A SWOT Analysis of Helping Babies Breathe in Sudan: Emerging Challenges

Session: Programming for Maternal and Newborn Health during Emergencies: Lessons Learned from Epidemics and Conflict

Presenter: Lisa McCarthy Clark, Stony Brook Children’s Hospital, Stony Brook University
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Neonatal mortality continues to be a significant global health problem. The first day of life is the most dangerous day for mothers and babies everywhere, especially in Africa. The World Health Organization estimates that 1 million newborns die on their birthday, many from birth asphyxia. In Sudan, the population is 31 million with a birth rate is 36/1000 and a neonatal mortality rate of 41/1000 of live births. The Sudanese Federal Health Ministry estimates that 80% of births occur at home in rural communities and may be assisted by the village midwife (VMW).   The American Academy of Pediatrics (AAP) Helping Babies Breathe (HBB) is an educational program for resource-limited areas to teach the VMW to provide care to the newborn in first minute of life. This is to keep the infant warm and to assist newborns who are stillborn or struggle to breathe at birth. The Sudanese government along with professional stakeholders created a strategic framework (2009) for reducing neonatal mortality.   In 2013, with the Irish-Sudanese partnership the national roll-out of HBB began with a plan for community training through the Continuous Professional Development Centre (CPDC). Over the past two years HBB Master Trainers (333) and Providers (1416) have been instructed throughout the 17 states of Sudan. The VMW’s have expressed high satisfaction with teaching and learning experiences in the HBB courses. Progress in Sudan has been limited.   While the partnership is successful, politically Sudan is confronted by many challenges internally and externally with ongoing HBB training.   A SWOT (strength, weakness, opportunities and threats) analysis to identify the needs, commitments and resources needed for local and regional training was conducted.   We identify barriers and strengths, to assist the next stages of training and dissemination, to include centralization of training and integration of HBB into VMW practice.

Turning Disaster into an Opportunity for Improving Maternal and Newborn Care Services in Philippines

Session: Programming for Maternal and Newborn Health during Emergencies: Lessons Learned from Epidemics and Conflict

Presenter: Mariella Castillo, UNICEF
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Super typhoon Haiyan resulted in disruption of health service delivery and infrastructure in 2013. The rapid re-establishment of essential services for mothers and children became a priority as part of the rebuilding strategy in the most devastated towns. Using a UNICEF Tool, rapid assessments of equipment and supplies, intra-partum service standards and providers skills were conducted in 59 facilities in Regions 6, 7 and 8. The assessments were followed by a training of local trainers, cascade training, evaluation and supervision visits after one month and three months. Equipping local health workers with skills on Essential Intrapartum and Newborn Care (EINC) and quality improvement was central to the approach.   Rapid assessments showed lack of essential MNH commodities such as bag and mask for newborns and antenatal corticosteroids. Oxytocin was available, but magnesium sulfate was available only in 38% of facilities in Region 8, the most devastated region.  Towels for drying the baby were available in less than 25% of facilities across all regions.  Providers had low skills in partograph use, administering antenatal corticosteroids, and early initiation of breastfeeding. After the intervention, the availability of antenatal corticosteroids in Region 8 facilities increased from 45% to 100%, magnesium sulfate from 38% to 94%, and bag and masks from 0% to 88%-100% and were sustained at the 3-month evaluation.  Capacity and quality in EINC was increased in 365 frontline workers. Improvements in service standards, such as partograph use, controlling delivery room temperature and completion of delivery records were seen. Dramatic increases in use of antenatal corticosteroids and Kangaroo Mother Care were also recorded. Lesser progress was observed for handwashing practices, companion of choice during labour, birth doses of BCG, and monitoring of postnatal care.   Restoring essential maternal and newborn is disasters can be used as an opportunity to improve quality and strengthen health systems.


Coordinating to Deliver Essential MNH Services in South Sudan

Session: Programming for Maternal and Newborn Health during Emergencies: Lessons Learned from Epidemics and Conflict

Presenter: Victor Guma, USAID’s Maternal and Child Health Integrated Program, Jhpiego
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Background: Decades of armed conflict in South Sudan has resulted in weak educational and health systems, a very low adult literacy rate (27%), low institutional delivery rate (11.5%) and maternal mortality rate of 2054/100,000.  Post-partum hemorrhage (PPH) is the single leading direct cause of maternal mortality.

Methodology:  To support the Ministry of Health to implement a community based PPH prevention program, HHPs were selected based on their interest and community recommendations. HPPs recruited for the initial learning phase were female, volunteers and illiterate. A 4-day training was designed to use pictorial IEC training materials and reporting forms.  Interactive, participatory training approaches included role-plays and community-based practical sessions.  Each HHP needed to demonstrate competence in interpersonal counseling skills for birth preparedness and complication readiness (BPCR) and use of misoprostol for PPH prevention in home births. A total of 260 HHPs were trained and supervised for seven months.

Results: After training, HHPs demonstrated adequate knowledge in counseling using the BPCR cards and to identify danger signs. Follow up after the initial training demonstrated consistent transfer of knowledge by HPPs to pregnant women and their families as measured by: 1) women’s identification of danger signs, 2) knowledge of BPCR core elements; 3) self-reported development of BPCR plans, including saving money. 533 women counseled by HHPs delivered at home. 437 (99.5%) of 439 interviewed reported self-administration of misoprostol correctly; 85% of women could correctly identify common side effects of misoprostol.

Conclusion: Although volunteers, the opportunity to actively participate in their communities to reduce maternal deaths from PPH, through BPCR counseling and provision of misoprostol for self-administration in home births motivated the HHPs. The program demonstrated a replicable and feasible model in a high-mortality setting for engaging illiterate female community members in the prevention of PPH.


Steps Taken to Maintain MNCH Services During the Ebola Virus Disease Outbreak in Liberia

Session: Programming for Maternal and Newborn Health during Emergencies: Lessons Learned from Epidemics and Conflict

Presenter: Rose Macauley, JSI Research and Training
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As in most emergency situations, the Ebola Virus Disease (EVD) outbreak severely impacted Maternal and Newborn health, reversing the gains that had been made in the past decade.

By November 17, 2014, the EVD outbreak in Liberia resulted in 7,082 cumulative cases and 2,974 deaths. In the same period, a total of 341 health workers were infected, with 170 deaths among the infected. Most health care workers (HCWs) who became infected with EVD are said to have contracted the disease while caring for pregnant women. As a result of these deaths, other HCWs panicked and abandoned their posts, creating closures of virtually all health facilities in the country. During the peak of the EVD outbreak, women were delivering in the street and many died alone with their unborn babies while in facilities that could accept them.

To mitigate the situation, we initiated an infection prevention and control (IPC) approach, which includes training of HCWs, provision of IPC supplies (including PPE, buckets, hand sanitizer, and chlorine), and supervision/mentoring to ensure adherence to IPC protocols.

In close collaboration with WHO, CDC and other partners, we assisted the MOH in developing a comprehensive standard operating procedure for IPC along with a training package known as “Keep Safe-Keep Serving”.

The aim of the approach was to interrupt EVD transmission and give HCWs confidence that they could continue to provide services while remaining safe. Within two months of implementing the approach, over 5,000 HCWs were trained in their respective work places. This measure enabled facilities to begin providing needed services safely to women, newborns, and other non-EVD patients.

At the same time, the USAID flagship project, implemented by the JSI-led RBHS project, refocused its resources and activities exclusively on the epidemic response, including partner coordination and communication, contact tracing and leading the National IPC task force.

Through these activities, JSI and other partners helped restore the provision of services to women and newborns.


The Effects of the Ebola Epidemic on Maternal Newborn Health – Experience from Sierra Leone

Session: Programming for Maternal and Newborn Health during Emergencies: Lessons Learned from Epidemics and Conflict

Presenter: Paul Pronyk, UNICEF
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Sierra Leone was the worst affected country in West Africa’s recent Ebola epidemic. Prior to the epidemic, the status of the health system was poor. The most recent public expenditure on health was just $15 per person, with an additional $12 per person from external partners. The ratio of skilled health provider was 2/10,000 people – just 10% of WHO minimum acceptable thresholds. Not a single facility in the country was Basic Emergency Obstetric Care compliant, and levels of maternal and under 5 mortality are among the highest in the world (1,165/100,000 and 156/1000 respectively).

The conditions of the health sector served to accelerate Ebola transmission. Poor infection prevention and control (IPC) procedures resulted in 300 Ebola Cases among health workers, with 220 deaths. Ebola ‘holding centres’ were established due to insufficient isolation facilities.

Alongside this, the indirect effects of the epidemic were substantial. Quarantine reduced in food production and transport, potentially increasing levels of maternal and child undernutrition. An established community health worker program was suspended due to concerns regarding infection risk. Finally, widespread mistrust in the health system by local communities threatened the delivery of maternal child health services. A recent survey of primary health facilities conducted at during October 2014 and April 2015* demonstrated reductions in utilization of maternal-newborn services including immunization, antenatal care and skilled deliveries – leading to a substantial additional non-Ebola related burden of under 5 deaths

In response to these challenges, a number of strategies were employed. IPC training was conducted in all primary health facilities, including the provision of personal protective equipment for health providers. Prevention campaigns were implemented for malaria including mass-drug administration and bed-net distribution. ‘No-touch’ guidelines were developed and implemented to restore the community health worker program. A network of 46 Ebola Community Care Centres were deployed across 5 provinces to ‘decentralize’ the Ebola response and re-establish primary health care units as safe spaces for the delivery of maternal-child health services. While these may mitigate the short-term consequences of the epidemic, longer-term efforts to improve the resilience of the health system are essential.

*Sierra Leone Health Facility Assessment. UNICEF, Ministry of Health and Sanitation. June 2015.

A Sustainable Community Health Volunteer (CHV) Quality Assurance Innovation in Madagascar: The MIKOLO Model of On-Site Mentorship/Support by Tas and its Impact On CHV Performance

Session: Community Health: Supporting Community Health Workers, Strengthening Systems

Presenter: Hajamamy Rakotoarisoa, Management Sciences for Health
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Madagascar’s community health policy promotes community-based maternal, neonatal, reproductive and child health service delivery by CHVs in areas at >5km from a health center. Despite many years of technical support to CHVs, the quality of services delivered by CHVs remains poor and uneven. A USAID evaluation of CHVs in 2011 found that between 49% and 60% of CHVs do not perform services according to norms and standards. The USAID MIKOLO project’s quality assurance (QA) strategy combines on-the-job supervision of CHVs by local NGOs with group-based supervision in partnership with the head of the nearest health center and systematic performance monitoring linked to step-wise certification. Performance is measured quarterly through observation using a checklist that generates a performance score.  When a CHV specialized in child health achieves at least 80% in two consecutive quarters, s/he will be trained and licensed to also provide maternal, neonatal and reproductive health services, and vice versa. Subsequent achievement of 80% then leads to certification as peer-supervisors. This QA approach was introduced among 4,138 CHVs in 375 communes in Madagascar in 2014. We analyzed performance improvement and measured the effectiveness of this approach over a 6 month period, using chi square tests.  Among CHVs offering maternal, neonatal and reproductive health services, 30% achieved >80%. Among CHVs offering child health services, 27% did. Among those who subsequently offered all services, 23% (958) became peer supervisors. Performance increased among CHVs who offer only child health services from 60% à 68% (p<0.02) and among CHVs who offer maternal, neonatal and reproductive health services from 49% à 68% (p<0.001).

Conclusion: Standardized performance monitoring linked to certification and opportunities for CHVs to expand their service range and become peer supervisors leads to improved CHV performance and thus increased uptake of maternal, newborn, reproductive and child health services.

Supporting Community Health Worker Systems to Improve the Care of Mothers and Newborns in 3 Countries in East Africa

Session: Community Health: Supporting Community Health Workers, Strengthening Systems

Presenter: Irene Mbugua, World Vision
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Background: Community Health Workers (CHWs) are an essential cadre needed to reach mothers and newborns in low resource settings. One of the challenges for building capacity of CHWs is ensuring a system-wide approach. We worked with 700 CHWs and the systems surrounding them in multi-country MNCH project in 3 countries in East Africa.

Methods:  We utilized the USAID CHW AIM toolkit, to retrospectively measure each CHW system against 15 functions. When applied at project baseline each function was scored and used to guide MNCH project implementation. Stakeholders included: Ministry of Health at facility, district and national levels; CHWs; NGOs; community-based organisations; community leaders; and community development committees. CHW supportive systems   had never been assessed in these districts.

Results:  All project areas demonstrated improvements in CHW functionality over the life of the projects. In Tanzania the score was 0.2 and “non- functional” in 2012 and by 2014 the score was 1.7 and “functional”. Improved referral systems, data collection and reporting by CHWs had improved. In Uganda the score was 0.9 and “partially functional” in 2012, by 2013 the score was 1.4 and by 2014 the score was 1.7 and “functional”. Continuous training, supervision and incentives for the CHWs are still areas of improvement. In Kenya the score of 1.4 and “partially functional” system in 2012 and by 2014 “functional” and a score of 2.2. Equipment and supplies for the CHWs, individual performance evaluation and opportunity for advancement have improved over the two year period. Sharing of results with the MoH in Kenya resulted in plans to scale up.

Conclusion: Assessing the functionality of the CHW system assists in planning and implementation of maternal newborn and child health programs which are reliant on CHWs to improve MNCH.