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Action Plan for Healthy Newborn Infants in the Western Pacific Region: Translating Evidence into Country ActionPresentation by Dr. Howard Sobel, WHO
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WHO-Western Pacific Region:
Howard Sobel MD, MPH, Reproductive, Maternal, Newborn, Child and Adolescent Health Programme Coordinator
Viet Nam:
Dr. Duong Thi Hai Ngoc, Maternal and Child Health Department, Ministry of Health;
Dr Hoang Tran, Da Nang Hospital for Women and Children
Philippines:
Dr Anthony Calibo, Newborn Care Program Manager, Department of Health
Translating Evidence into Country Action 10-12 April 2015
Source: China other NS, Cambodia DHS 2000-2014, Lao PDR 2000,2006 MICS, 2011 LSIS; Philippines 1993-2014 DHS, FHS, PNG: DHS 1996 & 2006 , Viet Nam, 1997 & 2002 DHS, 2000, 2006, 2011 MICS
Trends- Deliveries assisted by trained health staff
Major causes of death in neonates and children under-
five in the Western Pacific Region - 2012
Source: WHO. Global Health Observatory (http://www.who.int/gho/child_health/en/index.html)
Neonatal deaths: 56%
Every 2 minutes, 1 newborn dies in the Western Pacific Region
231 000 neonatal deaths in the Western Pacific Region every year
1 represents 100 neonatal deaths WHO Global Health Observatory, 2011
Source: Sobel, Silvestre et al, Acta Paediatrica (2011), Philippines
Philippines: documenting the problem
If this benefits babies,
Skin-to-Skin Contact Separated from mother
Why is this so common?
Immediate drying, delayed cord clamp
Immediate cord clamp, delayed drying, suction
All
At Risk
First Embrace
Preterm and Low Birth Weight
Sick Newborns
Intrapartum Care Newborn Care
• Labour Monitoring (Partograph) • Intrapartum care
Preterm Labour
• Drying • Skin-to-skin contact • Clamping and cutting the cord appropriately • Initiating exclusive breastfeed
Routine care – eye care, vitamin K, immunizations, weighing and examinations afterwards
• Eliminate unnecessary inductions &C-section
• Antenatal steroids • Antibiotics for
pPROM
• Kangaroo Mother Care • Breastfeeding support • Immediate treatment of suspected infection
Obstructed/Prolonged Labour, Foetal Distress
• Assisted delivery • C-section
Not breathing at birth • Resuscitation
Suspected sepsis • Antibiotic treatment
Benchmark KHM CHN LAO MNG PNG PHL SLB VNM
Newborn situation analysis +++
+++ +++ +++ +++ +++ +++ +++
EENC Action Plan +++
+++ +++ +++ +++ +++ +++ +++
EENC Action Plan costed +++
+ +++ +++ No +++ +++
+++
EENC technical working / coordination group formed
+++ +++ +++ +++ +++ +++ +++
+++
Full-time EENC/newborn MOH focal person identified
+++ No +++ No +++ +++ +++
++
EENC stakeholder group organized to engage political leaders and champions
No ++ +++
No ++ +++ No +
Clinical Protocol adapted +++ No +++ +++ ++ +++ ++ +++
Consensus-building workshop
+++ + +
+
+++
+++ ++ +++
Mechanisms established to ensure professional assoc membership implement EENC
+
No +++
++ +++ +++ No No
WHO-UNICEF scale up readiness (Aug-Nov 2014)
+++ Yes, Done ++ On-going/Partial, + planned no
Regional tools to support countries to change practitioner behaviour
Modules for EENC • National Situation Analysis and
Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching (Facilitator Guide) • Annual Implementation Review and
Planning • Monitoring and Evaluation • Communications: Info kits, promotional
videos, website www.thefirstembrace.org
Viet Nam – Full Speed Ahead
Regional tools to support countries to change practitioner behaviour
Modules for EENC • National Situation Analysis and
Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching (Facilitator Guide) • Annual Implementation Review and
Planning • Monitoring and Evaluation • Communications: Info kits, promotional
videos, website www.thefirstembrace.org
Planning process for EENC • Bottleneck Analysis conducted June-Aug 2013
• Additional pre-plan info collected
May- July 2014
• National consultations on EENC National Action Plan for 2014-2020
Sep 2014 – Jan 2015
• Adoption by MOH • Part of Master Plan on RMNCH Dec 2014
• Mobilizing resources for supporting implementation 2014-2015
Establish Stakeholder Coordination
• MOH and WHO initiated process • Government: MOH, national and regional,
provincial and district hospitals • UN agencies: WHO, UNICEF • INGOs: A&T, Save Children, Plan
International, World Vision • Reproductive Health Technical Group
Current progress • National guidelines on EENC approved by MOH • National Action Plan on EENC developed • Clinical Pocket book adapted • Three Centres of Excellence initiated:
– EENC support team formed – Health staff coached on EENC – Health Facility Strengthening approach introduced
• 124 provincial facilitators trained • About 3000 health staff of provincial level
coached on EENC
Regional tools to support countries to change practitioner behaviour
Modules for EENC • National Situation Analysis and
Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching (Facilitator Guide) • Annual Implementation Review and
Planning • Monitoring and Evaluation • Communications: Info kits, promotional
videos, website www.thefirstembrace.org
Update clinical protocol (July 2014 – April 2015)
• Local expert team established • WPRO pocket book translated into local
language • Technical workshop to review the pocket
book with TA from international consultant • Finalization • Formatting, printing and distributing
Regional tools to support countries to change practitioner behaviour
Modules for EENC • National Situation Analysis and
Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching (Facilitator Guide) • Annual Implementation Review and
Planning • Monitoring and Evaluation • Communications: Info kits, promotional
videos, website www.thefirstembrace.org
Why do traditional training-based approaches not change practice?
• Do not start with understand the larger context • Assume participants have no previous
knowledge; – do not identify & start with health worker beliefs
• Do not change systems in which health workers operate
• Do not affect facility policies which support incorrect or harmful practices
• Do not change attitudes of senior decision-makers, often based on outdated standards
How is coaching different? • 2-day coaching in a delivery room creates
a realistic environment • No lectures • Health workers demonstrate their current
practices unassisted to establish baseline • Facilitators coach participants until
newborn care steps are mastered • Pre- and post-coaching evaluations of
clinical practice, knowledge and hand hygiene ensure participants meet minimum standards
20
Hand Hygiene Pre and Post Tests
• Draw an outline of both hands (front and back) on A4 paper.
• Rub Glow Germ all over hands.
• Wash their hands. • Shine UV Light onto their
hands. • Mark areas with Glow
Germ still present on the hands outlined on the A4 paper.
WHO Western Pacific Regional Office
Checking equipment Setting up newborn resuscitation
area
No more waiting until a non-breathing baby to set up resuscitation area and find leaking equipment 22
Setting up delivery space, dry towel on “bare” abdomen
Left-handers discover it is easier if the equipment is on the left side 23
Dry baby, remove wet cloth, put in immediately in skin-to-skin contact,
and cover with dry cloth
Every participant has to demonstrate supervised drying alone and as part of sequenced actions 24
Clamp and cut the cord once after pulsations stop
No more unnecessary separations and exposure to dirty surfaces needed for “trimming” the cord
25
Counseling mothers on feeding cues
• Babies will be ready to breastfeed when they show the following signs: – Drooling – Mouth opening – Tonguing/licking – Rooting – Biting hands/fingers – Crawling No more forced breastfeeds
26
Practicing Bag and Mask Ventilation for non-breathing babies (after
thorough drying)
Each movement of health workers are examined. Unnecessary movements are eliminated so that chest rise can happen in the “golden minute” 27
Results of Coaching, 6 countries
28
Status of INC coaching in Cambodia (June, 2014)
70% 53%
30% 47%
0%10%20%30%40%50%60%70%80%90%
100%
Referral hospitals Health centers
Staff not trainedStaff trained
Results of Coaching • “Staff usually don’t want to go back to the next day, but they
were excited to continue” -- Viet Nam
• “After practicing the new approach…the babies are stronger, they breathed better than the other approach; they turned pink faster”-- Cambodia
• “The delivery room was quiet”… “The babies were so quite, we were worried. We prodded them to make them cry to make sure they were ok” -- Mongolia
• “Oh, that feels so good, thank you doctor”--Philippines – “That was the first time I was thanked’ --Philippine doctor
• “Thank you doctor for bringing this to my country”—Viet Nam
• “Until this coaching, I thought of newborns as specimens needing things to be done; now I realize they are highly emotional beings…” –Solomon Islands 30
Da Nang Hospital for Women and Children, Viet Nam: Translation of
National and International Guidelines into local action
ĐÀ NẴNG • Surface area: 1257,3km2 • Population: 1 million • Hospital catchment: 10 million • Hospital births:~15,000
Timeline of Events in Da Nang Hospital, Viet Nam
May
• Da Nang Health Department and A&T discussions • Attending EENC WHO/UNICEF workshop • Training key staff
Jun-Jul
•First EENC case for normal delivery 5/7/2014 • Training more staff with A&T financial support •Being trained by WHO and MOH
Aug-Sep
•First EENC case for C-section baby 15/9/2014 •Participating EENC workshops run by WHO and MOH •Establishing official Hospital EENC team •Protocol for EENC in operating room
Oct-Nov
• EENC for all applicable C-section baby 20/10/2014 • Training for staff with A&T financial support • Decree and EENC guidelines from MOH
Jan-Mar
• Training staff with WHO support on health facility strengthening and M&E
• Reinforcement of EENC activities
2014
2015
• 20 hospital staff were trained to be EENC facilitators • EENC facilitators coached
– 185 hospital staff – 86 health professionals from other Da Nang
hospitals – 90 health professionals in Quang Nam Province
• Monitoring trips to Gia Lai, Quang Ngai province
Coaching results and extent in central region
Normal delivery
478
539 489
401 382 334
459
533
468
377 369
305
0
100
200
300
400
500
600
Sep Oct Nov Dec Jan Feb
Total S2S
C-section
877
760 696
741
576
159
671 656 691
546
0
100
200
300
400
500
600
700
800
900
1000
Oct Nov Dec Jan Feb
Total S2S
Outcome
“As compared to the 2 previous C-sections, I found warmer, happier and more satisfied to be with my baby
After C-section for twins
Midwife “We now do not use much resuscitation area as baby and mother are well themselves
Outcome
3.2
5.3
6.8
5.5
2.7 2.5 2.7
5.7
8.3
6.6
0
1
2
3
4
5
6
7
8
9
NICU admission % oflivebirths
Antibiotic use % oflivebirths
Death ‰ of livebirths Exclusive breastfeedingon discharge per 10
babies in neonatal unit
Exclusive breast feedingper 10 randomly babies
in normal nursery
Before EENC After EENC
Gaps found during health facility strengthening process
• High C-section rate • Formula feeding during hospital stay • Short period skin-to-skin for two-thirds
babies with normal delivery • Resuscitation areas not in operating
theatre
Next steps
• Continue regular meetings • Perform monthly exit interview and
observation with checklist • Solve problems • Train staff in hospitals in the regions • Monitor other hospitals • Establish EENC team for the region • Make use of public media • Attract support from all possible sources
Regional tools to support countries to change practitioner behaviour
Modules for EENC • National Situation Analysis and
Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching Session Facilitation • Annual Implementation Review and
Planning • Monitoring and Evaluation • Communications: Info kits, promotional
videos, website www.thefirstembrace.org
Using evidence to inform practice: Health facility data collection in the
Philippines
EENC in the Philippines
• National Action Plan for EENC adopted and costed in 2013
• WPR EENC M&E Framework pilot led by DoH
• Data collection forms sent to facilities implementing EENC
• On-going guidance provided to facilities, visits made
• Data being entered into web-based DHIS 2 or Excel
• Pilot in April & May 2015 Source: Wikipedia map, 2015
EENC in the Philippines
Facilities included in the EENC M&E Framework Pilot
Facility Level Total, #
Implementing EENC, # (%)
EENC facilities included in pilot,
# (%) DOH (National Capital Region)
10 8 (80%) 8 (100%)
DOH Regional 47 39 (83%) 39 (100%) NCR LGU and military hospitals
25 20 (80%) ?
Provincial and Chartered City Hospitals
105 87 (83%) ?
Philippines EENC Coverage Indicators
Coverage measure 2014 Target 2020
% of live births attended by skilled health personnel
72.8% 90%
% of live births that take place at health facilities 61% 90%
% of live births delivered by caesarean section 9.3% 5-15% % of live rural births delivered by caesarean section
7.6% 5-15%
% of newborns breastfed within one hour of birth 49.7% 100% % of live births with a reported birth weight 80.1% 100% % of women who received postnatal care within two days of birth following discharge from facility
70.1%* 80%
% of newborns receiving postnatal care within two days of birth following discharge from facility
52.6% 80%
Source: NDHS 2013 *By skilled providers (doctors, nurses, midwives) only
EENC M&E in the Philippines
Impact Indicators for Newborn Health
Data required
Indicator 2014
Neonatal deaths
Neonatal mortality rate (per 1000 LB) 13 Perinatal mortality (per 1000 LB) 22 Proportional causes of NN death: • Sepsis • Birth asphyxia • Complications of pre-term birth
? ? ?
Prematurity/Low birth weight
Prevalence of low birth weight (<2500g)
21.4%
Prevalence of pre-term birth (< 37 weeks)
2.6%
Source: NDHS 2013
Regional tools to support countries to change practitioner behaviour
Modules for EENC • National Situation Analysis and
Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching Session Facilitation • Annual Implementation Review and
Planning • Monitoring and Evaluation • Communications: Info kits, promotional
videos, website www.thefirstembrace.org
Review & Planning Process • May 2015
• 14 national and sub-national hospitals will be visited to observe practice, review charts & interview mothers and staff
Twelve-Month Detailed Implementation Plan for Early Essential Newborn Care, PHL, 12/3/2013
1. Establish Steering Committee 2. Finalize the Newborn Action Plan 3. Local adaptation of the Clinical
Pocketbook for EENC 4. Health facility strengthening 5. Review and revise pre/in-service
training curriculae 6. Develop EENC information tool kit 7. Implementation review 8. Enforce Milk Code 9. Strengthening MBFHI/accreditation
Activity Actions Responsible Timing 1.Establish Steering Committee
• Develop Terms of Reference. • Agree on membership (proposal: Dr
Bounnack to chair, MCH, Dept Training and Research, Dept Hygiene and Health Promotion, National Hospital representatives (Mitaphap, Sethathirath, Mahosoth, Mother and Newborn Hospital), WHO, CICH, UNICEF, UNFPA, Save the Children, Pediatric Society, Obstetric Society, representatives of midwives, nurses).
• Develop and pass decree. • Monthly meetings; intense follow up
between meetings • Development of timelines, annual
reviews and operational plans.
Somanah Rattana (Terms of reference, membership, frequency of meetings etc)
January 2014 - decree
2.Finalization of the Laos Action Plan for Healthy Newborns (LAP)
• Validation of worksheets on policies and guidelines.
• Develop Zero draft LAP. • Steering committee review of LAP. • Stakeholder review of LAP. • Finalization of the LAP. • MOH adoption of the LAP. • Printing copies
Somanah Rattana Eunyoung Final edited version Approval for draft Print and distribute
January 2013
3.Local adaption of the Clinical Pocketbook for Early Essential Newborn Care
• Presentation of the regional clinical pocket guide (CPG) to Steering Committee.
• Identify sub-group who will work on the local adaptation. • Adaptation by sub-group. • Translation of first draft adaptation. • Visit by Dr. Mianne Silvestre to coordinate final review of
adapted and translated guidelines. • Stakeholder reviews of adapted version. • Report progress to the Steering Committee and finalization of
CPG • Complete translation – back translation – consensus on final
version • Format, produce and print final consensus version
Eunyoung Tiengthong
January – February 2014 final translated version agreed Formatting, printing, production February – April 2014
4.Health Facility Strengthening for EENC
• Identify group who will be responsible for initial work and planning the scale up in 2 national hospitals; get approval from hospital directors
• Field visit to Philippines – EENC sites + implementation training
• Begin process of early implementation into hospitals (Adapt/translate EENC implementation training materials/course guidelines; adapt/translate EENC implementation guide – based on existing PHL version – including monitoring and evaluation indicators; adapt/translate resource person training guide; train hospital teams
Eunyoung Phommady Vesaphong (MCH)
Mahosot ( TBD) J. Murray/M. Silvestre
Oct 6-11- 2-3 staff visit PHL for EENC training and field visits Begin adaptation of EENC implementation materials and guidelines February/March 2014 – June 2014
5. Review and revise pre-service training curriculae and in-service training materials
• Local consultant reviews pre-service curricula and in-service materials
• EENC gaps identified • Consultative process to propose edits/modification • Consensus on modifications needed • Begin process of adapting or modifying curriculae or materials
MOH: Dr. Saiyadeth Local consultant to make edits/changes nd to coordinate review meetings Eunyoung
January 2014 – May 2014 review June 2014 – December 2014 consultative process
6. Develop EENC information tool kit for use by trainers, academic staff in pre- and in-service training
• Map existing materials • Adapt and translate for Lao context • Print and produce materials
Eunyoung WHO/WPRO
Identification, adaption and translation of materials - April 2014 – June 2014
7. Develop social marketing and advocacy approach for EENC and begin implementation
• Develop social marketing approach • Develop messages, materials, media • Begin implementation of social marketing approach
coordinated with hospital implementation
MOH: Eunyoung WHO/WPRO Menzies/Merritt
Approach and materials - May 2014 – onwards Implementation – July 2014 – onwards
8. Conduct EENC program implementation review – early implementation hospitals
• Develop method, materials and indicators • Conduct review • Use data to make program decisions
MOH: J Murray/M Silvestre Eunyoung WHO/WPRO
Method, materials, indicators September 2014 Conduct review – November 2014
9.Strengtheni Code on Marketing of Breast-milk Substitutes
• MOH and UNICEF to lead stakeholders for planning for legislative development.
• MOH-UNICEF drafting of the legislation with participation from WHO + Save the Children
• WHO to support developing briefing materials • ?Role of Ministry of Culture and ?
MOH UNICEF WHO
Regular updates of Steering Committee from UNICEF and WHO 2014
10.Institutionalizing BFHI+ accreditation
• Need inputs from Dr Bounnack what is feasible and how to do it.
Sommana Rattana Discuss with Dr. Bounnack