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Transcript of Nsungwa-Sabiiti: Uganda
7/28/2019 Nsungwa-Sabiiti: Uganda
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Facility-based Newborn care – Country
Successes and Challenges
Dr. Jesca NsungwaAss. Commissioner, Child Health
Ministry of Health
UGANDA
MINISTRY OF HEALTH
17th April 2013
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• Implementation arrangements
• Progress
• Successes
• Challenges
• Way forward
OUTLINE
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Uganda at a glance
Total Population ≈ 32,000,000
MMR 438/100 000 LBs
U5MR 90/1000 LBs
NMR 27/1000 LBs
Number of Newborn Deaths 39,000Number of Stillbirths 38,000
Proportion of U5 deaths that are newborns 41%
NB Deaths due to prematurity 16,090
Stillbirths as a proportion of deaths 26%
Sources: UDHS 2011
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STATUS : Trends in Mortality 1995-2011
33 29
27
85 8976
54
152 158
137
90
1995 2001 2006 2011
Neonatal Mortality Infant Mortality Under five Mortality
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Causes of newborn deaths
Sources: UDHS 2011, Mbonye et al 2012
3 causes account for 90% of all newborn deaths
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Implementation Arrangements - Process
1. Policy Framework for Implementation
2. Newborn Health Service Standards
• Facility level
• Community level (Village health Teams)
3. Quality Improvement Approach – mentoring, coaching, learning
sessions between different facilities
4. Linking Health facility and Village Health Teams
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Policy Implementation Framework
Health Sector Strategic and InvestmentPlan 2010/11-2014/15
(1) Roadmap to Reduction of Maternaland newborn Mortality
(1) Child Survival Strategy
– Newborn Health ImplementationFramework
– Newborn Health ServiceStandards
– Integrated Community CaseManagement (includes newborn postnatal home visits)
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Include the most relevant parameters and
service practices that need to be in place
for ensuring quality newborn health
services. Grouped into seven sections
standards for
1. Infrastructure and equipment
2. Management systems
3. Infection prevention
4. Information, Education and
Communication
5. Clinical Services
6. Client services
7. Village Health Teams
Newborn Service standards
Percent among facilities offering
delivery service (N=261) with items
available in delivery room
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Example of page in the standards handbook
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NEWBORN STANDARDS
How to verify
STANDARD
OPERATIONAL
DEFINITION
MEANS OF
VERIFICATION
Health facility has
infrastructure tocater for both high
risk and normal
babies
Resuscitation space
Nursery spaceKMC beds
Physical check for
their presence
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1. Joint health facility Audit using service standards district and national team
(assessment teams, and tools)
2. On site mentoring of health workers (master trainers, mentoring diaries etc…)
3. Uganda adapted ”Helping Babies Breathe PLUS” Curriculum (PLUS action
plan, flip chart, Hand book, OSCE etc…)
4. Quality Improvement Collaborative (Team in facilities, best practice
identification, select indicators to show practice etc)
5. Facility death audits and response
Implementation Steps
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12
New bo rn R e susci t a ti on
UGANDA HELPING BABIES BREATHE PLUS
American Academy of Pediatrics
American Academy of Pediatrics
PLUS = Es sen t ia l New bo rn Ca r e
ThreeAction Plan
- Infection
- Preterm
- Normal baby
Flip Chart
Learners Handbook
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Present and demonstrateThe cord can present life threatening
complications if no t properly observed
and cared for.
Demonstrate how to clean the cord stump
•Wash hands before touching the stump•Wash with clean water only and put
nothing on the stump
•Keep cord stump dry and uncovered
•Do not apply anything on the cord stump
Demonstrate signs and treatment of umbilical infection
•Reddening around umbilicus or pus
draining from cord
•Treat infection with cleaning cord and
gentian violet
•Treat local umbilical infection three times a
day
Obsep
Practice with ActionPlan
Ask the learners to
practice
• Cleaning the cord
• Make sure the cord is
clean and dry
Follow the Action Plan:
Ask a learners to poin t out
•The action step “advise on
cord care”
Check yourself □Apply nothing on the cord
□ Baby powder and herbs
should be applied to facilitate
cord drying
□Umbilical redness is normal
□A cord should dry and fall off within a few days
Group discussion1. Experience with serious
umbilical cord infection or
tetanus?1.Local practices around
cutting, tying, and treating the
cord?
2.Availability treatment for cord
infection?
Background and educational advice:
Common cord prob lems are bleeding from the cord and infections. Infections of the cord in a newbornand can spread to the whole body causing disease and death. Thus it is important to prevent cord infections bypracticing good care for the cord.
It is important to teach the mother how to observe the cord stump for any bleeding on the first day and
to prevent cord infection: Wash your hands with water and soap before caring for the cord, Use saline waterfor cleaning the cord if it is soiled, do not apply anything such as herbs, animal dung and other treatments on thecord, and do bandage the cord, cover it with a loose piece of clean cloth
The mothers should b e taught th e signs of cord in fection. She should seek medical care if any rednessaround the umbilicus or pus draining from the cord is observed
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Mother Child Health Passport
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• Implementation arrangements
• Successes
• Challenges• Way forward
OUTLINE
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Coverage of facility interventions/packages
Helping Babies Breathe Plus
(HBB Plus)
Maternal and Perinatal DeathReviews (MPDR)
HBB Plus and ICCM
HBB Plus and MPDR
Integrated Community Case
Management
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Successes
1. Zonal/regional master trainers and mentors formed to support MOH and district roll out
– working with national newborn steering committee2. HBB training adapted to cover essential newborn care (HBB Plus) for mentoring –
better counseling and treatment skills
3. Service standards useful for district planning and dialogue for health systems
strengthening + benchmarks for quality improvement
4. Common understanding how to roll out facility newborn care
5. Not only on building health worker skills - institutionalize quality improvement activities
many months after training through regular coaching, learning sessions
6. Newborn indicator manual – addendum of health sector indicator manual
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Results from a maternal and newborn improvement
collaborative in Uganda
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
# of deliveries at a facility in which a
partograph was used265 382 635 966 1159 1270 1264 1779 2122 2149 2110 2335
Total # of women who delivered at the
facility2980 2664 2863 2743 2980 2793 2875 2827 3213 2979 2864 3094
% of mothers in labor monitored with
partograph9 14 22 35 39 45 44 63 66 72 74 75
% of mothers who developed
prolonged/obstructed labor4.7 3.5 3.0 2.9 3.6 2.9 3.0 3.6 3.2 2.9 2.8 3.9
0
10
20
30
40
50
60
70
80
Percent
Partograph use for monitoring labor (45 facilities)
Data reported in
1st learning session
Datareported in
2nd learning session
sensitized staff on
partograph use
reminders to use a
partograph for everymother in labor
IC methodology
introduced
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Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Newborns that received ENC
package650 679 817 1118 1445 1540 1761 2342 2683 2751 2541 2636
Total live births at facility 2745 2668 2766 3070 3235 3290 3401 3405 3740 3688 3345 3528
% new born babies that received
ENC package24 25 30 36 45 47 52 69 72 75 76 75
0
20
40
60
80
Percent
New born babies that received ENC package (45 facilities)
IC methodologyintroduced
1st learning
session 2nd learning
session
Introduced a
checklist for
ENC services
OUTLINE
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• Overview implementation
arrangements
• Progress so far
• Successes
• Challenges
• Way forward
OUTLINE
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Model for Improving facil ity NBC
Improvement in
HW Skills
Strengthening
Health Facility
ClinicalManagement
Skills
Linkwith Village
Health Teams
FacilitySupport
Mentoring Teams Tools
Monitoring
VHTPNC visitsMentoringScaling Up
Standards AssessmentChecklist
Death AuditHF collaborative
Actions
h ll
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Challenges• Health system challenges
– availability of medicine e.g. corticosteroids, antibiotic use at lower levels
• Capacity building
– H/Worker shortage, turnover or transfer constrain mentoring
– Training materials especially procurement dummies
• Lack of equipment – desirable to have all equipment and commodities soon after
training
– Procurement procedures e.g. competitive bidding
– Penguin suction bulbs
• Lack of data for planning and decision making
– Data driven process to solve problems and source support
– Routine HIS not able to report on QI processes, little information on premature births
– Poor staff reporting – e.g. more macerated compared to fresh still births
– Weak birth death registration
Ch ll
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Challenges
• Low utilisation of facility services – combined communication activities needed
– Health facility delivery currently 57%
– Post natal care attendance 29%– Poor referral systems
• Coordinating available resources - it is important to map who is doing what, where and resources
– Piecemeal implementation of the core inputs
– Lesser investment in community mobilization– Human Resource – staffing, housing, poor salaries, training specific cadres
• Tapping other vehicles for NBC implementation – PMTCT, Malaria etc.
• Public private facility engagement
• Focus and awareness on newborn good – negative public reaction, media, politicization and
criminalization of maternal and newborn deaths. Need to have more inclusive implementation
OUTLINE
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• Implementation arrangements
• Progress so far
• Successes
• Challenges
• Way forward
OUTLINE
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Way Forward
• Nationwide health worker mentoring
• Re-equipping all health facilities (MNH)
• Advocacy on newborn survival and rights
• Pre-service training
• Institutionalize further death auditing and problem identification,
response
• Improve data systems for decision making
• Emphasis on preterm births and deaths
• Resource mobilization and better tracking/ synergies with otherinterventions