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Reducción de la mortalidad y morbilidad neonatal en América Latina y El Caribe

UN CONSENSO ESTRATÉGICO INTERAGENCIAL

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Reducing neonatal mortality and morbidity in Latin America and The Caribbean

AN INTERAGENCY STRATEGIC CONSENSUS

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Redução da mortalidade e da morbidade neonatal na América Latina e Caribe

UM CONSENSO ESTRATÉGICO INTERINSTITUCIONAL

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Réduire la mortalité et la morbidité néonatale en Amérique Latine et dans Les Caraïbes

UN CONSENSUS STRATÉGIQUE INTERAGENCES

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Esta publicación ha sido posible gracias al apoyo económico proporcionado por la Agencia de los Estados Unidos para el Desarrollo Internacional (USAID) División de América Latina según los términos estipulados en la subvención de ACCESS No. GHS-A-00-04-00002-00 y con apoyo económico proporcionado por USAID’s División de América Latina a la Organización Panamericana de la Salud (OPS/OMS) según los términos estipulados en la subvención No. LAC-G-00-04-00002-00 y con apoyo económico proporcionado por USAID’s División de América Latina según los términos estipulados en el contrato de BASICS No. GHA-I-00-04-00002-00. Las opiniones expresadas en este documento pertenecen al Grupo de Trabajo Interagencial Regional para la Reducción de la Morbilidad y Mortalidad Neonatal y no refl ejan necesariamente el punto de vista de USAID.

Agradecimiento

Esta publicación ha sido posible gracias al apoyo de todas las agencias miembros del Grupo de Trabajo Interagencial Regional para la Reducción de la Morbilidad y Mortalidad Neonatal. Incluyendo: la Organización Panamericana de la Salud (OPS/OMS), el Fondo de las Naciones Unidas para la Infancia (UNICEF), la Agencia de Los Estados Unidos para el Desarrollo Internacional (USAID), ACCESS, BASICS, CORE Group y la Iniciativa Salvando la Vida de las y los Recién Nacidos (SNL)/Save the Children/USA.

Agradecemos a las siguientes personas del Grupo de Trabajo Interagencial:

PAHO: Yehuda Benguigui, Ricardo Fescina, Virginia Camacho UNICEF: Osvaldo Legón, Judith Standley, Nancy TerreriUSAID: Peg Marshall ACCESS: Pat Daly, Maria MayzelBASICS: Indira Narayanan, Diana Silimperi, Goldy Mazia CORE Group: Lynette Walker, Lisa Bowen (Plan USA), Alfonso Rosales (CCF)Save the Children: Bertha Pooley, Elizabeth Bocaletti (ACCESS/SNL)

Agradecemos a los funcionarios de los Ministerios de Salud de los siguientes países que contribuyeron al desarrollo del Consenso Estratégico Interagencial de Reducción de la Mortalidad y Morbilidad Neonatal en América Latina y el Caribe:

Esta publicación fue impresa en los talleres gráfi cos de Serviprensa, S.A. Guatemala, marzo de 2007. Fotos de portada: Save the Children, Michael Biseglie, Aldo Cardoso - OPS

BoliviaBrasil

ColombiaCuba

EcuadorEl SalvadorGuatemala

Guyana

Haití

Honduras

Nicaragua

Paraguay

Perú

República Dominicana

Venezuela

Abraham Salinas OPS, residente, programa Fulbright Alejandra Villafuerte PROCOSI, BoliviaAlejandro Silva Ministerio de Salud, Guatemala Alfonso Rosales CORE group, regionalAna Cecilia Sucupira Ministerio de Salud, BrasilAna Garces Consultora, Guatemala Ana Maria Cavalcante e Silva Secretaria de Salud, BrasilAndrés Morilla Guzmán Grupo nacional de neonatología, CubaÁngel Coca USAID, HondurasAnnie Portela OMS, globalBertha Pooley ACCESS /Save the Children, BoliviaBetzabe Butron OPS, CLAP/SMR, regionalByron Arana González Asociación de Perinatologia, GuatemalaCarlos Gril OPS, HaitíCarlos Parr Intervida, El SalvadorCarlos Quan URC, Guatemala Cecilia Santana Ministerio de Salud, Cuba Chantal Baril Targete Hospital Universitario, Haití Consuelo Mendoza Ministerio de Salud, Republica

Dominicana Daniel Frade OPS, Guatemala David Shanklin USAID, Bolivia Dilberth Cordero BASICS, regionalElizabeth Bocaletti ACCESS / Save the Children, regionalEric Baranick Cruz Roja, regional Fernando Amado OPS, BoliviaFidel Arévalo USAID, GuatemalaGerardo Cabrera-Meza Hospital de Niños de Texas, regional Gerardo Martínez OPS, CLAP/SMR, regionalGina Tambini OPS, regionalGuillermo Frías CARE, PerúHéctor Pereyra Pathfi nder, PerúIndira Narayanan BASICS, globalIsabel Chaw Ortega Ministerio de Salud, Perú Ivonne Gómez Pasquier Proyecto Garantía de Calidad, Nicaragua Janice Woolford Ministerio de Salud, Guyana Javier Espindola OPS, ParaguayJean-Claude Beneche Hospital Dame-Marie, Haiti Jorge Roberto Cruz González Ministerio de Salud, El SalvadorJosé Luis Díaz Rossello OPS, CLAP/SMR, regionalJuan Carlos Reyes Ministerio de Salud, Guatemala Judith Standley UNICEF, globalLenin León Hospital Isidro Ayora, EcuadorLisa Bowen CORE group/Plan, global Luis Amándola OPS, HondurasLuis Codina OPS, Ecuador

Para la elaboración de este documento se contó con la contribución de los participantes al Taller Regional: Promoviendo la Salud Neonatal en Latino América y el Caribe, así como valiosos aportes de otros profesionales, dentro de ellos:

Luis Ricardo Henríquez Sociedad Pediátrica, El Salvador Luis Seoane OPS, GuyanaLuz Elena Monsalve Ministerio de Salud, ColombiaLydia Fraser Cruz Roja, Guyana Magda Palacios OPS, ColombiaMarcia Ramírez Ministerio de Salud, BoliviaMaria del Pilar Rodríguez UNICEF, ColombiaMariano Cáceres Ministerio de Salud, Nicaragua Mario Tavera UNICEF, Perú Maritza Romero OPS, El SalvadorMartha Mejia OPS, Bolivia Melanie Swan Plan, regional Mercedes Portillo Ministerio de Salud, ParaguayMiguel Guevara Ministerio de Salud, Nicaragua Mohammed Hamid UNICEF, GuyanaNaomi Brill BASICS, globalNelson Arns Pastoral de Crianza, BrasilNelson Diniz de Oliveira Escuela Superior de Ciencias de la Salud,

Brasil Odalys Rodríguez UNICEF, CubaOscar Gonzales PROCOSI, BoliviaOscar Merlo Faella Hospital Nacional Itaugua, Paraguay Oscar Suriel OPS, Republica Dominicana Osvaldo Legón UNICEF, TACRO, regional Pat Daly ACCESS, global Patric Delorme UNICEF, Haití Pedro Marte Hospital Materno, Republica Dominicana Peg Marshall USAID LAC bureau, globalPushpa Panadam La Liga de la Lecha, Paraguay Quintín Hernández Ministerio de Salud, HondurasRachel Kaufman OPS, regional Rajiv Bahl OMS, global Ramiro Rojas Arispe Neonatólogo, Bolivia Rejane Silva Cavalcante Facultad de Medicina UEPA, BrasilRicardo Fescina OPS, CLAP/SMR, regionalReynaldo Aguilar OPS, Nicaragua Roberto Cisneros CARITAS, NicaraguaRoberto Zea López Plan, GuatemalaRolando Cerezo OPS, Guatemala Rolando Figueroa CRS, regional Soledad Pérez OPS, VenezuelaSonia Noriega UNICEF, VenezuelaVirginia Camacho OPS, CLAP/SMR, regionalVictoria Vivas de Alvarado Manoff Group, BoliviaWalter Torres Ministerio de Salud, EcuadorYehuda Benguigui OPS, regional

REDUCING NEONATAL MORTALITY AND MORBIDITY IN LATIN AMERICA AND THE CARIBBEAN

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Reducing Neonatal Mortality and Morbidity in Latin America and The CaribbeanAN INTERAGENCY STRATEGIC CONSENSUS

Contents

Abbreviations and Acronyms 38Executive Summary 391. Introduction 412. Context and Supportive Initiatives 43

2.1 Global strategies 432.2 Regional strategies 432.3 Neonatal death in LAC region 442.4 Causes of neonatal death 452.5 Maternal factors affecting neonatal health 46

3. Lessons learned and the LAC context 473.1 Health systems reform 473.2 Continuum of care 473.3 Delivery of care to the newborn 483.4 Care and access to skilled birth attendance 503.5 Community based care 503.6 Integrated Management of Childhood Illness 513.7 Immunization 513.8 Micronutrients 523.9 Breastfeeding 523.10 Mother to child transmission of HIV 523.11 Surveillance 53

4. The Interagency Regional Strategy for Reducing Neonatal Mortality 54A. Create an Enabling Environment for Promotion of Neonatal Health 54B. Strengthen Health Systems to Improve Access to MNCH Services 56C. Promote Community Based Interventions 61D. Develop and Strengthen Monitoring and Evaluation Systems 63

5. Financial Implications 666. Next steps 67Appendix 1 68Appendix 2 69References 70

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Abbreviations and Acronyms

ART Antiretroviral therapyCDC The U.S. Centers for Disease Control and PreventionCHV Community health volunteerCHW Community health workerDHS Demographic Health Survey EOC Essential obstetric careEONC Essential obstetric and neonatal careENC Essential newborn careFBO Faith-based organizationHIV-AIDS Human Immunodefi ciency Virus / Acquired Immune Defi ciency SyndromeIMCI Integrated Management of Childhood IllnessIMR Infant mortality rateLAC Latin America and the CaribbeanLBW Low birth weightM&E Monitoring and EvaluationMADLAC Monitoreo del Apoyo Directo a la Lactancia Materna- Monitoring and Support

for Breastfeeding MCH Maternal and child healthMDG Millennium Development GoalsMNCH Maternal, newborn and child healthMOH Ministry of HealthMTCT Mother-to-child transmission (of HIV)NGO Non-governmental organizationNMR Neonatal mortality ratePAHO Pan American Health OrganizationPMTCT Prevention of mother-to-child transmission (of HIV)PVO Private voluntary organizationSNL Saving Newborn LivesSUMI Seguro Universal Materno Infantil- Universal Mother Child InsuranceTBA Traditional birth attendantUNICEF United Nations Children’s FundUSAID United States Agency for International DevelopmentWHO World Health Organization


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Executive Summary

Interagency Working Group, which is com-posed of representatives from the Pan American Health Organization (PAHO/WHO), the United Nations Children’s Fund (UNICEF), the United States Agency for International Development (USAID), ACCESS, BASICS, CORE and Saving Newborn Lives (SNL)/Save the Children/USA.

The purpose of the strategy is to highlight and promote evidence based interventions for newborn care in communities and through health services, with a focus on the most vul-nerable and marginalized population groups. As interventions implemented to reduce ma-ternal mortality also decrease neonatal mortal-ity and improve newborn health, the strategy builds upon the close link between newborn and maternal health.

Based on lessons learned, the proposed strat-egy focuses on evidence based sector wide in-terventions to: 1) create a favorable environ-ment to develop and promote effective public

Neonatal mortality is a major contributor to child mortality in the Latin America and the Caribbean (LAC) region and is an obstacle to the attainment of the Millennium Development Goals. Neonatal mortality in LAC is estimated to be 15 per 1,000 live births. Newborn mortality accounts for 60% of infant deaths and 36% of under fi ve mortality. Each year nearly 12,000,000 babies are born in the LAC region. Each year, 400,000 die before fi ve years of age; 270,000 before one year of age, and of these, 180,000 die during their fi rst month of life The majority of these deaths are preventable and cost-effective interventions are well documented.

Even though infant mortality rates have been decreasing in the Region, neonatal mortality trends have shown practically no progress over the past ten years. This stagnation is due in part to a lack of programs specifi cally targeting neonates; instead the focus has been on infants and older children. The causes of neonatal death in the Latin America and Caribbean region include infections, asphyxia, prematurity, and congenital malformations. While some are direct causes, others, as in most cases of preterm and low birth weight, may constitute predisposing factors. Several underlying factors also contribute to poor neonatal health including inequalities in access to health care, low percentage of births with skilled birth attendants, and poor maternal health.

This regional strategy for neonatal mortality and morbidity reduction is the culmination of a collaborative effort that began on World Health Day 2005 and has involved many Latin American countries as well as the support of the

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policies at all levels using the maternal, new-born and child health (MNCH) ‘continuum of care’ model while stressing newborns and with special emphasis on community; 2) build linkages across programs; 3) improve the re-sponse capacity and quality of health services by strengthening primary health care and lev-

Take the baby for medical check-up within the fi rst three days of life.

els of referral; 4) provide effective, integrated and culturally appropriate health care; 5) up-date and strengthen the competencies of the health workforce; 6) promote interventions to empower individuals, families and communi-ties; and 7) develop a surveillance, monitoring and evaluation system to assess progress.

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The LAC region has considerable inequity between countries and within countries. Poor urban and rural populations, indigenous peo-ple and Afro-descendants have lower literacy rates, lower access to basic infrastructures and insuffi cient coverage of essential maternal, neonatal and child health services. Inequities are often exacerbated in overlapping marginal-ized populations. For example, in Bolivia and Guatemala almost half of the poor population is indigenous and in Brazil, the Afro-descen-dents represent half of the poor population in the country.1 Although the Region has made great strides in reducing child and infant mortality, the high newborn mortality rate in many LAC countries has not improved to the degree expected.2, 3 For example, Bolivia’s neonatal mortality rate (NMR) fell by 34% between 1994 and 2003, but it is still one of the highest in the Region.4 In Haiti, the NMR rate has decreased only 19%; however it still remains high at 32 deaths per 1,000 live births. 5

The proposed neonatal regional strategy is the culmination of a collaborative process that began in April 2005 during a World Health Day workshop in Washington, DC.

The workshop explored ways to improve the health of the newborn and brought together representatives from the ministries of health of sixteen countries (Argentina, Bolivia, Brazil, Chile, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, Peru, and Uruguay). This ongoing regional col-laboration is supported by the Interagency Working Group, which is composed of rep-resentatives from the Pan American Health Organization (PAHO/WHO), the United Nations Children’s Fund (UNICEF), the United States Agency for International Development (USAID), ACCESS, BASICS, CORE and Saving Newborn Lives (SNL)/Save the Children/USA.

The purpose of the Latin America and Caribbean strategy for the reduction of neo-natal mortality and morbidity is to promote evidence based interventions for newborn care in communities and through health services, with a specifi c focus on the most vulnerable and marginalized population groups. As interventions implemented to reduce maternal mortality also decrease neonatal mortality and improve newborn

1. Introduction

The birth of a child is an event that deserves to be celebrated with joy. However, this is not the case in thousands of poor households in Latin America and the Caribbean (LAC) where a new life often ends too early or is burdened with health problems.

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health, the strategy builds upon the close link between newborn and maternal health. This document provides guidance for policy makers and health authorities for setting priorities, mobilizing resources and coordinating efforts to improve newborn health. It also provides

Breast-feed exclusively the baby from the fi rst hour of life.

guidance for community based organizations, non-governmental organizations, scientifi c societies and donors that wish to join the regional efforts to improve maternal and newborn health.


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2.1 Global strategies

Since the UN Millennium Summit in 2000, the international community has elevated its commitment to achieving the Millennium Development Goals (MDGs) to unprecedented levels by supporting international, national and local initiatives aimed at reducing maternal, newborn and child morbidity and mortality. The fourth goal (MDG-4) targets reducing mortality in children less than fi ve years old by two-thirds between 1990 and 2015. The fi fth goal (MDG-5) focuses on reducing the maternal mortality rate by three- quarters for the same time period.

growing global focus on the health of women, newborns and children. The aim of the partnership is to coordinate and intensify actions at country, regional, and global levels in support of MDGs 4 and 5 and save the lives of millions of women and children by expanding access to proven, cost-effective interventions.

2.2 Regional strategies Despite numerous challenges there has been important progress in the Latin American and the Caribbean region to improve maternal and child health; however, this progress has been unequal. The Regional Strategy for Maternal Mortality and Morbidity Reduction, launched in 2002, promotes key interventions for reducing maternal morbidity and mortality. 7 Strategies and interventions implemented to reduce maternal mortality will decrease neonatal mortality and improve newborn health to a signifi cant extent. The national governments of the Latin American

2. Context and Supportive Initiatives

The World Health Report 2005 Make every mother and child count was launched on World Health Day in New Delhi, India and calls for a new approach to saving the lives of mothers, newborns and children.6 The report is a study of the health obstacles facing women before and during pregnancy, in childbirth, and in the period that follows for them and their children. It pays particular attention to newborns, whose specifi c needs have not been adequately addressed with the separation of maternal and child health programs. Following World Health Day 2005, a forum was convened by the global Partnership on Maternal, Newborn and Child Health (PMNCH). The forum brought together key health offi cials, international agencies, development partners and civil society groups. Participants affi rmed a commitment to maternal, newborn, and child health in the resulting Delhi Declaration.

The PMNCH, offi cially launched in September 2005, marks a milestone in a

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and Caribbean endorsed Goals 4 and 5–to reduce maternal and under-fi ve mortality–in the declaration of the September 2000 United Nations Millennium Summit.8 To help address widespread inequity in the Region, PAHO/WHO in collaboration with partners is working towards universal coverage of maternal, newborn and child health interventions.9

The Millennium Goal 4, which calls for a reduction in child mortality by two-thirds, can be achieved in the Region only if a signifi cant reduction (approximately 50%) in neonatal mortality is achieved. Studies show that it is possible to decrease child mortality by improving neonatal health through simple, low cost, evidence based healthcare interventions.10 In order for LAC countries to achieve reductions in child and neonatal mortality through these proven interventions, the serious inequities of access to care in the Region must be addressed.

Although there has been progress, the majority of maternal and child health programs in LAC address mothers, infants and children, but have a limited focus on the newborn. However, several countries such as Brazil, Chile, Cuba, Dominican Republic and Uruguay have created a national post for a neonatal care coordinator under their child health units and developed a specifi c package of newborn health interventions.

Many LAC countries are undergoing health system reforms to increase access to health care for children under fi ve. Over the past decade, Argentina, Bolivia, Brazil, Dominican Republic, Ecuador, Guatemala, and Peru have enacted programs to improve access to, and

use of, maternal and child services. Brazil’s Family Health Program (PSF) ensures the implementation of a series of health programs such as the Child Health Program and the National Pact for the Reduction of Maternal and Infant Mortality. These programs aim to reduce maternal and infant mortality rates by 15% by the year 2006, and by 75% by the year 2015. The Brazilian Ministry of Health’s Program for the Humanization of Prenatal and Childbirth Care aims to improve access to, and coverage and quality of, prenatal, childbirth, postpartum and newborn care.11

In Bolivia, the national government has been implementing insurance programs since 1996 to increase access to maternal, neonatal and child health services. The fi rst scheme, the National Insurance Program for Mothers and Children (MCHI), targeted a reduction in maternal mortality and under-5 mortality by fi fty percent. The program’s goal was to improve and increase MCH service utilization by reducing economic barriers. Ecuador’s Free Maternity Program, which grew out of the country’s national law for free maternal and child health care, is another good example of increasing access and utilization of maternal and child services. 2.3 Neonatal death in LAC region

Each year nearly 12.000,000 children are born in the LAC region. Each year, 400,000 die before fi ve years of age; 270,000 before one year of age, and of these, 180,000 die during their fi rst month of life.12 Neonatal mortality (defi ned as death in the fi rst 28 days of life)13 in Latin America and the Caribbean is estimated to be 15 per 1,000 live births, ranging from


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14 (South America) to 19 (the Caribbean) per 1000 live births.14 In the Region, the stillbirth rate approximates the neonatal mortality rate.15, 16 Newborn mortality accounts for 60% of infant deaths and 36% of under-fi ve mortality, and the majority of these deaths are avoidable.17, 18, 19, 20 Mortality rates are highest in Haiti, Bolivia and Guatemala, where rates are 5 to 6 times higher than in the countries with the lowest mortality rates such as Chile, Costa Rica, Cuba and Uruguay.21

While exact proportions vary in individual countries, an approximation, especially in countries where the infant mortality rate (IMR) is not extremely high, is that about two-thirds of infant deaths take place in the fi rst month of life. Of these, two-thirds or more deaths occur in the fi rst week of life and, among these, nearly two-thirds occur in the fi rst twenty-four hours.22, 23

Even though infant mortality rates have been decreasing in the Region, neonatal mortality trends have shown practically no progress over the past ten years. This stagnation is due in part to a lack of programs specifi cally targeting neonates; instead the focus has been on infants and older children. Several underlying factors also contribute to poor neonatal health including inequities in access to health care at the primary level and poor maternal health.

2.4 Causes of neonatal death

The causes of neonatal death in the Latin America and Caribbean region for 2004 include infections (32%), asphyxia (29%), prematurity (24%), congenital malformations (10%), and others (5%).24

While some are direct causes, others, as in most cases of preterm and low birth weight may constitute predisposing factors. PAHO estimates that approximately 9% of newborns in the LAC region suffer from low birth weight (less than 2,500 grams at birth).25 Low birth weight is closely associated with increased neonatal morbidity and it is estimated that between 40-80% of infants who die during the neonatal period are associated with this condition.26 A complicating factor in the correct identifi cation of low birth weight infants is that children born at home are often not weighed. The proportion of deaths reportedly due to prematurity needs further careful evaluation. Prematurity by itself is the primary cause of death only in a limited number of extremely preterm newborns. The majority die of complications such as sepsis that may be acquired at home or in the hospital, respiratory problems, and birth asphyxia.27 The correct diagnosis of preterm is particularly diffi cult, especially at the community level and in more peripheral centers where assessment of gestational age is often inaccurate.

There is, however, no doubt that low birth weight and prematurity constitute very important factors that predispose morbidity and mortality and thus need to be addressed, particularly with regard to their association with maternal health. While prevention is ideal, and there are known preventable causes, this area has been challenging. Hence, improving maternal health and the quality of prenatal care, and management of these small children is essential, including the addition of supportive newborn care such as kangaroo mother care (continuous skin-to-skin contact

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between mother and preterm infant), extra care for prevention of infection, and support during breastfeeding including alternative methods of oral feeding until full breastfeeding can be established.

Other indirect causes of neonatal mortality include socioeconomic factors such as pov-erty, poor education-especially maternal edu-cation, lack of empowerment, poor access to health services and harmful traditional prac-tices. The rural and urban poor, other mar-ginalized communities and indigenous and Afro-descendant populations experience dis-proportionately high neonatal mortality.

2.5 Maternal factors affecting neonatal health

The wellbeing of a newborn depends to a great extent on the health of its mother. The risk of a mother dying in Latin America and the Caribbean is 1 in 130. In contrast, in more developed countries such as Canada, it is 1 in 7,750.28 In developing countries, the

death of the mother in childbirth may lead to the subsequent death of the infant.

Maternal factors affecting neonatal health in-clude maternal malnutrition, the age of the mother (less than 18 years or older than 35 years); a parity of more than 5, a short birth in-terval (less than three years between pregnan-cies), third trimester hemorrhage and compli-cations in delivery (prolonged or obstructed labor). Other factors affecting the survival of newborns include maternal infections such as sexually transmitted infections (including HIV/AIDS and syphilis) and other infections such as urinary tract infection and malaria. Low maternal education levels, poor diet, lim-ited resources, and inadequate access to health services, poor care during labor, childbirth and post partum, as well as little power to make their own decisions are also important factors. Sickle-cell anemia is a genetic disor-der found in 5% of the populations, mainly among Afro-descendant populations, and can be prevented by implementing screening and genetic counseling programs for women.


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3.1 Health systems reform

Many LAC countries are facing health system reform to increase access and use of quality health care services. One of the identifi ed barriers to access in many countries is user fees to access basic maternal and neonatal health services; this is a critical issue especially for the poor and most vulnerable populations. In addition, there is a lack of culturally appropriate models of care and outreach strategies to address geographical barriers as well as a scarcity of quality health services.

In order to address the fi nancial, cultural and structural obstacles to health care for women and children, some countries in the Region are undergoing successful reform processes target-ing access to quality maternal and child health services. These reforms focus on the continu-ity of care across women and children’s health (Brazil), maternal and child national health insurance initiatives (Bolivia), and free ma-ternity programs (Ecuador). Other countries are implementing outreach strategies such as

mobile brigades, community pharmacies, and community health worker (CHW) networks (Guatemala, Bolivia, Nicaragua, among oth-ers). Due to the close link between maternal and newborn health, essential obstetric care (EOC) has been expanded to include essential neonatal care (Honduras, Peru and Paraguay, among others) and integrate the needs for skilled personnel, supplies, community sup-port and referrals. 3.2 Continuum of care

Addressing newborn health within the con-text of maternal, neonatal and child health is a critical move from fragmented service pro-vision to a holistic and integrated approach. This ‘continuum of care’ focus meets the health needs of mothers and babies pre-con-ception, during pregnancy, childbirth, and the postnatal period, and necessitates a coor-dination between the household, the commu-nity, and health facilities where women and children can receive their care.

3. Lessons learned and the LAC context

In recent years there have been several documents on evidence based, cost effective, interventions to improve newborn health. The key ones have been summarized in a recent Lancet series on neonatal survival.29, 30 Some of these interventions are applicable to specifi c levels, such as the health facility or community, and some at both. Comprehensive lists are available for countries to review and adapt to their local requirements.31, 32, 33

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Globally, the continuum of care model has been adopted by WHO and the Partnership for Maternal, Newborn, and Child Health as essential to the survival and wellbeing of mothers and newborns. The newborn cannot be viewed separately from the mother, and the survival of the newborn falls to the skilled attendant who cares for both mother and newborn during the critical hours following birth or a well trained CHW when a skilled attendant is not available.34 The evidence suggests that the fi rst week of life is the most vulnerable in terms of neonatal mortality risk and that the fi rst 24 hours of life may determine a child’s survival. In countries where the IMR is not extremely high, about two-thirds of infant deaths take place in the fi rst month of life.

Integrating health interventions between home and health care facility is essential for addressing deaths in the newborn period, given that many births occur at home and babies born in facilities are frequently discharged early. Support with immediate and exclusive breastfeeding, keeping the newborn warm, delaying the baby’s fi rst bath, essential management of asphyxia, prevention of infection, extra care for low birth weight babies, and care of the sick infant are important for keeping newborns healthy. A large number of sociocultural factors infl uence the care of the mother and newborns in the home and in health facilities. Communication, community mobilization and empowerment strategies are necessary to promote healthy behaviors related to basic preventive care and to motivate appropriate care-seeking.

Despite health promotion and disease prevention efforts, babies could develop health problems which necessitate the family seeking care from an appropriate provider. Eventual health problems result in a high community demand for treatment and this shared need for treatment services can help mobilize the community to insist upon improved service provision. To assist community mobilization efforts, effective empowerment, participation- including community involvement in planning maternal and newborn health programs, and communication strategies are needed. Strengthened providers who possess good interpersonal and intercultural skills, and the effective use of popular communication methods and integrated mass media can help promote healthy behaviors in the home and increase appropriate care seeking behavior, all of which can lead to reduced neonatal mortality.

3.3 Delivery of care to the newborn

Countries have different pathways to becoming a skilled birth attendant. For example, Chile, Ecuador, Paraguay, Peru, Uruguay, Argentina, the United States and Canada have four to fi ve year university programs for midwifery. In addition, all countries have nursing training and others provide a specialization for nurses in midwifery. The English-speaking Caribbean, Jamaica, Trinidad and Tobago and Guyana have made special efforts to continue to offer direct entry programs for midwifery. These programs include training in institution-based maternal and newborn care and some are based on the ‘continuum of


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care’ model. It has been demonstrated that the availability of and care by midwives and nurses with newborn care skills are critical factors in reducing neonatal mortality. However, many LAC countries still do not have programs for training professional nurse midwives (e.g. Guatemala, Bolivia).

If proper care at delivery is inadequate in some countries, postpartum care presents even greater challenges. For instance, according to recent data from Peru, 3 out of 10 women delivered their babies at home, and more than half of these (54%) did not receive any postnatal care.35 In Bolivia, only 25% of all women who had a baby received postnatal care.36 Not receiving care after childbirth represents a high risk situation since a high incidence of complications occurs in the postpartum period for both mother and babies. There may not only be inadequate quality of care, but also inappropriate timing of health visits. Mothers and babies are often asked to return to the health center four to six weeks after birth, although in some countries they are told to come earlier. This, however, does not address the critical early postpartum period of the fi rst week of life, when most of the maternal and neonatal deaths take place.

Mothers and their babies are often discharged from hospitals and facilities within six to twelve hours after delivery when the probability of developing a life threatening complication is still high. It is essential that mothers and newborns receive early postnatal care, within

three days of delivery, either at a health facility or at home, to prevent or manage problems during this vulnerable time. Standards and protocols for the care of babies at high risk, like preterm and low birth weigh infants, or babies who underwent resuscitation, are usually lacking. In some LAC countries, cultural practices relating to delivery and postpartum periods tend to keep mothers and babies secluded within their homes for periods up to six weeks. Lack of empowerment of women, lack of awareness of maternal and newborn needs, diffi culties in transport, and the poor quality of care in some health facility services constitute additional barriers to utilization of health services.

The neonatal mortality rates are highest in countries where newborns are primarily delivered at home. The greatest proportion of home deliveries, as noted by demographic and health surveys, is found in Haiti (77%), Guatemala (60%), Honduras (44%), Bolivia (40%) and Nicaragua (33%).37 These births are often attended by a traditional birth attendant or, in some communities, only by a family member.

Unfortunately, except in countries where the NMR has decreased considerably, even basic essential newborn care is inadequate, espe-cially at peripheral or fi rst level centers where prevention of infection and management of asphyxia can be lacking. One of the challeng-es, even in larger hospitals, is the occurrence of hospital acquired infections that can con-tribute signifi cantly to neonatal mortality and morbidity.

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Essential obstetric care has been expanded in the Region in countries such as Paraguay and Bolivia to include essential neonatal care, in what is labeled Essential Obstetric and Neonatal Care (EONC). This expanded care model includes monitoring infant body temperature and specifi c antibiotic treatment for sepsis, among other components. Implementation of EONC requires skilled personnel, necessary supplies, community support, and, where needed, an emergency plan for referrals to a facility with more comprehensive EOC services. The components of basic and comprehensive EONC are noted in Appendix 2 and need to be applied where feasible.

At a global level, other successful methods of newborn care have been reported. It is important to learn from these country experiences and identify those that can be adapted to the LAC region. The SEARCH model from Asia was instituted by community health workers linked with traditional birth attendants and included home based care for the newborn, including both preventive and curative care addressing primarily birth asphyxia and sepsis. Sepsis was managed with oral and injectable antibiotics. Neonatal mortality decreased by 62% over a period of three years.38, 39

3.4 Care and access to skilled birth attendance

Access to quality skilled care at birth is low in many areas of the Region where the highest maternal and neonatal mortality and morbidity rates occur. On average, 79% of

deliveries in LAC occur at the institution level [see Appendix 1], although there are wide variations among and within countries. In rural areas, access to skilled birth attendants, supplies, functioning equipment and referral services is frequently limited. In addition, a signifi cant proportion of rural births may be attended by auxiliary nurses who do not have the necessary midwifery skills. Further, even “skilled birth attendants” may not always have the necessary competencies to deal effectively with problems of both the mother and the baby. In those countries where babies are mostly delivered at home, the neonatal mortality rates are the highest.

3.5 Community based care

The Bolivian WARMI Project, which reduced perinatal (the period fi ve months before, and one month after birth) mortality by nearly 50% in project communities, was the basis of fi ve community neonatal care projects in the Region.40 The interventions, detailed in case studies, were primarily carried out in peripheral and remote areas not easily reached by government health services. Private voluntary organizations (PVOs) and nongovernmental organizations (NGOs) –such as SNL in Bolivia and Guatemala, CARE in Peru and BASICS in El Salvador– played a major role in providing these communities with low-cost, tested interventions to reduce neonatal mortality at the community level. It was found that such organizations are useful links between communities, health care providers and the government. The key operational elements noted in the case studies


51

included the need for 1) multiple roles and a range of personnel; 2) specifi c roles that CHWs and traditional birth attendants (TBAs) performed, including an enhanced technical role for CHWs in selected areas; 3) a proposed package of essential newborn care interventions; 4) minimizing start-up time for neonatal health care programs; 5) recognizing and catering to different program needs in rural and periurban environments; 6) identifying and promoting ways to improve utilization; and 7) using partnerships to build sustainability and scalability.41

3.6 Integrated Management of Childhood Illness

The general strategy of Integrated Management of Childhood Illness (IMCI) addresses children aged one-week to fi ve years old and aims to reduce child mortality and morbidity by combining improved management of common childhood illnesses with proper nutrition and immunization. The strategy includes interventions to improve the skills of health workers, the health system, and family and community practices. The recently developed neonatal component incorporates care in the fi rst week of life and has been recognized as crucial to achieving a reduction in infant mortality. Since 2003, the strategy has been implemented to varying extent in Bolivia, Colombia, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Panama, Paraguay and Peru. In some instances, it has been accompanied by training health workers at the institutional level for neonatal resuscitation in

collaboration with the American Academy of Pediatrics, non-governmental organizations, and nonprofi t institutions. In addition, medical school curricula have been adapted to include newborn components in countries such as Bolivia, Guatemala and Honduras.

The dissemination of the expanded IMCI strategy has been supported by PAHO in col-laboration with ministries of health; national professional bodies of pediatricians, perina-tologists and neonatologists; and community organizations. The community component of the neonatal IMCI was fi rst developed in 2002 and initially tested in the Dominican Republic and Peru. It was further adapted based on lessons learned. With the support of PAHO, UNICEF and NGOs such as SNL/Save the Children, the community compo-nent has been implemented in Bolivia and Paraguay. It is expected that the cumulative experience of implementation of the neona-tal IMCI strategy and the lessons learned will shape neonatal-related policy and program development in these countries.

3.7 Immunization

Immunizations have made signifi cant con-tributions to the reduction of neonatal and child mortality throughout LAC. Since 1990, mortality from measles, neonatal tetanus and bacterial meningitis caused by Haemophilus infl uenzae has been reduced by greater than 95% compared with 1990 fi gures, and mortality caused by pertussis decreased by more than 80%. Immunization has also played an important role in reducing postpartum

52


tetanus, and vaccination against rubella has contributed to decreasing congenital rubella syndrome prevalence.

3.8 Micronutrients

Micronutrient defi ciencies are common in women of reproductive age. Many women enter pregnancy with inadequate micronutrient reserves and with defi ciencies that could seriously affect their health as well as that of their newborn. Anemia is a recognized risk factor for maternal mortality and perinatal health when associated with ante-partum and postpartum hemorrhage, still births and low birth weight, accordingly. Anemia, present in 40% of pregnant women in LAC, ranges from slightly over 20% in Argentina, Chile, Mexico and Uruguay; to over 50% of pregnant women in Cuba and Peru, to 60% in some islands of the Caribbean.42 Folate insuffi ciency is a risk factor for neural tube defects in newborns, a devastating birth defect that causes mortality or life-long disability. Vitamin A and zinc defi ciencies may contribute to perinatal sepsis by impairing the physiological response to infections.

3.9 Breastfeeding

Breastfeeding is recognized as a key factor in newborn and infant health, especially immediate and exclusive breastfeeding. While an estimated 90% of mothers in LAC breastfeed their newborns, only 35% breastfeed exclusively for six months.43 Giving newborns teas or other fl uids before breast milk or the early introduction of other fl uids

is a common harmful practice in the Region. Special interventions such as keeping mother and baby together after birth, skin to skin contact within the fi rst hour, and monitoring breastfeeding (e.g. MADLAC in Ecuador and El Salvador) have been found to improve breastfeeding outcomes. In El Salvador, the Ministry of Health with the support of BASICS has expanded the intervention to MADLAC PLUS to include other components of basic essential newborn care.44

3.10 Mother to child transmission of HIV

Since the early 1990’s the HIV epidemic has become a serious threat to child survival in Latin America and the Caribbean mainly due to mother to child transmission (MTCT). In Brazil, an estimated 13,500 pregnant women were infected by HIV in 2002. In addition, between the years 2000 and 2003 there was a 24% increase in the annual incidence of AIDS among children less than 13 years old as a result of mother to child transmission of HIV.45 In the Caribbean, PAHO/CAREC estimated that between 2,500 and 4,000 children were born infected with HIV in 2002 alone.

One cost-effective intervention to reduce HIV infection among children under 10 is the prevention of mother to child transmis-sion (PMTCT). This comprehensive preven-tion strategy involves voluntary counseling and testing for pregnant women and referral for antiretroviral treatment for those testing HIV positive. Quality prenatal care can be a


53

key entry point for HIV care and treatment. If integrated into prenatal care, PMTCT may prevent at least 50% of HIV infection in chil-dren. Currently, several countries in Latin America and the Caribbean offer PMTCT in 100% of their prenatal services; however, there are wide disparities among countries in PMTCT coverage and the level of its integra-tion into primary care. Out of 21 reporting countries, 60% are below coverage.46

Success with PMTCT has been documented in the Region. For example, the Bahamas showed HIV incidence among children less than 1 year old decline from 3 cases per 1000 live births in 1994 to 0 cases per 1000 live births in 2002.47 Other LAC countries have reported some degree of success in halting the spread of HIV among children and making available public health interventions that can help achieve HIV-free-generations in the Americas by 2015.48

3.11 Surveillance

Several LAC countries such as Brazil, El Salvador, Guatemala, Honduras, Paraguay, and Peru have maternal mortality surveillance systems in place and have set up maternal mortality analysis committees at the national and departmental level. Countries such as Paraguay and Bolivia have integrated neonatal mortality into these systems, although implementation has yet to occur.

An ongoing challenge for the Region is to improve the registration of stillbirths and neonatal deaths in offi cial record systems. In many countries, a stillbirth or newborn baby who dies is not considered a person needing to be offi cially registered. Most LAC countries do not routinely monitor the indicators used for data collection. Local review, analysis and use of the information collected for decision-making are also grossly inadequate.

54


Based on lessons learned, the proposed strat-egy focuses on evidence based sector wide in-terventions to create a favorable environment; to develop and promote effective public poli-cies at all levels using the MNCH ‘continu-um of care’ model while stressing newborns and with a special emphasis on community; build linkages across programs; improve the response capacity and quality of health servic-es by strengthening primary health care and levels of referral; provide effective, integrated and culturally appropriate health care; update and strengthen the competencies of the health workforce; promote interventions to empow-er individuals, families and communities; and develop a surveillance, monitoring and evalu-ation system to assess progress.

Countries need to act now, focusing on the following key areas within the context of maternal, newborn and child health:

A. Create an Enabling Environment for Promotion

of Neonatal Health

In order to reduce neonatal mortality, an enabling environment must exist that takes into account the political commitment of authorities to implement policies, promote evidence-based protocols and standards, and procure technical and fi nancial resources to facilitate and support required activities. Government authorities should not only strengthen their health systems, but also address community needs. Similarly, organizations, notably NGOs and faith-based organizations that work well at the community level, should link with government and health systems. All programs should proactively build in strategies to target the poorest and marginalized groups in order to ensure adequate and appropriate coverage.

4. The Interagency Regional Strategy for Reducing Neonatal Mortality

What can be done to improve newborn health

Neonatal mortality is a major contributor to child mortality in LAC and is an obstacle to the attainment of the Millennium Development Goals. Most neonatal deaths are preventable and effective interventions have been well documented. Countries need to defi ne key strategies and actions to establish, implement, strengthen and expand interventions to promote newborn health within the framework of maternal and child health. Activities need to be carried out and coordinated at several levels.


55

Efforts must be made to increase the visibility

of neonatal health and develop greater capacity

for national policy development and priority-

setting in the context of maternal, newborn

and child health (MNCH). Strengthened

evidence based MNCH interventions are

needed for improved policy development and

advocacy activities, more focused priority-

setting, and increased program effectiveness at

service and community levels. Without this,

substantial reductions in neonatal mortality

will not occur, and the Region will not achieve

the child mortality reduction targets in the

Millennium Development Goal 4.

Policy frameworks should be developed to

improve newborn health and reduce neonatal

mortality through high-level political com-

mitment. Needed are clear national guidelines

and initiatives to establish and strengthen vital

registration systems, ensure reliable fi nancing

for essential interventions and address neona-

tal health workforce issues including the pre-

service and in-service training requirements of

doctors, midwives and nurses.

It is also critical to work with key partners

with clear roles and goals, and integrate

neonatal health into existing programs such

as reproductive and maternal health (both

essential and emergency obstetric care), and

child survival, including IMCI, breastfeeding,

and nutrition. As newborn health tends to be

overlooked during the integration process,

it is necessary to increase the visibility of

the newborn to prioritize actions to assure

neonatal health.

Strengthening partnerships through a partic-

ipatory plan should include global, regional,

national and local partnerships with minis-

tries of health, donors, international coop-

eration agencies, and other key stakeholders

including civil society, traditional healers and

non- governmental organizations. Stronger

links need to be developed between profes-

sional bodies, such as associations of obstet-

rics and gynecology, pediatrics, perinatology,

neonatology and nursing. PAHO technical

cooperation with countries and other part-

ners focuses on policy development, advoca-

cy for family and community health, service

delivery, development of human resources,

support for resource mobilization, informa-

tion and knowledge management, surveil-

lance, and monitoring and evaluation.

Keep the baby dryand warm.

56


B. Strengthen Health Systems to Improve Access to Maternal, Newborn and Child Health Services

Universal access to MNCH care should include the provision of skilled care at birth. Services should provide continuity of care, ensuring that access to care during pregnancy, childbirth and the postpartum period extends through the fi rst month of life and beyond. Effective monitoring to ensure adherence to standards, guidelines and protocols is key. This includes continuous supportive supervision, strengthening of referral systems and formative management with accountability, scheduled follow-up, support with a focus on primary health care and a social audit process to validate outcomes.

Promote an Enabling Environment at the Policy Level1) Carry out continued, targeted advocacy to incorporate newborn health as a high priority in policies of na-

tional and local governments.

2) Identify ‘champions’ to support the agenda and raise awareness and funds.

3) Establish and strengthen ‘cells’ or sections in the national ministry, subnational and local governments to focus

on newborn health within the framework of maternal and child health and develop and implement evidence

based norms, protocols, and standards addressing both health systems and the community.

4) Develop built-in strategies during planning and implementation to target vulnerable and marginalized groups

and promote equity-based care.

5) Promote advocacy and activities for procuring fi nances from:

(a) Country governments

(b) Stakeholders, local and international

6) Seek additional technical support as required from local and international agencies thus benefi ting from les-

sons learned from other regions. Promote ‘south to south’ collaboration.

7) Ensure close collaboration with partners (national and local governments, other stakeholders, bilaterals,

NGOs, traditional healers, faith based organizations, key community leaders, and other organizations includ-

ing professional bodies) with plans for progressing quickly to scale.

8) Integrate newborn health activities with existing programs such as those for maternal health (both essential

and emergency obstetric care), child health activities including IMCI, and HIV/AIDS-PMTCT programs and

congenital syphilis, taking care to maintain clear visibility of the newborn health component.

Universal access to care

It is essential to review the curriculum of in-service training and pre-service education to assess and improve the adequacy of training courses, particularly related to newborn care. Priority needs include skills and knowledge for essential newborn care, care of vulnerable babies such as low birth weight infants and those born to HIV positive mothers and the identifi cation of essential care for the sick newborn. Priority should be given to knowledge and skills related to the effective management of infections, birth asphyxia, and hypothermia (thermal regulation of the preterm newborn), which are the leading causes of death.


57

Government policy and programmatic responses should also be strengthened to address women’s education and empowerment issues. It is critical to link women’s and community development organizations, notably NGOs and faith-based organizations with proven effectiveness and credibility at the community level, with government and health systems to achieve the synergies needed to empower women, assure broad-based support for maternal and newborn health needs by family and community, improve coverage and quality, and extend care to the most marginalized. Marginalized groups include the urban and rural poor, and indigenous and Afro-descendant populations.

Continuum of care

A holistic and integrated approach refl ected in the continuum of care model is required to address newborn health within the framework of maternal, neonatal and child health.49 This includes the following:

(a) Care from pre-pregnancy to the postpar-tum period includes health care to young girls and women of reproductive age and counseling for healthy behaviors, fam-ily planning, and nutrition including the need for appropriate folic acid supple-mentation. This needs to be linked with care for the mother in the prenatal, deliv-ery and postpartum periods and with the care of the newborn after delivery. This approach is extremely important given

the very close link between maternal and newborn health.

(b) Home to hospital continuum of care is a key issue. As a number of births and deaths in the newborn period take place at home and even children born in facili-ties are discharged early, there is a need to involve the family and the community. A large number of traditional factors in-fl uence family behaviors such as when and where to seek care. Hence commu-nication and community mobilization strategies are critical to promote healthy behaviors related to basic preventive care and to motivate appropriate care-seek-ing. These components are covered in the BASICS/CDC/USAID framework called the ‘pathway to survival’.50 This model incorporates the need to integrate and co-ordinate the care that takes place inside and outside of the home. Merely encour-aging care-seeking is not enough and may even result in loss of credibility if there are not improvements in the quality of servic-es available at facility level, including im-proved supportive behavior by the health staff. The latter is needed to promote utilization of health services. A respected functioning link between the community and facilities is also benefi cial.

(c) Continuum of care from preventive to curative services is essential to achieve a greater reduction in neonatal mortality. While prevention is important, babies will inevitably develop health problems

58


and need to be treated. In fact, the latter is often the greater demand of the community.

Because of several challenges including inadequate resources, both fi nancial and human, providing the full continuum of care may be diffi cult. Hence, prioritizing activities to suit local requirements, commencing with the more feasible interventions and subsequently phasing in the others will help. Similarly, working with partners who can address different components and bring in additional resources will also provide some support.

Improve skills and competencies of health care providers

The Universal Declaration of Human Rights states that “motherhood and childhood are entitled to special care and assistance” and the Convention of the Rights of the Child guarantees a children’s right to the highest attainable standard of health.51

So that children are able to reach their highest standard of health, it is necessary to review the roles and functions of care providers, doctors, nurses, midwives and auxiliary nurses including those in peripheral areas (fi rst line workers) to ensure competence in the area of child, especially newborn, health. Ensuring that care providers are skilled in basic essential and emergency newborn care is critical to avoid mortality and prevent morbidity in the

neonate.52, 53 Training programs for health workers who care for newborns need to emphasize:

1) Prenatal care, including tetanus immu-nization, nutrition, birth preparedness, family planning, early detection and treatment of complications.

2) Essential care for the healthy newborn including care at birth such as immediate drying and wrapping, delay of fi rst bath, encouraging immediate and exclusive breastfeeding without pre-lacteal feeds, cord care, extra care for low birth weight and preterm infants, including kangaroo mother care and early postnatal visits within three days of birth with proper assessment and care.

3) Immediate care for the sick newborn including management of birth asphyxia, administration of antibiotics for sepsis, and effective referral for problem cases requiring additional specialized care.

4) Postnatal care, assuring early neonatal evaluation.

5) Basic skills for obstetric and neonatal emergencies including the use of incubators, IV’s, and transfusions.

Ideally, mothers and newborns should be managed by a qualifi ed birth attendant such as a doctor, nurse, or midwife. However, in the


59

Region there are a signifi cant number of services provided only by an auxiliary nurse and there are communities in which home deliveries are common. It is thus crucial to involve and link with traditional birth attendants (‘parteras’ in Spanish) and community health workers as noted below in the section on community based interventions.

The adoption of IMCI by many LAC countries has provided a framework that can be improved by strengthening elements such as the newborn component, quality of health care and supplies, highlighting the management of infections and identifi cation of low birth weight, and improved care at birth.

Although countries with the lowest NMRs tend to show a high percentage of births attended by skilled personnel, merely having skilled birth attendants does not always improve outcomes as indicated by data from some LAC countries (Appendix 1). Reduction in neonatal mortality requires better training with quality assurance and supportive supervision; improvements in infrastructure, procurement and maintenance of basic equipment; and supplies and drugs for preventive, curative and emergency care. In addition to the necessary technical skills, consideration of local cultural

practices and improved supportive behavior and interpersonal communication by care providers can contribute signifi cantly to family acceptance of health services.

Improve quality of hospital-based newborn care

At larger hospitals, neonatal special care and intensive care units need to pay more attention to quality. In particular, they need to focus on asphyxia management, prevention of infection- especially hospital acquired infection, and to acquiring adequate competent staff experienced in newborn care, equipment use and accurately dispensing drugs. In the larger centers, separate units are required to care for at-risk and sick neonates. The choice of procedures and equipment is also important. Priority should be given to procedures that are less invasive and thus less likely to result in infections, and to equipment that can be easily maintained and serviced. While equipment such as incubators and ventilators are useful, they should be procured only by units with access to the above resources and with skilled staff that can use them effi ciently. Otherwise, they may lead to problems such as infection and increased mortality. Having properly trained, competent doctors and nurses and appropriate equipment is extremely important to providing optimal care to newborns.

60


Strengthen and involve the private sector

Private practitioners such as doctors or nurses should be included in capacity building as they too can be involved in providing care for newborns. In LAC, formal health care personnel such as doctors may not have received obstetric training or may not have full competency in this area. Qualifi ed personnel can be trained in neonatal care and supported as noted above in the public sector.

At the community level, private providers also include persons who sell medicines and some of the traditional healers. These may

Improve Quality of Services at Facility Level

1) Promote a holistic approach with continuum of care from (a) preconception, pregnancy, childbirth, neonatal

period and childhood, (b) home to hospital, and (c) prevention to curative care.

2) Plan and implement actions to promote scaling up and sustainability

3) Ensure adequate training of health professionals along with quality assurance and supportive supervision.

4) Promote procurement of adequate and ongoing supplies (appropriate drugs and suitable equipment), par-

ticularly for fi rst level facilities.

5) Strengthen and implement a triage system with provision of appropriate quality of care at different levels with

good referral and counter referral systems.

6) Promote communication strategies at facility level for key family behaviors to improve newborn health

7) Develop functioning links between the facility skilled birth attendants and the community based traditional

birth attendants and other CHWs/CHVs to increase referrals of mothers.

8) Plan and initiate activities early to achieve long term goals such as:

a. Improvement of the pre-service education of medical, nursing/midwifery and other para-medical per-

sonnel.

b. Increased numbers of competent skilled birth attendants, especially nurses and midwives available

twenty-four hours a day, supported by adequate drugs, supplies, equipment and effective referral sys-

tems

be trained to promote healthy behaviors, somewhat similarly to CHWs.

Improve pre-service education

In-service or continuing education can be time consuming and costly. It also takes personnel away from work during periods of training. Consequently, it should be reserved for updates and refresher courses. It is therefore essential that the pre-service education of doctors, nurses, midwives and paramedical personnel is improved so that at or soon after qualifi cation, the relevant staff has competency and skills in essential newborn


61

care. At a minimum, necessary skills include basic preventive care, resuscitation of birth asphyxia, care of minor problems including infections, administration of both oral and injectable antibiotics, and identifi cation of danger signs and effective referrals.

C. Promote Community Based Interventions

A signifi cant number of births and neonatal deaths take place at home. Even in institutional deliveries, mothers and newborns are discharged early. Therefore involving the community in the promotion of healthy behaviors (e.g., immediate and exclusive breastfeeding, keeping infant warm and dry) and early and appropriate care seeking for problems is extremely important. The Region also needs to invest in birth preparedness plans, community transport and surveillance systems. Transporting a mother or newborn with problems to an appropriate health care facility will improve health outcomes.

Role of community health workers

Community based care involves more than just TBA training programs, but rather capacity building of all available community health workers and volunteers such as health promoters, TBAs and other social actors such as school teachers, members of youth groups and unions, suitable to their level of understanding. Interventions should include

communication and community mobilization strategies that will promote healthy behaviors and increase appropriate use of existing health services. Community based care is important in all countries and regions, but increased emphasis and greater involvement of CHWs and CHVs including TBAs are crucial in areas with diffi cult geographical access as these areas typically are not covered by other health services. TBAs have been in communities a long time and have a close relationship and credibility with many families. Through community mobilization and by establishing a good link with the TBAs, the CHWs/CHVs can be promptly notifi ed of new births. This can promote early postnatal home visits.

In locations where untrained family members are the birth attendants, there are obvious challenges in addressing birth complications and neonatal problems. With regards to appropriate care seeking, mothers may feel uncomfortable receiving care from formal health care workers or cultural practices and superstitions may inhibit seeking neonatal and postpartum care. There is a growing interest in establishing links between TBAs and qualifi ed midwives using the former to detect danger signs and institute early referral of problem cases. Promotion of key practices in maternal and newborn care and general information for the community should go hand-in-hand with promoting the use of health services. There may also be a place for home-based life saving skills.54

62


Community and social mobilization

Community participation and family com-mitment are critical to maternal and neona-tal care. NGOs, faith based organizations, civil authorities, and local health services can play major roles in community mobili-zation and capacity building of community based groups. Women’s groups that have received capacity building in maternal and neonatal care are well known for their roles in promoting and advocating for appropri-ate care. The special role of grandmothers in promoting behavior change in the com-munity has also been highlighted.55

The involvement of men is also required in community mobilization. They are especially needed in facilitating the empowerment of women, sharing health care roles, and arranging emergency transport. Community groups can also play a benefi cial role in establishing emergency support networks. Access to transportation may represent the difference between life and death for women and newborn infants who are at risk or have developed complications.

There is also a need to implement innovative home or community case management of at least some of the neonatal problems where referral is not possible, especially in situations where geographical access to health services is the main barrier to receiving timely care.

The adoption of healthy behaviors such as accessing prenatal care and skilled attendance at birth, immediate and exclusive breastfeeding, and appropriate care seeking for neonatal problems is key to improved care at both the community and health facility level.

Strategies that are useful in achieving healthy behavior change includes:

Interpersonal communication: Key messages can be effectively conveyed through com-munity health workers, volunteers and health facility workers. Capacity building with em-phasis on good communication and negotia-tion skills and limited, key and clear messages are helpful. As with all training, quality assur-ance, supportive supervision and monitoring are essential. Communication strategies at the health facility level may be more challeng-ing as the staff tends to be more involved in delivery of care and less so in health educa-tion. However, utilizing established and well-trained community workers at the peripheral facility level or assigning a specifi c health worker by rotation to deliver messages may lessen the burden.

Traditional methods: In some communities, traditional methods such as street plays and puppet shows are useful and acceptable for relaying important information.


63

Mass communication: In addition to the above methods, the use of mass media can be a valuable tool for widely broadcasting key messages; however, the high cost

D. Develop and Strengthen Monitoring and Evaluation Systems

Monitoring and evaluation (M&E) at all lev-els are key elements within health systems planning, programmatic service delivery and health information systems. Strengthened ca-pacity to assess impact as well as monitor per-formance is crucial to reducing neonatal mor-tality, mitigating vulnerability and improving

Support Community Based Interventions and communication strategies

1. Build capacity building of key community health workers, volunteers and TBAs (parteras) and other suitable

actors, with quality assurance and supportive supervision.

2. Implement communication strategies to promote healthy behaviors (see section on communication).

3. Promote social/community mobilization strategies for active involvement of civil and religious leaders, groups

such as those comprising women, grandmothers, youth, and men to promote healthy behaviors and specifi c

needs including birth preparedness, transportation, and fi nances.

4. Establish and strengthen links between the community and health facility.

5. Implement alternative suitable home and community based case management where referral is not possible.

6. Develop prioritized simple messages to promote key healthy behaviors.

7. Deliver the messages through a number of suitable strategies including interpersonal communication, tradi-

tional methods and mass media.

8. Explore ways to subsidize cost of using mass media.

associated with this strategy is problematic. Securing government support to subsidize the cost and motivate donor involvement is recommended.

neonatal health. The establishment of feasible intermediate goals is a key priority in the de-velopment of a M&E system.

In order to track the progress of neonatal health programs and actions, it is critical to have monitoring and evaluation programs in place to document results and evaluate both the care service and community response. It is also important to monitor whether or not planned public policies have been implement-

64


ed. A successful monitoring system also helps to identify barriers and equity gaps in terms of access to quality services. Monitoring should be an integral part of program implementa-tion, and data analysis for decision-making should be part of the work culture among health staff. There needs to be established M&E systems to help ensure that vulnerable or marginalized groups are visible and covered by health services.

The establishment or strengthening of vital registration systems, including birth registration (with birth weight), stillbirth and neonatal death registration (with age at death) is a critical step in the development of monitoring and evaluation systems. These systems must, at a minimum, enable the accurate and timely recording and reporting of results, and provide the data for the evaluation of service coverage, quality and community response. As monitoring is also an essential component of program planning and implementation, data analysis for operational decision-making must become part of the job descriptions for health staff. For this reason it is essential to develop a set of minimum standard indicators that are feasible to collect. In addition, data must be regularly reviewed at key levels to monitor results and plan and implement changes to promote achievement of the defi ned goals and outcome.

Ways to strengthen and improve the health system for and through data collection and analysis include compulsory registration

of newborns and reporting of stillbirths and neonatal deaths; evidence based policy development in priority settings; reliable fi nancing for essential interventions through predictable budget allocations; ensuring adequacy in human resource development, achieving effi ciency in the supply chain and logistics systems, and guaranteeing free access to an essential package of health services.

Evaluation methods such as case analysis, perinatal audits, and verbal autopsy have been useful in the detection of neonatal health problems related to the supply of health services and community demand for them. While each method has its advantages, care has to be taken to involve care providers and the community, and choose the appropriate technology for the local situation.

Ideally, newborns should be weighed and registered at birth. Records of birth weight help to effectively monitor the occurrence of low birth weight newborns. Currently this data is available predominantly from institutional births (see Appendix 1). The recent review of global action on child health has also suggested monitoring the prevention of mother to child transmission of HIV, although this requires follow up into infancy.56 Thus while a large number of indicators are available,57, 58 in practice it is essential to limit them to a few key ones that are feasible for collection.

Countries have been taking advantage of the external Demographic and Health Surveys and


65

the Maternal and Child Health Surveys which are conducted routinely in all countries of the Region. However, countries and ministries of health need to improve their own routine data collection systems, incorporating not only critical neonatal indicators and vital statistics, but also capacity building for the appropriate use of the collected data at the local and district level.

Community surveillance systems are aimed at engaging the community and social actors to generate dynamic processes to collect, analyze, and respond with concrete actions to observed health issues. For a community, the very act of recording morbidity and mortality events can be a powerful tool for focusing attention on maternal and neonatal health.

Promote Key Strategies for Monitoring and Evaluation

1) Select prioritized, key, feasible indicators such as

(a) Neonatal mortality rate

(b) Still birth rate – preferably differentiating between fresh and macerated stillbirths as some of the fresh

stillbirths can be prevented and some are actually early neonatal deaths.

(c) % of births attended by skilled birth attendants

(d) % of births at facility level

(e) % of pregnant mothers receiving two or more antenatal care visits

(f) % of newborn infants breastfed within one hour of birth

(g) % of newborn exclusively breastfed within the fi rst month

(h) % of babies who receive postnatal care within three days

(i) % communities with emergency transportation plans

(j) % of women accessing prenatal care with a birth preparedness plan

2) Promote continuous monitoring of vital statistics by local authorities/governments

3) In addition to collecting data for onward transmission to national centers, promote review and use of data

locally to improve services with the involvement of community leaders

4) Monitoring systems should also have inbuilt systems to ensure that poor and marginalized groups are cov-

ered

5) Develop community surveillance systems with community action plans

66


5. Financial Implications

WHO’s 2005 Report Make every mother and child count emphasized that “more than 6 million children can be saved with simple health care.”59 The Bellagio Child Survival Series states that if the coverage of evidence based interventions were increased, 63% of all infant deaths and 35% to 55% of neonatal deaths could be averted.60 This analysis also suggests that 90% of women and newborns could be covered by these interventions for just US$ 1 per capita.

It is essential that LAC countries allocate re-sources in their national and local budgets for implementation of their planned interven-tions. In addition, the international coop-eration agencies must also designate funds to make country efforts viable.

The new Global Partnership for Maternal, Newborn and Child health is evidence

Vas

sil A

nast

asow

that international agencies such as USAID,

PAHO/WHO, UNICEF and the World

Bank are committed to reducing infant

and neonatal deaths. This provides an

opportunity to create coordinating bodies,

at the country and regional level, for both

technical and fi nancial assistance.

Fill the baby with much love and care.


67

6. Next steps

A regional strategy document such as this is useful only if it is applied at the country level, and neonatal mortality and morbidity is reduced. Individual countries will need to determine what actions are most suitable for them to progress towards achieving MDGs 4 and 5. Noted below are a few suggestions for the next steps that countries may like to consider for moving ahead.

1) Review key components of the regional strategy and develop an adapted version that can be applied within the country to suit local requirements.

2) Work with partners and:

a. Develop a Task Force or National Committee with key partners inter-ested in newborn health, including representatives from the government, other key stakeholders, NGOs, faith-based organizations, professional bodies and other organizations.

b. Form smaller working groups for specifi c components such as capacity building with quality assurance and supportive supervision, community based care, communication strategies and monitoring and evaluation

c. Develop active functioning links with partners working at government, health facility and community levels in the public and private sectors.

3) Develop a work plan for improving newborn health within the framework of maternal and child health over a defi ned period.

4) Identify key prioritized feasible actions to commence with during the initial phase, such as the fi rst one or two years.

5) Defi ne the budget required to imple-ment planned activities, identify suitable sources for funds, and carry out advocacy and appropriate actions to procure the resources from the national government and through other stakeholders.

68


Appendix 1

Neonatal and Maternal Mortality, Deliveries Attended by skilled personnel and Low Birth Weight Babies in selected countries of LAC Region, 1994-2000

Sources:a WHO. Neonatal and Perinatal Mortality 2006: Country, Regional and Global Estimates. Retrieved

(07/12/06) from http://www.who.int/making_pregnancy_safer/publications/neonatal.pdfb OPS/OMS, Situación de la Salud en las Américas. Indicadores Básicos, 2006. Retrieved (07/27/06) from

https://intranet.paho.org/DD/AIS/INDICADORES2006_SPA.PDFc UNICEF. State of the world´s children 2006. Accesssed (07/27/06) from http://www.unicef.org/sowc06/pdfs/

sowc06_fullreport.pdfd Saving Newborn Lives. State of the World’s Newborns 1995-2000. Save the Children. Washington, DC.e WHO. Maternal Mortality in 2000: Estimates developed by WHO, UNICEF, UNFPA. Retrieved from

http://www.who.int/reproductive-health/publications/maternal_mortality_2000/mme.pdf

Country Neonatal mortality ratea

Perinatal mortality ratea

Maternal mortality Ratio

(100,000lb.) b,d,e

% Deliveries attended by skilled

personnel b% of Low Birth Weight Babies c

Scenario 1: NMR 20 or more

Haiti 34 54 523 24.2 21Bolivia 27 31 230 60.8 7Guyana 25 40 123.3 94 12

Scenario 2: NMR 15-19Dominican Republic 19 28 91.7 97.8 11

Guatemala 19 23 77.7 31.4 12Suriname 18 30 n/a 90 13Honduras 18 28 108 62 14Nicaragua 18 23 87.3 77.2 12Ecuador 16 20 76.4 78.6 16

Peru 16 20 185 71.1 11Paraguay 16 20 174.1 85.9 9

El Salvador 16 20 173 79 7Brazil 15 20 64.6 96.6 10

Mexico 15 22 62.4 93.4 8Scenario 3: NMR less than 15

Colombia 14 23 77.8 95.7 9Trinidad & Tobago 13 26 67d 99.6 23

Venezuela 12 18 57.8 99.7 9Panama 11 15 43 91.3 10

Argentina 10 14 40.1 99.1 8Jamaica 10 17 95 95 10

Barbados 8 17 n/a b 100 10Uruguay 7 14 51d 99.3 8

Costa Rica 7 13 36.3 97.5 7Chile 6 8 17.3 99.8 5Cuba 4 14 52.2 99.9 6


69

Appendix 2

• Antibiotics• Oxitocyn• Anticonvulsive (injectable)• Manual removal of the placenta• Removal of retained embryonic

products (Dilation and Curettage or MVA)

• Attended vaginal delivery

Figure 1 Essential obstetric and neonatal care (EONC)

For the mother (EOC) For the newborn (ENC)

• Neonatal resuscitation with bag and mask

• Monitoring baby’s body temperature

• Specifi c antibiotic for neonatal sepsis

• Essential Newborn Care (ENC)

Plus Basic EONCfunctions

ComprehensiveEONC

Functions

• ENCPLUS• Assisted ventilation• IV solutions

• Basic EOCPLUS• C-Section• Blood transfusion

EOC: Essential Obstetric CareENC: Essential Neonatal CareEONC: Essential Obstetric and Neonatal Care

70


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