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overview of MNCH burden of disease & Emergency referral for mothers and newborns

This overview provides information on the burden of disease for mothers and newborns in the context of Millennium Development Goals (MDGs) 4 and 5. It highlights the progress made in reducing child and maternal mortality rates, as well as the challenges that remain. The importance of emergency referral systems in reducing maternal and neonatal deaths is also emphasized.

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overview of MNCH burden of disease & Emergency referral for mothers and newborns

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  1. overview of MNCH burden of disease &Emergency referral for mothers and newborns Emily Keyes 27 September 2012

  2. MDGs 4&5 – counting down to 2015 MDG 4: reduce under 5 child mortality by 2/3 • Global rate fallen by 41% since 1990 • 6.9 million deaths in 2011 (down from 12 million in 1990) • Rate of decline is increasing (from 1.8% in 1990s to 3.2% from 2000 to 2011) • Deaths are increasingly concentrated in SSA and S. Asia (more than 80% of <5 deaths) MDG 5: reduce maternal mortality by 75% • Very few countries on track to meet goal (16 on track, 25 insufficient or no progress)) • 287,000 maternal deaths in 2010 (declined by 47% since 1990) • 56% of maternal deaths in SSA, 29% in S Asia

  3. 3.3 million neonatal deaths occur each year 50% occur in the first 24 hours Asphyxia 75% occur in the first week (2.3 million) Preterm/LBW Source: Oestergaard MZ, Inoue M, Yoshida S, Mahanani W et al. Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities. PLOS Medicine. 2011; 8(8): 13 pages.

  4. When do women die?

  5. Rates and absolute numbers Rapid rates of decline Highest absolute numbers (M+Neo) • Laos (<5) • Malawi (<5) • Nepal (<5) • Bangladesh (<5 + M) • Egypt (M) • Romania (M) • India (M) • China (M) • India • Nigeria • Dem. Rep. of Congo • Afghanistan • Ethiopia • Pakistan • Bangladesh Sources: UNICEF 2009; WHO 2007

  6. India – annual statistics • 117,000 maternal deaths • 0.9 million newborn deaths (28% global deaths) • 20% of global births • 49% of global underweight children • 34% stunted children • 46% of wasted children

  7. Evidence-based interventions for children • Supplementary feeding (6-9 months) • DPT3 • Measles • Vitamin A (2 doses) • Sleeping under insecticide-treated bednets • Care seeking for pneumonia • Malaria treatment • Diarrhea treatment • Improved sanitation • Improved drinking water

  8. Evidence-based interventions for newborns • Folic acid • Tetanus toxoid • Syphilis screening • Intermittent preventive Rx malaria • Detection, Rx bacteriuria • Antib for PPROM • Corticosteriods preterm labor • Detection, management of breech, twins • Labor surveillance • Clean birth practices • Newborn resuscitation • Breastfeeding • Prevention, management of hypothermia • Kangaroo mother care • Community-based pneumonia case management Source: Darmstadt et al. 2008

  9. Evidence-based interventions for women • Contraception • Antenatal care • Skilled birth attendant • Postnatal care for mothers • Cesarean delivery • Safe abortion • Active management of the third stage of labor • Magnesium sulfate for pre-eclampsia/eclampsia • Blood transfusion Tracked in DHS

  10. Drivers of maternal mortality reduction • Declines in fertility • Increases in income per head • Greater educational attainment among females • Increases in access to skilled care at birth and emergency obstetric care • In the absence of HIV infection, declines would have been more dramatic in last 2 decades

  11. Emergency Referral for Women and Children

  12. Why referral? The continuum of care Preconception  Pregnancy  Delivery  Postnatal Care  Infant and Child Care

  13. Terminology and concepts • Referral – any upwards movement of health care seeking by individuals in the health system • Categorizations • Point of initiation: Front line provider or self-referral • Urgency: Elective (cold) or emergency • Timing: Antenatal, delivery and postpartum referrals • Acceptance vs. compliance with referral • Appropriateness of referral

  14. The 3 Delays Model Referral has the potential to reduce all 3 delays DELAY #2 Reaching a facility DELAY #3 Receiving adequate care DELAY #1 Deciding to seek care Onset of Recovery or death Complication

  15. Time between the onset of a complication and death

  16. Pyramidal structure & bypassing Regional Hospital Resources to treat Clinical judgment Protocols Feedback QOC Financial accessibility Transport Communication Receiver District Hospital Transport • Perceived • risk • etiology • QOC • Costs • transport • care • Distances & roads • Socio-cultural • preferences Health center/post/dispensary Sender Community Adapted from Jahn & De Brouwere, 2001

  17. Requisites of a well functioning system Communication Transport Functioning referral center Source: Murray SF, Pearson SC. Maternity referral systems in developing countries: Current knowledge and future research needs. Soc Sci & Med 62, 2006.

  18. Requisites of a well functioning system Communication Transport Functioning referral center Protocols for senders & receivers

  19. Requisites of a well functioning system Collaboration across levels and sectors Communication Supportive supervision Transport Monitoring system Functioning referral center Protocols for senders & receivers

  20. Requisites of a well functioning system Collaboration across levels and sectors Communication Supportive supervision Monitoring system Transport Functioning referral center Referral strategy informed by population needs and HS capabilities Protocols for senders & receivers Policy support Pro-poor protection for referral & transport

  21. Referral in Bo North, Sierra Leone 2007

  22. What to do at the community level? • Birth preparedness includes planning for delivery attendant and (emergency) transport • Increasing family and male involvement in the awareness of danger signs and where to seek care -- to reduce gender driven barriers to care • Community mobilization for support of pregnant women and their infants

  23. How to address the cost of referral? • Strategic solutions to cover transport + services • Community-based health insurance • Community loans • Conditional cash transfers: NGO / government incentives to pay for referral • Voucher schemes targeted at poor / fee waivers

  24. How to address transportation? • All terrain vehicles are costly • Need for greater accountability • Exclusive use for emergency transport • Regular maintenance and repair • Driver coverage and training • Solutions • Less costly transport options – ex. Motorcycle ambulances • Private-public partnerships – ex. Dondo, Mozambique • Operational guidelines / protocols • Use of transport unions & on-call rotations

  25. How to improve feedback? • Where feedback/counter-referral doesn’t exist, does it make sense to phase it in by ensuring feedback for those cases where follow up is critical? • Whose responsibility is it – patient or provider? • Solutions: • Tie feedback to financial reimbursement • Make forms simple • Use telephones

  26. Unmet need for referral • Non-compliance with referral can be high • Compliance for fetal, newborn (and child) referral may be particularly low • Fear, discrimination, male providers, poverty, etc. • Provider reluctance to refer • Over confident / fear of losing credibility • Poor diagnostic skills / poor patient monitoring • Lack of communication skills to overcome patient reluctance

  27. Bypassing when seeking treatment for obstetric complications • Bypassing highlights the relative importance of distance or cost as opposed to internal facility factors • Quality of care – HR, drugs, supplies, open 24/7 • Provider attitudes, greater privacy • First level referral sites sometimes refuse referrals, reportedly because they don’t want a maternal death on their books • Pervasive or anecdotal? • A problem of private referring to public facilities?

  28. How do we ensure the appropriateness of referral? • Consequences of “too much” referral • Overburdening referral centers with normal cases (false positives), thus, increasing cost of care • Travel and opportunity costs increase for families • Overmedicalization • Solutions • Clinical criteria for referral (decision trees) • Upgrade sending facilities to be more self sufficient • Penalize patients for accessing tertiary facilities without a formal referral?

  29. Key Messages • Successful referral systems are multifaceted and tailored to suit specific environmental contexts; all require careful consideration of what is needed in addition to affordable transport • A functioning referral system promotes equity and trust in the health system • Referral will reduce morbidity and mortality only if the care at the receiving end is of high quality

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