Care seeking for newborn

illness: A changing

paradigm?

Steve WallSave the Children

CORE MeetingBaltimore

April 25, 2013

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1990 1995 2000 2005 2010 2015 2020 2025 2030 2035

Source: UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report 2011; UNICEF, Required Acceleration for Child Mortality Reduction beyond 2015, 2012; team analysisSNL/Save the Children team analysis for NMR projection for Call for Action meeting

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Accelerated U5MR ARR = 5.1%Current U5MR ARR = 2.2%

* ARR = annual rate of reduction

MDG 4 target = 34 U5MR

Global Progress for child survivalU5MR and NMR decline 1990-2010, projected to 2035

15

Current NMR ARR = 1.8%

If 1-59 month mortality accelerates further but neonatal mortality continues on same trend then with

2 million child deaths in 2035, 1.5 million may be neonatal.

Why are we focused on newborn survival?

Three killers – prematurity,

asphyxia, and infections -

account for 81% of all neonatal

deaths3.1 million

Sources: CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010. UNICEF, State of the World's Children,

2011.

Causes of death in children under-five in developing countries –Newborn deaths are almost half of all deaths of children under five

REGION Neonatal mortality rateAverage annual change 1990-2010

Africa 1.3%

East Med 1.6%

Southeast Asia 2.2%

Western Pacific 4.2%

Americas 3.6%

Europe 3.6%

Maternal mortality ratio = 4.2%1- 59 month mortality rate = 3%Neonatal mortality rate = 1.8%

All 3 measures show increased progress since 2000

Source: Lawn J,E. et al. 2012. Newborn survival: a multi-country analysis of a decade of change. Health Policy and Planning. 27(Suppl. 3): iii6-ii28. Data sources: Oestergaard et al 2011 PLoS, UNICEF 2012 www.childinfo.org

2165

2085

Mortality average annual rate of reduction

WHEN WILL REGIONS REDUCE NMR TO CURRENT RATE OF HIGH INCOME

COUNTRIES (3 per 1000)?

Care seeking for NBs: Our Original Assumptions

• Home-based management of sick newborns is effective and saves lives

• Care seeking from qualified providers outside the home is low, influenced by entrenched cultural beliefs and practices.– Seclusion, contamination– Evil eye– Traditional beliefs about illness and remedies– Lack of trust in “western” medicine

• Case identification in Projahnmo (Bangladesh) coincided with the days of scheduled post-natal home visits “active” case detection seemed needed

Baqui et al. BMJ, 2009.

Family acceptance of referral to facilities: Bangladesh – ~ 1/3 Pakistan – 20%

Baqui et al. Lancet. 2008; Zaidi et al. XXX.

Evidence “confirming” these assumptions

More recent evidence and program experience

• Nepal:• MINI – FCHVs counseled family, who notified

FCHVs of suspected newborn illness• FCHVs identified signs of PSBI, treated with

cotrimoxazole and referred to gov’t CHW for injectable gentamicin

• CHW provided 7 days of gentamicin• Initially at home; but families became willing to go to

health posts/centers for gentamicin MINI model incorporated into 10-district pilot of

Community-Base Newborn Care Program (CB NCP)

Recent CB NCP data show families infrequently contact FCHVs, but tend to directly seek care at health posts/centers

More recent evidence and program experience - 2

• Ethiopia • COMBINE (cRCT) introduced NBS management

(amoxicillin + gentamicin x 7 days) by Health Extension Workers (HEW) at Health Posts

• Expectation of “active case detection” by volunteers and HEWs

• Initially, very low case identification in intervention areas.

• Qualitative research identified barriers – cultural/religious taboos against taking newborns outside the home; lack of knowledge of newborn illness, treatment, and availability of such treatment at HPs.

• Project worked with community/religious leaders, volunteers to provide information.

• Increased care seeking for sick newborns was largely ‘self-referral’

COMBINE care seeking for NB illnessTable 1: Expected births & care-seeking

For newborn illness 2011 2012

Q3 Q4 Q1 Q2 July

Intervention Expected No. of births 2711 2395 2123 2468 880

No. (%) seen at HP 8 (0.3) 28 (1) 131 (6.2) 170 (7.0) 54 (6.1)No. (%) seen at HC 0 (0) 8 (0.33) 102 (4.8) 38 (1.5) 12 (1.6)

Control Expected No. of births 2731 2394 2068 2419 894

No. (%) seen at HP 5 (0.18) 6 (0.25) 16 (0.75) 7 (0.28) 8 (0.91)

No. (%) seen at HC 3 (0.1) 5 (0.2) 42 (2) 31 (1.3) 13 (1.5)

Implications

• Families ARE willing to seek care for NB illness (from qualified providers) outside the home.– Taboos can be overcome (rapidly ?) if

families/communities have knowledge about preventable newborn deaths, need for early care seeking, and availability of services

– Services must be reliable (set times for health worker at HP, medicines in stock)

Issues/Questions

• Is care seeking timely enough for effective treatment? Any prior care seeking from unqualified providers?

• Can community participation and CHW role(s) help “facilitate” care seeking?

• How different might this care seeking pattern be in different regions or different country contexts (eg, need for formative research and pilots)?

• How rapidly can community norms be changed and will these changes be sustained?

Additional questions for discussion?

• In some countries (eg, India, Pakistan), care seeking for newborn illness may be mostly from private providers (many unqualified). How to address this challenge?

• What is care seeking pattern for sick newborns in the first week of life, and how can this be increased?– First week NBS is more lethal condition,

requires early identification and treatment, and is more prevalent than later neonatal NBS.

Further considerations

• Roles of CHWs (SNL 2 experiences) in changing household practices and care seeking

• Role of community mobilization in changing expectations & norms, household practices and care seeking, and care quality

Learning from implementation of community-based

maternal & newborn health programs:

The role of CHWs Deborah Sitrin

Save the Children

CORE Group MeetingBaltimore

April 25, 2013

SNL2 Vision

To have reduced global neonatal mortality by providing catalytic assistance to develop, and implement, effective evidence-based newborn care interventions at scale.

Guatemala

Bolivia

Indonesia

Vietnam

BangladeshNepal

India

Pakistan

Afghanistan

SNL2: Where?

South Africa

Mozambique

Malawi

Tanzania

Uganda

Ethiopia

Ghana

Mali

Nigeria

60% of the world’s 3.1 million neonatal deaths

18 countries•Africa: 9•Asia: 7•Latin America: 2

Global & Regional

Description of programs

Program elements:• Home visits by Community Health Workers during pregnancy & after birth to:

Encourage ANC and facility deliveryPromote optimal care practices for newborn and mother Counsel families to identify danger signs and seek careIdentify sick newborns and refer to facilities (+ pre-referral oral antibiotic in

Nepal only)

• Facility strengthening (varied)

• Community engagement (varied)

Data from pilot districts in 4 countries:• Malawi• Uganda• Nepal• Bangladesh

Community workers conducting home visits

Differences across programs:• Population catchment size• Gender • Education level• Salaried government

employee vs. volunteer• Incentives• How workers are recruited• Residency• Time in community• Length of pre-service training

Similarities across programs:

• Length of training in maternal newborn health package

• Content of counseling on newborn care practices

• Made home visits during pregnancy and soon after birth

LESSON: Delivery platforms vary substantially and delivery systems can change.

Implementation Questions

1. How many women and newborns received home visits?

2. What did CHWs do for newborns during visits?

3. How many families sought timely and appropriate care when their newborns had danger signs?

4. What was the role of CHWs in identifying and referring newborns with danger signs?

5. What have we learned about increasing uptake of healthy newborn care practices?

Percent of mothers/babies receiving home visits

FINDINGS:• Low in Malawi, higher in

Bangladesh and Nepal

• More received pregnancy visits than postnatal visits

• If a postnatal visit was received, it was usually within 3 days after birth

LESSON: Percent receiving home visits varied substantially and we need to consider what each community platform can handle.

Nepal (N=615)

Bangladesh (N=398)

Malawi (N=900)

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1 or more home visits during pregnancy1st postnatal home visit 0-3 days after birth1st postnatal home visit 4-7 days after birth

Percentage of mothers/newborns that re-ceived home visits

Data from interviews with mothers with a live birth in previous 12 months

What was done for newborns during postnatal home visits within 3 days after birth

FINDINGS:• Nearly all newborns that received an early postnatal home visit had

at least one key function done• Weighing baby low in Nepal, but FCHVs only instructed to weigh

babies not previously weighed at facility

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Nepal(N=307)

Malawi(N=95)

Percentage of newborns that received a postnatal home visit ≤3 days after birth and signal functions were performed by CHW

LESSON: When postnatal visits are done, CHWs performed key tasks. BUT need to monitor quality.

Data from interviews with mothers with a live birth in previous 12 months

Care-seeking for newborns with danger signs

Malawi Uganda Nepal Bangladesh

Endline Endline Baseline Endline Baseline Endline

NB with danger sign 23.4% 50.0% 21.4% 28.8% 52.3% 40.7%

Care-seeking for those with a danger sign:

Sought care (any source) 82.9% 94.2% 85.8% 98.9% 82.0% 88.3%

Sought care <=24 hours at a facility (public or private)

41.2% 48.3% 36.6% 67.8% NC 20.4%

FINDINGS:High levels of care-seeking• High in all countries (baseline & endline, intervention & comparison areas)

Yet fewer newborns taken to a facility within 24 hours after onset of danger signs• % newborns with danger signs taken to a facility within 24 hours increased in

Nepal, was moderate in Malawi and Uganda, low in Bangladesh

Data from interviews with mothers with a live birth in the previous 12 months

Care-seeking for newborns with danger signsLESSONS:

Families will leave the home and seek care.

Need to address delays in seeking care from a facility within 24 hours after onset of illness. Noting we found high levels of newborns with danger signs. Difficulty in relying on survey data – mothers may not accurately recall or report illnesses.

Need to ensure families are accessing appropriate care. Use of private facilities and pharmacies/drug shops high in Nepal, Bangladesh, and Uganda. We saw decreases in Nepal but no change in Bangladesh (no baseline information from Uganda or Malawi).

Access to full course of treatment for newborn sepsis

MALAWI

NEPAL

1 facility per 300,000 people

1 facility per 7,000 people

LESSON: Community-based programs may create demand, but treatment needs to be available closer to home

Role of CHWs in referring sick newborns

FINDINGS:

CHWs have good understanding of newborn danger signs and appropriate care• >95% of CHWs in Malawi and Nepal

could name 3+ newborn danger signs

BUT low volumes of CHW referrals of newborns with danger signs• Many newborn not visited by CHWs

within the first week after birth• Families going straight to facilities

when newborn has danger sign• Issues with CHWs not getting required

supplies/equipment

Data from interviews with mothers with a live birth in previous 12 months

Nepal (N=615)

Bangladesh (N=398)

Malawi (N=900)

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1 or more home visits during pregnancy1st postnatal home visit 0-3 days after birth1st postnatal home visit 4-7 days after birth

Percentage of mothers/newborns that re-ceived home visits

Role of CHWs in referring sick newborns

LESSONS:

Need appropriate expectations for the role of CHWs in identification and referral: Focusing on increasing family-initiated care-seeking may be more important and more feasible than detection by CHWs.

Examine role of CHW in follow-up and treatment completion: May be feasible and effective to involve CHWs in follow-up of sick newborns. Counter-referral systems are needed to implement follow-up.

Strengthen monitoring of referrals and outcomes: Weak systems to track referrals and referral outcomes.

Uptake of 4 key newborn care practices

Malawi* Nepal* Bangladesh Uganda*0

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Baseline Endline

Immediate breastfeeding

Malawi* Nepal* Bangladesh* Uganda*0

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Baseline Endline

Bathing delayed ≥6 hours

Malawi Nepal Bangladesh Uganda0

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Baseline Endline

Skin-to-skin contact

Malawi Nepal* Bangladesh* Uganda*0

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Baseline Endline

Nothing applied to cord after cutting

*Statistically significant at p<0.05Data from interviews with mothers with a live birth in previous 12 months

Newborn care practices

FINDINGS:• Practices improved over time with a few exceptions (immediate breastfeeding in

Bangladesh, applying nothing to cord in Malawi and Uganda)

• Practices increased in both intervention and comparison areas, though endline rates often higher in interventions areas. (Note: comparison area data only available in Bangladesh and Uganda.)

• Newborn care practices associated with receipt of home visits from CHW during pregnancy (except in Uganda)– Only statistically significant if mother received 3+ home visits during

pregnancy

LESSON: Home visits during pregnancy are an opportunity to improve newborn care practices and programs able to reach large numbers of women during pregnancy. BUT may be difficult to achieve 3+ visits.

Mobilizing communities for sustainable change in newborn health expectations, care giving practices, and care seeking

Angie Brasington, Save the ChildrenCORE Group SPRING MEETING

April 25, 2013

Mobilizing communities for improved maternal & newborn health: lessons and questions

Angie Brasington, Save the ChildrenCORE Group SPRING MEETINGApril 25, 2013

Outline:

CORE Group Newborn Health Survey CM for Newborn Health – what are we learning? Questions that need exploration

Carolyn Kruger, Ph.D.Sr. Advisor MNCH

PCI

CORE Group co-chair: Safe motherhood & reproductive Health Working Group

CORE GroupNewborn Health Survey Results

USAID Priority Countries: Supporting Newborn Care

BelizeDominican RepublicGuatemalaMexicoNicaragua

ColombiaEcuador Peru

EthiopiaKenyaSenegalSouth SudanMali

India

Newborn Health Areas Supported(18 Organizations)

Number of organizations

16

16

15

15

12

12

12

1110

10

9

9

8

7

6

53

2

2

1

Cross-Cutting Approaches• CHW capacity building - 100%

• Behavior change/communication - 78%

• Community mobilization - 70%

• Community health system strengthening - 70%

• Care groups - 50%

• mHealth approaches - 48%

• Mass communication - 42%

• C-IMCI/CCM - 38%

Innovative Strategies

• mHealth reminders on assessment of mothers and newborns

• Mobile job aids - counseling messages

• Newborn screening on birth defects

• Preconception care

• Casa Materna birthing home model

• Community Kangaroo Mother Care

• CHW capacity to recognize danger signs

• Involving fathers during pregnancy, delivery and PP care

• EBF among adolescent mothers using text messaging and support groups

Mobilizing Communities…..

Community-based Activities

=Community Mobilization

• Day celebrations, competitions, use of action cards to stimulate group dialogue are all examples of behavior change strategies.

• The process of stimulating a community to identify, plan and implement strategies and activities to achieve an agreed upon goal is community mobilization.

• CM often incorporates participatory behavior change strategies, however

• BC strategies can be effective without CM, so why…..

Mobilizing Communities…..

1. We have evidence it works:

WEWE problems

So, why mobilize communities?

Costello et al, Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomized controlled trial. Lancet 2004; 364: 970 – 979. Baqui et al, Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomized controlled trial. Lancet 2008; 371: 1936–44. Kumar et al, Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomized controlled trial. Lancet 2008; 372: 1151–62.

Costello et al, Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomized controlled trial. Lancet 2010; 375: 1182-1192

2. The principles behind CM fit with our mission and context:

• Decentralization and democratization require increased community level decision-making --- CM is an entry point for civil society strengthening and democracy building.

• CM builds mechanisms and systems to sustain improvements in individuals’, families’ and communities’ well-being.

• Communities can apply political pressure to improve services. • CM can strengthen community members’ capacity to address

the underlying causes of poor health.f problems

So, why mobilize communities?

LESSONS: Men want to be involved Communities are able and

willing to contribute resources

Communities are changing rapidly

Communities take action: emergency transport systems and funds, advocacy for satellite clinics and staff, pregnancy surveillance.

What have we learned from communities lately?

Challenges and lessons

LESSONS:

Need appropriate expectations for the role of CHWs: MOH staff who are closest to the community are already thinly stretched.

• Should CHWs lead or only support CM efforts?

• Can existing community leaders, volunteers or members of civil society organizations feed input from communities to the health system?

• ‘Sharing the burden lightens the load’

Challenges and lessons

LESSONS:

Community mobilization competes with many other priorities (clinical training, infrastructure development) within a resource limited environment.

• Make every effort to integrate CM into broader national health strategies, especially when existing MOH policy calls for strong community engagement.

• When communities, CHWs and program managers experience results, the relative value of CM is compelling and support is more likely.

Challenges and lessons

LESSONS:

Community mobilization takes time. • Simplify the process as much as possible before you start and refine

further as you roll out. • As staff becomes more confident and skilled , CM processes speed up.

Good training is essential.• CM successes build momentum and can lead to organic expansion.• Communities and groups with prior experience organizing to solve

problems can move more quickly.

Challenges and lessons

LESSONS:

Community mobilization at scale takes thoughtful planning. It can be done when: • Designed with scale in mind• Effective training materials and guides are produced to support the

process• Financial and political support is available• Partners are interested in adopting the approach• Systems are in place to support capacity-building of program teams

(including monitoring and evaluation, training and ongoing technical assistance)

So how can we ensure communities are engaged?Questions:Why are communities consistently left out of the Household to

Hospital Continuum of Care (HHCC)?

What do we as PVOs/INGOs require to inspire and equip more partners to engage communities for improved MNH?

• More evidence on ‘how’ CM works?• More advocacy?