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Bangladesh Overview:

Progress of Newborn Health Activities


and Vision for the Future
Professor Dr. Mohammod Shahidullah
Helping Babies Survive
Asia Regional Workshop
Dhaka, April 8, 2015

Structure
Context
Policy response
Program response
Key challenges
Way forward

Context

Bangladesh has achieved MDG 4 !


140

133

120

100

80

60

Bangladesh
is 1 of 23 countries on track to
116
achieve MDG4
MDG
UN-IAGCME
Target
94
&
2013
88
87
82 th
has the 4 most rapid rate of decline in childU-5 MR
IMR
66
65
65mortality
NMR
52

48

40

52
42

41

37

53

43
32

20

48
41
33
24

31
22

0
1993

1997

2001

2004

2007

2011

2013

2015

Source: BDHS, UN-IAGCME- UN Inter-agency group for Child Mortality Estimation, 2013

Proportion of neonatal deaths among U5: Increasing trend


70%

57%

60%
50%
40%

39%

41%

45%

60%

47%

30%
20%
10%
0%
1989-93

1992-94

1995-99

1999-03

2002-06

BDHS 2011

National burden of mortality


Neonatal mortality rate 24.4 per 1,000 live births (2012) [2]
75,903 neonatal deaths (2012) [2]
Stillbirth rate 36.0 per 1,000 total births (2009) [1]
stillbirth (2009) [4]

117,442

Maternal mortality ratio- 194 per 100,000 live births (2010) [3]
7,300 maternal deaths (2010) [3] [1] WHO (2013): Global Health Observatory Data Repository ( still birth rate originally published in Consens et al, Lancet 2011);
[2] UNICEF/WHO/The World Bank/UN Pop Div. Levels and Trends in Child Mortality. Report 2013.
[3] Bangladesh Maternal Mortality Survey 2010
[4] Estimated

Mortality rate by age group: Bangladesh, region and globe


25

22.5
20

15

Bangladesh

Region

Global

19.3

14.2

14

10

5.4
5

6.4

13.2

13.1
10.5
7.6

4.4

Early NMR

Late NMR

Post neonatal IMR Post infant Under


5 Mortality
IGME Estimate- 2013

Causes of newborn mortality (Bangladesh)


The Three Major Causes
Contributes 88% of all
newborn deaths
1. Complications of
preterm birth
2. Intra-partum related
(Birth Asphyxia)
3. Severe Infection
1.

Data source: Bangladesh-specific


mortality estimtes (Liu et al. 2012).

The first day of life : The most dangerous day


Worldwide, the day a child is born is
by far the most dangerous day in a
childs life because mortality is very
high in the first 24 hours after birth.
In Bangladesh 21% of all deaths in
children younger than 5 years
happened in first day of their life and
the estimated first day death in 2012
was 28,100. **

Surviving the First Day. State of the Worlds Mothers


2013, Save the Children

Day 828
19%

Day 27
31%

BDHS 2011 data

Day 0
37%

Day 1
13%

Reducing neonatal mortality is key to future progress


Neonatal Deaths

Neonatal Infections and


Pneumonia (38,000 deaths)

Prematurity
/LBW 11%

Undefined
20%

Pneumonia
13%

BDHS 2011

Reducing neonatal mortality is key to future progress


Neonatal Deaths

Neonatal Infections and


Pneumonia (38,000 deaths)

Prematurity
/LBW 11%

0-28 d

Undefined
20%

Pneumonia
13%

BDHS 2011

Preterm birth (12,000 deaths +


20,000 deaths as underlying cause)

Reducing neonatal mortality is key to future progress


Neonatal Deaths

Neonatal Infections and


Pneumonia (38,000 deaths)

Prematurity
/LBW 11%

Undefined
20%

Preterm birth (12,000 deaths +


20,000 deaths as underlying cause)
Birth Asphyxia (21,500 deaths):

Pneumonia
13%

BDHS 2011

Neonatal sepsis, birth asphyxia and


prematurity/LBW accounts for 63% of all
newborn deaths; significant portion of these
deaths could be averted through Immediate
Newborn Care and Ante Natal Care

Policy response

Milestone research initiatives in Bangladesh


Projahnmo trial 34% reduction in neonatal mortality through a package of community

based interventions. A home care strategy to promote an integrated package of preventive and
curative newborn care is effective in reducing neonatal mortality in communities with a weak
health systems, low health care use, and high neonatal mortality. (Lancet, 2008)

Chlorhexidine trial Significant neonatal mortality reduction with single application of

CHX, and severe cord infection reduction with multiple application of CHX was observed.
Chlorhexidine cleansing of a neonates umbilical cord can save lives, but further studies are
needed to establish the best frequency with which to delivery the intervention. (Lancet, 2012)

SATT trial

Results suggest that the two alternative antibiotic regimens (i. gentamicin single
dose and oral amoxicillin twice daily for 7 days and, ii. procain bezylpenicillin and gentamicin
single dose for 2 days followed by oral amoxicillin twice daily for 5 days) for outpatient treatment
of clinical signs of severe infection in young infants whose parents refused hospital admission are
as efficacious as thee standard regimen (procain bezylpenicillin and gentamicin single dose for 7
days). This finding could increase treatment options in resource-poor settings when referral care
is not available or acceptable. (Lancet 2015)

Policy and strategic initiatives for newborn health during 2009-2014


National Neonatal
Health Strategy and
Guidelines developed in
2009

Scale-Up Plan
incorporated in the
MNCH-OP in 2013

SOP developed for


Facility Newborn Care in
2011

National Scale-up of
HBB initiative 2012-13

National Technical
Committee formed in
2013

Training modules
developed in 2012

Capacity building of
service providers on
newborn care 2012

National IEC materials


developed and
distributed on newborn
care 2012

Community based
newborn care scaled-up
in >20 districts 2012

SCANU scaled-up in 34
districts by 2015

HIMS on newborn
health developed and
integrated in DHIS 2
(2013)

BNA conducted and


draft BENAP developed
in 2014-15

Bangladesh Declaration for Ending Preventable Child Deaths by


2035

Bangladesh Declaration for Ending Preventable Child Deaths by


2035: Interventions
Maternal Health
interventions

1. Skilled birth attendance


(CSBAs and Midwives)
2. Functional and 24/7
BEmONC and CEmONC
at strategically located
facilities

Newborn health
specific
interventions
3. Essential newborn care with
newborn resuscitation &
application of
Chlorhexidine
4. Antenatal steroids for
premature labor and
Kangaroo mother care
(KMC) for premature/low
birth weight babies
5. Neonatal sepsis
management at PHC level
6. Specialized newborn care at
district & sub-district level

Child Health specific


interventions
7. Effective referral linkage to
ensure continuum of care
from community clinics to
district /tertiary hospitals
8. IMCI at all levels

9. Multi-sectoral approach to
promote exclusive BF and IYCF
10. Community based child
drowning prevention activities
11. New vaccines:
pneumococcal and rotavirus

Benchmarks for progress tracking of key interventions


Maternal
Health
Interventions

Current

Target 2020

32%
50%

Skilled attendant at birth

80%
Antenatal corticosteroid

Newborn Health
Interventions

Target 2016

CHX umbilical cord cleansing

KMC for pre-term baby

40%

New
Interventions
20%

0%

20%

50%

90%

50%
28%

Neonatal sepsis treatment

80%

40%

50%
60%

80%
80%

100%

Linking with global initiatives towards a national action plan

Partnership: MOH&FW, DPs, NGOs, Academicians and Researchers


APR
National
Policy
Dialogue
initiated in
2012

Consensus
build on
priority
intervention
2012

COIA

UNCoLSC
Global
Initiative for
Child
Survival Call
for Action &
APR

Political
Commitments
and Target
Fixation
2013

National
Guideline
Development
under NTWC
and NCC

4 Guideline
Developed
2014

EMEN

ENAP
Initiatives

EPMM
GAPPD

Bangladesh
Every
Newborn
Action Plan
2014

Program response

Development of national guideline for 4 new newborn


interventions
Four Technical sub-groups formed by
NTWC on NBH for development of
Guideline and Protocols (CHX, ACS, KMC
and NB Sepsis) in light of HBS.
We are heading towards development,
pilot testing finalization of a
comprehensive newborn care package
for national use.
A comprehensive national newborn
campaign is being planned.

Strengthening Health Systems:


Quality Improvement: implemented in 97 hospitals with 5S-CQI-TQM approach
QA National Steering Committee (MoHFW)

National Quality Improvement Committee


(HEU, MoHFW)

QI Secretariat (HEU, MoHFW)


National Technical
Committee for QA (DGHS)

Quality Improvement
Team (Facility level)

Divisional QI Committee
District QI Committee

Type of Hospitals/Facilities

# of facilities

Medical College Hospitals


District Hospitals
MCWC
Upazila Health Complexes
Total

3
14
3
77
97

Policy advocacy through demonstrating innovations for


Improved Quality of Newborn Care in SCANU
Quality Improvement of
services adopting TQM
approach

Competency based
training and use of audiovisual tools for skill
development

Paper-based record
keeping and reporting to
individual case-tracking
through web-based MIS
23

Strengthening Health Systems:


Scaling-up SCANU for full supportive care of sick newborn
Case Fatality Rate in the SCANU of
Tangail District Hospital

Existing SCANU (17)


Planned SCANU (34)

40

30.6

20

22.2

20.7

0
CFR

2012

2011-13
District
Hospital

UNICEF
JICA
USAID
GOB/DPs

2014

2014-15

MCH District
Hospital

SDF (GOB)

2013

2015-16

MCH District
Hospital

MCH

2017-18
District
Hospital

MCH

10
12

7
1

10
2

3
5
12

18

Total

12

12

32
01
03
18

12

64

Strengthening Health Systems:


HMIS: Integrated web-based MIS for all MNCH program
Individual case tracking of every newborn through DHIS 2

Strengthening Health Systems:


Maternal and perinatal death review for program actions

Scaling-up

National
Scaling of
Up HBB
of Helping Babies Breathe
National
scaling-up
Initiatives in Bangladesh
Pilot study, National
consensus for scaleup, Policy adoption
with High political
commitment

Development of National Scale-up plan,


Incorporate into Sector Program and Operation
Plans

Partnership
development
and ensure
resource

Refreshers training

Incorporation in
training curriculums

Ensure Logistics

Training

Supervision Monitoring &


Evaluation

Planning and review

National preparedness for CHX scale-up

Evidence Generation
Dissemination and
Advocacy
Consensus Building

Policy endorsement
Development of national
Guideline that includes
productione, application,
distribution and
communication guideline
Incorporation in OP with
budget allocation

Pilot study
Ensure Availability of
CHX
Partners engagement
Development of BCC
material and training
materials

The way we work in partnership

Capacity building

Technical assistance

Attain effective coverage of


high impact interventions

National Core
Committee (NCC) for
newborn health
Develop Leadership and
policy advocacy

MOH&FW
Systems strengthening
Intensive/pilot
implementation

Innovations and research


for evidence generation

Provision of Adequate skilled HR,


commodities and technology

Newborn Technical
Working Committee
(NTWC)
DGHS, DGFP, DPs, NGOs, Professional
Agencies, Academia, Research Organizations

Technical Support
Groups (TSG)

Technical Support
Groups (TSG)

As needed

As needed

Support from the partners to the MOH&FW


UNICEF, SNL, MaMoni, JICA provides support towards intensive
implementation in several districts
UNICEF, WHO, JICA, GIZ, icddr,b, Mamoni support MoHFW for system
strengthening of QI initiatives for MNH
icddr,b supports evaluation and implementation research and
documentation
NHSDP, UPHCP, BRAC and other NGOs provide newborn care with
nationwide coverage through clinic and community networks
SIAPS provide support to strengthen supply chain management of
essential commodities
SMC and BRAC produces clean delivery kit (planning to include CHX)
Pharmaceuticals has started commercial production of 7.1% CHX

Challenges

Low coverage of skilled care


100

All Services are increasing gradually , slowest progress in ANC 4

90
80
70
60

50

50

50

40
30
20

17

22

50

32

26
16

21

27
16

20

10
0

ANC 4 by MTP

Delivery by MTP
BDHS2004

BDHS2007

BDHS2011

PNC by MTP <2days


Target 2016

Challenges

Demand side:

High home delivery


Low essential newborn care practices
Low utilization

Supply side:

Low home based service delivery


Primary facilities are not well prepared yet

Health system:

Inadequate skilled HR for maternal and newborn care


Weaker supervision and monitoring
Newborn indicators are yet to be incorporated at the process level

Inequity:

Geographic inequity in mortality


Very low effective coverage of interventions
Poor still remains underserved

Way forward

Global mortality targets for 2035

Mortality rate (per 1,000 live births)

Unless we greatly accelerate newborn survival efforts, goal to end preventable child deaths
by 2035 unreachable
100
2035 target:

90

National U5MR of 20

80
70

2000-2012
AAR = 3.8%

Global U5MR

Proposed NMR target 2035:


National NMR of 10 (ENAP)

Business as
usual: U5MR

60
50
40

Business as
usual: NMR

30
20

Global NMR

2000-2012
AAR = 2.7%

10
0
1990

AAR = 4.3%
1995

2000

Scenario

2005

2010

2015

2020

2025

2030

2035 global NMR

2035 neonatal deaths

If current trends are unchanged

13

1.8 million

Every country to NMR of 10 per 1000

0.9 million

2035

Actual NMR and Projections for Bangladesh:


2010 to 2030

60
55
50
45
40
35

52
48
42

41
37
32

30
25
24

20

19

15

15

10

12

5
0

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Actual NMR (BDHS)

Projected NMR

Priority actions
Launch massive, comprehensive campaign to promote newborn
behavior and practices, care seeking and utilization of services
Focus on quality improvement and ensure adherence to SOPs.
Improvement in effective coverage of services
Strengthen measurement and monitoring of adequacy of inputs,
processes and outputs
Prepare facilities with skilled HR and supplies. Primary level for
preventive, screening and follow-up care and, Secondary and tertiary
level for full supportive care for sick newborn
Reduce equity gap to reach the unreached and most vulnerable,
marginalized population with differential programming

Thank You