Transcript GLOBAL NETWORK FOR WOMEN’S AND CHILDREN’S HEALTH RESEARCH S. Parida, P. Panigrahi, R.

GLOBAL NETWORK FOR
WOMEN’S AND CHILDREN’S
HEALTH RESEARCH
S. Parida, P. Panigrahi, R. Satpathy,
S.
Mohapatra, P. R. Misra, L. Pradhan,
I.
Gewolb, J. Johnson, J. G Morris, L. Wright, K.
Poole, V. Rao.
SCB Medical College, Capital Hospital, Ispat General
Hospital, Kalinga Hospital, Orissa, AIIMS, New Delhi,
University of Maryland School of Medicine; NIH; and
RTI, USA
Impact of
Village level training
and maternal education
for reducing neonatal
and infant mortality in
Orissa
Global Burden of Neonatal
Death 4 million per year
33%
63%
4%
India
Developing
Countries
Rest
Primary Causes of
Neonatal Death in India
13%
Sepsis
15%
Asphyxia
Community
Immaturity
52%
Other
20%
9%
12%
22%
Sepsis
Asphyxia
Immaturity
Hospital
Other
31%
26%
Malformed
Sites In Orissa
Aims of the Ongoing Project
A. Create a neonatal sepsis surveillance
system:
• Early vs. late sepsis
• Microbiology of infection
B. Evaluate the effects of a community-based
educational intervention on infant and
neonatal mortality
C. Design and implement interventions to
reduce/prevent neonatal sepsis
Specific Aims of the Current
Global Network Project
•
•
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Surveillance of Neonatal Sepsis
Early sepsis (<3 days) or Late sepsis (>3 days)

Microbiology of infection, drug resistance, mode of
acquisition/transfer of infection)

Blood/CSF culture

Stool culture (baby)

Surface cultures Baby/Mother
Hospital vs. Community
Intervention to prevent reduce sepsis
Training on neonatal resuscitation
Hospital and Laboratory Sites
NICHD
· Program Officer(s)
· Grants Management
Officials
Cuttack
Senior Foreign
Investigator
· SCB Medical College
Neonatal Unit
Bhubaneswar
Site Director
· Capital Hospital
Neonatal Unit
· Kalinga Hospital
Microbiology
· Kalinga Research
Unit Data Center
Rourkela
New Delhi
Mumbai
Site Director
Site Director
Site Director
· Ispat General
Hospital
(IGH) NICU
· IGH Microbiology
· AIIMS Microbiology
Reference Lab
· Nair Hospital NICU
· Nair Microbiology
UMB
· Principal Investigator
· Co-Investigators
Pediatrics, Microbiology,
Epidemiology
Community Sites
Bhubaneswar Center
Director, Field Operations
Head Quarters for Community Studies
RTI
Monitoring Body
· Data Management
Bhubaneswar Office
· Medical Liaison
Officer (with the
Dept. of Health &
FW, Govt. of Orissa)
· Public Relations
Officer
Bhubaneswar
Community Sites
Rourkela
Community Sites
· Supervisors
· Anganwadi workers
· Consultants
· Program Officer
· Supervisors
· Managers
· Anganwadi workers
· JSS (Jana Siksha
Sansthan)
collaborating
personnel
“See
what everyone else has
seen, but think what no one else
has thought!”
Albert Szent-Gyorgi
Nobel Prize Winner in Medicine, 1937
THE GROUND WORK started 2001
NEED OF A STRONG EXISTING INFRASTRUCTURE
Which can achieve all the following
A. CONACT EVERY MOTHER BEFORE BIRTH
B. RECORD EVERY BIRTH
C. FOLLOW EACH BABY FROM BIRTH TO 60 DAYS
D. IDENTIFY SICKNESS
E. REFER TO NEAREST HOSPITAL
F. FOLLOW UP AT HOME AFTER DISCHARGE
AWW IS THE FIRST CHOICE
WHY AWW
 One AWW for each village
 Knows the family members
 Belongs to the same village
 ANM visits each village in
rounds
 Medical officer is too busy
Community Surveillance
Methods
A. 254 villages in the State of Orissa
B. Village health workers (Anganwadi workers,
AWW) register women in 7th mo of
pregnancy; monitored wkly
C. Monitor newborns daily for 60-days after
birth for signs of sepsis
D. “Suspect” sepsis cases referred to
collaborating hospital for evaluation,
enrollment and treatment
Reduction of IMR and NMR
How it was possible
A. Development of a new training
module on neonatal health and
sepsis
B. Training of Anganwadi workers
C. Use of existing facilities
(Hospitals, PHCs, CHCs)
Overview of AWW Training
A. Classroom teaching
(special training module)
A. Completion of the 60-day
follow-up card
A. Pre- and post-training
evaluation
AWW Classroom Training
A. Pretest
B. Two-day training session:
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Normal newborn
Common neonatal problems
Neonatal sepsis (based on WHO)
Hands’ on demonstration
C. Post test evaluation
SEPSIS CRITERIA

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Not taking feeds properly
Lethargic, not crying on stimulation
Body is very cold or hot to touch
Bluish discoloration of the tips of fingers/toes, tongue and lips
Passing watery stool
Distention of abdomen
Redness and swelling around the umbilicus
Apneic spells (breathing cessation) along with bluish discoloration of skin
Bleeding from nose, mouth or skin
Jaundice
Respiratory distress rate more than 60/min
 Intercostal/subcostal recession
 Movement of alae nasi and
 Wheezing/Stridor (adventitious sounds)

Convulsion
60 Day Card
Death Card
Pre- Post Evaluation of
AWWs on Newborn Screening
Topic/Subject % Correct (pre)
% Correct (Post)
Basic knowledge
on neonatal period
35
76
Recognition of
normal physical
findings
35
90
Pre- Post Evaluation of
AWWs (Contd.)
Topic/Subject
% Correct (pre)
% Correct (Post)
Correctly identified
sepsis as a cause of
neonatal death
18
56
Knowledge on
symptoms of
Sepsis (at least
5 of 12 pts)
43
81
95 AWW participated in the study
Infant Status Card
A. AWW recorded maternal data on weekly
visits during pregnancy
B. AWW also recorded “daily” infant status
on infant status card
C. 60 day description was signed off by 3tier monitoring signature system
Study Staff Community
Support
A. Study managers and supervisors provided
added help in case identification, monitoring
and transportation
B. Study managers communicated with hospital
staff and parents about baby’s status
Study Field Monitoring
A. AWWs monitored by a 2-tier system involving
managers and supervisors
A. Study investigators (physicians), field officers and
project coordinators supervised field activities
A. SFI, PI, NICHD and RTI staff conducted
scheduled/unscheduled site visits and monitoring
DIVERSITY IN STUDY AND
CONTROL AREA
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Over 400 village included
234 study village
Khurdha district 3 time more population dense
< population growth in Sundargardh due to lack of
migration
• Distinct socio cultural practices in tribal
Deliberate attempt has been made to select Geographically
and socio economically distinct communities
Khurda District IMR* Results
Prior to Study Study,
Year One
Study,
Year Two
Study
Villages
49.8
42.9
40.5
78/1566
80/1864
87/2148
Control
Villages
56.6
54.2
57.1
108/1906
96/1770
108/1890
* IMR=deaths in 1st yr/1000 live births
Khurda District NMR* Results
Prior to Study Study,
Year One
Study,
Year Two
Study
Villages
38.8
35.4
32.1
60/1566
66/1864
69/2148
Control
Villages
42.4
39.7
45.5
81/1906
77/1770
86/1890
* NMR=deaths in 28 days/1000 live births
Sundargarh District IMR*
Results
Prior to Study Study,
Year One
Study,
Year Two
Study
Villages
50.9
34.8
34.0
111/2177
80/2300
81/2381
Control
Villages
58.2
65.5
54.9
99/1702
104/1587
92/1673
* IMR=deaths in 1st yr/1000 live births
Sundargarh District NMR*
Results
Prior to Study Study,
Year One
Study,
Year Two
Study
Villages
40.4
30.0
26.0
88/2177
69/2300
62/2381
Control
Villages
38.8
37.8
38.6
66/1702
60/1587
65/1673
* NMR=deaths in 28 days/1000 live births
Village Level Education
A. Focus group meetings of the
mothers/village women by informationeducation and communication
specialists
A. Informational videos and movies
A. Street plays
Hospital Admissions
Before
Maternal
Training
After
Maternal
Training
Accompanied by
AWWs and
Mothers
78% 22%
Accompanied by
Mothers Only
21% 79%
CONCLUSION
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Have we introduced a novel idea or technology to achieve the
current drop in IMR & NMR
NO
We have merely utilized and strengthened the already existing
AWW Network in a rigorous and constructive manner
A gratifying outcome of our sensitization of the mothers and
training of AWW in preparation for infection related protocol
led to a dramatic drop in IMR and NMR in the study area
Our intervention is purely educational
We have not introduced any treatment modality
A modest increase in curriculum by including other neonatal
problems will probably have far reaching effect without putting
unacceptable financial and logistic burden on the health care
delivery system of this State.
ACKNOWLEDGEMENT
A. NICHD
B. Bill and Melinda Gates Foundation
C. Govt. of Orissa, Dept of Health and
Family Welfare
D. Govt. of Orissa, Dept of Woman and
Child Development
E. Indian Council of Medical Research
F. Department of Family Welfare, Govt. of
India
G. Over 200 AWW who took the challenge
with a smile and made it possible
“Although some children
may be the victims of fate,
none will be the victims of
our neglect.”
John F. Kennedy