Implementing Interventions to Reduce the Burden of Preterm and Stillbirth_Gravett NEW_10.10.12

Implementing Interventions to Reduce the Burden of Preterm and Stillbirth: How do we do it?

Courtney Gravett, MPHResearch Associate IIGlobal Alliance to Prevent Prematurity and Stillbirth (GAPPS)Seattle Children’s

[email protected]

October 2012

Preterm deaths and Stillbirths can be prevented now• Effective implementation of current, known

interventions can reduce preterm deaths by 75% and stillbirths by 45%

• Many preterm deaths and stillbirths are due to lack of action, or an inability to act

• Prevention and intervention is possible all along the continuum of care

Many premature babies can be saved before intensive becomes available...

Neonatal intensive care introduction and scale up

Over 60% reduction can be achieved before neonatal intensive care and history shows the impact would be huge

Data sources for UK and US historical data: (CDC, 2012, Office for National Statistics, 2012, NIH, 1985, Smith et al., 1983, Jamison et al., 2006, Lissauer and Fanaroff, 2006, Baker, 2000, Philip, 2005, Wegman, 2001). With thanks to Boston Consulting Group

Public health approaches

Improved individual neonatal care eg feeding, warmth, hygiene, antibiotics, resuscitation

Continuum of Care

Source: Kerber K, et al. Continuum of care for maternal, newborn and child health: from slogan to delivery. Lancet 2007; 370:1358=69

Interventions for preterm birth and stillbirthalong the continuum of care

PRE-PREGNANCY

CHILDHOODPOSTNATAL/ NEWBORN

BIRTHPREGNANCY

•Prevent & treat sexually transmitted infections•Nutrition

•Screen& treat for syphilis•Nutrition

•Active management of labor•Emergency obstetric care, including c-section•Magnesium sulfate•Antibiotics•Induction of labor after 41 weeks

•Postnatal follow-up

•Family planning/birth spacing•Prevent & treat sexually transmitted infections•Nutrition

•Prevent & treat sexually transmitted infections•Nutrition

•Antenatal steroids•Tocolytics to slow labor•Identify preterm babies

•Essential & Extra care• Kangaroo Mother Care•Management of sick newborns•Neonatal resuscitation

PTB

SB

Prevention of preterm birth and stillbirth must be acceleratedCare before and between pregnancy

Implement:

• Family planning strategies, including birth spacing and provision of adolescent-friendly services

• Prevention and management of STIs and NCDs

• Education and health promotion for girls and women of childbearing age

• Promotion of healthy nutrition and addressing life-style risks like smoking

Source: Born Too Soon

Prevention of preterm birth and stillbirth Care during pregnancy and childbirth

Implement:

• Antenatal care for all pregnant women

• Screening & treatment of sexually transmitted infections, especially syphilis

• Management of pregnant women at higher risk of preterm labor

• Management of preterm labor with provision of essential equipment and drugs

• Reduce non-medically indicated early induction of labor and cesarean

• Promotion of healthy behaviors and life-style risks during pregnancy

• Active management of the third stage of labor

• Comprehensive emergency obstetric careSource: Born Too Soon

Home and low levels of health system

•Essential newborn care (warmth, cleanliness, feeding)•Support for early breastfeeding and cup feeding if needed

•Facilitated referral, transport schemes

Hospital•Kangaroo Mother Care

•Neonatal resuscitation with bag and mask if needed•Supportive care for RDS eg safe oxygen therapy

•Other supportive care eg NG tube feeding, IV fluids •Treatment of infections with antibiotics

Referral hospital

•Increased nursing and medical support •Phased introduction of intensive care eg ventilation•Surfactant (cost issues)

Care of the premature newbornCOMMUNITY LEVEL/HOME

FACILITY LEVEL/OUTREACH

REFERRAL LEVEL/DISTRICT

Source: Born Too Soon

Moving Forward to Reduce Preterm Deaths and Stillbirths

Examples of Barriers to Scaling Up Interventions

• Community/Household level– Sociocultural barriers (eg stigma), financial constraints

• Health service level– Lack of resources and trained providers

• Health sector and management level– Weak supply management– Lack of competent district health management teams

• Lack of political will

Prevention and management of preterm birth and stillbirth must be included in the wider agenda

• Functional health systems are a prerequisite for comprehensive antenatal and childbirth care

• Implementation research is needed• Must integrate with other RMNC health programs

– Antenatal corticosteroids

• The steps for scaling up interventions are highly context specific

Start where you are

Source: Born Too Soon

• Sri Lanka • Turkey• Belarus• Croatia• Ecuador• El Salvador• Oman• China

8 Countries have reduced preterm death in the last decade

Contributing factors:

•National commitment to improved obstetric and

neonatal care

•Systematic referral systems for neonatal care

•Strengthened equipment and personnel

•Re-invigorated community-based healthcare

•Promotion and training of skilled birth attendants

Some middle income countries have halved deaths due to preterm birth in a decade

Source: Analysis conducted using data from Liu et al., 2012. Credit: Boston Consulting Group with the Global Preterm Birth Mortality Reduction Analysis Group

Turkey

•Upper middle-income country that reduced NMR from 21 to 10

•Implemented demand and supply strategies, including cash incentives for expectant women

•Invested in quality care improvements, such as focusing on nursing staff skills, resuscitation, basic care of preterm babies

Sri Lanka

•Lower middle-income country that reduced NMR from 13 to 10 and halved preterm specific mortality •Long term investment in primary care with free health care at government facilities•Reinvigorated community-based care, including referral networks for women in preterm labor•Recent introduction of advanced care at tertiary centers

Source: Born Too Soon

Factors contributing to successful implementation of interventions• Buy-in by key stakeholders• Intervention is context specific i.e., culturally

sensitive, locally adapted to staffing levels, burden of disease, causes of mortality, etc.

• Intervention builds on/ complements existing programs

• Intervention is supported by national policies, service guidelines, training materials, job aids, supervisory systems and indicators to track outcomes

• Robust supply chain

Who is involved?• Government and policy makers at local, national

and global levels• United Nations and other multilateral

organizations• Donors• Private Sector• Academic and research institutions• Healthcare workers and professional associationsCoordination, collaboration, and commitment among all the

players is crucial to success

Conclusion: Advance a Coordinated Agenda for Preterm and Stillbirth Prevention and Care

• Scale up what works – practical and feasible interventions for care

• Improve integration with existing programs• Address common challenges in the wider

reproductive, maternal, newborn and child health agenda: • Access and utilization of quality healthcare

Important Resources

www.biomedcentral.com/bmcpregnancychildbirth/supplements/

www.who.int/pmnch/media/news/2012/preterm_birth_report/en/index.html

Born Too soon: The Global Action Report on Preterm Birth

Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health

Global report on preterm birth & stillbirth: the foundation for innovative solutions and improved outcomes

www.who.int/pmnch/topics/part_publications/201112_essential_interventions/en/index.html

Increase Awareness and Visibility of the Problem

November 17th is World Prematurity Day

For more information visit the March of Dimes website:

http://www.marchofdimes.com/mission/prematurity_wpd.html