Presentation_Jurczynska - Catalyzing Investments in RMNCAH at the Community L...
Implementing Interventions to Reduce the Burden of Preterm and Stillbirth_Gravett NEW_10.10.12
1. Implementing Interventions to Reduce
the Burden of Preterm and Stillbirth:
How do we do it?
Courtney Gravett, MPH
Research Associate II
Global Alliance to Prevent Prematurity
and Stillbirth (GAPPS)
Seattle Children’s
courtney.gravett@seattlechildrens.org
October 2012
2. Preterm deaths and Stillbirths can
be prevented now
• Effective implementation of current, known
interventions can reduce preterm deaths by 75%
and stillbirths by 45%
• Many preterm deaths and stillbirths are due to
lack of action, or an inability to act
• Prevention and intervention is possible all along
the continuum of care
3. Many premature babies can be saved before intensive
becomes available...
Public health
approaches
Improved individual neonatal care eg
feeding, warmth, hygiene, antibiotics,
resuscitation
Neonatal intensive care
introduction and scale up
Over 60% reduction can be achieved before neonatal intensive care
and history shows the impact would be huge
Data sources for UK and US historical data: (CDC, 2012, Office for National Statistics, 2012, NIH, 1985, Smith et al., 1983, Jamison et al., 2006, Lissauer and Fanaroff, 2006, Baker,
2000, Philip, 2005, Wegman, 2001). With thanks to Boston Consulting Group
4. Continuum of Care
Source: Kerber K, et al. Continuum of care for maternal, newborn and child health: from slogan to delivery. Lancet 2007; 370:1358=69
5. Interventions for preterm birth and stillbirth
along the continuum of care
PRE- PREGNANCY BIRTH POSTNATAL/ CHILDHOOD
PREGNANCY NEWBORN
•Family planning/ •Prevent & treat •Antenatal •Essential & Extra care
birth spacing sexually steroids • Kangaroo Mother Care
PTB •Prevent & treat transmitted •Tocolytics to •Management of sick
sexually transmitted infections slow labor newborns
infections •Nutrition •Identify preterm •Neonatal resuscitation
•Nutrition babies
•Prevent & treat •Screen& treat •Active management of •Postnatal
sexually for syphilis labor follow-up
transmitted •Nutrition •Emergency obstetric
infections care, including c-section
SB •Magnesium sulfate
•Nutrition
•Antibiotics
•Induction of labor after
41 weeks
6. Prevention of preterm birth and stillbirth
must be accelerated
Care before and between pregnancy
Implement:
• Family planning strategies, including birth
spacing and provision of adolescent-friendly
services
• Prevention and management of STIs and
NCDs
• Education and health promotion for girls and
women of childbearing age
• Promotion of healthy nutrition and addressing
life-style risks like smoking
Source: Born Too Soon
7. Prevention of preterm birth and stillbirth
Care during pregnancy and childbirth
Implement:
• Antenatal care for all pregnant women
• Screening & treatment of sexually transmitted
infections, especially syphilis
• Management of pregnant women at higher risk
of preterm labor
• Management of preterm labor with provision of
essential equipment and drugs
• Reduce non-medically indicated early
induction of labor and cesarean
• Promotion of healthy behaviors and life-style
risks during pregnancy
• Active management of the third stage of labor
• Comprehensive emergency obstetric care
Source: Born Too Soon
8. Care of the premature newborn
COMMUNITY LEVEL/HOME
Home and low levels of health system
•Essential newborn care (warmth, cleanliness, feeding)
•Support for early breastfeeding and cup feeding if needed
•Facilitated referral, transport schemes
Hospital
•Kangaroo Mother Care
FACILITY LEVEL/OUTREACH
•Neonatal resuscitation with bag and mask if needed
•Supportive care for RDS eg safe oxygen therapy
•Other supportive care eg NG tube feeding, IV fluids
•Treatment of infections with antibiotics
Referral hospital
•Increased nursing and medical support
REFERRAL LEVEL/DISTRICT
•Phased introduction of intensive care eg ventilation
•Surfactant (cost issues)
Source: Born Too Soon
10. Examples of Barriers to Scaling Up
Interventions
• Community/Household level
– Sociocultural barriers (eg stigma), financial constraints
• Health service level
– Lack of resources and trained providers
• Health sector and management level
– Weak supply management
– Lack of competent district health management teams
• Lack of political will
11. Prevention and management of
preterm birth and stillbirth must be
included in the wider agenda
• Functional health systems are a prerequisite for
comprehensive antenatal and childbirth care
• Implementation research is needed
• Must integrate with other RMNC health programs
– Antenatal corticosteroids
• The steps for scaling up interventions are highly
context specific
13. 8 Countries have reduced preterm
death in the last decade
• Sri Lanka Contributing factors:
• Turkey
•National commitment to improved obstetric and
• Belarus
neonatal care
• Croatia
• Ecuador •Systematic referral systems for neonatal care
• El Salvador •Strengthened equipment and personnel
• Oman •Re-invigorated community-based healthcare
• China •Promotion and training of skilled birth attendants
14. Some middle income countries have
halved deaths due to preterm birth in a
decade Sri Lanka
•Lower middle-income country
Turkey that reduced NMR from 13 to 10
and halved preterm specific
•Upper middle-income country that reduced NMR mortality
from 21 to 10 •Long term investment in
primary care with free health
•Implemented demand and supply strategies, care at government facilities
including cash incentives for expectant women •Reinvigorated community-
based care, including referral
•Invested in quality care improvements, such as networks for women in preterm
focusing on nursing staff skills, resuscitation, labor
basic care of preterm babies •Recent introduction of
advanced care at tertiary centers
Source: Born Too Soon
Source: Analysis conducted using data from Liu et al., 2012. Credit: Boston Consulting Group with the Global Preterm Birth Mortality Reduction Analysis Group
15. Factors contributing to successful
implementation of interventions
• Buy-in by key stakeholders
• Intervention is context specific i.e., culturally
sensitive, locally adapted to staffing levels,
burden of disease, causes of mortality, etc.
• Intervention builds on/ complements existing
programs
• Intervention is supported by national policies,
service guidelines, training materials, job aids,
supervisory systems and indicators to track
outcomes
• Robust supply chain
16. Who is involved?
• Government and policy makers at local, national
and global levels
• United Nations and other multilateral
organizations
• Donors
• Private Sector
• Academic and research institutions
• Healthcare workers and professional associations
Coordination, collaboration, and commitment among all the
players is crucial to success
17. Conclusion: Advance a Coordinated Agenda
for Preterm and Stillbirth Prevention and
Care
• Scale up what works – practical and feasible
interventions for care
• Improve integration with existing programs
• Address common challenges in the wider
reproductive, maternal, newborn and child
health agenda:
• Access and utilization of quality healthcare
18. Important Resources
Global report on preterm birth & stillbirth: the foundation
for innovative solutions and improved outcomes
www.biomedcentral.com/bmcpregnancychildbirth/supplements/
Born Too soon: The Global Action Report on Preterm
Birth
www.who.int/pmnch/media/news/2012/preterm_birth_report/en/index.html
Essential Interventions, Commodities and Guidelines for
Reproductive, Maternal, Newborn and Child Health
www.who.int/pmnch/topics/part_publications/201112_essential_inter
ventions/en/index.html
19. Increase Awareness and Visibility of
the Problem
November 17th is World Prematurity Day
For more information visit the March of Dimes
website:
http://www.marchofdimes.com/mission/prematurity_wpd.html
Editor's Notes
-Not much out there -The wider reproductive, maternal, newborn and child health agenda is inextricably linked with preterm birth and stillbirth -Most interventions that prevent stillbirth, also prevent maternal and neonatal mortality Do not need to create a new program
-Gap between what is known to work and what is done in practice- nearly all the deaths in babies born after 32 weeks could be prevented by essential newborn care
Basic care and infection case management interventions have an important effect on neonatal deaths and deaths among moderate and late preterm births 2. More targeted care for preterm 38 to 32 weeks, including antenatal steroids and KMC reduces deaths 3. Neonatal intensice care may be necessary to reduce death among very preterm babies (those before 28 weeks)
The continuum of care is a core principle of maternal, child and newborn health programs which considers the dimensions of time (over the lifespan) and place of care giving (level of care). Saving lives depends on high coverage and quality of integrated service=delivery packages throughout the continuum, with functional linkages between levels of care in the health system. Integrated service delivery packages within the continuum of care have many advantage: cost-effectiveness is enhanced; available human resources are maximized; and services are more family friendly Ideally women in preterm labor would deliver in a facility, but in reality, there are many places when half of women deliver at home, so interventions aimed at reducing PTB and SB must be available at all levels.
Community level- behavior change, home-visit packages including breast feeding support and awareness of danger signs and when to seek care Risk factors for PTB- history of a previous preterm birth; insufficient cervix
We have the interventions, but to date, none has been successfully scaled up.
In large part the barriers and constraints to scale-up of interventions are the same as those encountered in the wider field of maternal newborn and child health. Specific to PTB and SB is stigma and prevailing myths and misconceptions about PTB and SB; and lack of visablility Affordabilty barriers, delayed use of services, poor quality of care- poor standards of care, scarcity of trained workers, erratic supply of essential drugs and supplies, lack of referral system Need the right people with the right supplies at the right time
Effective implementation will require a focus on systems issues, especially human resources (like nursing skills for obstetrics and neonatal care); and increasing commodities for family planning, obstetric and newborn care As mentioned, the existing proven interventions have yet to be successfully scaled up -Refer to GAPPS two by two chart -Context- rural vs urban; what are the causes of mortality- asyphixia vs infection
Afghanistan could reduce newborn deaths by 10% through public health approaches, or with increased focus on improved care of preterm newborns Case management of infection and improved thermal care and feeding support would reduce death in places like India and China Brazil- NICU care would halve neonatal mortality
Reduced preterm death unintentionally! Imagine what targeted strategies for reducing preterm death would do.
Government- strengthen health systems- commodities supply, workforce; strengthen community care and link to referral system; promote family planning services UN- define norms and guidelines for preventing and managing PTB and SB; work with partners to strengthen technical and programmatic support to prevent PTB and SB- help countries scale up high-impact interventions Donors- support implementation research Private sector- partner with public sector to improve service delivery and infrastucture (eg. Helping Babies Breathe) Research- ensure accurate data on PTB and SB outcomes is included in research studies assessing other pregnancy outcomes; understand mechanisms Health care workers- adopt and adapt evidence based practices, implement training plus continuus education, share best practices, audit clinical practice; treat women and children with repect and sensitivity
Right people at the right time with the supplies Ensure frontline workers are skilled in the care of premature babies and improve supplies of life-saving commodities