ETHIOPIAN MEDICAL JOURNAL ISSN0014-1755 NOVEMBER 2019 Supplement 3 Special Issue on Community Based Newborn Care ETHIOPIAN MEDICAL ASSOCIATION P.O. Box 3472, Addis Ababa, Ethiopia Tel. No. 251-1-5533742 www.emjema.org www.emaethiopia.org Fax: 251-1-5533742 Addis Ababa Ethiopia Addis Ababa, Ethiopia The Ethiopian Medical Journal is the official quarterly publication of the Ethiopian Medical As- sociation. It is devoted to the advancement and dissemination of knowledge pertaining to medi- cine in Ethiopia and other developing countries. EDITORIAL BOARD Editor-in-Chief Sileshi Lulseged Associate Editors-in-Chief Abraham Aseffa Rawleigh Howe Abebe Bekele Editors Demissie Habte Girmay Medhin Workenesh Ayele Eyasu Makonnen Meaza Demissie Daniel Admassie Corresponding Editors : Charles Larson, Frances Lester, Paulos Quana’a Solomon Tesfaye, Carmela G. Abate, Henry Blumberg, Russell Kempker Business Manager Executive Secretary Asmelash Gebre Meaza Aklilu ETHIOPIAN MEDICAL JOURNAL November 2019 FOREWORD Amir Aman 179 OVERVIEW Community Based Newborn Care in Ethiopia: Introduction to the Special Issue Mary E. Taylor 181 PERSPECTIVE The Four Cs in Ethiopia: Framing a Community Approach to Management of Possible Serious Bacterial Infection in Neonates Mary E. Taylor 185 BRIEF COMMUNICATION Newborn Care Corner: A Simplified Approach To Providing Optimal Newborn Care Immediately After Birth Assaye Kassie Nigussie, Bogale Worku 193 COMMENTARTY Reaching Every Newborn: Delivering an Integrated Maternal and Newborn Health Care Package Abeba Bekele, Yunis Mussema, Yenealem Tadesse, Mary E. Taylor 197 ORIGINAL ARTICLES Integrating Chlorhexidine for Cord Care into Community Based Newborn Care in Ethiopia Yenealem Tadesse, Yunis Mussema Abdella, Yared Tadesse, Bereket Mathewos, Smita Kumar, Efrem Teferi, Abeba Bekele, Abebe Gebremariam Gobezayehu, Stephen Wall 201 Poor Postnatal Home Visits Compromised the Identification of Possible Serious Bacterial Infections in Young Infants (0-59 Days) from Southern Tigray, Ethiopia Abadi Luel, Tadelle Hailu, Loko Abraham, Alemayehu Bayray, Wondwossen Terefe, Hagos Godefay, Mengesha Fantaye, Quazi S. Ahmad, Samira Aboubaker, Ephrem Tekle, Afework Mulugeta 207 Do Caretakers of Sick Young Infants with Possible Serious Bacterial Infection Adhere to Referrals from Health Posts to Health Centers? Yunis Musema Abdella, Abeba Bekele, Bereket Mathewos, Yenealem Tadesse, Stephen Wall, Heather Gardner, Mary V. Kinney, Lara M. E. Vaz, AyeleBelachew Aschalew 215 Effectiveness Of Supervision On The Consistency Of Neonatal Sepsis Management Skills Of Health Extension Workers Gizachew Tadele Tiruneh, Ali Mehryar Karim, Bantalem Yeshanew Yihun, Bizuhan Gelaw Birhanu, Agazi Amaha, Bereket Mathiwos, Biruk Tensou Tessema, Abera Workneh Wanboru, Wuleta Aklilu Betemariam 223 Readiness of Primary Health Care Units in Addressing Facility-Based Newborn Care in Ethiopia Agazi Ameha, Endale Engida, Mariame Sylla, Negusu Worku, Macoura Oulare, Hailemariam Legesse, Bizuhan Gelaw, Yayeh Negash, Lisanu Tadesse, Meles Selemon, Yunis Musema, Ephrem Teklu 231 The Effect of Community-Based Newborn Care Intervention on Service Utilization for Sick Newborn and Children Agazi Ameha. Hailemariam Legesse, Mariame Sylla, Macoura Oulare, Yejimmawerk Ayalew, Biruk Tensou, Amanuel Birru, Lisanu Taddesse, Yunis Mussema, Abraham Tariku 239 Supply Chain Management for Community-Based Newborn Care in Rural Ethiopia: Challenges, Strategies Implemented and Recommendations Hailemariam Legesse, Habtamu Seyoum, Abdurahman Abdo , Agazi Ameha, Sufyan Abdulber MSc, Mariam Sylla, Ephrem Tekle 247 Modeling the potential reduction of newborn mortality with national scaling up of community based newborn care in Ethiopia Lisanu Tadesse, Mariam Sylla, Luwei Pearson, Yvonne Tam, Abraham Tariku, Bilal Avan 255 Community-Based Newborn Care in Afar: Lessons Learned Abebe Gebremariam, Hajira Mohammed, Aynalem Hailemichael, Hailemariam Legesse, Abebe Teshome, Tamiru Kassa, Afework Mulugeta, Yasin Habib, Abdella Mohammed, Tina Asnake, Lynn M. Sibley 263 Community-Based Newborn Care in Ethiopia: Implementation Strength and Lessons Learned Bereket Mathewos, Yunis Musema, Abeba Bekele, Bantalem Yeshanew, Gizachew Tadele, Efrem Teferi, Agazi Ameha, Tedbabe Degefie 269 BRIEF COMMUNICATION Making Community Based Newborn Care Sustainable in Ethiopia Yirdachew Semu, Ephrem Tekle, Abeba Bekele, Efrem Teferi, Lisanu Taddesse, Wuleta Betamariam, Addis Ashenafi, Mariame Sylla, Yenealem Taddese 281 CONCLUSIONS Introduction of Community-Based Newborn Care in Ethiopia Mary E. Taylor 287 GUIDELINES FOR AUTHORS 291 ACKNOWLEDGMENT 295 SUBSCRIPTION 295 NOTICE TO MEMBERS OF THE ETHIOPIAN MEDICAL ASSOCIATION 295 179 FOREWORD It is my pleasure to have seen that the publication of this Special Issue of the Ethiopian Medical Journal (EMJ) on Community Based Newborn Care (CBNC) is realized. CBNC provides lifesaving services and is part of our com- mitment to reducing the morbidity and mortality among newborns, thereby also enhancing wellbeing among their families. Indeed, Ethiopia is one of the first countries in the world to provide these services at the community level, which has been now been scaled up and provided nationally. The dissemination of our experience and lessons learned to date through this Special Issue of the EMJ, I hope, will encourage other country programs to adopt simi- lar approaches to improve newborn health. During the period 2000 - 2016, Ethiopia reduced under-five child mortality by 60%, a reduction from 166 to 67 per 1000 live births. The leadership and political commitment from the government, the advances in evidence-based interventions, and the improvement in health, nutrition and family planning services provided the impetus for this notable achievement. It is widely recognized that Ethiopia has been at the forefront in reaching vulnerable women and children, especially in rural areas, rapidly and progressively scaling-up its Health Extension Programme (HEP) since 2003. More than 38,000 salaried Health Extension Workers (HEWs), the majority of them young women, have been deployed to over 15,000 health posts across the country. Women volunteers organized under the Health Development Army and working with communities have been instrumental in expanding healthy behaviours and practices among the population, including early care seeking for newborn illnesses. The Federal Ministry of Health (FMOH) introduced and scaled-up Integrated Community Case Management dur- ing 2010-2012. The package constitutes high quality basic curative interventions for children under five years of age. When referral is not possible and depending on the diagnosis, HEWs provide treatment with oral antibiotics, oral rehydration solution/zinc, or anti-malarial drugs. However, evidence showed limited care seeking by young infants under-two months of age, a group vulnerable to serious infection. Combined with the observation that new- born mortality declined, much more slowly since 2000, accounting for some 43% of all under-five deaths, the FMOH intensified relevant and required interventions. The FMOH designed and launched the implementation of CBNC in 2013. This was incorporated into the National Newborn and Child Survival Strategy. Guidelines, training materials, and provider support tools were developed and made available to service providers. Under the leadership of the Ministry, resources were mobilized and part- ners, including the United Nations Children’s Fund (UNICEF), The United States Agency for International Devel- opment (USAID), the World Health Organization (WHO), Children's Investment Fund Foundation (CIFF) and technical agencies worked together to roll out and support implementation in all of the four agrarian regions in the country. CBNC has been initiated in selected woredas in the regions requiring special support to learn from and replicate in the remaining woredas. The program is a priority of the government’s Health Sector Transformation Plan (HSTP) and is to be expanded nationwide by the end of the first HSTP period. This Special Issue of EMJ documents the efforts of the government and development partners to introduce and scale up CBNC to improve the coverage and quality of services, to create demand, and to strengthen health system performance. I sincerely believe that the evidence generated will be instrumental in improving policy and decision making on critical issues related to CBNC in Ethiopia and beyond. Amir Aman, M.D Minister, Federal Ministry of Health, Ethiopia 181 Mary E. Taylor, Abeba Bekele. Ethiop Med J, 2019, Supp. 3 OVERVIEW COMMUNITY BASED NEWBORN CARE IN ETHIOPIA: INTRODUCTION TO THE SPECIAL ISSUE Mary E. Taylor, PhD 1*, Abeba Bekele, MD, MPH, MA 2 In 2012, Ethiopia achieved an under-five mortality rate (U5MR) of 68 per 1000 live births, and therefore success- fully reached Millennium Development Goal 4, having reduced the U5MR by two-thirds from its level of 204 in 1990m(1). Improvements in nutrition, immunization, management of childhood diarrhea and pneumonia, water and sanitation, and use of insecticide treated bed nets contributed to Ethiopia’s success. However, most of the be- nefit was realized by reducing mortality among older children, as the neonatal mortality rate (NMR) declined more gradually from 54 to 29 per 1000 live births. By 2013, neonates accounted for fully 43% of all under-five deaths (2). Earlier, the Ethiopian Ministry of Health (FMOH) had prioritized newborn health in its fourth Health Sector De- velopment Plan (HSDP IV) and the