Transcript Overview of home care for the newborn

WHO/UNICEF Joint Statement on
Home Visits for Newborn Care
Rajiv Bahl
Newborn Health R&D
Department of Child and Adolescent Health and Development
The problem
 Close to 3.5 million newborn deaths occur in the world each year
 40% of all under-five deaths in the newborn period – most within 7 days
 80% of newborn deaths due to preterm birth, asphyxia and infections
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Deaths that Could be Prevented
 About half of mothers and newborns in low and middle
income countries do not receive skilled care during birth
 Three quarters of all babies born outside a hospital do not
receive any postnatal care
 Most sick newborns do not receive appropriate treatment
Over 60% of newborn deaths could be
prevented if all newborns received the above
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Rationale for Community Care
 Global decline of child mortality is too slow,
stagnating or even reversing in 52/68 low-income
countries
 Optimal coverage of effective interventions will not be
achieved by health facility-based interventions alone
in most high burden countries
 Evidence that delivery of selected interventions at the
community level improves health outcomes
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Evidence-base for the Joint Statement
Home Visits for Neonatal Care by Community Health
Workers for Preventing Neonatal Mortality in
Developing Countries: Systematic Review of
Controlled Trials
Gogia S and Sachdev HPS
(accepted for publication in the Bulletin of the World
Health Organization)
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Characteristics of included studies
Sylhet 2008
Hala 2008
Shivgarh
2008
Barabanki
2008
Gadhchiroli
2005
Country
Bangladesh
Pakistan
India
India
India
Baseline NMR
48
52.1
84.2
45.8
65.2
CHW, training
Recruited, 6
weeks
Existing,
days
Recruited, 7
days
Existing,
days
Number of
home visits
Antenatal: 2
Postnatal: 3
in first week
Antenatal: 2
Postnatal: 4
in 4 weeks
Antenatal: 2
Postnatal: 2 in
first week
Antenatal: 1
Postnatal: 1
in 4 weeks
Antenatal: 2
Postnatal: 812 in 4 weeks
Done at
postnatal
home visits
Promote care
Promote care
Promote care
Promote care
Promote care
Assess for
illness
Assess for
illness & refer
Assess for
illness & refer
Assess for
illness & refer
Assess for
illness
Treat sepsis
Treat only
pneumonia
-
-
Treat sepsis
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6
6
Recruited,
4 weeks
Provide care
at birth
38% reduction in neonatal mortality
Pooled effect on NMR: 0.62 (0.44, 0.87)
Risk
%
Study ID
Ratio (95% CI)
Weight
Gadhchiroli 2005
0.39 (0.27, 0.56)
18.49
Barabanki 2008
1.06 (0.81, 1.38)
20.46
Hala 2008
0.70 (0.54, 0.90)
20.67
Shivgarh 2008
0.47 (0.38, 0.58)
21.47
Sylhet 2008
0.66 (0.47, 0.93)
18.91
Overall (I-squared = 86.4%, p = 0.000)
0.62 (0.44, 0.87)
100.00
NOTE: Weights are from random effects analysis
.2
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.5
1
2
5
Effect on newborn care practices
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Barabanki Hala 2008
2008
Shivgarh
2008
Sylhet
2008
Pooled RR
(CI)
Antenatal
care visit >1
1.29
(1.23 - 1.36)
1.20
(1.10-1.32)
1.52
(0.91-2.53)
1.47
(1.39-1.55)
1.33
(1.20-1.47)
Skilled care
at birth
1.03
(1.00 - 1.10)
2.64
(1.99-3.52)
1.38
(0.91-2.09)
-
1.54
(0.81-2.93)
Breastfeedin
g initiated
<1h
6.54
(5.88 - 7.27)
3.14
(2.55-3.86)
4.37
(3.23-5.91)
1.42
(1.36-1.49)
3.35
(1.31-8.59)
Clean cord
care
1.63
(1.57 - 1.70)
47.28
(20.3110.2)
1.15
(1.02-1.29)
1.56
(1.50-1.62)
1.70
(1.39-2.07)
Delayed
bathing >24h
38.49
(28.0 - 52.9)
1.66
(1.39-2.00)
2.49
(2.22-2.79)
3.12
(2.86-3.40)
4.63
(2.29-9.37)
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New evidence expected in 2010
 Pakistan: Hala main study completed, under publication
 India: Evaluation of IMNCI study in Haryana will be
completed at the end of March
 Ghana: Newborn Home Intervention Study will be
completed at the end of March
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Key recommendation:
Home visits for newborn care days one and three after birth,
and if possible, a third visit on day seven




Promote early and exclusive breastfeeding
Help keep the newborn warm
Promote hygienic umbilical cord and skin care
Help the family to recognize signs of illness and promote prompt
care-seeking
 Promote birth registration and timely vaccination
 Identify and newborns who are low-birth-weight, have illness and
those born to an HIV-infected mother and provide or refer for
additional health care
 Counsel the mother about her own health.
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Examples of workers who can conduct
home visits
 Community midwives in Indonesia
 Anganwadi workers and ASHAs as part of the IMNCI
programme in India
 Female community health volunteers in Nepal
 Health Surveillance Assistants in Malawi
 Health Extension Workers in Ethiopia
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Recommendations for countries
 All newborns should receive appropriate care especially in the first
hours and week of life when they are most vulnerable;
 Each country should analyse the current policies and practices to
provide such care;
 A home visitation programme is recommended where access to
facility-based skilled care is limited;
 Home visits should be initiated as soon as possible after birth or
after returning home; and
 Postnatal home care by community health workers should be linked to
the health system and the full continuum of care.
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WHO-UNICEF Community Health Worker
Training Package
Caring for the newborn at
home
 Promotion of ANC and
skilled care at birth
 Promotion of care for the
mother
 Newborn care in first week
 Recognition and referral
for danger signs
 Additional care for Lowbirth-weight babies
Treatment of illness in the
community
Treatment in the community
of
– Diarrhoea
– Malaria
– Pneumonia
Referral of children with
danger signs
Caring for the infants and children at home
Care-giving skills and support for child development
Infant and young child feeding
Family response to child’s illness
Prevention of illness
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Caring for the newborn at home
SEARCH
India
UNICEF/ESARO
Package
2006
C-IMCI
Bolivia
NEWHINTS
Ghana
WHO-UNICEF
Package
CARING FOR THE
NEWBORN AT HOME
2009
WHO
Package
(under development)
IMNCI
India
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2008
4 Field tests
Caring for the Newborn at Home
 Two units:
– Home visits before birth
– Home visits after birth
 Target: literate CHWs (about 8 years of school)
 Duration: 6 days
 Methods: Classroom discussion, games, role plays,
videos, clinical practice and field visit.
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Conclusions
 Home visits for newborn care by community health
workers improve newborn care practices and survival
 The joint WHO-UNICEF statement recommends two
home visits each during pregnancy and first week of life
 Home care by community health workers should be
linked to the health system
 The generic WHO-UNICEF training package for CHW is
one of the tools to make the joint statement operational
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