Improving access to quality care for pre-terms & Low birth weight

babies in Northern Nigeria

A PRRINN-MNCH - A KMC Implementation review (July

Anthony Aboda&

Abimbola WilliamsIX International ConferenceAhmedabad, Gujarat, India

Nov 2012

Improving access to quality care Presentation Outline

• Introduction & Background• Objectives of review of KMC implementation• Methodology of the review• Key findings • Major recommendations• Emerging Issues & action

Introduction & Background• Population >160million –Nigeria is the most

populous country in Africa• Neonatal mortality remains high at 39 /1000

live births with wide regional variations & no significant change in the last decade

• 28% of deaths in under-fives take place in the first month of life

• In Nigeria alone, over a quarter of a million (284,000) babies die every year; about 700 newborns each day

• Nigeria ranks the highest in Africa in terms of the number of neonatal deaths and the third highest in the world

• Complications of prematurity is the second major cause of mortality contributing 40% of all newborn deaths

WHY do Nigeria Newborns die?

Estimated causes of newborn deaths in Nigeria

20

2.33 0.4 0.170

5

10

15

20

25

30

35

Early neonatal(Day 0-6)

Late Neonatal(Day 7-28)

Post-neonatal(1 - 11

months)

Age 12-59monthsW

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JE Lawn based on global ENMR, NMR estimates by WHO, and IMR and U5M by UN child mortality group around the year 2008

The riskiest week of life Birth and first week is key:

yet coverage of care is low for mothers and babies

When? The first week is the riskiest week of lifeMortality risk by week of life for the first 5 years:

Where do Nigerian newborns die?

About two thirds of births in Nigeria occur at home: the place where the majority of Newborns also die

Private facility, 14%

At home, 66%

Other/missing, 1% Public facility,

18%

Distribution of births in Nigeria by place of birth

Majority of births still occur at home!

NDHS 2003 MICS 2007

Home Health facilityHealth facility

Public Private Total facility

North Central 55% 27% 18% 45% 42%

North East 82% 15% 3% 18% 45%

North West 89% 9% 2% 11% 9%

South East 13% 20% 64% 84% 75%

South South 45% 30% 24% 54% 51%

South West 21% 34% 44% 78% 68%

National 66% 18% 14% 32% 41%

Place of birth in 2003 and 2007, by zone

Kangaroo Mother Carein Nigeria

• KMC was introduced to Nigeria in the late 1990s

• The first study on skin to skin care for Nigerian newborns was conducted in 2001

• Was re-introduced in 2 northern states; Kano and Zamfara in 2007 by ACCESS programme

• KMC training Manual adapted by FMOH in 2008

• Although KMC has been included in the Infant and Young Child Feeding Guidelines, the National Child Health Policy, and Key Strategies for CIMCI

• No routine data collection existed for KMC

• In 2009, PRRINN-MNCH programmeexpanded access to KMC in 3 additional northern states

PRRINN-MNCH• Partnership for Reviving Routine

Immunisation in Northern Nigeria and Maternal, Newborn and Child Health initiative

• Managed by consortium of HPI, SC and GRID• PRRINN commenced in Nov 2006, MNCH

added in 2008• Two contracts but one combined

implementation framework• PRRINN and MNCH to end by Dec 2013

9

Four states• Zamfara

• Katsina

• Jigawa

• Yobe

Federal Level– FMOH & NPHCDA

10

Estimated population in four states (2012) = 18,870.805– Women child bearing age group (22%) = 4,151,577– Under 5 yr (20%) = 3,774,161– Under 1 yr (4%) = 754,832

Where does PRRINN-MNCH operate?

Cluster Approach to Interventions

• The target states are divided into clusters comprising of 2-3 LGAs around a selected CEOC hospital with a target population of about 500,000 for each cluster.

• Each cluster therefore consists of 1 CEOC health facility serving 4 BEOCs and 8 PHCs -(24/7) health facilities

KMC Implementation

• Programme began training of trainers in Kangaroo Mother Care (KMC) in 2009 from Katsina, Yobe and Zamfara.

• By July 2011, 31 master trainers had carried out step down KMC training to over 150 health care providers.

• Trained at least 3 HWs in 50 HFs in target states as well as provided KMC kits to enable KMC implementation.

• 120 National Master Trainers trained by the FMOH from 2010 to date

Objectives of the KMC ReviewTo assess the:• Availability of KMC services in selected

facilities, their accessibility and level of service utilization

• Quality of KMC services, including follow up after discharge

• Supervision and monitoring mechanisms in place including job aids, guidelines, protocols, registers, and HMIS forms

• Support system including staffing, drugs and consumables, equipment, space, and organization

• Sustainability and acceptability of KMC• Feasibility for scaling up KMC to other

clusters

Review Approach & Methodology

• The sites were assessed using a standard methodology and questionnaire tool for monitoring the progress of KMC implementation developed and tested by the South African Medical Research Council Research Unit for Maternal and Infant Health Care Strategies.

• Each site received a total score out of 30 based on three phases: pre-implementation, implementation and institutionalisation.

• A team of 4 evaluators visited 20 health facilities across the 3 states.

• Following these visits, investigators met together to systematically review notes and apply a score to each site based on set constructs

Location and level of facilities assessed

ZamfaraKatsina Yobe

Training facility; CEOC facility ;BEOC facility; PHC facility *icons placed within LGAs, not on exact geographic location of facility

Summary Findings- KMC Implementation status.

• 6 sites (2 training facilities, 3 CEOCs, 1 BEOC) were identified as demonstrating ‘evidence of routine and integrated KMC’.

• 7 sites (2 CEOCs, 4 BEOCs and 1 PHC) showing evidence of ‘practice’

• 5 facilities (1 training site, 3 BEOCs and 1 PHC) showed evidence of ‘taking ownership’

• 1 PHC site showing evidence of ‘adopting the concept’.

Summary Findings – KMC Implementation status of health facilities

Key Recommendations

1. Strengthen feeding practices to ensure weight gain and other positive outcomes - refresher training for facility staff - improving support and guidance to mothers

regarding feeding practices

2. Improve tracking of weight gain to flag potential problems

- Provision of job aides- training of staff on proper use of weighing scale

Recommendations

3. Ensure KMC messages are isseminatedthrough multiple channels to increase demand for KMC services

4. Encourage KMC practice at home since mothers prefers to be discharge early

- use checklist for discharging mothers from KMC

5. Follow up on babies who do not return to the health facility after discharge from KMC

- Engage CHEWs and Community Volunteers (CE)

Conclusion &Emerging issues

• Quality of training was good, retention high, but on-site orientation could fill knowledge gaps & sustain services in the event of staff turn over.

• Weight measuring and reporting needed to be improved.

• Demand for services was a major challenge.• Supervision key to improving services & was

needed to be strengthened.

Immediate Action• HWs had refresher courses on KMC & on

the use of the digital weighing scales to improve the tracking of weight gain

• Feeding practices were strengthened to ensure weight gain and other positive outcomes through provision of job aides

• KMC messages were developed and disseminated through multiple channels

• Women were encouraged to continue KMC practice at home after discharge

• Babies who do not return to the health facility after discharge from KMC, were followed up

THANK YOU