Country Assessment On Stillbirths, Newborn Deaths And Small & Sick Newborn Care

1. Country Assessment On Stillbirths, Newborn Deaths And Small & Sick Newborn Care

2. Scope of the Assessment

3. Newborn & Young Infant Care

4. TYPES OF INFANT CARE UNITS 19 16 9 KANGROO MOTHER CARE UNIT (PIMS) The type of infant care unit was accepted as defined by the facility at the time of data collection.

5. AVAILABILITY OF ESSENTIAL EQUIPMENT FOR THE CARE OF NEWBORNS & YOUNG INFANTS

6. ROUTINE MAINTENANCE OF EQUIPMENT (n=23)

7. AVAILABILITY OF SPECIALIST CADRES (n=23)

8. TRAININGS RELATED TO NEWBORN AND YOUNG INFANTS CARECONDUCTED BY FACILITIES n=23

9. QUALITY ASSURANCE PRACTICES RELATED TO NEWBORN & YOUNG INFANTS (n=23)

10. PRACTISE OF CASE REVIEWS AT THE FACILITIES (n=23) Case reviews: A case review is a formal meeting (not daily rounds) where information about a current or discharged patient is presented (Primary Physician), and issues related to diagnosing, treating, and improving the outcome are discussed. Near Miss: Newborns that almost died at birth.

11. FACILITY MANAGEMENT PRACTICES (n=23)

12. AVAILABIILITY OF NEWBORN & YOUNG INFANT SERVICES & INTERVENTIONS (n=23)

13. AVAILABILITY OF INFECTION CONTROL SUPPLIES (n=23) • = All facilities have the indicated parameters • + = Number of facilities with the indicated parameter • Empty Box= No facilities in the region have the parameter

14. RECORDS OF NEWBORNS AND SICK INFANTS Admission History and Physical Examination n=105 (3-59 days) Newborn assessment n=74 (0-59 days) • Birth weight recorded in 74% of the reviewed records • Gestational age found to be documented in 45% of the records • Note on the assessment of congenital anomalies –only 19% of the reviewed record • Note on danger signs found in 42% records • Reason for admission was noted in 89% of the records • Information on referral was present in 60% of the records • History of pregnancy was found in 46% of the records • Assessment of Danger signs was recorded in 17%

16. REVIEW OF HEALTH MANAGEMENT INFORMATION SYSTEM • Majority of the facilities submit electronic or paper-based HMIS reports to DHO and birth information to national vital statistics • None of facilities had compiled the information on neonatal deaths and stillbirths • Majority of the DHIS or HMIS in the facilities routinely monitors important indicators • low birth weight (<2500gm), • preterm birth, neonatal sepsis • asphyxia. • Only 25% of the facilities reported monitoring very low birth weight (<1500gm) as indicator of newborn monitoring.

17. REFERRAL CARE SERVICES FOR OF NEWBORN AND YOUNG INFANTS (n=23) • Tools commonly reported for referral information were registers, printed referral forms. • Only 23% of the facilities reported ever receiving feedback on out-referral • All of the facilities reported using ambulance services • Majority of the facilities had the fuel available for vehicle

18. Identified Gaps from Facility Assessment of Newborns & Young Infant Care in Pakistan Infant care units & Preventive maintenance of equipment Most of the facilities lack Kangaroo Mother Care Units & doesn’t routinely undertake maintenance of incubators, radiant warmers and phototherapy lights. Staffing & Capacity building Neonatologists, Neonatal Surgeons and Neonatal Nurses were reported to be unavailable in most of the facilities. Majority (87%) of the facilities had no training of staff on counseling of parents Quality assurance practices Majority (61%) of the surveyed facilities are not designed as “baby friendly”. Most of the facilities (65%) don’t monitor nosocomial infection rates. Facility management practices Approximately 40% of the facilities lack authority over budget • Majority of the facilities do not conduct inter-disciplinary (87%) and management team meetings (83%).

19. Identified Gaps from Facility Assessment of Newborns & Young Infant Care in Pakistan • Case reviews Perinatal and neonatal death reviews is not a common practice across 57% of the surveyed facilities • Patients record reviews • None of the facilities record all essential aspects in newborn assessment and admission history None of the facilities undertakes the complete newborn assessment • Health Management Information System • None of facilities had compiled the information on neonatal deaths and stillbirths • Recording of very low birth weight is missing in most (75%) of the facilities • Out-referral feedback Most (77%) of the facilities doesn’t receive feedback on out-referrals

20. Perceptions & Experiences Of Parents/Caregivers During Their Stay In The Facility

22. Experiences and Perceptions Regarding Behavior & Staff Communication of HealthCare Providers (n=77) Satisfactory (40-20%) Poor (<20%) Good >50%

23. Caregivers’ satisfaction with facility Amenities (n=77): Satisfactory (40-20%) Poor (<20%) Good >50%

24. Experiences and Perceptions of caregivers’ regarding financial burden during their stay in the facility. Around 90% of the caregivers reported spending out of pocket payments to bear expenses for infant care. 54% of the caregivers considered Out of pocket payment expensive.

25. Experiences And Perceptions Of Caregivers’ Regarding Financial Burden During Their Stay In The Facility.

26. Stillbirths & Neonatal deaths in Pakistan: An Opportunity to Improve a Serious Situation

27. Sources Data from surveyed facilities across Pakistan Surveys, Gray Literature & Reports PDHS 2007-08,2012-13 &2017-18, WHO and UNICEF reports MNH Registry in Thatta • In Pakistan, MNHR has been established in 9 union councils of District Thatta in Sindh province (2 lakhs population) which documents birth outcomes and provides population-based rates of stillbirth, neonatal and maternal deaths. PublishedLiterature

28. The Existing burden of Neonatal deaths and Stillbirths in Pakistan The PDHS is not reliable source of data on Stillbirths in Pakistan. Stillbirths are under-reported in Pakistan.

29. Pakistan reports the highest Stillbirths (43.1/ 1000 births and neonatal death rates (42/1000 live births) Source (PDHS) Source (GN registry Thatta-AKU)

30. Stillbirth and Neonatal death rates in surveyed facilities across Pakistan: • The data related to stillbirths and newborn deaths were collected from 23 surveyed facilities. • More specifically the data on number of deliveries, stillbirth and early neonatal deaths of past three months were collected. • Sources: • Health Management Information System (HMIS), • District Health Information System (DHIS) reports and • Available reports from the Gynecology and Pediatrics department

31. * Facility Data for Previous Three Months

32. Number of neonatal deaths were 58 per 1000 live births in the surveyed facilities and highest proportion of deaths was reported in Sindh.

33. Determinates & Causes Of Stillbirths & Neonatal Deaths

34. Determinants at Societal level (Distal Factors) Determinants at Family-Community (Intermediate Factors) Direct Causes (Proximal) • Poverty • Illiteracy • Unregulated private maternity hospitals • Poor Quality of care • Poor access to care • Lack of ANC visits and follow-up • Inadequate routine monitoring • Extremes of maternal age and parity • Poor decision making • Anemia • Tobacco Use • Intimate Partner Violence • Indoor air Pollution • Consanguinity • Poor Health Seeking Behavior • Poor obstetric history • Antepartum hemorrhage • Placental conditions • Pre-eclampsia and eclampsia • Obstructed Labor • Pregnancy induced hypertension & Diabetes • Intrauterine growth restriction (IUGR) • Asphyxia and infection • Congenital Anomalies • Preterm birth & LBW • Fetal distress & RDS • Birth asphyxia

36. Source: PDHS 2006-07

38. Source: PDHS 2006-07

40. Identified Gaps • Lack of coordination & Consistent Definition Inconsistencies in the classification of stillbirths (fresh and macerated) and neonatal deaths (early and late). Lack of coordination between the Government and facilities and between the departments (Peds & Obs/Gynae). • Inadequate capacity of staff to diagnose leads to under reporting of stillbirths • Underreporting of stillbirths, hence not depicting the true picture of stillbirths in Pakistan. • Inadequate capacity of staff to diagnose stillbirths • Inadequate ANC leads to poor maternal health condition leading to stillbirth. • ANC visits

41. Review Of Strategies & Policies & Key Stakeholder’s Insights

42. REVIEWED POLICY DOCUMENTS AT NATIONAL LEVEL

43. REVIEWED POLICY DOCUMENTS AT PROVINCIAL LEVEL

45. Reference: UNICEF Data Collection Tool 2

46. NATIONAL DOCUMENTS ADHERING TO ASSESSMENT STANDARDS

47. PROVINCIAL DOCUMENTS ADHERING TO ASSESSMENT STANDARDS

48. Key Stakeholder’s Knowledge about the Available Policies 1-Reproductive, Maternal, Neonatal, Child andAdolescent Health and Nutrition Coasted Action Plan 2016-2020 2-National Vision Reproductive Maternal and Child Adolescent Health 2016-2020 3-National Integrated Reproductive Maternaland Child Adolescent Health & NutritionStrategy (2016-2020) • Stakeholders were not well aware with the strategic plans on MNCH • Inconsistencies among national level respondents - policy documents on strengthening In-patient care of NYIs.

49. Commitment, Political Will & Coordination Among National & Provincial Level Role of Health Care Commission • National level respondents perceived that there is a strong commitment and political will to improve NYIs care. • Dissatisfaction among Provincial about lack of actions taken by the government to address unavailability of service providers. RMNCH technical working group • Discrepancies in opinion among national and provincial level key informants about provincial support and coordination

50. Identified Gaps