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

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

17. 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

18. 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.

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

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

21. 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

22. Referral in Bo North, Sierra Leone 2007

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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?

29. 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?

30. 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