Models of Care for Managing Preterm Birth and Premature Babies

Severin von Xylander WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA)
The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this presentation and they do not necessarily represent the decisions, policy or views of the World Health Organization.

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Rationale Transpose Born Too Soon (BTS) recommendations in the existing implementation framework of the MNCH continuum of care Identify health system requirements by level of care
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Objective
Ensuring women at risk for preterm birth and prematurely born babies get the right care, at the right time, by the right team and in the right place What should be provided? When should it be provided? Who should provide it? Where should it be provided What is needed (commodities)?
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Models of Care
Defines the way in which health services should be delivered Outlines evidence-based practice throughout the continuum of care at different levels of care Identifies and guides implementation during pregnancy and childbirth and care for the preterm Based on existing evidence and guidelines, intervention outcomes and consultation with key stakeholders at global level Includes guidance on interventions (what), provider competencies (who) and health service delivery level (where)

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What: Interventions
Antenatal and delivery care for all pregnant women Essential newborn care for all babies Additional care for women at risk of preterm birth Additional care for preterm babies

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Key Elements
Second referral level tertiary level Operational categorization by gestational age and birth weight groups Decision Trees for Preterm Labour and Preterm Birth Health systems requirements: Human Resources, supplies, medicine & technologies Simplified Reporting Categories (Dimension of productivity / benchmarking) Minimum level of services
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Operational GA & BW Categories

Gestational Age (completed weeks) 37 34-<37 30-<34 <30 Birth Weight Ranges (g) * >2500 Level of Care Community / home

2000 - 2500 1500 - 2000 <1500

First (primary level) community / home Referral-level /small hospital (secondary level) Second referral-level / regional hospital (tertiary level)

* These are practical birth weight ranges that roughly correspond to the expected birth weight in the at proposed ranges of gestational age and to facilitate decision making and statistical reporting if gestational age is not known

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Additional Interventions for Women at Risk of Preterm Labour and Preterm Babies
Gestation (Completed Weeks)

HEALTH SYSTEM DELIVERY LEVEL

Community 2nd referral 1st referral

WOMEN AT RISK OF PRETERM LABOUR

Guidance on medical indications for induction of labour or caesarean section Tocolytics to slow down preterm labour, provide for corticosteroid effect and allow transfer if appropriate (KEY)

<37 <34 X

Primary

X X

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Decision Tree: Pregnant Women / Preterm Labour

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Decision Tree: Admission after Delivery at Primary Level

Provide essential newborn care & basic resuscitation Record gestational age from the maternal record, measure birth weight, and assess feeding ability & ability to maintain temperature

34-<37 weeks Stable

<34 weeks OR sick preterms 34-<37 Refer to 2nd referral level

Community with follow-up if: Weight >1.8-2kg Infant can suck & swallow & breastfeed effectively Maintain temperature in normal range 3637C

Refer to 1st level facility for Feeding support for baby & KMC if feeding difficulty and/or temperature instability

Thermal protection provided during transfer with skin to skin Reliable transport is available Infection control measures in place Contact made to referral centre

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Human Resources' Competencies

Community (Does not include outreach by health professionals, includes family care and community health workers)
As transitory or emergency measure: CHW present at birth or as soon as possible after birth with competencies in: Identifying preterm/low birth weight babies Examining and assessing for danger signs and referring if necessary Counselling on essential newborn care & special care for small babies, if referral not possible Promotion of ANC Advising women to seek care for danger signs in pregnancy

Primary (including outreach, target level for normal birth and minimum additional support needed)
Health professionals trained to proficiency in skills to: Manage normal labour and delivery Recognize & initiate treatment of complications Essential newborn care including basic neonatal resuscitation Basic emergency obstetric and newborn care Outpatient management of sick newborns Follow-up care of preterm babies

1st Level Referral Facility

2nd Level Referral Facility

Doctors competent in newborn care (24 hour presence or on call) Nurses/midwives competent in newborn care (24 hour presence or on call) Comprehensive emergency obstetric and newborn care

Doctors and nurses/midwives with specialized competency in the care of high risk pregnancies & preterm newborns present 24 hours a day (shifts) Obstetricians Paediatricians with neonatal skills or neonatologists Nurses with neonatal nursing skills Access to individuals within specific clinical & diagnostic sub-specialities or professionals with competencies in maternal & newborn care: anaesthesiology, surgery, ophthalmology, intensive care, cardiology, radiology, laboratory services, audiology, nutrition & pharmacy Data collection system for obstetric & newborn statistics

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Routine Data for Decision Making

Birth weight and gestational age for all births Live births (including singleton and multiple births with no lower limit in weight or gestation including proportion <500g/22 weeks and <1000g or 28 weeks) Stillbirths (including singleton and multiple births with proportion <500g/22 weeks and <1000g or 28 weeks) Survival rates disaggregated by the following birth weight categories: 2500 g; 2000 - 2499 g; 1500 1999 g; < 1500 g

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Productivity and Service Levels

It is proposed to include:
a population-based / territorial approach for services, based on size of population, expected number of cases and distance Minimum level of service to maintain quality of services, e.g. xx number of incubators and step down cods

Avenue:
Detailed descriptions of the factors to consider Benchmarking (Case studies)

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Conditions, complications, interventions

Gestational Age (Completed Weeks) Range of Birth Weight (g) Respiratory distress syndrome Intraventricularhemorrhage Complications / Conditions Necrotizing entercolitis Feeding problems (attachment, sucking, swallowing) Thermoregulation problems (Nosocomial) infections Tocolytics to slow down preterm labour Antenatal corticosteroids to reduce neonatal mortality Antibiotics for pPROM to prevent infection in women at high risk for preterm birth Routine Essential Newborn Care Kangaroo mother care (<2000g, stabilized)1 Interventions Placement in incubator or undet overhead heater Surfactant (endotracheal) CPAP 2 Parenteral feeding Supported enteral feeding 3 Active breastfeeding Management of common neonatal complications
1 2 3

<28

28 800 - 1500

29

30

31

32

33

34

35

36 1950 - 3300

37 2150 - 3450

38 2350 - 3600

39 2500 - 3700

40 2600 - 3800

41 2650 - 3850

900 - 1600 1000 - 1750 1150 - 1950 1250 - 2150 1400 - 2450 1550 - 2750 1700 - 3050

Recommendations for management of common childhood conditions: evidence for technical update of pocket book recommendations: newborn conditions, dysentery, pneumonia, oxygen use and delivery., common causes of fever, severe acute manutrition and supportive care (2012). Guidelines on optimal feeding of low-birth-weight infants in low- and middle-income countries (2011). Guidelines on basic newborn resuscitation (2012).

*In the community and health systems level including: Promotion of antenatal and skilled delivery for all women, counselling on birth preparedness and emergency/complication readiness planning, smoking cessation and exposure to other pollutants, reduction of violence against women, monitoring and referral of women with danger sighs/complications,
counselling on essential newborn care, referral for danger signs and very LBW if born at home

Levels of Care: 1 Primary care (normal maternity care with basic emergency obstetric care available) First referral-level care (Comprehensive emergency obstetric care available + ANCS, KMC and 2 feeding support) 3 Second referral-level care (Leve 2 + specialized services)

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Where: Levels of Care

Risks < 34 wks

2nd Referral Level (MNP)

Risks 34 - 36 wks

1st Referral Level (MCPC, Pocket Book) Primary Level (PCPNC) Community: Preventive/Promotive, Follow-up (Care of Newborn at Home)

Low rik > 37 wks

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Thank you