upreti_ensuring newborns with infections get prompt treatment nepal

8/2/2019 Upreti_Ensuring Newborns With Infections Get Prompt Treatment Nepal

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Ensuring Newborns with Infections

get Prompt Treatment:

Nepals Experience

Dr. Shyam Raj Upreti

Director

Child Health Division

MOHP

May 2012


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Nepal in context

Population: 26.6 million with 1/3 of the population living

below the poverty line

TFR 2.6

CPR 43.2%

CMR 54/1000 (down 64% since 1991)

NMR 33 / 1000SBA 36%

MMR 281 / 100,000 (DHS 2006)


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Health Care Delivery System

75 districts

50-100 villages (VDCs) Population of 5,000-10,000 per village

Sub Health Post

Health Post

Primary Health Care Center

OR

OR


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Health Care Delivery SystemCommunity level

50-100 villages (VDCs)

75 districts

50-200 households

9 wards (hamlets)Population 500-2000 per ward

52000 FemaleCommunity

Health Volunteers


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Key Newborn Indicator Progress


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Child Mortality in Nepal (DHS)

54

34

15

153

118

91

61

54

48

64

79

102

46

4650

3933 33

0

40

80

120

160

200

1991 1996 2001 2006 2011 2015 -MDG

U5MR IMR NMR


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Causes of Newborn Deaths

Injury

19%

Severe

Infections

42%

Birth

Asphyxia

15%

Preterm/L

BW

6%

Congenital

Anomaly

8%

Others

10%

Source:NDHS 2006

65 % of births take place athome

35% of deliveries occur in healthfacilities

36% of deliveries were assistedby skilled birth attendants

Harmful practices for cord careand essential newborn care

Misconception that newborn

care required better technologyand specialized HR

Infection is the major cause of Neonatal Deaths


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Continuum of Care

Maternal and Neonatal Health

50

82

56

36 35

25

45

70

35

96

31.1

68.3

20.7

9.49.110.914.3

45.3

22.7

82.9

35.4

53.0

33.0

9.3

17.617.718.7

29.4

59.363.2

93.2

0

20

40

60

80

100

120

4 ANC s 2 TTs Iron during

pregnancy*

Delivery by

SBA**

Institutional

Delivery

Clean Home

Delivery Kit

Delayed

Bathing -

a f ter 24 hrs

PNC Visit * Exclusive Bf

up to 6

months

Bf within 1

hr

B C G

percentag

e

NDHS 2001 NDHS 2006 NDHS 2011


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Evidence GenerationManagement of Newborn infection

Pilot to scale up

Morang Innovative Neonatal

Intervention (MINI) pilot


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Evidence Generation: MINI pilot

Based on evidence from successful

implementation of CB-IMCI program at scale

MINI pilot tested whether the most

peripheral health volunteers and health

workers could successfully identify, treat and

manage neonatal infections


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MINI Program

Sick Neonates Assessed

FCHV classifies

LBI

FCHV classifies PSBI

3rd day F/U by

FCHV

VHW/MCHW tx with

Gentamicin for 7 days

FCHV Treats asper guidelines

FCHV gives 5 days

CotrimCalls VHW/MCHW

Also does 3rd day F/U

All births - FCHV

visits within 24 Hrs

If low birth weight

Counsel on ENC

Four F/U Visits

Takes birth weight


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Key Finding from MINI

Indicators Results for final year (May 2008-April2009)

Total Live Births recorded 50,618Total deaths 776Episodes of Possible Severe BacterialInfection (PSBI) 3,614 (7%)% of PSBI episodes receiving

Cotrimoxazole-P 98%% of PSBI episodes receiving

Gentamicin 86%% of PSBI episodes completing full 7

doses of Gentamicin 94%


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Conclusions from MINI

1. Community-based management of neonatal sepsis is

feasible and effective through existing governmenthealth system

2. Female Community Volunteers (FCHVs) can follow analgorithm for classification of sick neonates, initiate

treatment, and facilitate referral

3. Community health workers (VHWs/MCHWs/HWs) canprovide gentamycin injection, with high treatment

completion rates and these likely contributes toreduction of neonatal deaths

Community Based Newborn Care Program (CB-NCP)

developed based on lessons learnt from MINI


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Community Based Newborn Care

Program

CB-NCP

An Innovation being piloted by the

Government of Nepal


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Components of Community Based Newborn Care

Seven key components:

1. Behavior Change and Communication2. Promotion of institutional deliveries & clean delivery

practices in case of home deliveries

3. Prevention and management of hypothermia

4. Recognition and management of birth asphyxia

5. Postnatal care

6. Care of low birth weight babies

7. Community based management of possible severebacterial infection


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Behavior Change and Communication

using the Birth Preparedness Package

BPP counseling


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Promotion of health facility delivery

HF delivery


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Management of LBW

KMC for VLBW newborn


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Postnatal Visit with Counseling on

Danger Signs

Id tifi ti d M t f N t l


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Identification and Management of Neonatal

Infection

Family or FCHV identifies danger sign during PNC

FCHV Assesses for Possible Severe BacterialInfection

PSBI

FCHV initiates Cotrim & refers to HW for Inj.Gentamicin

HW provides in x 7 days

Baby recovers / referred / dead

No PSBI

Counsels onENC & FU PNC

visitsconducted


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Monitoring & Evaluation System

Monitoring framework developed for CBNCP

Monitoring data collected and reported

through the existing reporting system but not

yet included in the HMIS only for pilot

period

When scaled up to all districts selected

indicators will be included in the HMIS.


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Key Finding from CBNCP districts

65

59

70 7

8

27

47

44

3

5

24

71

0

20

40

60

80

100

Bardiya Dang Sunsari Doti Kavre Morang Chitwan Palpa Dhankuta Parsa

Pregnant women registered with FCHVs in

CB-NCP FY 2010/2011As percentage of Expected Pregnant Women


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73

95 100 100 95 100

81

9085

100

73

95 100 100 95 100

81

9085

100

0

10

20

30

40

50

60

70

80

90

100

Bardiya

Dang

Sunsari

Doti

Kavre

Morang

Chitwan

Palpa

Dhankuta

Parsa

Essential Newborn Care PracticesAs percentage of home deliveries that happened in FCHVs presence

Skin to Skin contact between mother and newborn after birth

Breastfeeding within an hour of birth


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Percentage of all births receiving home

visits by FCHVs on days 3, 7 of birth

97

95 9

795

94

86

71

94

93 9

599

97 9

997

96

95

76

98

97

95

0

1020304050607080

90100

Bardiya

Dang

Sunsari

Doti

Kavre

Morang

Chitwan

Palpa

Dhankuta

Parsa

%o

fallbirths

3rd day 7th day


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Percentage of possible severe bacterial infection

among babies 0-59 days

11.7%

0.7%

2.9%

2.2%

0.8%

2.9%

2.4%

0.6% 0.5%

2.3%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Bardiya Dang Sunsari Doti Kavre Morang Chitwon Palpa Dhankuta Parsa


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100

97 9

9

96

73

99

89

84

0

96

81

32

79

89 9

6

49

92

00

10

20

30

40

50

60

70

80

90

100

Gentamycin Treatment and Compliance for

7 doses

Treated by Gentamycin Compliance of Gentamycin


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Delivery Practices, BardiyaDistrict Nepal, 2008and 2010

Baseline and endline HH surveys

CB-NCP implementation

66

34

30

64 65

19

81

75

9396

0

10

20

30

40

50

60

70

80

90

100

Delivery at hom e Deliver y at HF Deliver y by SBA PNC 48h - m o PNC 48h - NN

Percentage

ofmothers

2008 2010


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Some initial conclusions

FCHVs have been able to reach more than50% of the expected pregnant women in 5 of

the pilot districts and less than 50 % in the

remaining 5 districts.

Essential new born practices satisfactory

FCHVs are capturing PSBI cases, but

performance varies across districts (11 to

0.5%)

Compliance for Gentamycin treatment is

satisfactory in most districts


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What have been the key enabling

factors?

f bl


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Creation of Enabling Environment

Policy Environment

Approval of policy for under five children pneumoniatreatment by Female Community Health Volunteers

1995

Approval of policy for management of neonatal Infection

by Female Community Health Volunteers under

Community Based Newborn Care Program 2007

Injection Gentamycin included in National Essential Drug

List 2007 Coordinated support by partners: USAID & NFHP II,

UNICEF, CARE, Plan, Health Right, One Heart, Save the

Children

W F d


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Way Forward

Assessment of the Community Based Newborn

Care Program Modification of package based on assessment

findings

Integration with IMCI & Safe Motherhood

program Incorporation of newer tested interventions -

Chlorhexidine

Strengthening of facility based newborn care

National level scale up

Focus on unreached population


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Thank You!

upreti_ensuring newborns with infections get prompt treatment nepal

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