Sri Lanka & MDG 4: beyond 2015

Sri Lanka & MDG 4: beyond 2015SAPA meeting:Lahore,Pakistan

November 2014Prof Dulanie Gunasekera

University of Sri JaywardnepuraSri Lanka

MDG & SL statistics

• MDG-4

Causes of U-5 mortality

Global (2010) Sri Lanka (2012)

Source: feto-infant mortality report(2012) FHB

Source: child health epidemiology group,Lancet;379(9832:2151-61

NND54%

Causes of Infant deaths- SL (2012)

Source: FHB 2012

Asphyxia 12%

Sepsis10%

Prematurity & LWB26%

Congenital abnormalities

41%

Other11%

Asphyxia

Sepsis

Prematurity & LWB

Congenitial Abnormalities

Other

Percentage distribution of infant deaths according to age at death 2012 (FHB)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2007 2008 2009 2010 2011 2012

Early neonatal deaths

Late neonatal deaths

Post neonatal deaths

Distribution of births in hospitals in SL(2010)- 99.9% births

Babies die in hospitals

Prevention/ management of preterm births(26%)

BOTTLENECKS

• Timely use of cortico-steroids, AB for PROM

• Rx of pre eccalmpsia

• Transfer high risk mother to tertiary facility

• Poor NN retrieval/transport system

• Weak communication between referring institutions

• implementation of guidelines/STP- further strengthened(SLCOG)

• Improve AN transfer & NN retrieval services(PNSSL started)

• Better communication/ ICU & NICU bed surveillance –initial system in place

• Needs strengthening

STRATEGIES & SOLUTIONS

Management of Birth Asphyxia(10%)Neonatal Resuscitation

BOTTLENECKS

• Standard training modules in place – BLS

• No regular in service assessments

• NNR not mandated as essential skill for all SBA’s

• No revalidation process

• Funding constraints-

• accelerated ,sytematictraining programmes by SLCP

• strengthen monitoring/ evaluation

• SLCP in process of mandating with MoH

• MoH to initiate revalidation process

• MoH to fund


Neonatal ResuscitationAdvanced Neonatal Resuscitation Module

BOTTLENECKS

• For MO’s – NALS optional a present

• Need to make requirement

• Emergency equipment - not ideal in labourrooms/theaters

• Training models –(mannikins) not freely available for simulation in units

• MoH/SLCP – to mandate NALS for MO’s in SCBU

• Regular training- MoH /SLCP

• MoH - provide funding- for training, equipment (rather than WHO/UNICEF)

• Stringent maintenance requirements (check lists) -implementation- MoH


Basic Newborn CareEssential newborn care Module

BOTTLENECKS

• Need to inculcate staff on ENC concepts -

• to deliver the baby to mother’s abdomen

• skin-to-skin contact

• Temperature control (KMC)

• Establishing breast feeding

• Delayed cord clamping (small baby)

• Mandatory training & re-validation of ENCC for SBA’s

MoH /SLCP to initiate

• Regular W/shops on ENCC

• Promote clinical audit by medical & nursing staff


Basic newborn careKangaroo Mother Care(KMC)

BOTTLENECKS

• Implementation of KMC at the facility level not ideal

• Staff not confident

• No system to deliver KMC at community level

• KMC not scaled up as intervention.

• Train/ motivate staff-paediatrician to play leadership role, scale up

• PHM to educate/train PN mothers at home

• Set up Mother-Baby Units(MBU)- low cost units, ideal for KMC


Prevention of neonatal infections(10%)barrier nursing principles

BOTTLENECKS

• hand washing protocol-poorly followed

• Barrier nursing principles

• Poor supplies of -

• Antiseptic liquid soap (iodophore-iodine or chlorhexidine scrub) -

• Single use clean, dry towels

• Use of hand alcohol scrub –not universal

• Infection control training

• Adequate funding for consumables

• Adequate supplies

• Infection audits & check lists


Evidence Based Intervention; Clean Delivery

Quality gap; Missed opportunity (Abeysekera, 2010)

Scaling up carefor the

Sick Newborn

Inpatient care for small and sick newbornsNICU care, feeding support and safe oxygen

BOTTLENECKS

• Poor utilization of CPAP/ proper ventilation

• Reluctance of initiation of early breast feeding

• TPN – not freely available

• Sick Newborn Manual –guidelines for NICU care-finalized: needs rolling out

• Staff training: on concept of CPAP/ ventilation – W/shops

• importance of trophic feeding/ assisted feeding

• TPN- MoH to initiate facilities & funding

• Paediatricians/SLCP to play key role in training


Treatment of severe infections

BOTTLENECKS

• Not adhering to clear guidelines on use of AB

• Overuse/ misuse of AB

• Early identification of sepsis at facility level

• delay in recognition of danger signs(community) and prompt referral

• Ensure universal use of guidelines/ STP’s

• Adherence to hospital Antibiotic policy - MoH to monitor

• Strengthen early identification of danger signs by PHM/ MOH & timely referral


INFRASTRUCTURE

distance to hospital /SCBU / NICU facility

Curative care: hospital distribution Distance to hospitals with SCBU

Human resources & equipment

BOTTLE NECKS

• Staffing constrains

• Adequate equipment

• Standard setting for SCBU/NICU


• Standard setting –Minimum requirements for levels of SCBU/NICU

• Minimum staffing ratio –nurses, doctors, MW

• EmNOC survey (2012) - did needs analysis- MoH to conform to needs

Reducing post neonatal causes

• Congenital defects

CHD (11%)

• Neural tube defects(5%)

• Severe RI (7%)

• DHF(<1%)

• Infrastructure

• Human resources/ staffing

• Financing

• Pre-preg FA supplementation

• Early detection

• AB policy

• Pneumococcal vaccine?

Dengue H’gic Fever

• early case detection- clinical- public awareness

lab – Dengue NS1 Ag test

• Improving case management – staff training(WHO team, Thailand), incorporated into paediatric PG curriculum

• Dengue corners in hospitals/wards

• PREVENTION – vector control – breeding site surveillance

• legal action taken

• Dengue Task Force/ Centre for Clinical Mx of DHF

Other issues - Nutrition

• Nutritional promotion &

support – IYCF strategy

• Supplementation –

thriposha

Vit A mega dose

Iron(anemia in pregnancy

and infancy)

Folic Acid ( pre pregnancy)

LBW 17%

Medical Information System(MIS)

• Transition into real time data base- E-IMMR

• Networking NICU/SCBU/maternity units

• Bed surveillance system initiated

• Feto- infant mortality survey & birth defect register initiated

• NN morbidity/paed. death reviews to start soon

Policy Framework• National Policy on Maternal and

Child Health, 2012

• Sri Lanka Code for Promotion,

Breastfeeding and Marketing of

Designated Products, 2002

• National Strategic Plan on Maternal

and Newborn Health, 2012-2016

• National Nutrition Policy, 2010

• IYCF strategy – 2007

• LBW prevention strategy( being

formulated)

Post 2015 agenda reduce NNMR

• Improve facilities/staffing of the neonatal units

• identify levels of NB care

• Staff training -improve knowledge/skills

• Establish NN retrieval system & proper communication

–

• Neonatal Forum established (2014)

24

Post 2015 agendaReduce U-5 MR- post NN causes

• Advanced Paediatric Life support

• PICU bed surveillance system & increase PICU beds

• Immunization - Pneumococcal vaccine?

• Case management- Paediatric STPs, DHF training

• Anaemia & nutritional support

• Expand paediatric cardiology

• Paediatric / neonatal retrieval system

• Paediatric death reviews

Thank you

• Acknowledgments:

• Dr. Srilal de Silva

• Dr. Dhammica Rowel

• Family Health Bureau

NN information system

New born formats used in all the hospitals

Information from the same included into the eIMMR

NICU surveillance & bed system(networking NICU’s) to be initiaited

feto infant mortality surveillance/birth defect surveillance initiated

NN morbidity audits – to be initiated

Born Too Soon

Of the 6.9 million who die

before their 5th birthday…..

Preterm birth is the second leading cause of death for children under 5 years, after pneumonia

1.1 million babies die directly from complications of preterm birth

Over 40% die in their first

month

Source: CHERG/WHO estimates for 2010, Li Liu et al Lancet in press, 2012

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Figure 1

Joy E. Lawn(2013) 74, 00-00. doi:10.1038/pr.2013.202

Where do we stand?MDG 4 - Reduce child mortality

– Under 5 mortality fell 41% from 1990– Sub-Saharan Africa doubled its average rate of reduction : 1.2 % in 1990-2000 to

2.4 per cent during 2000-2010

MDG 5a - Improve maternal healthMaternal mortality fell 47% from 1990

MDG 5b - Universal access to reproductive healthBy 2008, more than 50%women aged 15 -49yrs were using contraception

MDG 6 - HIV/AIDS, malaria and other diseasesNew HIV infections declined; Proportion of women living with HIV remains stable at

50%

SRILANKA

MDG 4: child mortality -

Starting at a baseline of 21.5/1,000 live births in 1990, the country has made progressed to 9.6/1,000 live births in 2010, very slightly off track to meeting the goal of 7/1,000 for 2015.

MG 5: maternal health -

Sri Lanka’s initial maternal mortality ratio of 85/100,000 live births in 1990 decreased to 35/100,000 by 2010. This is on track to meeting the MDG target of 21/100,000 maternal deaths by 2015.

32

Intervention packages for reduction of neonatal deaths by current mortality rates

Estimated effect of the number of neonatal lives saved by the different intervention packages by the year 2025

33

The Lancet Newborn Interventions Review Group and The Lancet Every Newborn Study Group . Every Newborn 3 - Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet Early Online Publication, 23 June 2014. doi:10.1016/S0140-6736(14)61001-1

Monitoring for quality issues

PRIORITY BOTTLENECKS

• Administrative, procurement and proper resource allocation issues.

• Out of pocket payments required by clients

• Quality issues and lack of proper monitoring / accountability mechanism

STRATEGIES AND SOLUTIONS


• Proper record keeping, monitoring / accountability mechanism in place

• Child Death audit have not initiated in the facilities (SCNUs) managing severe infections

Goal 4: Reduce Child Mortality

MDG 4 Target

Reduce by two-thirds, between 1990 and

2015, the under-five mortality rate

Indicator

Under-five mortality rate

Infant mortality rate

Proportion of 1 year-old children

immunized against measles

35

Causes of Under 5 mortality

In Sri Lanka Globally

Neonatal 75.1

Child Health Epidemiology Reference Group. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000, 2012. Lancet; 379 (9832):2151-61

Global causes of childhood deaths in 2010

WHO Regional Office for South East Asia. Situation of Newborn and Child Health in South East Asia, Progress towards MDG 4, 2014

Causes of under 5 mortality in Sri Lanka

Progress towards MDGs in SEA Region countries-2010

37

RH services- preconception

BOTTLE NECKS

• Preconception folic acid

• Family counseling by PHM


• In place – compliance?

• Strengthen awareness-publicity campaigns

• Mass media

Causes of Child(u-5) Mortality SL - 2009

Source: Registrar General’s Office

Treatment of severe infections

PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS


• late identification and referral to facility for treatment

• Not following guidelines on use of antibiotics

• Overuse and misuse of antibiotics

• Clear identification of early and late sepsis at facility level

• Poor care seeking behavior -(delay in recognition of danger signs and prompt referral) of the community

• Strengthen on early identification of danger signs by PHM and MOH, timely referral

• application of Standard Treatment Protocols

• Adhere to antibiotic policy

13th Annual Academic Sessions Perinatal Society of Sri Lanka 2014

41

Goal 4: Reduce Child Mortality

Indicator Data Source

Baseline Current Target

Under-five mortality rate (per 1000 live births)

SL 22.2 (1991) 12.1(2009) 8

UNIGME

21(1990) 10(2012) 7

Infant mortality rate (per 1000 live births)

SL 17.7 (1991) 9.7(2009) 6

UNIGME

18(1990) 8(2012) 6

Proportion of 1 year-old children immunised against measles

84 % (1990) 97.2% (2006/7)

100%

Care around the time of birth; a triple return on investment

Source: Special analysi;The Lancet ,Every Newborn Series,,May 2014

More than 3 million babies and women could be saved each year through investing in quality care around the time of birth.

Causes of Under 5 mortality

Sri Lanka Globally

Neonatal 75.1

Child Health Epidemiology Reference Group. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000, 2012. Lancet; 379 (9832):2151-61

Global causes of childhood deaths in 2010

Source: Registrar General 2009

Causes of under 5 mortality in Sri Lanka 2009

54%

Trends in IMR & NNMR - SL

Source – FHB,SL: 2012

Healthcare

Sri Lanka & MDG 4: beyond 2015