REPBLICA DE MOAMBIQUE MINISTRIO DA SADE

Facility based newborn care: Country successes and challenges

Mozambique

Dra. Bernardina Gonalves Pediatrician

GLOBAL NEWBORN HEALTH CONFERENCE April 15-18, 2013 Johannesburg, SA

National Health Services at glance

1387 Health Facilities 7 Provincial Hospitals and 3 Central Hospitals 1292 Health Facilities with Maternities- 24 hours/day 1033 provide ANC/PMTCT/FP/PNC- 8 hours/day Density of midwives, nurses and doctors per 1,000 population: 0.3 Health Facilities/habitants: 1/10.000 hab

Mortality & Causes of Deaths

Type of HF Frequency # deliveries Intra hospital NM Rate /1000 Live births 57.4 27 0.86 7.34 1.09 7.96

Central Hospitals Provincial Hospitals General Hospitals Rural Hospitals Health Centers Total

1.261 639 20 350 214 2.484

21.983 23.617 23.219 47.668 195.664 312.151

The main causes of Death were Prematurity (50%), Severe asphyxia (32%), Neonatal sepsis ( 29%)

Source: Maternal & newborn health needs assessment,2009

Causes of Newborn Deaths

Neonatal Sepsis constitute the main cause of death among Newborns born in Rural Health Centres (27.3%) and at community level (44.9%) This demonstrated a need to improve our actions and interventions at these levels to better address the NB sepsis more efficiently

Source: National Survey : Causes of Mortality, INE 2007

Newborn Health Interventions

Intervention Packages
Focused 4-visit antenatal package (tetanus immunization, detection & management of syphilis, other infections, pre-eclampsia, Malaria intermittent presumptive therapy, folic acid, PMTCT, Counseling and health education) Emergency obstetric care /ENC Antibiotics for preterm rupture of membranes Corticosteroids for PT

Type of HF
District, Provincial, General Rural Hospitals and Urban, Rural Health Centers ,and Outreach services

Type of Service Provider

MCH nurses, Preventive medicine agents and technicians for vaccination Doctors (High risk ANC)

Maternal

1/500.000 hab (Emoc Basic; 5/500.000 hab (Emoc Complete) Central, Provincial, General and Rural Hospitals (specialized) Central, Provincial, General Rural Hospitals and Urban, Rural Health Centers and Outreach services Central, District, Provincial, General Rural Hospitals and Urban Health Centers, Health Centers with maternities

MCH nurses, surgical technicians, Doctors Gynecology& Obstetric specialists MCH nurses, curative medicine agents& technicians, Doctors MCH nurses, technicians, Doctors, surgical technicians

Family Planning

Model Maternity /Quality performance base d standards (2009 & 2011)

Newborn Health Interventions

Intervention Packages
Essential Newborn Care / Neonatal Resuscitation (ventilation & cardiac massage)/Management of moderated and Severe Newborn Illness Essential Newborn Care/ and Helping Babies Breathe (2011) Integrated Management of Childhood Illness Neonatal component (2008)- including treatment for infections with ATB & PMTCT Kangaroo Mother Care (2009)

Type of HF
Central, District, Provincial, General Rural Hospitals Urban and Rural Health Centers District, Provincial, General Rural Hospitals and Urban, Rural Health Centers and Health Posts * Central, District, Provincial, General Rural Hospitals and Urban, Rural Health Centers District, Provincial, General Rural Hospitals and Urban, Rural Health Centers and outreach services

Type of Service Provider

MCH Nurses, pediatric nurses, Generalists, Gynecology& Obstetric specialists Elementary/basic midwives, MCH Nurses MCH Nurses, pediatric nurses, Curative Medicine Agents & Technicians , Generalists MCH Nurses, pediatric nurses, Curative Medicine Agents & Technicians , Generalists, specialized Doctors MCH Nurses, pediatric Nurses,

Newborn

Post-natal care with focus on the 1st week of life (visit on day 3, 7) and between day 21-28 to support health practices and earlier detection and referral of complications

Model Maternity (2009) Neonatal component Central, District, Provincial, General (immediate skin-skin contact, early breastfeeding early Rural Hospitals and Urban Health - first hour after birth , neonatal resuscitation and Pos Centers, Health Centers type I and A Natal Care - 3, 7 and 21-28 days after deliver)
Quality performance base standards (2011)

Technicians , Generalists, Managers

MCH Nurses, pediatric Nurses, Generalists, Gynecology& Obstetric specialists, Curative Medicine Agents &

COVERAGE OF SPECIFIC INTERVENTIONS

IMNCI :

Number of health facilities with Emergency Obstetric &Newborn Care: 530 out of 1.292 HF More than 1.000 health workers have been trained in ENC from 2009 to 2010

Since 1998 the package has been scaled up to 144 Districts with support from country collaboration partners. In 2008 the strategy was updated to add Neonatal Care and HIV/AIDS. Implementation of an action plan for effective roll out will start in May 2013

KMC: The method have been introduced to all Provinces. In most HF it is an integrated service( no specific units) KMC is integrated as key thematic issue in most continuing education MNCH trainings. HBB : Recently adopted by the Country. 330 Health Workers and 43 National master trainers have been trained , an action plan to accelerated the roll out of HBB is currently being prepared .

The coverage of the interventions within the provinces is variable depending on local partners support..The country still need to improve M&E system to monitor implementation of these interventions as well as certification of the HF that implement it. Preliminary data from national quality assessment of newborn services done in 2012 is still to be finalized.

Successes: Improving Quality with Performance based Standards

Data from 28 Health Facilities

Percentage

Quality Standards Areas

Inclusion of NB Quality Standards indicators in the HIS

Comparison between the Baseline (2009-10) and the Last Measurement (Q4 2011 or later)
Data from 28 Health Facilities

Inclusion of NB Quality Standards indicators in the HIS

Successes : Working towards Sustainability

Training of health professionals in the area of Maternal & newborn health, targeting all District Staff(not only specific HF staff to overcome the issue of high turn over) Inclusion of the package interventions in pre service training curriculum ( HBB in discussion for inclusion) Inclusion of materials & equipment as an essential item in existing material & equipment Kits(Penguin, Bag & Mask, essential drugs for NB resuscitation, ATB( IM/IV) for Sepsis/infections, EmOC kits) Emerging Maternal and Newborn audit committees based on clear operational guidelines Community Health Communities & Co-management Committees operational Guidelines to promote effective Community-HF linkages

Challenges
Insufficient availability of human resources/Weak institutional capacity for retention of qualified human resources

Implementation of an action plan to accelerate roll out of IMNCI, HBB and KMC( training and mentoring of HW, supplies, certification criteria and Inclusion of specific indicators for those interventions at HIS/routine data management ) Improve the health infrastructure to the newborn (to reduce overcrowding services neonatology to prevent sepsis)

Challenges
Improve the availability of ATB (parenteral) to treat sepsis and other commodities/material and equipment at all levels Upgrading of existing Health Post Update IMNCI training curricula for Revision of training curricula, role & responsibilities of TBAs, APEs and other Community Health Volunteers