Project Brief USAID’s MaMoni HSS Project

Managing Sick Newborns at Special Care Newborn Units in District Hospitals in

Photo Photo by: GMB Akash

Background Each year, around 62,000 newborns die in Bangladeshi. The main causes of these deaths are preterm birth, intrapartum complications, and severe infectionii. Access to high-quality neonatal care can prevent most of these deaths. Yet, in Bangladesh, until recently, specialized care for sick newborns has largely been unavailable outside of tertiary level referral facilities. Without the equipment, staff and referral systems to provide specialized care, newborn health complications cannot be effectively managed.

The Ministry of Health and Family Welfare (MOH&FW ) is working hard to change this. In 2013, the Government of Bangladesh committed to scaling up evidence-based newborn interventions at district and sub-district levelsiii, including Special Care Newborn Units (SCANUs) at secondary and tertiary levels. SCANUs provide standardized, safe, specialized care for sick newborns who do not require mechanical ventilation or major surgeryiv. Currently, the MOH&FW is establishing SCANUs around the country with the support of UNICEF and other partnersv. The USAID-funded MaMoni Health Systems Strengthening Project (MaMoni HSS) supported the establishment of five of these SCANUs. This brief

September 2018 describes findings and lessons from a review of service data from the first two MaMoni HSS SCANUs to become operational.

MOH&FW initiative to improve Sick newborn care at secondary and tertiary-level health facilities

National Framework In 2014, a national strategy for the scaling-up of SCANUs was published5. The focus of the scale-up plan is to establish and/or upgrade 64 SCANUs across Bangladesh one in each district at secondary and tertiary level care facilities. Standard operating procedures had been developed prior to this. They outline the recommended services, space, equipment, staffing and operational specifications for SCANUsvi.

Operational Guidelines The SCANU standard operating procedures indicate that each unit should have four to five beds for every 1,000 annual births. SCANUs with 10 beds are to be staffed around the clock by at least two nurses and one pediatrician/neonatologist or trained medical officer. These staff are to receive specialized training at a designated national training center (further details on this are in the following section). A web-based individual case tracking system was developed and integrated with the national health information system. Patient information is initially collected in a SCANU register and then entered into the web-based system. The information collected includes birth weight, admission and discharge weight, symptoms, diagnosis, treatment and outcome.

MaMoni HSS’ support to the MOH&FW In 2015 and 2016, MaMoni HSS established a new SCANU in and provided start-up support for the establishment of four additional SCANUs located in the project supported districts of , , Lakshmipur, Noakhali, and Pirojpur.

Equipment Procurement, Installation and Maintenance In Bhola, Habiganj, Noakhali, and Pirojpur, the MOH&FW procured equipment through funding from the South Asian Association for Regional Cooperation Development Fund (SDF) as part of the national scale-up plan. In , MaMoni HSS supported the facility renovations and procured the hospital’s SCANU equipment. The MOH&FW lacked the funds to install, conduct preventive maintenance for, and repair damaged equipment. Therefore, for all five SCANUs, the project contracted with a third party entity for these services.

Capacity Building MaMoni HSS funded the training of 102 nurses and 46 doctors at the designated training centers. Management support for this was provided by Bangabandhu Sheikh Mujib Medical University (BSMMU). According to the national guidelines, all clinical providers working in a SCANU are to participate in a 5-day Emergency Triage Assessment and Treatment (ETAT) and Sick Newborn Care training. This is a competency-based training facilitated by national level pediatricians and neonatologists. Content covers triage, newborn examination, management of common newborn conditions, and demonstration of the use of SCANU equipment. In addition to this, SCANU nurses participated in a month long hands on training at BSMMU and Medical College Hospital. In this training, nurses built their competencies in case management, use of SCANU equipment, and online reporting through instruction, practice, mentoring and coaching.

Supervision and Mentoring The project facilitated quarterly routine supervision of each SCANU by neonatologists from national level professional institutions. Supervision encompassed monitoring the quality of care provided, and providing feedback and on the job coaching. A checklist was used during each supervision visit and an action plan was developed after each visit with recommendations for follow up. Remote follow up and mentoring was carried out through Skype calls between the supervision team and SCANU staff. BSMMU provided technical and management support for this activity.

Service Documentation and Reporting In addition to recording services in the national SCANU register, MaMoni HSS provided a supplemental form for monthly reporting directly to the project. This enabled analysis of service data, as use of the web-based system is not yet consistent.

Supplemental Staffing In consultation with local authorities, the project temporarily deployed eight nurses to fill critical vacant positions. They worked under the clinical and managerial guidence of SCANU authorities and were put into the daily duty rosters along with available MOH&FW nurses. These nurses were gradually withdrawn as the MOH&FW filled these positions.

Analysis of service data Data were analyzed from January 2016-March 2017 from two of the five SCANUs supported by the project (at Noakhali and Lakshmipur district hospitals). These two SCANUs were selected because they were the earliest of the five that were fully operational. The services were thus more mature in Noakhali and Lakshmipur than at the other three district hospitals.

In addition, they also offer an opportunity for comparison given their somewhat different operational contexts. hospital has 250 beds, while Lakshmipur district hospital has 100 beds. In Noakhali, the SCANU receives much of its support via the national scale-up program, while in Lakshmipur MaMoni HSS provided overall support to the hospital, including renovation and procurement of SCANU equipment. In addition, the district hospital in Noakhali has access to more technical and clinical resources due to its linkage with Noakhali Medical College (part of University). The Noakhali SCANU is also larger than Lakshmipur’s (Table 1), and serves as a referral facility for Lakshmipur hospital because the two districts are close to one another. Noakhali’s SCANU had a 100% bed occupancy rate for 14 of the 15 months examined. In contrast, the bed occupancy rate at the Lakshmipur SCANU varied greatly from 0 to 89%, with an average bed occupancy rate of 37.5%. A bed in a SCANU is a radiant warmer, used to maintain newborns’ body temperature.

Newborns’ symptoms, diagnoses, treatment and case fatality rates are examined in the following Table 1: Number of SCANU Radiant Warmers sections. Notable differences between the two and Staff Radiant SCANUs are highlighted in the tables, charts Hospital Staff and/or text. Where there were no notable Warmer differences, the data are presented in aggregate. Noakhali 12 3 doctors, 8 nurses Lakshmipur 8 2 doctors, 8 nurses

Profile of Newborns Admitted to SCANUs In total, 1,270 newborns were admitted in both the SCANUs Table 2: Age at Admission during the period examined. Noakhali Lakshmipur Both Days Over half (771, 61%) were (n=762) (n=494) (n=1,256) admitted to the Noakhali 1 day 277 36% 135 27% 412 33% SCANU, while the rest (499, 39%) were admitted to the 2-3 days 202 27% 129 26% 331 26% Lakshmipur SCANU. 4-7 days 172 23% 113 23% 285 23% >7 days 111 15% 117 24% 228 18% Among newborns seen, one- third were one day old (Table 2). Overall, just under 60% were less than four days old, while the remaining 41% were between 4 and 92 days old. It was more common for newborns at the Noakhali SCANU to be admitted in their first three days of life than it was at the Lakshmipur SCANU (63% versus 53%).

Close to two thirds of newborns stayed for one week or less (Table 3). A higher proportion of newborns at the Noakhali SCANU stayed for more than one week as compared to the Lakshmipur SCANU (41% versus 8%).

Table 3: Duration of Stay Noakhali Lakshmipur Both Days (n=699) (n=490) (n=1,189) <3 days 212 30% 257 52% 469 39% 4-7 days 199 28% 194 40% 393 33% 8-14 days 236 34% 34 7% 270 23% >15 days 52 7% 5 1% 57 5%

Close to 50% of newborns were born at home (Table 4). Thirty percent were born either at another government facility or at a private facility. A greater proportion of newborns at the Noakhali SCANU (21%) were born at a private facility, compared to 11% in Lakshmipur.

Table 4: Place of Birth Noakhali Lakshmipur Both Place (n=764) (n=496) (n=1,260) Home 358 47% 255 51% 613 49% Same Facility 129 17% 130 26% 259 21% Other Govt. Facility 114 15% 54 11% 168 13% Private Facility 163 21% 57 11% 220 17%

Symptoms of Admitted Newborns Upon admission, newborns’ primary symptoms (as reported by their caregivers) and diagnoses are documented. Multiple symptoms and diagnoses was common. These are shown in charts 1 and 2 below.

Chart 1: Primary Symptoms Reported on Admission to SCANU (N=1,225) (Multiple symptoms reported) 1,000 946 900 800 663 700 600 500 400 264 300 248 200 NumberNewborns of 107 100 6 0 Poor Feeding Temp. Low or Convulsions Breathing Lack of Other High Difficulty Movement Symptoms

The most common symptom was poor feeding (reported for 946, or 77%, of the 1,270 newborns). This was followed by having either a low or high temperature (663 newborns, 54%). Among this group, a low body temperature (reported for 599 newborns) was much more common than a fever (90% low body temperature vs. 10% fever).

Reported symptoms differed significantly between the two SCANUs (Charts 2 & 3). In Noakhali, having a low body temperature or a fever was the primary symptom (reported for 588 newborns, or 78%). This was followed by poor feeding, reported for 519 newborns (69%). However, in Lakshmipur, poor feeding was by far the most frequently reported symptom (reported for 427 newborns, or 90%), while having a low or high body temperature was only reported for 75 newborns (16%).

Chart 2: Noakhali Chart 3: Lakshmipur Reported Symptoms on Admission to Reported Symptoms on Admission to SCANU (N=751) SCANU (N=474)

Number of Newborns Number of Newborns 0 200 400 600 800 0 100 200 300 400 500 Temp. Low or High 588 Poor Feeding 427 519 75 Breathing Difficulty 225 Convulsions 43 221 23

Symptom Lack of Movement Symptom Lack of Movement 92 15 12 3

Diagnoses of Admitted Newborns Slightly over half of newborns (715, or 56%) were diagnosed with multiple conditions (Chart 4). Preterm and/or low birth weight (PT/LBW) was the most common condition, followed by pneumonia/respiratory infection, sepsis/other infection, intrapartum related events (including asphyxia and respiratory distress), jaundice, and congenital abnormalities.

Chart 4: Newborns' Diagnoses on Admission to SCANU (N=1,270) (Includes multiple diagnoses)

Other 38

Congenital Abnormality 7

Jaundice 120

Intrapartum Related Event 146

Diagnoses Sepsis/Other Infection 333

Pneumonia/Respiratory Infection 659

PT/LBW 799

0 100 200 300 400 500 600 700 800 900 Number of Newborns

The number of PT/LBW newborns shown in Chart 4 is the actual number, calculated from newborns’ documented birth weight. However, this number was significantly higher than the number that received a documented PT/LBW diagnosis in the MaMoni HSS reporting form (799 vs. 461). Twenty- two percent of the PT/LBW babies (178) were under 1,500 grams and thus considered to be very low birth weight. Among this group, 22 were extremely low birth weight (<1,000 grams).

Diagnoses also differed between the two SCANUs (Charts 5 & 6). In Noakhali, about the same number of newborns were diagnosed with pneumonia or another respiratory infection as were PT/LBW. However, in Lakshmipur, 40% more newborns were PT/LBW than were diagnosed with pneumonia or another respiratory infection.

Chart 5: Noakhali Chart 6: Lakshmipur Newborns' Diagnoses on Admission to SCANU Newborns' Diagnoses on Admission to SCANU (N=771) (N=499)

Other 7 Other 7 3 4 Jaundice 67 Intrapartum Related Event 19 125 53

Sepsis/Other Infection 211 Sepsis/Other Infection 122 Diagnosis Diagnoses 429 228 Pneumonia/Respiratory… 431 PT/LBW 370 0 200 400 600 0 100 200 300 400 500 Number of Newborns Number of Newborns

Treatment Provided to Admitted Newborns Over 90% of all SCANU newborns received antibiotics, thermal care with a radiant warmer, and other (Chart 7). Some examples of treatments included in the category of other are provision of vitamin K, saline infusion, steroid injection (oradexon), and barbiturates.

Chart 7. Treatment Provided to SCANU Newborns (N=1,182) (Newborns received multiple types of treatment) 1,400 1,143 1,200 1,104 1,134 1,000 800 600 400 110

NumberNewborns of 200 36 8 0 Antibiotics Radiant Phototherapy Tube Feeding Resuscitation Other Warmer Type of Treatment

Among the PT/LBW newborns, 721 (90%) received thermal care with a radiant warmer and 89% received antibiotics. A quarter of PT/LBW babies at the Lakshmipur SCANU were referred to another facility. This represenents 80% of all of Lakshmipur’s SCANU referrals.

Among newborns with pneumonia or another respiratory infection, 605 (92%) received antibiotics. Eighty-nine percent of newborns with sepsis or another infection received antibiotics. Among the 120 newborns diagnosed with jaundice, only 64 (53%) received phototherapy.

Twenty-four of the 36 tube fed newborns were PT/LBW, 18 had been diagnosed with pneumonia or another respiratory infection, and 14 were diagnosed with sepsis. Among the eight newborns who were resuscitated (four of whom had multiple diagnoses), five were PTLBW, four had pneumonia and two had sepsis or another infection. Treatment did not differ significantly between the two SCANUs.

Photo Photo by: Akash GMB Treatment Outcomes Treatment outcomes for all newborns admitted to the two SCANUs are in Figure 1.

Figure 1. Newborn Outcome Flow Chart

Newborns Admitted to a SCANU: 1,266

Died: Discharged: Transferred to Not recorded: 206 (16%) 564 (45%) KMC: 69 (5%) 74 (6%) 206

Discharged or left Referred: Transferred to:

prior to recommended 158 (12%) time: 173 (14%) Pediatric Ward - 20 (2%) Surgical Ward – 2 (.2%)

Close to half of newborns (45%) were discharged following treatment. Among these, 285 (51%) stayed for less than a week, while 279 (49%) stayed for seven days or more. Nineteen percent were either transferred internally to the KMC area (69, 5%), the pediatric ward (20, 2%), or the surgical ward (2, .2%), or referred to another hospital (158, 12%). Fourteen percent (173 newborns) were discharged or absconded prior to the time recommended by a provider. Sixteen percent (206 newborns) died.

There were notable differences in patient outcomes between the two SCANUs (Tables 5 & 6). The death rate at Noakhali (23%) was higher than that of Lakshmipur (6%), possibly due to Noakhali receiving more very sick newborns than Lakshmipur. This may be linked to the finding that newborns were referred out of the Lakshmipur SCANU at a higher rate (23%) than from Noakhali (6%). In addition, 22% of newborns at the Lakshmipur SCANU were discharged or absconded prior to the time recommended by the doctor or nurse, whereas only 9% did in Noakhali. These differences may be indicative of an overall higher quality of care provided at the Noakhali SCANU. This is likely a result of Noakhali being a teaching hospital, and thus having access to more, and more specialized, doctors, as well as more resources overall.

Table 5: Noakhali (n=769) Table 6: Lakshmipur (n=497) Discharged 362 47% Discharged 202 41% Died 178 23% Referred to Another Facility 115 23% Discharged on Request, or Left, Discharged on Request, or Left, Prior to Time Recommended by 66 9% Prior to Time Recommended by 107 22% Provider Provider Not Recorded 60 8% Died 28 6% Transferred to KMC 49 6% Transferred to KMC 20 4% Referred to Another Facility 43 6% Not Recorded 14 3% Transferred to Surgical Ward or 11 1% Pediatric Ward Transferred to Pediatric Ward 11 2%

Newborn Deaths The overall case fatality rate (CFR) was 16.2. Case fatality rates varied over time, and by district (Charts 8 and 9). Case fatality rates were significantly lower in Lakshmipur than in Noakhali. The CFR reported is comparable to the CFR reported from other SCANUs in the country (13, across all SCANUs nationwide in 2017, DHIS2). It is important to note that various factors influence CFR, such as rate of admission, duration of stay, staffing and that new SCANUs can take some months to reach full functionality.

Chart 8. Lakshmipur Case Fatality Rate Among Newborns Admitted to SCANU

January 2017 - March 2018

80 Highest 70 Lowest CFR 20 60 49 47 42 43 CFR 0 45 45 50 34 36 39 40 28 33 31 30 22 20 5 10 2 3 2 1 1 3 2 2 5 1 4 3 2 0

Newborns Admitted Newborn Deaths Case Fatality Rate

Chart 9. Noakhali Case Fatality Rate Among Newborns Admitted to SCANU January 2017 - March 2018 75 Highest Lowest 80 73 74 60 CFR 33.3 CFR 12.2 60 49 51 47 46 50 49 49 40 40 43 40 25 19 18 17 15 15 13 12 11 13 20 10 8 8 6 5 8 0

Newborns Admitted Newborn Deaths Case Fatality Rate

Case fatality rates also varied by diagnosis. Intrapartum related events had the highest CFR (23.6). This was followed by pneumonia/respiratory infections (19.1), PT/LBW (16.3), congenital abnormalities (14.2), sepsis/other infections (10.2), and jaundice (0.5). The CFR among very low birth weight newborns was 31 was 30.8 and for extremely low birth weight newborns it was 45.4.

Among all 206 newborn deaths, the proportion attributed to each diagnosis is displayed in Chart 10.

Chart 10. Causes of Newborn Deaths (N=206) (Includes newborns diagnosed with multiple conditions)

200

150 131 126

100

50 NumberNewborns of 34 34

6 4 0 PT/LBW Pneumonia/ Sepsis/Other Intrapartum Jaundice Other Respiratory Infection Related Event Infection Newborn Diagnoses/Causes of Death

Duration of stay by newborn outcome (either survival or death) is presented in Chart 11. Seventy-two percent of newborns who survived stayed in the SCANU for four days or more. In contrast, two-thirds of newborns who died stayed in a SCANU for three days or less.

Chart 11: Duration of Stay by Outcome (Survival or Death) *Excludes newborns who were referred 350 309 300 287

250 192 200

150 100 100

NumberNewborns of 38 43 50 33 23

0 1 day 2-3 days 4-7 days >7 days Duration of Stay

Died (n=206) Survived (n=832)

CFR by duration of stay was also examined. CFR was highest among newborns who stayed for only one day and declined by duration of stay. Among newborns who stayed 1 day it was 38.3. A duration of stay of 2-3 days had a CFR of 29.4, 4-7 days had a CFR of 10.9. and >7 days had a CFR of 6.7.

Lessons learned

1) Preterm and Low Birth Weight Newborns – Forty-two percent of PT/LBW newborns did not receive this diagnosis in the reporting forms shared with MaMoni HSS. This group also made up the largest group of newborn deaths. In addition, very and extremely LBW newborns had the highest case fatality rates among all sick newborns. This is therefore a critical group that may require more attention and care than they currently receive.

2) Kangaroo Mother Care – The SCANUs supported by the project have limitations with regard to facilitating intermittent kangaroo mother care (KMC), or even privacy for breastfeeding. Opportunities to create private spaces for breastfeeding should be identified. Appropriate space, furniture, supplies and staffing for intermittent KMC should also be explored.

3) Quality of Care – There are still implementation gaps that could improve the quality of care, if addressed. While supervision visits were conducted quarterly, monthly supervision visits would likely support more rapid follow up of visit recommendations. There are also areas for improvement related to service documentation and reporting. At the national level, the MOH&FW aims to report newborn diagnoses following International Classification of Diseases codes. However, misdiagnoses (e.g., PT/LBW newborns) make this challenging. Further, providers are not oriented around using these codes in their service documentation. Lastly, greater use of the web-based reporting system, and routine analysis of data at the facility level, would enhance opportunities to improve services.

4) Dedicated Human Resources - The staffing levels at the two SCANUs did not reach the minimum doctor/bed and nurse/bed ratios recommended in the national SCANU standard operating procedures. In addition, doctors stationed in SCANUs frequently also oversee hospital pediatric wards at the same time. Further, providers who have received the ETAT and Sick Newborn Care Trainings continue to be rotated out of the SCANU they are placed in, with untrained providers rotating in. Finally, the new hospital SCANUs frequently do not have dedicated support staff to ensure cleanliness and an aseptic environment. These issues should be addressed to align with the national SCANU scale-up plan and continue to improve service quality.

5) Equipment Maintenance and Repair – There is a lack of capacity within the public sector for maintenance and repair of SCANU equipment. Efforts are being made by various organizations (e.g., UNICEF and Save the Children) to build the capacity of government technicians at the national and district levels. However, in the meantime, preventive maintenance and repair is handled through third party contracts. There is a need for greater capacity within the public sector for SCANU equipment maintenance and repair.

About MaMoni Health Systems Strengthening (MaMoni HSS) Project

The MaMoni HSS is a 5-year project of United States Agency for International Development under Contact Us the global Maternal and Child Health Integrated ______Program. The focus of this project is strengthening the systems and standards for maternal, newborn, MaMoni Health Systems and child health, family planning, and nutrition to Strengthening (MaMoni HSS) contribute to declines in maternal, newborn, and Project child mortality in Bangladesh. The project supports Save the Children the Ministry of Health and Family Welfare to introduce and leverage support for scale-up of Save the Children Hs No CWN (A) evidence-based practices already acknowledged in 35, Road 43, Gulshan 2, Dhaka Bangladesh. 1212, Bangladesh MaMoni HSS is primed by Jhpiego in partnership Email: with Save the Children, John Snow Inc., and Johns [email protected] Hopkins University/Institute for International Web: http://www.mamoni.info Programs, with national partners icddr,b; Dnet; and Bangabandhu Sheikh Mujib Medical University; and six local nongovernmental organizations. The project covers 40 in six districts and serves around 12.2 million people. The six focus districts are Habiganj, Lakshmipur, Jhalokati, Noakhali, Pirojpur, and Bhola.

Authors

Anna Williams, Marufa Khan, Sabbir Ahmed, Imteaz Mannan, Sanjida Alam, Joseph Johnson, Joby George, Iftekhar Rashid

Acknowledgments This work would not have been possible without the technical leadership of members of the MOH&FW, the National Technical Working Committee for Newborn Health under the National Core Committee – Neonatal Health, USAID, the Obstetric and Gynaecological Association of Bangladesh, BSMMU, the Saving Newborn Lives program, the dedicated staff of Habiganj and Noakhali district hospitals, and the MaMoni HSS district teams.

REFERENCES

1 UNICEF. (2018). Every Child Alive, The urgent need to end newborn deaths. 1 Liu L et al. (2014). Global, regional, and national causes of child mortality in 2000–2013: an updated systematic analysis. The Lancet. doi:10.1016/S0140-6736(14)61698-6. 1 Government of Bangladesh. (2013). Ending Preventable Child Deaths by 2035: Bangladesh Call for Action. 1 Moxon, S. et al. (2015). Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy and Childbirth 15(Suppl 2):S7. 1 MOH&FW , UNICEF. (2014). National Strategy of Scaling-Up Special Care Newborn unit (SCANU) in Bangladesh. 1 MOH&FW , WHO, Bangladesh Neonatal Forum, UNICEF (2012). Standard Operating Procedures for Newborn Care Services at Primary and Secondary Level Hospitals.

Disclaimer: This brief is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents are the sole responsibility of USAID’s MaMoni HSS Project and do not necessarily reflect the views of USAID or the United States Government.