpoint

presentations, clinical pocket guide, training aids.

MOH, EENC TWG, MCH Center, , local

or international consultant, Training institutions - faculties of nursing,

medicine, midwifery), pediatric, nd

midwife associations, (a - December 2014

– December 2015).

EENC TWG, WHO (b- April-July 2014)

10. Integrate up-to-date EENC guidelines into existing in-service

curriculae

Advocacy and coordination meetings to ensure that revised guidelines (8)

are used for in-service training and technical updates by all partners.

Develop EENC education/training materials (see #9).

MOH, EENC TWG, MCH Center, local

or international consultant, training

institutions*, hospital training staff, ,

WHO, UNICEF, UNFPA.

11. Develop EENC information and training toolkit – including teaching materials, presentations and training aids

MOH, EENCTWG, WHO/WPRO,

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A number of EENC materials are available. An inventory of available

tools will be developed. Materials may include documents for policy and

decision-makers, evidence-base references, implementation training

guidelines, DVDs of correct practice, the EENC documentary, and the

clinical pocket guide for EENC

J.Murray/Sobel, UNICEF

12. Update the MCH Card to include EENC practices

The current card will be updated to ensure that key EENC practices and

PNC contacts at 2 and 7 days are included

MOH, EENC TWG, WHO, UNICEF

Operational Objective 1.3: To enable providers of newborn care to practice Early Essential

Newborn Care at every delivery by providing appropriate system support and training. Activity Responsible and timing

13. Incorporate social marketing principles into EENC implementation process using hospital-based teams - to support

health workers to adopt and apply EENC at every birth

a. Develop implementation training/implementation approach using

hospital teams and local resource persons. Approaches may

include use of adult-learning methodologies (ensuring that

training is participatory and practice-based), monitoring,

supportive supervision, changes in physical environment of

delivery facilities and IEC materials and methods which support

or reinforce improved practices in the delivery room.

b. Pre-test the proposed intervention mix and methods in the MCH

Center.

c. Expand use of tested approaches that are effective.

MOH, EENC TWG, MCH Center, WHO, Hospital clinical staff (March – August,

2014).

Operational Objective 1.4: To scale up centers of excellence implementing Early Essential

Newborn Care Activity Responsible and timing

14. Develop standards for centers of excellence (CoE), indicators for

tracking status, and a description of roles and responsibilities for

CoE.

CoE should be able to provide all elements of EENC, EmONC, IMNCI, KMC, and NICU. Components to be considered include: Facility

supports; availability of essential medicines and commodities; quality of

care; infection control; referral and transport (2-way); MBFHI accredited.

A system foraccrediting facilities meeting standards may be proposed -

and a 2-3 yearly award process.

MOH, EENC TWG,WHO, UNICEF.

Pediatric, obstetric and midwife

associations (January – July 2015)

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15. Select Centers of Excellence sites

Initial sites reviewed will include the MCH central hospital. Also

consider 4 regional diagnostic centers, and the Aimag hospital in the

UNICEF supported northern region.

As above (Mid-2015)

16. Support CoE to develop a leadership role in supporting EENC

implementation

Support hospital administrators, and hospital implementation teams, and

others to define their role as a CoE, and ensure that they continue to meet

standards. Centers of excellence to be used for training, study visits,

sentinel surveillance.

As above (Mid-2015 – ongoing)

Strategic Action 2. Improve political and social support to ensure an enabling environment

for Early Essential Newborn Care

Operational Objective 2.1: To mobilize political commitment and social support of key

stakeholders for policies, programmes and services for the implementation of Early Essential

Newborn Care Activity Responsible and timing

17. Develop an advocacy, behavior change and communication strategy for EENC (LINK WITH ON-GOING

COMMUNICATION ACTIVITIES)

a. Review current availability of IEC messages, materials and

methods – use existing resources as much as possible.

b. Define key target groups including: policy-makers,

legislators, health providers, hospital administrators, civil

society leaders, development partners, media practitioners, academia and health professional associations, health

workers, community midwives, volunteers and communities.

c. Develop strategies, channels, methods and materials –

consider branding the first embrace and creating a campaign

around this – use Philippines Ulang Yakap experience to

inform development.

MOH, EENC TWG, National Center for

Public Health, National Center for

Communicable Disceases,UNICEF,

Hospital teams, EENC facilitators(First

quarter 2015)

18. Implement advocacy, behavior change and communication strategy for EINC

Implementation requirements will depend on the strategy to be used, the

communication channel selected and the target audience. Higher level

advocacy activities may include: development of and distribution of

policy briefs and other materials, technical meetings/workshops or

summits, one-on-one meetings, mass media (television, documentaries or

radio), and other print media. Behavior change and communication

activities may include: messages and materials for use by health workers

or community groups, messages and materials for use by hospital-based teams for use in hospitals and delivery rooms, and in health worker

training and briefing.

MOH, EENC TWG, , WHO, UNICEF, Hospital teams, EENC facilitators,

development partners (Firstquarter 2015 -

onwards)

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19. Convene EENC national consensus-building meeting to launch

EENC action plan, present technical basis for EENC and get

widespread consensus on technical standards

MOH, EENC TWG, , WHO, UNICEF,

Hospital teams, EENC facilitators,

development partners (First quarter 2015

)

Operational Objective 2.2: To strengthen legislation, regulations, and enforcement to meet

international standards to support implementation of Early Essential Newborn Care


20. Strengthen legislation, monitoring and enforcement of the

International Code for Marketing of Breastmilk substitutes.

Provide technical support to advocate for a strengthened code and for the

development of a monitoring and enforcement system – in particular in

implementation hospitals using hospital teams.

MOH, EENC TWG, Food and Drug

administration, UNICEF, ILO, UNFPA

(March 2014 – onwards)

21. Advocate to Ratify revised Maternity Protection Convention 183 and move toward adoption by GO and non-GO sectors

Provide technical support and advocacy to ensure adoption of the revised

legislation

Responsible: MOH, EENC TWG,

UNICEF,UNFPA, ILO (March 2014 onwards)

22. Review and update all official documents, regulations, orders,

decrees related to maternal and newborn health

Ensure technical recommendations are consistent with EENC.

MOH, EENC TWG, WHO, UNICEF,

UNFPA

Strategic Action 3: Ensure availability, access, and use of skilled birth attendants and

essential maternal and newborn commodities in a safe environment

Operational Objective 3.1: To ensure availability of a skilled birth attendant for every delivery


23. Ensure that MWs are authorized to conduct normal deliveries,

provide newborn resuscitation prevent and manage uncomplicated

prematurity/LBW

Advocate to ensure that they are midwives are authorized to conduct

normal deliveries. Current policy is that MWs cannot deliver on their

own but need supervision of doctor.

MOH, EENC TWG, professional

associations, WHO, UNFPA (March

2014 onwards)

24. Develop a strategy for better accrediting doctors and midwives to ensure they meet minimum practice standards for EENC.

Including: incorporation of EENC standards into existing curriculae

and training materials; setting criteria on the amount and type of

clinical experience that should be received during training;

establishing standards for the amount and type of on-the-job training

they should receive. This may also require development of minimum

EENC accreditation standards for training institutions.

MOH, EENC TWG, MCH center,

training colleges, Professional associations, UNFPA, WHO, UNICEF

(March 2014 – onwards)

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25. Advocate at national and sub-national levels to improve retention

and equitable distribution of SBAs – doctors and midwives.

This may need more attention to incentives, better supervision and other

forms of support.

MOH, EENC TWG, WHO, profesional

associations, UNICEF, UNFPA

Operational Objective 3.2: To ensure availability of equipment, supplies essential medicines and

infrastructure for EENC in routine and emergency situations


26. Review and update essential medicine, supplies and equipment lists to include those needed to provide EENC (including EmONC and

IMNCI) – as necessary.

MOH, EENC TWG, pharmacy

department/medical products and supply

center, WHO/UNICEF (June 2014 –

onwards)

27. Monitor availability of essential medicines and supplies for EENC

and take action to address gaps

Incorporate monitoring of essential medicines and commodities into:1)

hospital and health center- based EENC implementation process –

including strategies for addressing gaps identified (linked with # 3 and 11)

MOH, EENC TWG, hospital teams and

facilitators, pharmacy department,

professional associations, WHO,

UNICEF, UNFPA(June 2014 –

onwards)

28. Advocate to improve procurement practices for essential medicines

Advocate to ensure that procurement practices are modified to ensure that

medicines at all levels meet minimum quality standards

As above

Strategic Action 4: Engage and mobilize families and communities to increase demand

Operational Objective 4.1: To increase community demand for skilled birth and newborn

attendance and Early Essential Newborn Care


29. Develop a community behaviour change and communication strategy

to improve EENC practices including home care, careseeking, and

insurance enrolments and coverage (LINK WITH ON-GOING

COMMUNCIATION/BCC ACTIVITIES BEING SUPPORTED BY UNICEF AND UNFPA)

a. Review existing messages, materials, approaches and formative

research; conduct formative research if necessary to identify

birth, delivery and newborn care practices to guide development

of IEC messages, materials and approaches. Each center

produces messages but not always well coordinated; need to

ensure that messages are consistent, and include EENC standard

messages.

b. Develop and field test messages, materials and approaches, or adapt existing materials as needed. Ensure that messages and

materials are tailored to cultural, economic and other

demographic differences.

EENCTWG, Working Group on

Behavior Change and Communication,

MCH Center, National Center for Public

Health, National Center for

Communicable Diseases, Aimag and

Soum staff, WHO, UNICEF/UNFPA/JHU Center for

Communications, NGOs (Last quarter

2014 – 2015).

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c. Focus on reaching high risk sub-groups and populations.

d. Link with materials and approaches currently being used to

support community volunteers, community health worker training, community midwives; and other NGO and project

strategies

30. Implement community behaviour change and communication strategy

using revised messages, methods and materials through existing

community structures, systems, NGOs and other projects

Encourage DOH, NGOs and other stakeholders to use common set of

standard messages and materials. Identify a mechanism for sharing tools

and information

MOH, EENC TWG, Aimag and Soum

staff, WHO, UNICEF, UNFPA, NGOs

(First quarter 2015 – onwards)

17

Strategic Action 5: Improve the availabilityand quality of perinatal information.

Operational Objective 5.1: To strengthen capacity of routine information systems collect

accurate data on perinatal health


31. Incorporate key maternal and NB indicators in national Health Management and Information System

Advocate and provide technical support to information management

service to advocate for NB measures in the HMIS. Indicators not included

currently that should be incorporated are: PNC visit within 2 days,

breastfeeding (BF) within 1 hour, neonatal mortality rate (mortality is

reported for all under-5 children and infants), number of cases of newborn

sepsis, LBW. Ensure that ICD-10 codes are used.

Responsible: Dr. Soyol,EENC TWG,HMIS department, National

Statistics Office, WHO (January 2015 –

onwards)

32. Advocate and provide technical support to ensure civil registration

includes all births, stillbirths, neonatal deaths and cause

Emphasize importance of birth and death registration – clarify definitions

– link with ongoing activities already in place

Responsible: MOH, EENC TWG,

WHO, UNICEF, (link with ongoing

activities (March 2014 – onwards)

33. Develop monitoring and evaluation approach for EENC – conduct

regular monitoring, use data to solve problems. Incorporate EENC tracking indicators into the MNCH hospital surveillance system – to

include stillbirths, newborn deaths and cause, and case fatality rates

for newborn sepsis, cases of asphyxia, cases of prematurity, and birth

weight strata.

Link with on-going surveillance coordinated and managed by the MCH

Center MNCH surveillance system

Develop indicators and monitoring framework for implementation

hospitals – including systems for reporting and using information. Link

with ongoing hospital implementation process.Develop process for

collecting, compiling, analyzing reporting and using hospital data.

Responsible: EENC TWG, MCH center

M and E staff, EENC hospital teams,

WHO/J. Murray/H. Sobel (January

2015- onwards)

Operational Objective 5.2: Improve collection and use of data on perinatal health and practices

through research, surveys, and audits Activity Responsible and timing

34. Ensure that key maternal and EENC/NB indicators included in national surveys – disaggregated by social stratifiers to monitor equity

(MICS, RHS, nutritional survey)

Review whether newborn mortality rate can be collected given current

rates and sample size limitations. Indicators on thermal care, cord care,

PNC within 2 days for mother and newborn, content of PNC available and

should be considered.

Responsible: MOH, EENC TWG,Statistics Bureau, MCH center,

Paediatric, obstetric, midwife societies,

WHO. (March 2015 – onwards)

18

35. Periodically conduct health facility assessments to track quality of

care for EENC, EmONC and IMNCI

a. Review and adapt facility assessment survey methods – use as

cross-sectional surveys or apply through supervision by resource persons – and link with annual program reviews

b. Consider alternative approaches to tracking quality, including

self-assessment, indirect measures of quality from hospital or

facility records – in early implementation facilities.

Responsible: Dr. Soyol, EENC TWG,

MCH Center, Hospital teams,

professional societies, WHO, UNICEF

(June 2014 - onwards)

36. Introduce perinatal death audits in selected health facilities.

a. Finalize method and begin implementation in selected early implementation hospitals – in particular CoE. Phase in as

hospitals become ready to implement,. Build into the EENC

implementation process, coordinated by hospital teams

b. Regularly review progress- and adjust process using review

findings. EENC resource persons may play a role in introduction

and review of progress.

Responsible: Dr. Soyol, EENC TWG,

MCH Center, Hospital EENC

implementation teams, WHO (First

quarter 2015- onwards)

19

4. Monitoring and Evaluation To determine whether EENC interventions are being delivered to their target populations, the programme

will track short term measures of implementation (activities conducted), medium term objectives

(changes in intervention coverage) and long term changes in health status (health impact measures). The programmatic pathway for improving material newborn health – and how each stage of this pathway will

be monitored and evaluated - is summarized in Figure5.

Impact indicators (goals) measure long-term improvements in newborn health and survival expected by

the programme. Goals are measured as changes in newborn morbidity or mortality (health impact).

Goals set the direction for all program activities. Since they require changes in morbidity or mortality, goals may take 5 – 10 years or longer to achieve.

Coverage indicators (objectives) measure the medium-term changes in intervention coverage that are

expected by the programme. Intervention coverage is expected to change as activities are implemented -

in the short or medium term (1-2 yearly). If intervention coverage does not increase, then it is unlikely that long term reductions in newborn morbidity and mortality will occur – and program goals will not be

met.

Implementation indicators measure whether activities needed to deliver interventions have been

conducted. Programme activities aim to increase intervention coverage by improving access to and

availability of EENC interventions. Activity indicators are expected to change in the short term as

activities are conducted. Activities may be conducted in all the main program areas: policies, standards and guidelines; systems for service delivery; and advocacy and social mobilization.

20

Figure 5: Progammatic Pathway for Improving Maternal and Newborn Health

Document review

MNCH

surveys rvesurvsurveysacility surveys

MNCH MN

MICS

DHS

Program activities conducted

Revise policies, standards and guidelines

Mobilize financial resources

Improve human resource capacity

Strengthen systems for service delivery

Improve advocacy and social marketing

Monitor and evaluate using data

Measurement method

Review of program reports, documents, policies and

guidelines

Review of program reports and

documents

Hospital assessments Health facility surveys

Household surveys

30-cluster HH surveys MICS

RHS

Nutritional surveys

HMIS

MICS

RHS

HMIS

Results of activities

Increased availability of/access to services

Improved quality of services

Increased demand for services/care

Improved information to/knowledge of caregivers and families

Increased population-based coverage of effective interventions

Improved survival and health (impact)

21

Impact indicators for newborn health, 2014-2020

Data required Measurement Source Data by year Target 2020

Most recent

2014

2015 2016

Stillbirths Stillbirth rate Number of stillbirths per 1000 LB (>22 weeks)

MCH Unit (Hospital-based data)

Proportional causes of stillbirth (infection, pregnancy causes, syphilis, mismanagement of delivery, above 42 weeks)

MCH Unit (Hospital-based data)

Neonatal deaths

Neonatal mortality rate (per 1000 live births)

HMIS MCH Unit IGME

10/1000 (IGME 2013)

5/1000 2020

Early neonatal mortality rate (0-6 days)

7 (Per 1000 LB)

Perinatal mortality 8 (per 1000)

HMIS MCH Unit (hospital and clinic data)

-

Case-fatality ratio: newborn sepsis, asphyxia, low birth weight

MCH Unit (hospital and clinic data)

-

Proportional causes of death: sepsis/pneumonia, tetanus, birth asphyxia, complications of pre-term birth, congenital anomalies

MCH Unit (Hospital data) CHERG

Prematurity/Low birth weight

Prevalence of low birth weight (<2500g) Prevalence of high birth weight (>4000g)

HMIS MCH Unit Surveys

4.7 (MICS 2010)

Prevalence of pre-term birth (< 37 weeks)

MCH Unit

7Early neonatal deaths are deaths at age 0-6 days among live-born children.

8Perinatal mortality:The sum of the number of stillbirths and early neonatal deaths divided by the numberof pregnancies of seven or more months' duration, expressed per 1000.

22

Coverage indicators for EENC interventions, 2014-2020

Period Intervention Coverage measure Source Data by year Target

2020 Most recent

2014 2015 2016

Labor and delivery

All deliveries by a skilled birth attendant

Percentage of live births attended by skilled health personnel

HMIS Survey

98.8 (MICS 2010)

100

Percentage of live births that take place at health facilities

HMIS Survey

98.5 (MICS 2010)

100

Identification and treatment of maternal emergencies such as eclampsia and obstructed labor

Percentage of live births delivered by caesarian section

HMIS MCH Unit Survey

5-15%

Percentage of live rural births delivered by cesarian section

HMIS MCH Unit Survey

17% (MICS 2010)

5-15%

Immediately after birth (1-2 hours)

Prevention of hypothermia

Percentage of newborns dried after birth

MCH Unit Survey

-

Percentage of newborns with delayed bath after birth9

-

Percentage of newborns placed on the mother’s bare chest after delivery (skin-to-skin)

-

Early initiation of breastfeeding

Percentage of newborns put to the breast within one hour of birth

MCH Unit Survey

97.5 (MICS 2010)

100

Percentage of newborns who did not receive a prelacteal feed

Survey 90.7 (MICS 2010)

100

Postnatal/ neonatal period 1-2 hours after birth – 28 days

Postnatal care contact

Percentage of women who received postnatal care within two days10 of birth following discharge from the facility

Survey Family Health Center Montly performance report

-

Percentage of newborns who received postnatal care within two days of birth following discharge from the facility

-

Postnatal care content

Percentage of newborns that received postnatal care within 2 days and at least 2 signal functions11 were done

Survey -

Percentage of newborns 0-28 days who are exclusively breastfed

Survey 65.7 (MICS 2010)

85

9 At least 6 hours after birth.

10 Postnatal care 0-71 hours or 0-2 days after birth

11Signal functions are 1) Checking the cord, 2) Counseling on danger signs, 3) Assessing temperature,4) Observing/counseling on breastfeeding,

and 5) Weighing the baby (where applicable).

23

Implementation Indicators–EENC scale-up readiness benchmarks Benchmark

2014 2015 2016 2017 2018 2019 2020 1. Newborn health situation analysis

conducted

Yes

2. EENC Action Plan developed based on Regional Action Plan for Healthy Newborns12- and approved

Partial (April 2014)

EENC Action Plan costed

Partial (April 2014)

3. EENC technical working/coordination group formed13 - steering committee

No (March 2014)

4. Full-time EENC/newborn health focal person identified in MOH

No

5. EENC stakeholder group organized to engage key political leaders and champions to support EENC14

No

6. Clinical Intra-Partum and Newborn Care Protocol adapted for local use (Clinical pocket guide for intra-partum and newborn care) - reviewed and endorsed by key stakeholders

No (2014)

7. Consensus-building workshop on EENC conducted (to brief key clinical, policy, programme staff on technical background to EENC, rationale and to launch EENC Action Plan)

No

8. Mechanisms established to ensure membership of professional associations are implementing EENC

Partial

12 WHO/WPRO, UNICEF. Draft Action Plan Towards Healthy Newborns in the Western Pacific Region (2014-2020). 2013. Manila: WHO/WPRO-UNICEF/EAPRO (Forthcoming). 13Including relevant MOH public health divisions, key obstetric and pediatric decision-makers, professional associations from obstetrics, pediatrics, midwives, development partners.

14e.g. policy-makers, legislators, health providers, hospital administrators, civil society leaders, development partners, media practitioners, academia and health professional associations)

24

Implementation indicators – roll-out of EENC

Activity Indicator Data Source Data by year Target 2020 2014 2015 2016 2017 2018 2019 2020

Proportion of MOH hospitals with functioning EENC hospital implementation teams (21 Aimag gen hospitals, 3 maternity homes, 2 district hospitals, MCH center – total 27)

Supervisory reports

0 100

Proportion of MOH hospitals meeting facility requirements for routine delivery care including EENC for mothers and babies

a(27 hospitals -

stratified by facility type)

Supervisory reports Facility assessment

0 100

Proportion of MOH Soum Family Health Centers meeting facility requirements for routine delivery care including EENC for mothers and babies (Soum FHC)

Supervisory reports Facility Assessment

0 0 100

Proportion of MOH hospitals meeting requirements for providing basic emergency obstetric and newborn carea

(27 hospitals - stratified by facility type)


100

Proportion of MOH hospitals meeting requirements for providing comprehensive emergency obstetric and newborn carea(27 hospitals - stratified by facility type)


100

Proportion of delivery facilities implementing EENC with no stock-outs of essential medicines and supplies the previous 6 months

Facility-based surveillance reports

100

Proportion of delivery facilities implementing EENC which have received a visit from an EENC facilitator in the previous month


100

Proportion of newborns receiving immediate drying and skin-to-skin contact with the mother


100

Proportion of newborns not separated from the mother at birth (EENC implementing hospitals)


100

Newborn sepsis rate (EENC implementing hospitals)


100

Proportion of newborns admitted to the NICU (EENC implementing hospitals)


100

Proportion of mothers in preterm labor receiving antenatal steroids (EENC implementing hospitals)


100

Proportion of pre-term babies managed with KMC (27 hospitals - stratified by facility type)


100

a – signal functions are described in the Table on the following page

25

Newborn and Obstetric Signal Functions for Health Facilities, 2012 15

Dimensions of family care Obstetric Newborn General requirements for facility

Service availability 24/7

Skilled providers in sufficient numbers

Referral service to higher level care, communication tools

Reliable electricity and water supply, clean and functional toilets

Routine care – all mothers and babies Birth plans Monitoring and management of labor using the partograph Infection prevention measures (hand-washing, gloves) including non-separation, limiting admissions to NICU or “observation areas” Active management of the third stage of labor (AMTSL) b

The First Embracea Immediate and exclusive breastfeeding Infection prevention including hygienic cord care c

Basic emergency care – mothers and babies with complications

Parenteral magnesium sulfate for pre-eclampsia Assisted vaginal delivery Parenteral antibiotics for maternal infection Parenteral oxytocic drugs for hemorrhage Manual removal of placenta for retained placenta Removal of retained products of conception

Antibiotics for preterm or prolonged PROM to prevent infection Corticosteroids in preterm labor Resuscitation with bag and mask for non-breathing baby KMC for premature/very small babies Alternative feeding if baby unable to breastfeed d Injectable antibiotics for neonatal sepsis PMTCT if mother HIV positive

Comprehensive emergency care – in addition to basic

Surgery (e.g. C-section) including anesthesia Blood transfusion

Intravenous fluids Safe administration of oxygen

a –The First Embrace: drying baby immediately after birth; skin-to-skin with mother; delayed cord clamping; appropriately timed early BF; no routine suctioning; no prelacteal feeding; no bath in first 24 hours, or where culturally unacceptable, no earlier than 6 hours b - AMTSL: oxytocin injection in thigh or arm within 1 minute of delivery of baby, controlled cord traction, uterine massage after delivery of the placenta. c- Hygienic cord care: cutting with sterile blade, clean and dry care in settings with low neonatal mortality and infection risk and no application of harmful substances (or application of 4% chlorhexidine on tip of the cord and stump in settings with high neonatal mortali ty). d- Breastmilk expression and cup/spoon feeding.

15 Gabrysch S, Civitelli G, Edmond KM, Mathai M, Ali M, et al. (2012) New signal functions to measure the ability of health facilities to provide routine and emergency newborn care. PLoS Med 9(11):01340.doi:10.1371/journal.pmed. 1001340

26

4. Cost Estimates Costing Framework: Mongolia Action Plan 2014-2020

Activity Tasks Unit cost US$

Annual costs Total cost – 2014 – 2020

2014 2015 2016 2017 2018 2019 2020

Operational Objective 1.1: To ensure Early Essential Newborn Care has been incorporated into national and sub-national health agendas, plans, budgets and financing mechanisms. 1. Complete EENC action plan Finalize and cost plan

Stakeholder consensus meeting; final approval Printing costs

5000

5000 0 0 0 0 0 0 10000

2. Develop EENC scale-up approach and begin scale-up(MCH center, 21 Aimag Hospitals, 3 Maternity homes, 2 District Hospitals and 300 Soum FHC)

Training in MCH Center and Aimag hospitals International consultants x 2 – 10 days each visit (3 visits) Training materials and supplies – training at MCH center and other early implementation site Conduct 3 day EINC implementation workshops – form hospital-based teams

Conduct EENC facilitator training

Facilitators provide support to implementation hospitals

5000

10K 40K -

10K X

10K X

X

X

X

X

30000 X

3. Improve coordination and management of EENC implementation

Form technical working group, regular monthly meetings Full time central staff person (if funded externally) Train provincial pediatric association staff as resource persons (included in #2)

0 8000 0

0 8000 0

0 8000 0

0 8000 0

0 8000 0

0 8000 0

0 8000 0

8000 0

0 56000

4. Make financial resources available to support EINC

Advocacy 0 0 0 0 0 0 0 0 0

5. Strengthen implementation of EmONC in implementation hospitals

Advocate to use revised guidelines, track indicators in implementation process, advocate for local funds

0 0 0 0 0 0 0 0 0

6. Strengthen implementation of IMNCI (management of the sick newborn)

Ongoing planned and budgeted MOH funds

0 0 0 0 0 0 0 0 0

7. Conduct programme implementation review of new EENC scale-up hospitals

Develop indicators, methods, conduct site visits, write up findings and incorporate into implementation plans

Cons- 10000 Local Costs

5000 X

5000 X

0 X

0 X

0 X

0 X

0 X

10000

27

Activity Ongoing planned and budgeted MOH activities

Unit Cost US$

Annual costs Total costs 2014-2020

2014 2015 2016 2017 2018 2019 2020

Operational Objective 1.2: To ensure Early Essential Newborn Care has been incorporated into clinical protocols, quality improvement cycles and accreditation mechanisms

8. Incorporate Early Essential Newborn Care interventions into clinical guidelines

Adapt, translate, format and print clinical pocket guide for EENC

Review and revise existing clinical guidelines – to incorporate EENC practices

20000 X

20K X

0 X

0 X

0 X

0 X

0 X

0 X

20000 X

9. Integrate up-to-date EINC guidelines into existing pre-service curriculae

Review – nursing, midwifery, medical curriculae – incorporate EENC interventions as needed

X

25K

0

0

0

0

0

0

25000

10. Integrate up-to-date EINC guidelines into existing in-service curriculae

Advocacy and coordination meetings to ensure that revised guidelines are used for in-service training and technical updates by all partners.

X X X X X X X X X

11. Develop EENC training package – including teaching materials, presentations and training aids

Review existing materials Adapt and translate for local use Format and print

Trans, print

20K 0 0 0 0 0 0 20000

12. Update the MCH Card to include EENC practices

Routine review and update – MOH

0 0 0 0 0 0 0 0 0

Operational Objective 1.3: To enable providers of newborn care to practice Early Essential Newborn Care at every delivery by providing appropriate system support and training.

13. Incorporate social marketing principles into implementation process using hospital-based teams - to support health workers to apply EENC.

Develop revise current implementation training/implementation approach using hospital teams and facilitators Pre-test the proposed intervention mix and methods in selected hospitals.

Add to annual review and facility Team-work

0

0

0

0

0

0

0

0

Operational Objective 1.4: To scale up centres of excellence implementing Early Essential Newborn Care

14. Develop standards for centres of excellence (CoE), indicators for tracking status, and a description of roles and responsibilities for CoE.

Meetings to plan and develop criteria and objectives

X 0 X X X X X X X

28

Activity Tasks Unit cost US$


2014 2015 2016 2017 2018 2019 2020

15. Select Centres of Excellence sites

Reviewing facilities and applying criteria

X 0 X X X X X X X

16. Support CoE to develop a leadership role in supporting EINC implementation

Meetings, site visits X 0 X X X X X X X

Operational Objective 2.1: To mobilize political commitment and social support of key stakeholders for policies, programmes and services for the implementation of Early Essential Newborn Care

17. Develop an advocacy, behavior change and communication strategy for EENC

Review current availability of IEC materials and methods , finalize strategies methods and materials

X X X X X X X X X

18. Implement an advocacy, behavior change and communication strategy for EINC

Development of policy briefs, messages and materials,mass media (television, documentaries or radio) approaches,conduct of technical meetings/workshops or summits, one-on-one meetings.

X X X X X X X X X

19. Convene EENC national consensus-building meeting to launch EENC action plan, present technical basis for EENC and get widespread consensus on technical standards

Consultative meetings, production/copying of materials. All meeting costs.

X 0 X 0 0 0 0 0 X

Operational Objective 2.2: To strengthen legislation, regulations, and enforcement to meet international standards to support implementation of Early Essential Newborn Care

20. Strengthen legislation, monitoring and enforcement of the International Code for Marketing of

Breastmilksubstitutes.

Advocacy, technical support 0 0 0 0 0 0 0 0 0

21. Advocate to Ratify Maternity Protection Convention 183 and move toward adoption by GO and non-GO sectors

Advocacy and technical support

0 0 0 0 0 0 0 0 0

22. Review and update all official documents, regulations, orders, decrees related to maternal and newborn health

Review meetings and technical support

0 0 0 0 0 0 0 0 0

Operational Objective 3.1: To ensure availability of a skilled birth attendant for every delivery Advocacy and technical support

0 0 0 0 0 0 0 0 0 23. Ensure that MWs are

authorized to conduct normal deliveries, provide newborn


0 0 0 0 0 0 0 0 0

29

resuscitation prevent and manage uncomplicated prematurity/LBW

Activity Task Unit Cost US$

Year Total Costs 2014-2020

0 0 0 0 0 0

2014 2015 2016 2017 2018 2019 2020

24. Develop a strategy for better accrediting doctors and midwives to ensure they meet minimum practice standards for EENC.

Meetings/coordination X X X X X X X X X

25. Advocate at national and sub-national levels to improve retention and equitable distribution of SBAs – doctors and midwives.


0 0 0 0 0 0 0 0 0

Operational Objective 3.2: To ensure availability of equipment, supplies essential medicines and infrastructure for EENC in routine and emergency situations

26. Review and update essential medicine, supplies and equipment lists to include those needed to provide EENC

MOH review of current list Meetings to make discuss and make updates

0 0 0 0 0 0 0 0 0

27. Incorporate monitoring of essential medicines and commodities in hospital implementation process – and take action to address gaps

Included in #2 and #33 0 0 0 0 0 0 0 0 0

28. Advocate to improve procurement practices for essential medicines


0 0 0 0 0 0 0 0 0

Operational Objective 4.1: To increase community demand for skilled birth and newborn attendance and Early Essential Newborn Care

29. Develop a behaviour change and communication strategy to improve community-based EENC practices including home care, care seeking, and ensuring all population groups have access to care

Development of messages, methods, materials – review of existing data, formative research, field testing, material development and production – link with on-going activities UNICEF, UNFPA

X X X X X X X X X

30. Implement community behaviour change and communication strategy using revised messages, methods and materials through existing community structures and systems – and by linking with DPs

Technical support, coordination meetings Other costs

X X X X X X X X X

Operational Objective 5.1: To strengthen capacity of routine information systems collect accurate data on perinatal health

30

31. Incorporate key maternal and NB indicators in national Health Management and Information System (HMIS)

Technical support and advocacy

0 0 0 0 0 0 0 0 0

Activity Tasks Unit Cost US$


2014 2015 2016 2017 2018 2019 2020

32. Advocate and technical support to ensure civil registration includes all births, stillbirths, neonatal deaths and cause

Technical support and advocacy

0 0 0 0 0 0 0 0 0

33. Develop monitoring and evaluation approach for EENC , conduct regular monitoring and use data to solve problems

Develop indicators, tools and methods for tracking progress – routinely collect and use data. Incorporate EENC tracking indicators into the MNCH hospital surveillance system – to include stillbirths, newborn deaths and cause, and case fatality rates for newborn sepsis, cases of asphyxia, cases of prematurity, and birth weight strata

Int cons Local staff Field visits

10K 10K

X X

X X

X X

X X

X X

X X

X X

Operational Objective 5.2: Improve collection and use of data on perinatal health and practices through research, surveys, and audits

34. Ensure that key maternal and EINC/NB indicators included in national surveys – disaggregated by social stratifiers to monitor equity

Technical support 0 0 0 0 0 0 0 0 0

35. Develop indicators and methods for tracking quality of care at facilities - EENC, EmONC and IMNCI

Development of indicators, tools and methods, linked with #2, #7 and #33.

0 0 0 0 0 0 0 0 0

36. Introduce perinatal death audits in selected health facilities.

Finalize methods and materials – begin use in national hospitals Track progress. Linked with # 14, #15 and #16

0 0 0 0 0 0 0 0 0

TOTAL

31

ANNEX 1: Interventions of Early Essential Newborn Care (EENC)

All mothers and newborn infants High-risk mothers and newborn infants

1)The First Embrace All mothers:

maintain a supportive environment (e.g. companion and position of choice, elimination of unnecessary/harmful procedures)

avoid environmental exposure to cold, draughts and infection

maternal and fetal monitoring during labour including use of the partograph

improved recognition of labour signs, care and referral of woman with risk factors (e.g. hypertension, diabetes, preterm labour); management of obstetric complications, especially pre-eclampsia/eclampsia

set up newborn resuscitation area, including checking equipment for functionality

organize delivery space

postpartum care visits: counselling for routine newborn care and danger signs

HIV and syphilis point-of-care rapid testing All newborn infants:

immediate and thorough drying

delayed bathing

immediate skin-to-skin contact

All newborn infants, if breathing:

appropriately timed cord clamping; cut once

exclusive breastfeeding when feeding cues occur

rooming in/keeping warm

routine care (e.g. eye care, vitamin K, immunizations and examinations) delayed until after a full breastfeed

elimination of harmful practices including routine suctioning, placing substances on the cord stump, and pre-lacteal feeds

postnatal care visits

All mothers and newborn infants: avoidance of exposure to nosocomial pathogens through:

hand hygiene and other infection prevention measures

non-separation unless urgent care required

2)Prevention and care of preterm and low-birth-weight newborn infants High-risk mothers and newborn infants:

elimination of unnecessary induction of labour and caesarean sections

antenatal steroids (and tocolytics)

antibiotics for preterm prelabour rupture of membranes

Kangaroo Mother Care

feeding with breast milk

monitoring for complications 3)Prevention and care of sick newborn infants Newborn infants who are not breathing despite thorough drying (asphyxia)

bag and mask ventilation

post-resuscitation care (including aseptic cord trimming), monitoring and referral of cases with incomplete recovery/severe conditions

Sick newborn infants and newborn infants with complications of birth:

standard case management of newborn sepsis and other newborn problems (e.g. pneumonia, meningitis, other infections, jaundice, malformations)

identification of at-risk newborn infants

stabilization (including prevention of hypothermia, hypoglycaemia, hypoxaemia, apnoea and infection) prior to timely referral

oxygen and/or continuous positive airway pressure (CPAP) for those with respiratory distress

care of the seriously ill newborn infants

antiretrovirals for infants exposed to HIV and penicillin for those exposed to syphilis

referral between levels of care and wards

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