Saving Newborn Lives Save the Children-US Postnatal Care: A missing link to save the lives of women and newborns Anne Tinker Women Deliver Conference October 19, 2007 Outline 1. WHY is postnatal care important? 2. WHAT is postnatal care? 3. WHEN? 4. WHAT delivery strategies (how)? WHY postnatal care? Coverage along the continuum of care 100 Coverage (%) 75 50 GAP The days of highest risk and lowest coverage of care require innovation of a PNC package 69 25 0 Antenatal care (at least one v isit from a skilled prov ider) Skilled attendant at birth Immediate Postnatal 65 42 37 8 Early Exclusiv e postnatal breastfeeding (w ithin 2 days) <6 months 3 doses of DPT v accination 30 * Immediate postnatal care is based on the DHS assumption that all facility births get PNC before discharge. Early postnatal care (within 2 days) at home was only measured for home births only in previous DHS Source: Opportunities for Africa’s Newborns, inputs from 28 African DHS from 1998-2005 Newborn lives saved at 90% coverage of packages Referral CHILDBIRTH CARE –Emergency obstetric care –Skilled obstetric care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation, PMTCT Clinical EMERGENCY NEWBORN CARE - Integrated management of childhood illness (IMNCI) –Extra care of preterm babies including kangaroo mother care –Emergency care of sick newborns Primary / First referral Antenatal –Focused 4-visit ANC, including: care •hypertension/preeclampsia8% management •tetanus immunisation •syphilis/STI (6–9%) management reduction •IPTp and ITN for malaria in NMR •PMTCT for HIV/AIDS ANTENATAL CARE –Knowledge newborn care and breastfeeding –Emergency preparedness Childbirth care 27% (18-35%) reduction in NMR –Where skilled care is not available, clean delivery and immediate newborn care including hygiene, warmth and early initiation of breastfeeding POSTNATAL CARE Postnatal care –Early detection and referral of complications 29% –Extra care of LBW babies –PMTCT for HIV (17-39%) reduction in NMR Family/community Outreach/outpatient –Promotion of healthy behaviours –Healthy home care including: promotion of exclusive breastfeeding, hygienic cord/skin care, warmth, danger sign recognition and careseeking for illness –Where referral is not available consider case management for pneumonia, neonatal sepsis Pre-pregnancy Pregnancy Birth Newborn/postnatal WHAT is “postnatal care”? Language… Postpartum = 6 weeks after childbirth for (mother) Neonatal = 28 days after birth (baby) Postnatal = literally means after birth. No specific time period. Taken for mother AND baby from birth to 4-6 weeks Immediate = the first hours after birth Early = the first week of life, with priority given to first 2-3 days What are the interventions in the routine package for MOTHERS? • Routine assessments to identify and manage complications e.g. bleeding, infections, breast abscess, and refer if needed • Promotion of preventive care practices, e.g. breastfeeding, hygiene, nutrition, child spacing etc • Counseling re danger signs • Provision of key services (complete TT course if needed, manage anemia and infections if needed, ITNs, family planning) Adapted from Postnatal chapter, Opportunities for Africa’s newborns. Lawn, Kerber eds, PMNCH, Cape Town 2006 What are the interventions in the routine package for NEWBORNS? • Routine assessments to weigh, and to identify and manage or refer complications • Promotion of preventive care practices – Ensure warmth by delaying the baby’s first bath to after the first 24 hours, practicing skin-to-skin care, and putting a hat on the baby – Support optimal feeding practices, particularly exclusive breastfeeding beginning within the first hour or appropriate feeding if HIV+ – Promote hygiene, cord care, eye care • • • • Encourage and facilitate birth registration Provision of key services – immunization, cotrimozaxole for HIV+ Counseling re danger signs Extra care for preterm and HIV+ babies Adapted from Postnatal chapter, Opportunities for Africa’s newborns. Lawn, Kerber eds, PMNCH, Cape Town 2006 WHEN postnatal care? 4 million newborn deaths - When? Up to 50% of neonatal deaths are in the first 24 hours 75% of neonatal deaths are in the first week – 3 million deaths Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths) WHEN for PNC visits? WHO old Visitmodel If born in facility If born at home After delivery Within 24 hours of birth Pre discharge 1 6 hrs Within 24 after discharge 2 NEW NEW 3 4 6 days 5 6 weeks Day 2 to 3 Day 6 to 7 Week 6 Mother check and FP Baby check, wt and immunisation Adapted from Postnatal chapter, Opportunities for Africa’s newborns. Lawn, Kerber eds, PMNCH, Cape Town 2006 HOW, WHERE and WHO for postnatal care? What delivery strategies can be used to scale up to save newborn lives? Delivery strategies for routine postnatal care Option Possible strategies to provide care for mother and baby Mother and baby go to facility for PNC Skilled provider visits the home Community Health Worker (CHW) visits home Combination: Facility birth and first PNC visit in the facility, then home visit within two to three days, with subsequent PNC visits at the facility Motherfriendly + Providerfriendly +++ Challenges for implementation Mother to come to the facility soon after birth. More likely following a facility birth. Conditional on sufficient human resources Requires policy, human resources, CHWs and management, supervision, and logistic support Requires team approach with facility and CHW, sufficient human resources, good management and supervision, good referral systems, and an efficient information/ tracking system 1 2 +++ + 3 +++ + 4 ++ ++ Postnatal chapter, Opportunities for Africa’s newborns. Lawn, Kerber eds, PMNCH, Cape Town 2006 Conclusions WHY postnatal care? • Current low coverage • Potential lives saved – high impact for mother and baby • Cost low • Achieving MDG 4 and 5 dependent on improved postnatal care WHAT? • Community/home care and behaviours • Routine postnatal care • Emergency care WHEN? • Modification of 6,6,6 to emphasize days 0-3 IMPORTANCE OF EVALUATION • For effective and efficient programs • For maximizing lessons for scale-up HOW, WHERE, WHO? • Examples follow of experiences in – Kenya: Rosemary Kamunya – Nepal: Neena Khadka – Bangladesh: Uzma Syed – Malawi: Evelyn Zimba
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