Home Based Newborn Care in Bangladesh:

Successes and Challenges

Imteaz Mannan
MaMoni
Integrated Safe Motherhood, Newborn Care, Family Planning Project

Progress in Bangladesh: On track for MDG4

100 90 80 70 60 50 40 30 20 10 0 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS2011 2015 MDG4 Target 42 41 37 24.3 27.7 23 13 15 10 11 48 32

24

Under-5 Mortality MDG4 Target 1-11 Month Mortality/1,000 LB

NMR/1000LB 12-59 Month Deaths/1,000 LB

Inequities in Coverage along Continuum of Care

120.0% 100.0% 80.0%

87.4%

94.7% 82.2% 63.8% 61.4% 49.9% 40.6% 11.5% 11.4%

PNC <2d by MTP Initiation of BF <1 hr

97.8% 90.3%

60.0% 40.0% 20.0% 0.0% Any ANC from MTP Births protected against NT Skilled attendance at birth

30.4%

DPT 3+

Lowest

Highest Source: BDHS 2011

District level variations in PNC<42d - 2010

Source: BMMHS2010

Estimated causes of neonatal mortality around the year 2010

3 causes account for 88% of all deaths, 68% need attention within 1st hour of birth
Data source: Bangladesh-specific mortality estimates (Liu et al. 2012).

Chronology of Home Based Postnatal Care in Bangladesh

Projahnmo CB-PNC OR/SNL

03

04

05

06

07

08 SMPP

09

10

11

SNL BRAC CARE BPHC

SMPP-2

ACCESS ISMNC

MaMoni

BRAC MANASHI UNICEF MNCS

Joint UN MNHi BRAC HP/MNCH AUSAID/BRAC IMNCS + Urban MNCH

HBB C-SBA Training

Sector Plan started

12

NNHS approved

Where are we on scale up pathway?

Early Setup JD Revised Service Package defined Service levels and platform defined Training package defined Demo projects Logistics needs identified Indicators defined Workload analyzed Supervision strengthened Providers trained Identify Alternate provider Fund leveraged for scale up Logistics procured MIS system developed Expansion National Srategy Services standardized New providers trained Clinical Guideline Special efforts for underserved LMIS strengthened HMIS tracks PNC indicators Maturity Mainstream in Operational Plans
QA scaled up

High coverage of services Supervision Institutionalized Multi-sector involvement Logistics at appropriate level Routine reporting at scale

Source: Country stakeholder consultations, 2013

Trends in essential newborn care

70 60 50 40 30 20 10 0 6 2 Nothing applied to Cord 17 51 43 33 28 56 50 59

Dried with in 5 Wrapped with in Bathed 72+ hours Initiation of min of birth 5 min of birth after birth Breastfeeding within 1 hour sfter birth BDHS 2007 BDHS 2011

Experience from recent programs - 1

Projahnmo (2002-09): CHWs can provide
quality care, and achieve coverage with proper training and workload redistribution

iMNCSP/BRAC (2005-): It is possible to provide

PNC at home by NGO CHW/volunteers at scale

MNCS/UNICEF (2008-12): Home visits by

dedicated NGO workers can increase coverage significantly, but may be prohibitively expensive on a national scale

Experience from recent programs - 2

CBPNC-OR/SNL(2007-09): For MOH&FW workers to provide PNC at home, timely pregnancy ID and birth notification is critical
Phone # collection, sharing # at union facilities

MaMoni/USAID(2009-13): PNC coverage heavily correlated with skilled attendance at birth HBB/USAID (2010-14): Possible to expand rapidly with proper planning, training, logistics and M&E system if funding and political will available

3 pathways to high PNC coverage

A. Short term Approach
1. Bring services closer to community: 13,500 Community clinics with new cadre CHCP an opportunity to bring PNC closer to home (1 CC=6,000 pop) 2. Complementary NGO/DP programs in underserved districts Large scale MNCH programs by DPs DP Investments to train MOH&FW providers on new skills, e.g. HBB, ENC, C-IMCI,KMC, ETAT

3 Pathways to high PNC coverage -2

B. Long term approach
1. Focus on skilled attendance at birth Deployment of midwives at different levels of govt clinics (2010-), Task shifting to allow C-SBAs (2003-) to provide PNC Convert nurses to nurse midwives Private C-SBAs for underserved areas

MaMoni Experience with Private C-SBAs: Coverage of PNC<2ds (May12-Feb13)

Source: National & Sylhet data from BDHS-2011. * As per BDHS, PNC1 is within 2 days of delivery 13 of delivery. but PCSBAs PNC1 is within 24 hours

Challenges
Skilled Human Resource Gap
Retention of trained manpower Filling vacant positions, multi sector advocacy needed Addressing geographic and economic inequities Resources for training at scale for clinical services: sepsis mgmt, antenatal corticosteroids, resuscitation Supervision system strengthening (e.g. C-SBAs) Ensuring Quality of care Facility capacity to meet increased demand for institutional deliveries, PNC Health seeking behaviors at grassroots level Establishing structured referral systems

Lessons
Addressing newborn care within integrated MCH services is feasible and desirable, but requires additional investments Evidence based low-cost interventions (e.g. HBB) can be scaled up and has high impact Local level planning (e.g. district plans) needed to prioritize interventions and allocate resources Bringing quality services closer to home may address inequities (e.g. CC, pvt cadres)

Thank You!