Neonatal Health and Survival

Generating Evidence and Translating into Practice

Abdullah BaquiProfessor

Department of International HealthJohns Hopkins Bloomberg School of Public

Health

Coregroup meeting, 11 October 2012

• Develop and test feasible, context-specific, and cost-effective interventions

• Use evidence to influence policies and programs

• Assist ministries, NGOs, and development partners to scale up tested interventions through real time monitoring, evaluation and implementation research

Baqui Newborn Research Activities

A Research Partnership to Generate Evidence PROJAHNMO in Bangladesh

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PROJAHNMO in Bangladesh: Context

• Partnership of Bangladesh MOHFW, ICDDR,B, Shimantik, CHRF, and Johns Hopkins University

• Established in 2001 to improve new-born and maternal health

• Study Site: Sylhet district in about 560,000 population

• Facility delivery rate = 9%

• Skilled attendance at delivery = 13%

• NMR ~ 50/ 1,000; 50% attributed to infections. Funded by USAID, SNL/Save the Children, Gates Foundation, NIH

Projahnmo-1: Interventions

• Between 2001-2006, developed, implemented and evaluated a package of community-based MNH interventions

• Package components included promotion of• ANC, TT, IFA supplementation• Birth preparedness including promotion of facility delivery or skilled attendance at delivery

• Recognition of maternal danger signs, and care seeking

• Essential newborn care • Recognition of newborn danger sign, care seeking

Projahnmo-1: Service Delivery Strategies

• One CHW/ 4,000 population

• 2-monthly home visits to identify pregnant women

• 2 antenatal home visits to promote the interventions

• 3 postnatal home visits (days 1,3,7 of births) to promote newborn care, assess babies and manage sick babies

• CHWs were trained to treat suspected infections if referral was not feasible

Projahnmo-1: Key Findings

• Home based delivery of a community-based package of MNH interventions reduced NMR by 34% (Baqui et al., Lancet, 2008)

• Early postnatal home visits on day 1 or 2 of life by a trained CHW was associated with 2/3rd lower NMR (Baqui et al, BMJ, 2009)

• Early identification and management of new-born infection, either at first level health facility or at home, had additional impact on neonatal mortality (Baqui et al, PIDJ, 2009)

Projahnmo: Policy and Program Impact

• MOHFW/Bangladesh developed a national neonatal health strategy

• USAID/Bangladesh supported scale up in two districts

• UNICEF/Bangladesh supported implementation through local NGOs in 6 additional districts

• WHO/UNICEF issued a joint statement recommending home visits for the newborn child as a strategy to improve survival

Evaluation/Implementation Research to Improve Program

Performance and Effectiveness

Evaluation of RACHNA Program in India (2002-

2006)

RACHNA Evaluation: Overview• A program at scale, covered ~100 million people in 8 states of

India• Integrated program addressed:

– Maternal health– Child health and nutrition including community-based

newborn care– Family Planning, HIV/AIDS

• A facilitation program, implemented through two existing government programs: ICDS and MoHFW

• Newborn package was similar to Projahnmo• Used a quasi-experimental design • Conducted annual assessments to provide feedback to

implementers so that program strategies can be adjusted

JHU/IIP’S STEPWISE EVALUATION DESIGNS

Are adequate quality services being provided?at health facility level?at community level?

Are these services being used by the population?

Have adequate levels of effective coverage been reached in the population?

Is there an impact on health and nutrition?

Are the interventions and plans for delivery technically sound and appropriate for the epidemiological and health system context?

To what extent can the impact be attributed to the program?

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Are adequate quality services being provided?at health facility level?at community level?

Are these services being used by the population?

Is there continuity of care?

Have adequate levels of effective coverage been reached in the population?

Is there an impact on health?

Are the interventions and plans for delivery technically sound and appropriate for the epidemiological and health system context?

To what extent can the impact be attributed to the program?

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RACHNA Evaluation – Results and interpretation

• No reduction in neonatal mortality – why?

• Modest increase in coverage

• A postnatal home visit within 3 days of delivery was associated with significantly lower neonatal mortality

• Modelling of data suggested that increasing coverage of postnatal home visit to 90% could reduce neonatal mortality rate by 30%

• Increasing coverage, sustaining quality, and achieving health impact in large programs remain a challenge

Optimizing integrated MNCH services in Tanzania

• MOHSW/ Tanzania implementing an integrated MNCH program emphasizing postpartum care with support from JHPIEGO

• The program components include: Development of a CHW program to provide behavior

change communication and selected services Capacity building of selected district hospitals and

health centers

• Conducting evaluation in partnership with MoHSW, Tanzania, Jhpiego, and Muhimbili University

Funded by USAID through HRCI cooperative agreement

• To monitor and document the implementation of the MNCH intervention package

• To provide feedback to program managers on barriers to access, coverage, and quality of essential MNCH interventions to facilitate adjustment of program strategies

• To assess effectiveness and cost of the final intervention package; and

• To disseminate lessons learned and provide policy support to facilitate scale up to other Regions of Tanzania

Evaluation objectives

Year -1 Evaluation Activities• Conducted baselines assessments using mixed

methods:

– Household Survey

– CHW surveys

– Facility assessments

– In-depth interviews

• Synthesized data and lessons learned• Shared in a participatory workshop and developed

recommendations for the program

Utilization of maternal health services

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Barriers to care seeking

• Supply side:

– Inadequate human resources, supervision, supplies

– Inadequate quality of care, both technical quality as well

as disrespectful behavior by providers

• Demand side

– No systematic community-based program

– Distance to facility, lack of transport, cost

Recommendations• Continued focus on improving quality

• Develop strategies for overcoming barriers to care seeking e.g, address transport and other costs

• Build linkages between the community and facility

• Formalize the CHW cadre, including recruitment criteria, training, and service packages

• Develop sustainable support systems for CHWs, with a focus on supportive supervision and create incentives for CHWs work

Concluding Thoughts• The burden of newborn and maternal mortality is still very

high• More than half of these deaths can be prevented by

scaling up evidenced based interventions• Successful implementation requires strengthening health

system including real time monitoring/ evaluation and real time use of data to adjust program strategies

• Close partnership between program managers and researchers and use of implementation/evaluation research can help us quickly attain the MDG goals

• Many lives are at stake

• We know what needs to be done • Deliver evidenced-based interventions at scale with high coverage and quality to reduce stagnated neonatal mortality

Thank you

Concluding Thoughts