Transcript Document

AMTSL and ENC at birth
Goldy Mazia & Indira Narayanan
BASICS
PPH Working Group Meeting
Washington DC March 20,2008
Outline of Presentation
• Burden of deaths in the early newborn period and the
need to address it
• Key programmatic priorities for addressing newborn
health and integration with maternal care
• Linking AMTSL and ENC at birth
Under-5 mortality rate
1-60 mo. mortality
100
< 1 mo. mortality
(NMR)
50
Present
trend
 MDG
0
Global mortality per 1000 births
150
Why Focus on Newborns?
1960
1980
Year
2000
2020
To achieve MDG 4 neonatal deaths must be addressed
Direct Causes of Neonatal Mortality:
Global Estimates
CONGENITAL
ANOMALIES
10%
INFECTIONS
INCLUDING
TETANUS 32%
OTHERS 5%
PREMATURITY 24%
ASPHYXIA 29%
The Lancet Series- Newborn Survival, 2005
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
Time
when most babies die is
when coverage of
quality care is lowest
Skilled attendant at delivery
100
Neonatal deaths
80
50
40
60
30
40
20
Source: WHO estimates 2000
20
10
0
0
Africa
Asia
Latin America
More
& the
developed
Caribbean
regions
Neonatal deaths per 1000
live births
Skilled attendant at
delivery (%)
Skilled Birth Attendants and NMR
Mere presence of a skilled birth
attendant is not sufficient
Quality of care and an enabling or
supportive environment are
important
– Skills/expertise (for both mother
and baby) using rational,
appropriate interventions
– Supportive supervision of staff
– Adequate appropriate drugs,
equipment and supplies of suitable
sizes and strengths with good
maintenance
– Appropriate referral center/system
including appropriate transport
Pre-service education must also
improve
Continuum of Care is Important
• Home to hospital continuum of care
• Pre-pregnancy to post partum
• Prevention to treatment - priority
sepsis and asphyxia
Newborn
health
Maternal
Inf./Child
health
health
Adol. School
health health
Where funds are limited:
– Prioritize key interventions with subsequent
phasing in of other components
– Link with partners leveraging additional support
Key Essential Newborn Care
Components linked with maternal care
Antenatal
Birth
Postpartum
Minimum 4 visits
Tetanus toxoid, iron
& folate (+ pre-preg),
iodized salt, birth
preparedness,
counseling for
breastfeeding,
detection and
treatment of STIs
and HIV/AIDS,
referral for maternal
danger signs
Skilled birth attendance,
clean delivery practices,
AMTSL, basic ENC
(temperature maintenance,
cord & eye care, early and
exclusive breastfeeding),
identification and treatment
for danger signs,
resuscitation, extra care for
LBW/premature babies,
PMTCT
Assessment
before discharge,
early visit,1st
within 3 days,
basic ENC;
vitamin A for
mother; detection
and treatment for
danger signs and
minor problems;
PMTCT
Facility-Based Minimum Package
Essential Maternal and Newborn Care
Minimum Package
•Birth preparedness
•Tetanus toxoid
Prophylactic
Family
•Partograph
Eye care
planning
•Infection prevention
•Active mgt of 3rd
Special care
stage of labor
Iron folate
for LBW
•Newborn resuscitation
Adequate
•Cord care
Immunization
nutrition
•Thermal care
•Immediate & excl breastfeeding
Basic
•Infection treatment
EmOC
Other Essential Interventions
Intermittent
presumptive
treatment
for malaria
Iodine
Syphilis detection
and treatment
Context-Specific Package
Prevention of
Mother-to-Child
Transmission
of HIV
USAID/BASICS/POPPHI: Integration of AMTSL and ENC
1.) Keep required items for mother & baby close by, load oxytocin in syringe
2.) Inform mother what is being planned at her level of understanding
Receive and dry the baby, discard wet linen
Baby cries well
Cry not heard
Place baby on mother’s abdomen
Dry and cover with dry cloth
Inform mother about baby &
AMTSL; administer oxytocin
Clamp cord when pulsations
stop/2-3 min. after the birth
Apply controlled cord
traction + uterine massage
Dry and wrap in fresh dry linen
exposing chest. Keep warm. Assess
breathing
Breathing well
Start AMTSL –
Get help to observe
baby
Not breathing/gasping/
breathing very slow
Cut cord; resuscitation
and AMTSL or if no
assistance, physiological
management of 3rd stage
Eye prophylaxis; tie the cord; warmth (skin-to-skin); initiate breastfeeding
Monitoring + rest of routine care of mother & baby
Integrating AMTSL and ENC at
Birth: Challenges
• It is at the same time of AMTSL that the newborn
requires care immediately after birth
• Integrated care may present as a “conflict of
interests” where there is only one attendant
• A trained second attendant should be available
for AMTSL in case the newborn requires special
attention (i.e. asphyxia requiring resuscitation).
Care of the Newborn at Birth Monitoring
Assess the baby with the mother (as a part of AMTSL):
• Every 15 minutes for first 2 hours
• Every 30 minutes during the third hour
• Every hour from hours 3 to 6 after birth
Breathing
• Regular breathing (30-50/min)
• No difficulty (nasal flaring, grunting, chest in-drawing)
Color
• Lips and tongue, palms and soles should be pink
• Blue palms and soles might mean the baby is cold
Temperature
• Normal axillary temperature is 36.50 to 37.50 C
• Promote skin-to-skin to keep the baby warm
Umbilical cord
• Check for bleeding/oozing; retie if needed
Dominican Republic- Clean
Delivery Practices In 3 Hospitals
100
90
80
70
Percentage 60
50
observed
40
30
20
Before
10
After
0
88
100
66
13
7
0
hand
washing
sterile linen
cut cord
sterile instr
Swaziland -Temperature
maintenance at birth
Swaziland - Breastfeeding in first
hour (interviews of mothers)
Ultimate Goal is to Achieve the MDGs
Through
• Prioritization; phasing in
of activities/interventions
with continued expansion
• Support to construct a
strong, cost-effective,
VISIBLE newborn strategy
to link with maternal and
child health programs
• Addressing inequities,
sustainability, scale and
adequate coverage with
adequate interventions