effective interventions for rmnch: what works? · community based newborn care • released in 2009...
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Effective interventions for RMNCH: what works?
Zulfiqar A. Bhutta
Women & Child Health, Aga Khan University & Global Child Health, Sick Kids, University of Toronto
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Outline
• Child mortality: interventions that address major causes of mortality
• What works and can be packaged together?
• How can we scale up and implement?
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Muslim majority countries
40% of the global burden of stillbirths 40% of the global burden of under 5 deaths
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717,200
713,000
1,077,800
Source: Liu et al. 2012. Global, regional and national causes of child mortality in 2000-2010: an updated systematic analysis. The Lancet. DOI:10.1016/SO140-60560-1.
Global causes of child death for 2010
Preterm birth is a DIRECTcause of 35%
of all neonatal deaths
Moderate to late Preterm
also increases risk of
mortality
Approx 50% of neonatal
deaths,are preterm
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The Challenge of Diarrhea & Pneumonia
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Reduction In Global U5MR By Disease, 2000 to 2010
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What can be done?
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Lawn UNAPSA SAPA 2008
MaternalSeries2006
Repro-ductive HealthSeries2006
The Lancet & MNCH Interventions
Child develop
ment series 2007
Newborn 2005
Child 2003
36 key interventions can make a huge difference if delivered in primary care settings
UnderNutrition
series 2008
Alma Ata
series2008
Stillbirthseries2011
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• First ever multi-stakeholder consensus on what works for RMNCH
• Led by WHO, Aga Khan University and PMNCH with 40+ friends…
• Based on 3 year review – over 50 000 scientific papers
• Packages of care across the continuum of care
• Supports policy making and resource allocation at global and national level
Consensus on essential RMNCH interventions
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Referral HospitalTertiaryUniversity Hospital
SecondaryDistrict General HospitalTaluka Hospital
PrimaryRural Health Center
Basic Health Units
Clinical or Facility-based care
Outreach
Family and Community
Packages
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Pre-pregnancy Pregnancy
Fam
ily/c
omm
unity
Out
reac
h/ou
tpat
ient
Clin
ical
ANTENATAL CARE
- 4-visit focused ANC package
- IPTp and bednets for malaria
- PMTCT
POSTNATAL CARE- Promotion of healthy behaviors
- Early detection of and referral for illness
- Extra care of LBW babies
- PMTCT
- Counselling and preparation for newborn care, breastfeeding, birth and emergency preparedness
Healthy home care including: - Newborn care (hygiene, warmth)- Nutrition including exclusive breastfeeding and appropriate complementary feeding- Seeking appropriate preventive care- Danger sign recognition and cares eeking for illness- Oral rehydration salts for prevention of diarrhoea- Where referral is not available, consider case management for pneumonia, malaria, neonatal sepsis
- Where skilled care is not available, consider clean delivery and immediate newborn care including hygiene, warmth and early initiation of breastfeeding
–OptimisingAdolescent and pre-pregnancy nutrition
– Health education and counseling on risk factors prevention
CHILDBIRTH CARE
– Emergency obstetric care– Skilled obstetric care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation– PMTCT
EMERGENCY NEWBORN AND CHILD CARE - Hospital care of newborn and childhood illness including HIV care
- Extra care of preterm babies including kangaroo mother care
- Emergency care of sick newborns
-Post-abortion care
- STI case management
- Multivitamin and folic acid supplementation
- Family planning - Youth
development programs
- Prevention of obesity
Intersectoral Improved living and working conditions – Housing, water and sanitation, and nutritioneducation and female empowerment
Birth
FAMILY AND COMMUNITY
Integrated Maternal, Newborn, and Child Health PackagesIntegrated maternal, newborn and child health packages of care -Screening and management of chronic diseases especially diabetes
-Genetic counselling
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Promoting Behavior ChangeDemand Creation
Scaling up
Integration as packages of careImproved Referral Systems FACILITATIVE INNOVATIONS
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Pneumonia Diarrhoea
PreventionAdequate nutrition for both mothers and childrenBreastfeeding promotionZinc supplementationHand washing with soap promotionPrevent and treat co-morbidities (e.g. HIV, malaria, among others)
TreatmentImprove care-seeking behaviourImprove IMCI case management at both the community and health facility levels
Vaccination: PCV, Hib, measles, pertussis
Reduce householdair pollution and overcrowding
Antibiotics for IMCI-classified pneumonia
Oxygen therapy
Vaccination:Rotavirus
Safe water and improved sanitation
Oral rehydration therapy, zinc and continued feeding
Antibiotics for dysentery
Prevention and treatment strategies for pneumonia and diarrhoea
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“The road to inaction is paved with research reports”
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®®®®®
®
24H
24H
24H24H
24H
MISSEDOPPORTUNITIES
38 75 40 11 85 49 45 58 73 27 61 88 84 88 95 28 56 40 11 28 50 770
20
40
60
80
100
Pre-pregnancy Pregnancy Birth Postnatal Neonatal Infancy Childhood
Median national coverage of interventions in Muslim Countdown countries based on the most recent measurement since 2006 (%).
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Multi-dimensional povertyIndex
Skilled Birth Attendance
Bhutta et al (Lancet in press)
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Reaching the unreached through community outreach programs
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Community based Newborn Care
• Released in 2009
• Focused on home visits for mothers and newborns in the first week of life – Early breastfeeding – Birth registration – Cord and skin care– Care of low birth weight infants– Birth spacing and maternal
counseling – Recognition of danger signs &
referral
• Few countries have as yet implemented this strategy at scale with data on post-natal visits
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Optimal management of diarrhea
• Approved in 2003
• Recommend for all cases of acute diarrhea1. Low osmolarity ORS2. Oral zinc sulfate 20 mg
daily for 14 days3. Antibiotics in dysentery
• No country has as yet implemented this strategy at scale
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Community management of Pneumonia
“CHWs can be trained to assess sick children for signs of pneumonia; select appropriate treatments; administer the proper doses of antibiotics; counsel parents on how to follow the recommended treatment regimen; follow-up sick children; and refer them to a health facility in case of complications.
There is strong scientific and program evidence to support the effectiveness of this approach.”
WHO/UNICEF Joint Statement, “Management of Pneumonia in Community Settings,” May 2004
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What works in community settings?
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Impact of Community-based Intervention Packages on Neonatal Mortality
29% reduction in neonatal mortality!
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Impact of Community-based Intervention Packages on Maternal Morbidity
Source: Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal. Cochrane Database of Systematic Reviews 2010
25% reduction in Maternal Morbidity!
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Impact of scaling up community based service delivery for diarrhea & pneumonia in Pakistan
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0%
Promotion of breastfeeding
Zinc
ORS
Oral antibiotics for Pneumonia
Poorer
Poorest
These four interventions alone can save 42% of all child deaths among the poorest
quintiles
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What will it take to implement
• Country ownership & Political will • A clear focus on equity as a goal • Evidence based policy making and scaling up interventions in neglected
areas such as – The first 1000 + days to address early risks through preconception care, IUGR
reduction and early nutrition– Target newborn survival as a priority – Linkage with the post-neonatal and young infant care agenda (a clear focus on
reducing Diarrhea & Pneumonia deaths )– Health systems functionality and Quality of Care
• Innovations to accelerate implementation and community demand creation
• Monitoring and Accountability• Changing mindsets
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“My greatest challenge has been to change the mindset of people. Mindsets play strange tricks on us. We see things the way our minds have instructed our eyes to see”
Mohammad Yunus (Nobel Laureate 2006)