For example, district hospitals and commune health centers are poorly equipped and have a lack of staff with adequate training in essential newborn care, and management of newborn compli
Trang 2JOURNAL OF SCIENCE, Hue University, N 0 61, 2010
EVIDENCE FOR EFFECTIVENESS OF INTERVENTIONS IN NEWBORN CARE: HAS DISTRICT NEWBORN CARE UNIT ADDRESSED NEWBORN HEALTH PROBLEMS IN NHU THANH AND NGOC LAC HOSPITALS,
THANH HOA PROVINCE, VIETNAM?
Nguyen Van Hai Save the Children
SUMMARY
Introduction: The Vietnamese health care system faces many challenges in ensuring the
survival of newborns with over 20,000 newborns still dying each year The hierarchical health system is not able to provide quality newborn care services For example, district hospitals and commune health centers are poorly equipped and have a lack of staff with adequate training in essential newborn care, and management of newborn complications Household-level newborn care is provided through village health workers who lack standard communication materials, training, supervision and monitoring Misconceptions about newborn care at birth and
breastfeeding exist, especially in places with high rates of home births Methods: This
Operation Research (OR) study consists of a comprehensive newborn care intervention package which was introduced The intervention included delivery care and postnatal care but more effort was focused on immediate postnatal care and management of newborn complications The
OR set four intermediate results (IRs): IR 1: Increased access and availability of newborn services and supplies; IR 2: Improved quality of newborn care at health facilities; IR 3: Enhanced community knowledge of newborn care practices and demand for newborn care services; IR 4: Promotion of an enabling policy environment for scaling up newborn care This paper only covers facility-based interventions while other impacts will be reported at the end of
the project Results: After 1.5 years of intervention, the OR has helped to significantly reduce
the neonatal mortality rate: 19.4%o (2006) to 14.4%o (2009) in Ngoc Lac, and 21.9%o (2006)
to 8.5%o (2009) in Nhu Thanh The referral rate of newborn complications and home birth
rates also declined sharply in both districts Conclusions: Neonatal deaths in Ngoc lac and Nhu
Thanh districts of Thanh Hoa province can be averted with low cost interventions through the establishment of a district newborn care unit, and the health care system will benefit from having a functional district newborn care unit
Key words: neonatal death, district newborn care unit, facility-based intervention
Trang 31 Introduction
Vietnam is poised to achieve most, if not all, of its Millennium Development Goals Vietnam has already met the target of reducing the under-five mortality rate to 18 per 1,000 live births by 2015 However, the Vietnamese health care system faces many challenges in ensuring the survival of newborns with over 20,000 newborn deaths each year Neonatal deaths account for over 70% of the infant mortality rate, and varies across 7 regions of Vietnam with the highest neonatal death rate occurring in the northern mountainous and the northern central coast regions One of the determinants is poor access to newborn care in rural areas (geographic access, cultural barriers and quality of care), where twice as many newborns die than in urban settings
The hierarchical health system is not able to provide quality newborn care services Both district hospitals and commune health centers are poorly equipped and staff lack adequate training in essential newborn care, and management of newborn complications such as neonatal resuscitation, thermal care, and infections Few CHCs and district hospitals are capable of managing particular neonatal complications, and most cases are referred to higher level facilities This often results in unnecessarily overloading provincial and central hospitals where only critical cases should be referred
Many people also often bypass health services at commune health stations and district hospitals and go directly to higher- level facilities, because they lack confidence
in the competence of services provided at lower-level facilities This may result in aggravating the condition of newborns during transportation, as they may not receive proper care for some manageable situations, such as attending to the newborn’s body temperature This situation also results in families spending more money, and increased human resources to care for the newborns in the hospital
There is a severe shortage of essential equipment for newborn care in all district hospitals Only 21.9% of district hospitals are equipped with a set of appropriate newborn resuscitation equipment (UNFPA, 2003) while most commune health centers have no essential newborn resuscitation equipment In fact, there is no unified neonatal care model for the provincial and district level, thus most of these facilities are facing difficulties in providing services for newborns, especially sick newborns Consequently, there is a gap in newborn deaths caused by preventable conditions At the household level, there are some misconceptions about newborn care at birth and breastfeeding, especially in places where the home birth rate is high
An annual report from the Thanh Hoa provincial center for reproductive health care indicates that its annual neonatal mortality rate is 4%, which is lower than other developed countries like Singapore, the Unites States and England (5%o) This means that the reported data is somehow underestimated A baseline survey (2007) in Ngoc Lac and Nhu Thanh, Thanh Hoa indicates that the neonatal mortality rate in Ngoc Lac is
Trang 419.4%o, and Nhu Thanh 21.9%o The home birth rate is 24% (Ngoc Lac) and 30% (Nhu Thanh) respectively
In short, Thanh Hoa – similar to situation throughout Vietnam – is facing huge challenges in addressing newborn health problems: lack of a functional newborn care system from community to district level; severe shortage of trained health workers in newborn care; absence of infrastructure, and appropriate equipment for newborn care at commune and district level; a high prevalence of home delivery; the community’s knowledge of newborn care is limited, and misconceptions about newborn care at home, and lack of information about breastfeeding, especially in places where home delivery is high
2 Methods
Design: This is an operation research (OR) study with simple pre-and-post
intervention comparison However, this paper is only an abstract report from preliminary findings of the district newborn care unit within the comprehensive intervention package
Location: Thanh Hoa province is 157 km southward from Hanoi, with a natural
its land are mountainous and midland area, 15% lowland and 10% coastal It has a population of 3.7 million inhabitants living and working in 27 districts, towns and Thanh Hoa city, 636 communes and 7 ethnic groups including: Kinh, Muong, Thai, H’Mong, Dao, Tho and Hoa These ethnic groups reside mainly in mountainous and bordering districts
Nhu Thanh and Ngoc Lac districts were selected in the OR These are mountainous districts with a total population of 226,663 people, and the total number of deliveries is nearly 3,000 per year They have 39 communes and 474 villages There are about 17 remote and especially disadvantaged communes Below are key health indicators for Nhu Thanh and Ngoc Lac districts:
Table 1 Key health indicators of Nhu Thanh and Ngoc Lac (2007)
Source: *Reports from neonatal death screening in Thanh Hoa, March 2007
Trang 53 Result
3.1 Results framework
This OR consists of a comprehensive newborn care intervention package including delivery care and postnatal care, but more effort will be focused on immediate postnatal care and management of newborn complications The project has set four intermediate results (IRs) IR 1: Increased access and availability of newborn services and supplies; IR 2: Improved quality of newborn care at health facilities; IR 3: Enhanced community knowledge of newborn care practices and demand for newborn care services; IR 4: Promotion of an enabling policy environment for scaling up of newborn care The OR study will address the continuum of care from household-to-hospital with interventions implemented by government staff and volunteers
The study is designed to demonstrate to policy makers, health managers, and authorities that quality newborn health care service can be provided with a small investment even in resource-poor settings It will also show that quality services along with improved household practices will lead to improved newborn health outcomes However, this paper will only refer to facility-based interventions (IR1 and IR2)
The Results Framework is graphically shown below
Data collection: Data collection tools were designed carefully in order to capture all information about newborn care and newborn complications in two selected districts Information collection relied on the government existing reporting system with village health workers in the community, CHC staff at the communal level and functional newborn care unit, and the district health center at the district level However, this system was optimal because it provided designated data collectors with formatted registers and forms, which facilitated them to fill out and reconcile the data To validate the intervention package, a Monitoring and Evaluation (M&E) Plan was designed
Trang 6Provision of
equipment for ENBC
in CHCs and district
hospitals
Communications, Advocacy, Partnerships Operations Research to inform Scale-up
Set-up referral
system
Establish Newborn
Care Unit at DH
IEC materials
availability at health
facilities…
Refresher training on ENBC for Pediatric Dept of DHs
Refresher training on ENBC for midwives/
nurses at CHC, DHs
Training courses on counseling, supportive supervision
Service quality improvement (COPE)…
Develop and distribute IEC materials on NBC
ToT courses on BCC for province and district trainers
Advocacy efforts to implement the scaling-up plan
Scale-Up of OR intervention package
Roll-out BCC training courses for commune and village staff…
Develop nat standards/
guidelines, action plan, and training manuals
Goal: Improved newborn health
and survival in Viet Nam
SO: Improved use of key practices and
services that protect and promote the health of
newborns
Intermediate
Result 1
Increased access to
and availability of
key services,
equipment, and
supplies for
newborn health
Intermediate Result 2
Increased quality of essential care and complication management for newborns
Intermediate Result 3
Increased community- level understanding and acceptance of using healthy NBC practices
Intermediate result 4
Strengthened enabling environment for newborn survival
SAVING NEWBORN LIVES (SNL) RESULTS FRAMEWORK
Trang 7cs Dept,
DH
Prov Project Management
Board (Provincial Health Department)
NBC Unit of
DH
Central Project Management
Board (Save the Children – MoH)
Commune Health Centers
General Planning Dept
of DH and District Health Center
Central Project Management
Board (Save the Children – MoH)
NBC Unit
of DH
Obstetrics Dept, DH
Prov Project Management Board (Provincial Health Department)
INFORMATION FLOW AND DATA BASE SYSTEM
VHW
Legend: Reporting to
Supervision and giving feedback
Trang 83.2 Preliminary results
The project was supposed to begin in January 2007 and finish in October, 2011 However, due to a delay in administrative procedure clearance with the local authorities and preparation for human resources (developing training manual and training of health workers at provincial, district and communal level) and purchase of essential equipment for district newborn care unit, actual service delivery began in June, 2008
The performance of district newborn care unit has actually improved health outcomes of newborns in the 2 intervention districts thanks to increased access to and availability of newborn care services Two respective newborn care units in 2 district hospitals were established using the recommended standards in the National guideline for newborn care at different levels i.e room space, infection control, a list of essential equipment for newborn care and integrated newborn care between the obstetric and pediatric specialty, and human resources With a functional referral system (community
to district), all newborns with complications in two districts were given care and transferred to either commune health centers (first point of contact) or the district newborn care unit for timely management and treatment
There was a big change in the number of newborn admissions to district hospital since the birth of the district newborn care unit – October, 2008 (Table 2)
Table 2 Situation of newborn complications at pre & post intervention periods
Indicator
Pre-intervention (2006) Preliminary results
(2008-2009) Ngoc Lac Nhu Thanh Ngoc Lac Nhu Thanh
# newborn admission to
Treatment outcomes
Collaboration between pediatric and obstetric departments in newborn care have improved and been implemented in a systematic manner Before intervention, most newborn health problems were handled by the obstetric department However since then newborn care unit was established, located at the pediatric department All deliveries suspected of difficulties had a joint consultation with obstetric and pediatric staff If complications were predicted, the newborn health would be handled by well-trained
Trang 9staff of the newborn care unit while the mother was cared by obstetric staff If the complications became serious, the baby would be transferred to the well-equipped newborn care unit for treatment and follow-up
In addition, other supporting communications materials, e.g., brochures, booklets and posters of maternal and newborn care were provided to the district newborn care unit and obstetric department of the hospital These materials will facilitate the hospital health workers to counsel and advice their patients or care takers about how to promote exclusive breastfeeding, how to recognize danger signs in infants, and what actions should be taken in particular clinical situations
There was a huge difference in neonatal death, referral rate and home delivery between pre-and-post intervention periods (Table 3)
Table 3 Key indicators in newborn health status in Ngoc Lac and Nhu Thanh
(2006)
Preliminary results (2008-2009)
1
Neonatal death
- Ngoc Lac
- Nhu Thanh
19.4‰
21.9 ‰
14.4‰
8.5 ‰
2
Referral rate
- Ngoc Lac
- Nhu Thanh
95% (25%)*
98% (24%)*
10.8%
14.2%
3
Home delivery
- Ngoc Lac
- Nhu Thanh
23.9%
30%
12.1%
7.7%
4
Institution delivery
- Ngoc Lac
- Nhu Thanh
76.1%
70%
87.9%
92.4%
After 1.5 years of intervention, the Operation research has helped to reduce significantly the neonatal mortality rate: 19.4%o (2006) to 14.4%o (2009) in Ngoc Lac, and 21.9%o (2006) to 8.5%o (2009) in Nhu Thanh The referral rate of newborn complications and home delivery also declined sharply in both districts
The presence and operation of the district newborn care unit has brought about not only medical benefits but also non-medical benefits for local community, health care givers and managers The district newborn care unit has helped fill the gap in the current health care delivery system This observation is reflected in following aspects obtained from expert opinions:
Trang 10Benefits for the health care provider
Increase opportunities of investments in neonatal care and treatment
Increase revenue for hospital from provision of newborn care services
Improve professional skills in newborn care for health workers
Regain the public’s confidence in district health workers for treating difficult cases
Take advantage of available human resources (took only 3 months for training)
Avoid wasting human resources as there was no need to recruit new staff
Benefits for the health sector
Bridge linkages between the grassroots and higher levels in treatment of neonatal complications
Reduce patient load of common neonatal diseases in provincial and national hospital Other districts in the vicinity also benefit from the functioning newborn care unit
Help provide technical support for lower levels more efficiently because the district hospital is able (personnel, infrastructure and equipment) to provide
Newborn care services are available for lower level
Help to improve management of all neonatal cases in the district through the information system at the newborn care unit
Create the availability of services to meet the people’s need for health care
Benefits for community
Place credit to hospital when seeking care
Reduce non-medical costs (food, transportation, accommodation, etc…) and medical costs of bypassed patients at higher levels
Convenient for patients when seeking care in the district hospitals due to shorter distance travel between the hospital and their home
Care givers are provided with information about newborn care at home
Lives and health of the newborns are taken care because of available well-trained health workers