Tanya Guenther

Newborn survival in Uganda: a decade of change and future implications

Each year in Uganda 141 000 children die before reaching their fifth birthday; 26% of these children die in their first month of life. In a setting of persistently high fertility rates, a crisis in human resources for health and a recent history of civil unrest, Uganda has prioritized Millennium Development Goals 4 and 5 for child and maternal survival. As part of a multi-country analysis we examined change for newborn survival over the past decade through mortality and health system coverage indicators as well as national and donor funding for health, and policy and programme change. Between 2000 and 2010 Ugandas neonatal mortality rate reduced by 2.2% per year, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period. While existing population-based data are insufficient to measure national changes in coverage and quality of services, national attention for maternal and child health has been clear and authorized from the highest levels. Attention and policy change for newborn health is comparatively recent. This recognized gap has led to a specific focus on newborn health through a national Newborn Steering Committee, which has been given a mandate from the Ministry of Health to advise on newborn survival issues since 2006. This multi-disciplinary and inter-agency network of stakeholders has been able to preside over a number of important policy changes at the level of facility care, education and training, community-based service delivery through Village Health Teams and changes to essential drugs and commodities. The committees comprehensive reach has enabled rapid policy change and increased attention to newborn survival in a relatively short space of time. Translating this favourable policy environment into district-level implementation and high quality services is now the priority.

Count every newborn; A measurement improvement roadmap for coverage data

BackgroundThe Every Newborn Action Plan (ENAP), launched in 2014, aims to end preventable newborn deaths and stillbirths, with national targets of ≤12 neonatal deaths per 1000 live births and ≤12 stillbirths per 1000 total births by 2030. This requires ambitious improvement of the data on care at birth and of small and sick newborns, particularly to track coverage, quality and equity.MethodsIn a multistage process, a matrix of 70 indicators were assessed by the Every Newborn steering group. Indicators were graded based on their availability and importance to ENAP, resulting in 10 core and 10 additional indicators. A consultation process was undertaken to assess the status of each ENAP core indicator definition, data availability and measurement feasibility. Coverage indicators for the specific ENAP treatment interventions were assigned task teams and given priority as they were identified as requiring the most technical work. Consultations were held throughout.ResultsENAP published 10 core indicators plus 10 additional indicators. Three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well defined, with future efforts needed to focus on improving data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing. Measurable process indicators to help monitor health service readiness are also presented. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care.ConclusionsThe ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. Real measurement change requires intentional transfer of leadership to countries with the greatest disease burden and will be achieved by working with centres of excellence and existing networks.

Measuring Coverage in MNCH: indicators for global tracking of newborn care.

In a PLOS Medicine Review, Allisyn Moran and colleagues introduce the work of the Newborn Indicators Technical Working Group (TWG), which was convened by the Save the Childrens Saving Newborn Lives program in 2008, and describe the indicators and survey questions agreed upon by the TWG to measure coverage of care in the immediate newborn period.

Benchmarks to measure readiness to integrate and scale up newborn survival interventions

Neonatal mortality accounts for 40% of under-five child mortality. Evidence-based interventions exist, but attention to implementation is recent. Nationally representative coverage data for these neonatal interventions are limited; therefore proximal measures of progress toward scale would be valuable for tracking change among countries and over time. We describe the process of selecting a set of benchmarks to assess scale up readiness or the degree to which health systems and national programmes are prepared to deliver interventions for newborn survival. A prioritization and consensus-building process was co-ordinated by the Saving Newborn Lives programme of Save the Children, resulting in selection of 27 benchmarks. These benchmarks are categorized into agenda setting (e.g. having a national newborn survival needs assessment); policy formulation (e.g. the national essential drugs list includes injectable antibiotics at primary care level); and policy implementation (e.g. standards for care of sick newborns exist at district hospital level). Benchmark data were collected by in-country stakeholders teams who filled out a standard form and provided evidence to support each benchmark achieved. Results are presented for nine countries at three time points: 2000, 2005 and 2010. By 2010, substantial improvement was documented in all selected countries, with three countries achieving over 75% of the benchmarks and an additional five countries achieving over 50% of the benchmarks. Progress on benchmark achievement was accelerated after 2005. The policy process was similar in all countries, but did not proceed in a linear fashion. These benchmarks are a novel method to assess readiness to scale up, an important construct along the pathway to scale for newborn care. Similar exercises may also be applicable to other global health issues.

A Health Systems Approach to Integrated Community Case Management of Childhood Illness: Methods and Tools

Integrated community case management (iCCM) of childhood illness is an increasingly popular strategy to expand life-saving health services to underserved communities. However, community health approaches vary widely across countries and do not always distribute resources evenly across local health systems. We present a harmonized framework, developed through interagency consultation and review, which supports the design of CCM by using a systems approach. To verify that the framework produces results, we also suggest a list of complementary indicators, including nine global metrics, and a menu of 39 country-specific measures. When used by program managers and evaluators, we propose that the framework and indicators can facilitate the design, implementation, and evaluation of community case management.

Beyond Distance: An Approach to Measure Effective Access to Case Management for Sick Children in Africa

Health planners commonly use geographic proximity to define access to health services. However, effective access to case management requires reliable access to a trained, supplied provider. We defined effective access as the proportion of the study population with geographic access, corrected for other barriers, staffing patterns, and medicine availability. We measured effective access through a cross-sectional survey of 32 health facilities in Malawi, Mali, and Zambia and modeled the potential contribution of community case management (CCM). The population living within Ministry of Health (MOH)–defined geographic access was 43% overall (range = 18–52%), but effective access was only 14% overall (range = 9–17%). Implementing CCM as per MOH plans increased geographic access to 63–90% and effective access to 30–57%. Access to case management is much worse than typically estimated by distance. The CCM increases access dramatically, again if providers are available and supplied, and should be considered even for those within MOH-defined access areas.

Contribution of community-based newborn health promotion to reducing inequities in healthy newborn care practices and knowledge: evidence of improvement from a three-district pilot program in Malawi

BackgroundInequities in both health status and coverage of health services are considered important barriers to achieving Millennium Development Goal 4. Community-based health promotion is a strategy that is believed to reduce inequities in rural low-income settings. This paper examines the contributions of community-based programming to improving the equity of newborn health in three districts in Malawi.MethodsThis study is a before-and-after evaluation of Malawi’s Community-Based Maternal and Newborn Care (CBMNC) program, a package of facility and community-based interventions to improve newborn health. Health Surveillance Assistants (HSAs) within the catchment area of 14 health facilities were trained to make pregnancy and postnatal home visits to promote healthy behaviors and assess women and newborns for danger signs requiring referral to a facility. “Core groups” of community volunteers were also trained to raise awareness about recommended newborn care practices. Baseline and endline household surveys measured the coverage of the intervention and targeted health behaviors for this before-and-after evaluation. Wealth indices were constructed using household asset data and concentration indices were compared between baseline and endline for each indicator.ResultsThe HSAs trained in the intervention reached 36.7% of women with a pregnancy home visit and 10.9% of women with a postnatal home visit within three days of delivery. Coverage of the intervention was slightly inequitable, with richer households more likely to receive one or two pregnancy home visits (concentration indices (CI) of 0.0786 and 0.0960), but not significantly more likely to receive a postnatal visit or know of a core group. Despite modest coverage levels for the intervention, health equity improved significantly over the study period for several indicators. Greater improvements in inequities were observed for knowledge indicators than for coverage of routine health services. At endline, a greater proportion of women from the poorest quintile knew three or more danger signs for pregnancy, delivery, and postpartum mothers than did women from the least poor quintile (change in CI: -0.1704, -0.2464, and -0.4166, respectively; p < 0.05). Equity also significantly improved for coverage of some health behaviors, including delivery at a health facility (change in CI: -0.0591), breastfeeding within the first hour (-0.0379), and delayed bathing (-0.0405).ConclusionsAlthough these results indicate promising improvements for newborn health in Malawi, the extent to which the CBMNC program contributed to these improvements in coverage and equity are not known. The strategies through which community-based programs are implemented likely play an important role in their ability to improve equity, and further research and program monitoring are needed to ensure that the poorest households are reached by community-based health programs.

Multi-country analysis of routine data from integrated community case management (iCCM) programs in sub-Saharan Africa.

Aim To identify better performing iCCM programs in sub–Saharan Africa (SSA) and identify factors associated with better performance using routine data. Methods We examined 15 evaluations or studies of integrated community case management (iCCM) programs in SSA conducted between 2008 and 2013 and with information about the program; routine data on treatments, supervision, and stockouts; and, where available, data from community health worker (CHW) surveys on supervision and stockouts. Analyses included descriptive statistics, Fisher exact test for differences in median treatment rates, the Kruskal-Wallis test for differences in the distribution of treatment rates, and Spearman’s correlation by program factors. Results The median percent of annual expected cases treated was 27% (1–74%) for total iCCM, 37% (1–80%) for malaria, 155% (7–552%) for pneumonia, and 27% (1–74%) for diarrhoea. Seven programs had above median total iCCM treatments rates. Four programs had above median treatment rates, above median treatments per active CHW per month, and above median percent of expected cases treated. Larger populations under–five targeted were negatively associated with treatment rates for fever, malaria, diarrhea, and total iCCM. The ratio of CHWs per population was positively associated with diarrhoea treatment rates. Use of rapid diagnostic tests (RDTs) was negatively associated with treatment rates for pneumonia. Treatment rates and percent of annual expected cases treated were equivalent between programs with volunteer CHWs and programs with salaried CHWs. Conclusions There is large variation in iCCM program performance in SSA. Four programs appear to be higher performing in terms of treatment rates, treatments per CHW per month, and percent of expected cases treated. Treatment rates for diarrhoea are lower than expected across most programmes. CHWs in many programmes are overtreating pneumonia. Programs targeting larger populations under–five tend to have lower treatment rates. The reasons for lower pneumonia treatment rates where CHWs use RDTs need to be explored. Programs with volunteer CHWs and those with salaried CHWs can achieve similar treatment rates and percent of annual expected cases treated but to do so volunteer programs must manage more CHWs per population and salaried CHWs must provide more treatments per CHW per month.

Reaching Mothers and Babies with Early Postnatal Home Visits: The Implementation Realities of Achieving High Coverage in Large-Scale Programs

Background Nearly half of births in low-income countries occur without a skilled attendant, and even fewer mothers and babies have postnatal contact with providers who can deliver preventive or curative services that save lives. Community-based maternal and newborn care programs with postnatal home visits have been tested in Bangladesh, Malawi, and Nepal. This paper examines coverage and content of home visits in pilot areas and factors associated with receipt of postnatal visits. Methods Using data from cross-sectional surveys of women with live births (Bangladesh 398, Malawi: 900, Nepal: 615), generalized linear models were used to assess the strength of association between three factors - receipt of home visits during pregnancy, birth place, birth notification - and receipt of home visits within three days after birth. Meta-analytic techniques were used to generate pooled relative risks for each factor adjusting for other independent variables, maternal age, and education. Findings The proportion of mothers and newborns receiving home visits within three days after birth was 57% in Bangladesh, 11% in Malawi, and 50% in Nepal. Mothers and newborns were more likely to receive a postnatal home visit within three days if the mother received at least one home visit during pregnancy (OR2.18, CI1.46–3.25), the birth occurred outside a facility (OR1.48, CI1.28–1.73), and the mother reported a CHW was notified of the birth (OR2.66, CI1.40–5.08). Checking the cord was the most frequently reported action; most mothers reported at least one action for newborns. Conclusions Reaching mothers and babies with home visits during pregnancy and within three days after birth is achievable using existing community health systems if workers are available; linked to communities; and receive training, supplies, and supervision. In all settings, programs must evaluate what community delivery systems can handle and how to best utilize them to improve postnatal care access.

Introduction of Newborn Care within Integrated Community Case Management in Uganda

Ugandas Ministry of Health, together with partners, has introduced integrated community case management (iCCM) for children under 5 years. We assessed how the iCCM program addresses newborn care in three midwestern districts through document reviews, structured interviews, and focus group discussions with village health team (VHT) members trained in iCCM, caregivers, and other stakeholders. Almost all VHT members reported that they refer sick newborns to facilities and could identify at least three newborn danger signs. However, they did not identify the most important clinical indicators of severe illness. The extent of compliance with newborn referral and quality of care for newborns at facilities is not clear. Overall iCCM is perceived as beneficial, but caregivers, VHTs, and health workers want to do more for sick babies at facilities and in communities. Additional research is needed to assess the ability of VHTs to identify newborn danger signs, referral compliance, and quality of newborn treatment at facilities.