Scaling-up National Newborn Programs in Malawi

Dr. Charles Mwansambo

Global Newborn Health Conference 15th April 2013 JHB RSA

Presentation Outline
Situation in Malawi Trends in NMR Moving to scale Progress Opportunities Challenges

Situation in Malawi
Population: 15.3 million Districts :28 MMR: 675/100,000 NMR: 31/1,000 Preterm Birth rate: 18% CPR: 42% TFR: 5.7

Source: DHS 2010

3

MDG 4 progress for newborn child survival in Malawi

250

Mortality per 1000 live births

200

Under-five mortality rate (UN) Under-five mortality rate (IHME) Under -five mortality rate (DHS/MICS) Neonatal mortality rate (UN) Neonatal mortality rate (IHME) Neonatal mortality rate (DHS/MICS)

150 113 100 104

73
50
MDG 4 target

31

30

0 1990 1995 2000 Year 2005 2010 2015

On track to meet MDG 4 for child survival but Under-5 mortality reduced at double the pace than neonatal mortality
Source: U5MR from UNICEF www.childmortality.org and Rajaratnam et al Lancet 2010. NMR from Oestergaard et al 2011 under review with journal [DO NOT SHARE] and Rajaratnam et al Lancet 2010. Malawi DHS 1999, 2000, 2004, preliminary 2010 and MICS 2006. MDG 4 target from Countdown to 2015, decade report -- 2/3 reduction from 1990 U5MR

Neonatal mortality trends from 1990

NMR reducing at 3.5% per year, more than double the regional annual average (1.5%)
Source: Zimba et al. 2012. Newborn survival in Malawi: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii88iii103. Data: Malawi DHS/MICS. UN estimates (childmortality.org) with a new analysis of mortality trends by age of death. IHME estimates (Lozano et al. 2011). Note: Survey point estimates are centred two years prior to survey date. MDG 4 target from Countdown to 2015 decade report reflecting a 2/3 reduction from 1990 U5MR.

Estimated causes of mortality around the year 2010 for 18,000 neonatal deaths

3 causes account for 89% of all newborn deaths

Source: Zimba E, Kinney MV, Kachale F et al. 2012. Newborn survival in Malawi: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii88 iii103. Data source: Malawi-specific mortality estimates (Liu et al. 2012). Note: Severe infection includes sepsis, meningitis, pneumonia and tetanus.

Trends in coverage data for newborn-related interventions and packages (2000-2010)

Increases in coverage of key newborn-related interventions and packages, some still remain low eg PNC
Source: Zimba E, Kinney MV, Kachale F et al. 2012. Newborn survival in Malawi: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii88 iii103. Data : Malawi Demographic Health Surveys. Note: Due to changes in the questionnaire and methodology, data for postnatal care across the surveys cannot be compared over time.

Moving to Scale
MOH-RHU strengthens coordination and collaboration of all partners in Newborn Health programing to leverage impact Incorporation of high impact interventions into national maternal and newborn health strategies: SRH Strategy Road Map to accelerate reduction in maternal and newborn mortality Harmonized IMNC training manual that integrates ENC, KMC and HBB Community Based Maternal and Newborn Care (CBMNC ) and Community mobilization (CM)

Moving to Scale
Incorporation of high impact MNCH interventions into pre-service curriculum Promotion of community, family and male involvement through CM Community case management (CCM) integrated with community newborn sepsis management Introduction of ANC waiting homes

High Impact Intervention packages implemented nationwide on Maternal and New-born

Focused antenatal care Skilled care at birth and immediate postnatal care Emergency obstetric and new-born care Helping Babies Breathe Essential new-born care Kangaroo Mother care Community based maternal and new-born care PMTCT Introduction of new interventions underway i.e.

corticosteroids for preterm birth community new-born sepsis Continuous positive airway pressure (CPAP)

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National scale up for facility- based newborn care

Helping Babies Breathe initiative launched in 13 districts in 2011, now scaled up to 21 out of 28 districts (2012), over 1173 service providers trained Pre-service ENC now includes HBB HBB is integrated into the IMNC training manual Aims to improve all aspects of care around the time of delivery especially neonatal resuscitation practices
Source: Zimba E, Kinney MV, Kachale F et al. 2012. Newborn survival in Malawi: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii88iii103.

National scale up for facility- based newborn care

Kangaroo Mother Care (KMC) was first introduced in the late 1990s First move to scale initiated in 2002 Over 121 KMC units now available, including in all of the government-run district hospitals KMC content is integrated into the IMNC training manual Malawi is a learning site for scaling up the intervention
Source: Zimba E, Kinney MV, Kachale F et al. 2012. Newborn survival in Malawi: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii88iii103.

Community Based Maternal and Newborn Care (CBMNC) Bringing Care Closer to the people

Community-based Maternal and Newborn Care (CBMNC) Package

HSAs are trained, equipped and supervised to : visit women three times during pregnancy to counsel on the importance of attending ANC clinic, birth preparedness, clean delivery, delivery by skilled attendant Visit postnatal women and their newborns three times to provide essential newborn care, identify and classify mothers and newborns with danger signs and refer Mobilize communities on maternal and newborn health Train health facility service providers on integrated maternal and newborn care Strengthen supervision and information systems

National scale up for communitybased newborn care

By 2011, 17 of Malawis 28 districts were implementing the standard CBMNC package

Source: Zimba E, Kinney MV, Kachale F et al. 2012. Newborn survival in Malawi: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii88iii103.

Key messages
1. A combination of efforts contributed to Malawis progress - scale up of community-based MNH; improved quality of facility-based services and community mobilization 2. Convening mechanisms played a key role in building consensus, catalyzing change and promoting coordination (e.g. SRH-TWG, Safe Motherhood Subcommittee, newborn-specific working groups)
3. Harmonization of training manuals for facility-based and community health workers (e.g: IMNC, CBMNC, CM, iCCM) helped to bring focus and standardization

Key Messages
6. Community mobilization assisted in raising

awareness of newborn health problems and promoting collective action in addressing the newborn problems 7. Improvements in newborn health possible despite low health worker density (3.3 per 10,000 population) 8. Task shifting of key life-saving MNH services to nurses, midwives and community health workers, coupled with supportive supervision and mentorship

Future Opportunities
High level Policy makers attention to address preterm birth Political will Presidential Initiative on Maternal Health & Safe Motherhood promotes interdisciplinary approach which includes local traditional leaders Inclusion of Newborn health indicators into the HMIS will increase attention on the progress of newborn care Everyone campaign launched in 2010 provides an ongoing advocacy forum to advance newborn health integration , implementation and funding

Challenges Human resource Data management and use Sustainability Conflicting priorities Resources for maternal and newborn health inadequate