Community case management of newborn infection in Bangladesh: BRACs experience in urban slums and rural areas

Global Newborn Health Conference Johannesburg, South Africa April 14-18, 2013 Dr. Morseda Chowdhury www.brac.net Project Lead, Improving Maternal, Neonatal and Child Survival Project BRAC Health, Nutrition and Population Programme

PRESENTATION OUTLINE
BRAC, an overview BRACs work in MNCH Newborn care Neonatal infection Challenges and lessons

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BRAC, which started with limited relief operations in 1972 in remote villages of Bangladesh has now turned into the largest development organization in the world

Vision A world free from all forms of exploitation and discrimination where everyone has the opportunity to realize their potential. Mission To empower people and communities in situations of poverty, illiteracy, disease and social injustice. Our interventions aim to achieve large scale, positive changes through economic and social programmes that enable men and women to realize their potential.
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BRACS HOLISTIC APPROACH

Poverty reduction Microfinance Social Enterprises Targeting the Ultra Poor Agriculture & Food Security

Education Health DECC WASH Capacity dev. & social safety net

Targeted Population
Mobilization

Community Empowerment Human Rights & Legal Aids Gender, Justice & Diversity Advocacy for Social Change

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BRAC HEALTH POPULATION AND NUTRITION PROGRAM

Reaching over 120 million people in Bangladesh

Improve reproductive, maternal, neonatal, child health and nutrition Reduce vulnerability to and control communicable diseases and common ailments Combat non-communicable diseases Improve quality of life
Reproductive Maternal Neonatal Child Health Health Centre Tuberculosis

Disability

Nutrition

Eye care

Malaria

Essential Health Care

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NCDs

MNCH INTERVENTIONS
Manoshi Community based maternal, neonatal and child health intervention in urban slums Launched in 2007 Operates in eight city corporations and covers a population of 6.3 million Funded by Bill & Melinda Gates Foundation, AusAID and DfID
Improving Maternal Neonatal & Child Survival (IMNCS)

Community based maternal, neonatal and child health intervention in partnership with GoB and UNICEF Launched in 2008 Operates in 12 districts and covers a population of 21.4 million Funded by AusAID, DfID, EKN

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2007

0.8 m

SCALE UP
2008

3.1 m
2009

1.5 m

3.1 m 11.0 m

2010

5.7 m
2011

11.3 m

6.1 m 18.8 m
2012

6.3 m
2013

19.4 m

6.8 m 21.4 m
Manoshi IMNCS
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FIELD ORGANOGRAM
SUB-DISTRICT
IMNCS (Rural MNCH) Manoshi (Urban MNCH)

Program Organizer (PO) 6-7 SK & CSBA

Program Organizer (PO) 4-5 SK & MMW

Shasthya Kormi (SK) 10 SS 1,500 HH

Community Skilled Birth Attendant (CSBA) 7 SS 1,000 HH Newborn Health Worker (NHW) 300 HH 36 births/year

Shasthya Kormi (SK) 10 SS 1,500 HH Shasthya Shebika (SS) 150 HH 18 births/year

Manoshi Midwife (MMW) 1 Delivery Centre 10,000 HH

VILLAGE

Shasthya Shebika (SS) 150 HH 18 births/year

Urban Birth Attendant (UBA) 1 Delivery Centre 250 births/year

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SHASTHYA SHEBIKA
Selection Criteria: Local inhabitant Age 25-45 years Married 5-8 years schooling Capacity Development: First year 27 days in house training Subsequent years 20 days in house training Continued on job training Task: Serves 150-200 households Visit all HH at least once in a month Behaviour change communication Provide limited primary care Attend deliveries and offer essential newborn care Screen for signs of neonatal sepsis and refer Supervision: Direct supervisor Shasthya Kormi
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SHASTHYA KORMI/COMMUNITY SKILLED BIRTH ATTENDANT

Selection Criteria: Local inhabitant Age 20-35 years 10 years schooling Capacity Development: 25 days in house training in first year, followed by 24 days in the subsequent years Six months institutional training in community midwifery, followed by 7 days refresher training for CSBAs Task: Serves 1500-2000 households Behaviour change communication Attend deliveries and offer essential newborn care Provide ANC and PNC Take birth weight and offer special care to LBW and pre-term babies Screen for signs of neonatal sepsis and refer Supervision: Direct supervisor Program Organizer/Paramedic
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MANOSHI MIDWIFE

Selection Criteria: Local inhabitant Age 20-35 years Married 10 years schooling Capacity Development: 3 years paramedic training 6 days community midwifery training (each year) 8 weeks training on obstetrics care Task: 4 midwives serves one upgrade delivery Centers Attend deliveries and offer essential newborn care Provide ANC and PNC Take birth weight and offer special care to LBW and pre-term babies Screen for signs of neonatal sepsis and refer Supervision: Direct supervisor Medical Officer
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IMPLEMENTATION STRATEGY
1. Intervention at community Awareness building oNeonatal care oDanger signs and emergency action Development of Promotion of breast feeding & hand washing CHWs Safe delivery care Training of village oCleanliness doctors oSterile cord care Detection of signs of sepsis oImmediate notification with mobile phone oConfirmation Post treatment follow up 2. Referral Arrival of pre-arranged transport Community Patient brought to Referral hub partnership Shift to functional facility

Establishment of SCANU

3. Intervention at facility Capacity development of doctors and nurses Management with antibiotics www.brac.net Facilitation by BRAC appointed referral staff

NEONATAL SEPSIS DANGER SIGNS

1. Not feeding well* 2. Convulsions* 3. Fast breathing (>60 breath/min on second count) 4. Severe chest indrawing 5. Low body temperature (less than 35.5C or 95.9F) 6. Fever ( more than 37.5 C or 99.5F) 7. Movement only when stimulated or no movement at all

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ASSISTED REFERRAL SYSTEM

PICK-UP POINT

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NEWBORN CARE PACKAGE

Essential newborn care Immediate drying and wrapping Assessment of the condition Sterile cord care Early initiation of breast feeding Management of birth asphyxia Tactile stimulation and mouth to mouth breathing Bag and mask Refer after initial management Special care for LBW babies Thermal care (Kangaroo care) Frequent breast feeding Infection prevention (hand washing) Detection and referral of Neonatal sepsis Referral of complications
BRAC DELIVERY CENTER

Privacy and dignity Cleanliness Women-sensitive/centric Culturally appropriate Prompt diagnosis and referral of complications to hospitals
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POSTNATAL CARE

Delivery

Referral of Complication to public/private health facilities

1st 24 visit hours Shasthya Kormi

2nd visit

3rd day

3rd visit

7th day

4th visit

14th day

5th visit

28th day

Program Organizer

Shasthya Kormi

Shasthya Shebika visits each newborn every alternate day and LBW baby every day
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NEWBORN CARE IN A SINGLE MONTH

44,036 neonates get care at home

150,068 visits offered by CHWs 41,304 babies get thermal care 40,855 babies feed breast milk within one hour
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PNC SERVICE COVERAGE 2012

99% 92% 94% 67% 88% 78%

97% 92% 84%85%

Special care to LBW babies

1st visit

2nd visit

3rd visit

4th visit

5th visit

Urban coverage

Rural coverage
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NEONATAL SEPSIS CARE

IMNCS
Case detection Assisted referral

Manoshi

10,158 9,328

10,700 9,606

4,779

5,221

6,538 6,224

4,159

3,789 3,577

2009 Phase I

2010

2011 Phase II

2012

2010

3,574

2011

4,135

2012

In general, over 90% of babies identified with neonatal sepsis were successfully referred and managed at formal facilities and/or by formal providers
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4,653

CHALLENGES & LESSONS

We achieved very high coverage with management of neonatal infections CHWs improved newborn care practices, case detection and referral of neonatal sepsis CHW competency and confidence is sustained by: Supportive supervision technical and managerial, and beyond check-lists Continued training (monthly) Assisted referral has been absolutely key to the high referral compliance, and improved outcome Use of mobile phone to provide real-time information reduces delay in care seeking, and improves referral and outcome Our efforts to engage village doctors did not work - due to lack of interest and confidence in treating these small babies Implementing standard protocols for neonatal care is critical for ensuring quality of care in facilities, e.g., reducing irrational use of drugs, unnecessary referral, etc.
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THANK YOU

Dont ever slow down. Dont ever stop innovating

Sir Fazle Hasan Abed
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