EVERY NEWBORN An Action Plan To End Preventable Deaths

Metrics Improvement Plan

Webinar 11 March 2015

#EveryNewborn ENAP Metrics Webinar Agenda

1. Overview core indicators and improvement Joy Lawn, LSHTM

2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO • Other UN groups and NBITWG Agbessi Amouzou, UNICEF • INDEPTH network Peter Waiswa, Makerere University,

3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF

4. Questions and discussion

5. Closing and how to get more information

www.everynewborn.org #EveryNewborn Every Newborn Series 5 papers 6 comments 55 authors from 18+ countries 60+ partner organisations

Main funders: Bill & Melinda Gates Foundation, USAID, Children’s Investment Fund Foundation Every Newborn Action Plan Based on the evidence from the Series Co-led by UNICEF & WHO, Consultation >60 country governments >80 organisations, >1000 individuals World Health Assembly 2014 resolution Launched June 2014

Now to action in many countries…

www.lancet.com/series/everynewborn @joylawn #EveryNewborn Every Newborn action now:

Three main streams of activities are ensuring the action plan leads to real change in countries:

1. Country implementation: identifying and responding to technical support needs, supporting translation of evidence into action, including Every Mother Every Newborn quality improvement initiative.

2. Data and metrics: improving and institutionalizing metrics to track coverage and impact based on the goals and targets of the ENAP and five strategic objectives.

3. Advocacy: strengthening maternal and newborn health advocacy efforts globally and in countries, building a movement for change.

Research as cross cutting

www.everynewborn.org #EveryNewborn ENAP Metrics work and who is involved CO CHAIRS WHO: Matthews Mathai LSHTM: Joy Lawn COORDINATION GROUP UNICEF: Agbessi Amouzou, Holly Newby (to link to existing metrics UNFPA: Sennen Hounton SNL/NBITWG: Lara Vaz work, and institutionalize) CIFF: Suzanne Fournier Gates: John Grove USAID: Allisyn Moran MHTF: linked via by ENAP management team TASK TEAMS Task teams with initial focus on specific newborn care interventions linked with existing initiatives especially UNCoLSC and others ACADEMIC PARTNERS Three countries with EMEN project sites (, Tanzania, Bangladesh) to promote leadership Two networks: especially Africa & Asia 1. Mortality focus: led by INDEPTH Maternal and Newborn Group (Peter Waiswa et al) 2. Beyond Survival /follow up of at risk newborns: led by All India Institute of Medical Sciences (Ashok Deorari et al) Also welcoming inputs from other institutions, partners and countries WIDER INTEREST >50 at ENAP metrics improvement planning meeting by WHO Dec 2014 GROUP >100 people drawn from wider metrics community including Newborn wide and inclusive Indicators Technical Working Group

www.everynewborn.org #EveryNewborn Three tracks of work linked with ENAP metrics - overview

1 • Indicators for impact, coverage, process of maternal & newborn care Technical • Initial focus on the 4 + 1 treatment interventions mapping & • KMC (led by KMC acceleration group) • Resuscitation (UNCoLSC, USAID, SNL Bangladesh, WHO, HBB etc) planning • Antenatal Corticosteroids (WHO and UNCoLSC TRT etc) of indicators, tools • Sepsis case mx (WHO, UNCoLSC etc) & work in progress • CHX cord cleansing (UNCoLSC, SNL etc) • Priority research to improve the metrics for use

2 Institutionalise • Birth and perinatal death certificates, coverage & quality in national collection • Develop and test Minimum Perinatal Dataset platforms and in • Perinatal Mortality audit tool, linked to Maternal Mortality audit global metrics • Inputs to facility HMIS, Health Facility Assessments such as SARA, architecture, with and to household surveys accountability

3 • Leadership Testing in countries also linked to EMEN work • Southern institutions as centres of excellence development • Integrated technical oversight especially with maternal health to improve & use • User friendly formats eg score cards, links to accountability and the data for action parent voices (eg partnerships with E4A and WRA)

www.everynewborn.org #EveryNewborn ENDING PREVENTABLE CHILD AND MATERNAL DEATHS

www.lancet.com/series/everynewborn @joylawn #EveryNewborn Ending preventable maternal deaths Maternal mortality target also included in Every Newborn Action Plan

Lancet GH Sept 2013 : Global Health 2013; 1:e176-e177 (DOI:10.1016/S2214-109X(13)70059-7) Global average MMR of 70 per 100,000 with different targets for different countries Also need clear target for sexual and reproductive health (MDG 5 b)

www.lancet.com/series/everynewborn #EveryNewborn Ending preventable child and newborn deaths Mortality targets in Every Newborn Action Plan and A Promise Renewed

Every Newborn target by 2030: National NMR of 12 or less

From 2.8 to 0.8 million neonatal deaths ~100 countries have already met the target – focus on equity gaps Source: LancetAbout Every Newborn 29 countries series, paper 2 will have to more than double their rates of progress www.lancet.com/series/everynewborn #EveryNewborn Also ending preventable stillbirths

Every Newborn target by 2030: National SBR of 12 or less

From 2.6 to 1.1 million stillbirths Aligned with NMR target but more ambitious change needed Stillbirths still NOT MENTIONED in any SDG document… Source: Lancet few Every Newborn weeks series, leftpaper 2 to change this – please sign the petition on Everynewborn.org www.lancet.com/series/everynewborn #EveryNewborn ACTING ON THE ACTION PLAN

11 www.lancet.com/series/everynewborn #EveryNewborn www.lancet.com/series/everynewborn #EveryNewborn 5 things to do differently

Intentional Investment for Integrated Plans leadership impact development Integrated service delivery, continuum of Governance, community Especially in countries care, coordination participation, partner with highest burden alignment

AMBITIOUS Implementation & MEASUREMENT Innovation Indicators & metrics Targets in post 2015 CHANGE IS Address health system Measurement of progress CRITICAL TO EVERY bottlenecks, Every Mother and impact Every Newborn initiative STEP Eg for HIV/AIDS, malaria and EPI

www.lancet.com/series/everynewborn #EveryNewborn Core indicators selection during ENAP development

Step 1: Developed matrix of relevant indicators Organised according to ENAP Framework from impact (mortality) down to inputs including financial (>120 rows in the Excel!)

Step 2: Graded each indicator as follows: Direct relevance to the 5 ENAP objectives and focus (from A to C) Current availability of the data (from 1 to 3)

Step 3: Ranked indicators By A to C, with A being closest match to ENAP focus. By 1 to 3 where 1 is most currently available

Ref: Every Newborn: From evidence to action to deliver a healthy start for the next generation. Mason et al for the Lancet Every Newborn Study Group. Lancet 2014. Ambition to count what matters Indicators prioritised by importance (category A) Urgent work to improve the input data, specific milestones in ENAP for this

www.lancet.com/series/everynewborn #EveryNewborn Every Newborn action plan included core indicators Core ENAP Indicators Additional Indicators 1. Maternal Mortality Ratio 2. Stillbirth Rate Intrapartum Stillbirth Rate 3. Neonatal Mortality Rate Low birth weight rate Impact rate Small for gestational age Neonatal morbidity rates Disability after neonatal conditions Coverage: 4. Skilled attendant at birth Care for all 5. Early postnatal care for mothers and babies mothers and 6. Essential newborn care (tracer of immediate newborns breastfeeding) 7. Antenatal corticosteroid use rate Coverage: 8. Newborn resuscitation Complications & 9. Kangaroo mother care, feeding support extra care 10. Treatment of neonatal sepsis Chlorhexidine cord cleansing Counting Birth registration Death registration, cause of death ENAP service Every Mother Every Newborn quality initiative delivery packages Care of small and sick newborn (process) Shaded = not currently routinely tracked. Bold = indicator requiring additional evaluation for consistent measurement

Ref: Every Newborn: From evidence to action to deliver a healthy start for the next generation. Mason et al for the Lancet Every Newborn Study Group. Lancet 2014.

www.lancet.com/series/everynewborn #EveryNewborn Improving, institutionalising & using ENAP metrics for action ENAP Milestones by 2020

• Count births and deaths in CVRS (women, newborns and stillbirths)

• Minimum perinatal dataset & perinatal mortality audit being widely used in countries

• ENAP core indicators to be defined , incorporated in national metrics platforms and widely used

2020

June 2015 - May 2018 June 2018 - May 2020 Testing indicators and Wide use in many countries tools in limited number CVRS, facility HMIS, surveys Jan- May 2015 of countriesx linked to health systems Refining and consulting on scale up Dec 2014 metrics plan Meeting & ENAP monitoring FW World To scope Health Assembly ENAP Metrics improvement plan May/June 2014

www.everynewborn.org #EveryNewborn Every Newborn action plan core indicators Core ENAP Indicators 1. Maternal Mortality Ratio Definitions clear – but need Impact 2. Stillbirth Rate better tools, improved 3. Neonatal Mortality Rate quantity and quality of data New work needed on 4. Skilled attendant at birth contentCoverage: of care – critical to Care for all mothers and 5. Early postnatal care for mothers and babies link with maternal metrics newborns 6. Essential newborn care (tracer of immediate breastfeeding) communities 7. Antenatal corticosteroid use 8. Newborn resuscitation Task Teams Coverage: 9. Kangaroo mother care, feeding support working. Complications & extra care 10. Treatment of neonatal sepsis Significant Chlorhexidine cord cleansing progress C-Section rate Counting Birth registration Every Mother Every Newborn quality initiative ENAP service delivery packages (process) Care of small and sick newborn

Shaded = not currently routinely tracked. Bold = indicator requiring additional evaluation for consistent measurement

Ref: Every Newborn: From evidence to action to deliver a healthy start for the next generation. Mason et al for the Lancet Every Newborn Study Group. Lancet 2014. Excel sheet has details of definitions and testing questions Please send questions or ideas to Harriet Rees-Forman [email protected]

www.everynewborn.org #EveryNewborn

Measurement tools to be improved/developed and linked . Civil Registration and Vital Statistics • Birth certificates (improved weight, possibly gestational age) • Perinatal Death certificates and ICD codes (linked to new WHO ICD-perinatal mortality classification)

. Facility and HMIS • Perinatal mortality audit (linked to maternal audit) • Minimum perinatal dataset • DHIS2 and other HMIS collation for highly prioritised data points • Health facility assessment tools (treatment indicators, process)

. Population based surveillance and surveys (DHS/MICS) • Mortality capture including recall, misclassification of stillbirth/neonatal death and pregnancy vs live birth • Verbal autopsy for stillbirths and neonatal deaths • Social autopsy • Birth weight, birth size and gestational age

Core perinatal Facility based More complex Research studies dataset facility setting

•Eg as per data •Eg South Africa •Eg Vermont •Potentially with on ICD perinatal •PPIP Oxford neonatal biodata death network certificate

www.everynewborn.org #EveryNewborn Networks to ensure testing and use in many contexts

Mortality data etc “Beyond newborn survival” data

INDEPTH Maternal & Newborn Interest Group With UNICEF and others partners in India 20+ sites in Africa and Asia and beyond . Population-based pregnancy . Follow up at risk newborns by surveillance of births, stillbirths, varying levels of health care neonatal deaths. . Opportunities to validate and . Opportunities to advance test feasibility of follow up, validation of pregnancy history modules, verbal autopsy, screening for disability, ROP and improved LBW assessment etc. models to improve care

www.everynewborn.org #EveryNewborn Building on 3 countries working on quality initiatives including “Every Mother Every Newborn”

Ghana Tanzania Bangladesh

Validation and feasibility testing for facility-based coverage data Also tools such as audit, min perinatal dataset, simplified gest age assessment etc

Also opportunities to test similar questions in other countries and with other organisations. Coordinated approach will yield the fastest collective progress

www.everynewborn.org #EveryNewborn

ENAP Metrics Webinar Agenda

1. Overview core indicators and improvement Joy Lawn, LSHTM

2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO • Other UN groups and NBTWIG Agbessi Amouzou, UNICEF • INDEPTH network Peter Waiswa, Makerere University, Uganda

3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF

4. Questions and discussion

5. Closing and how to get more information

21 www.lancet.com/series/everynewborn #EveryNewborn Linking metrics for maternal & newborn health WHO & partners are considering forming a Maternal Newborn Measurement Expert Reference Group (MNH MERG) . Why? • Convergence of efforts to end preventable mortality – maternal, newborn, child • Opportunities through harmonisation – effectiveness,, more coordinated support for countries, more efficiency • Greater potential for synergies in metrics innovations, especially for tracking content and quality as well as coverage • Less chance of falling through the gaps – eg stillbirths • Important common lessons learned eg on mortality audit scale up and linking this to change

. Who? • WHO and partners will convene, learning from lessons learned in other MERGs. May be time limited. Needs to link to clear technical outputs

www.everynewborn.org #EveryNewborn ENAP Metrics Webinar Agenda

1. Overview core indicators and improvement Joy Lawn, LSHTM

2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO • Other UN groups and NBTWIG

Agbessi Amouzou, UNICEF • INDEPTH network Peter Waiswa, Makerere University, Uganda

3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF

4. Questions and discussion

5. Closing and how to get more information

www.everynewborn.org #EveryNewborn Linking ENAP metrics improvement with other ongoing work by the UN and (many!) others . A Promise Renewed report 2014 had focus on newborns . Links to many current work-streams including with H4 eg on EmOC indicators

. Countdown to 2015 linked to ENAP and the metrics work is linked in all the 4 CD technical working groups

. Hopkins (JHU) grant on Improving Coverage Measurement testing specific indicators including for essential newborn care

. Secretariat of NBITWG is with Saving Newborn Lives. Meets twice a year. Linked with ENAP by many organisations and individuals

. Coverage Task teams for various treatment indicators (eg resuscitation, antenatal corticosteroids, Chlorhexidine etc) directly link with and build on the relevant UNCoLSC teams

www.everynewborn.org #EveryNewborn ENAP Metrics Webinar Agenda

1. Overview core indicators and improvement Joy Lawn, LSHTM

2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO • Other UN groups and NBTWIG Agbessi Amouzou, UNICEF • INDEPTH network Peter Waiswa, Makerere University, Uganda

3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF

4. Questions and discussion

5. Closing and how to get more information

www.everynewborn.org #EveryNewborn INDEPTH Maternal & Newborn Interest Group Leader: Dr Peter Waiswa Makerere University

Unique opportunity to test and improve population-based metrics especially for stillbirths and neonatal deaths, LBW and preterm birth, with mhealth innovations

AND capacity- building

www.everynewborn.org #EveryNewborn ENAP Metrics Webinar Agenda

1. Overview core indicators and improvement Joy Lawn, LSHTM

2. Integrating and institutionalising • Maternal and newborn health metrics Matthews Mathai, WHO • Other UN groups and NBTWIG Agbessi Amouzou, UNICEF • INDEPTH network Peter Waiswa, Makerere University, Uganda

3. ENAP Metrics meeting at WHO and outputs Suzanne Fournier, CIFF

4. Questions and discussion

5. Closing and how to get more information

www.everynewborn.org #EveryNewborn WHO ENAP Metrics meeting December 2014 . Who? >60 technical experts from Africa, Asia, North and South America and Europe including UN, academics, clinicians, programme experts, DHS, MICS, SARA , SPA, DHIS, CVRS & many others

. What? Two days of hard work! Emphasis on harmonisation with related metrics work eg WHO QoC metrics,100 core indicator list

. Results? Advances for core indicators and accelerating improvement (ENAP metrics Improvement Plan). WHO Meeting Report in process Selected quotes.... “Measurement of care for small and sick newborns is a total GAP! Could be tackled like EmOC core competencies” “Important to remember essential newborn care in our metrics’’ “Treatment indicators “stink” and the worst part is the denominator!” “Prioritization is key as ambitious timeline for collecting data at-scale!”

www.everynewborn.org #EveryNewborn ENAP Metrics Webinar

DISCUSSION

www.everynewborn.org #EveryNewborn Action now 1. Advocacy now for post 2015 targets • Neonatal and maternal mortality expected in SDGs but not yet clear if universal or relative (%) targets • Stillbirth counting still absent from SDGs! Sign petition at EveryNewborn.org! • Join ENAP advocacy - Anita Sharma, Lori McDougall & E4A. • Post-2015 health measurement discussion (18th March 8.15- 10.00 ET – after this call!)

2. Improve and use the data in countries • Some metrics ready for wider scale use now • ENAP for technical advances and linked tools

3. Intentional capacity development • To improve, use and further improve the data

www.lancet.com/series/everynewborn @joylawn #EveryNewborn More technical information 1. Which indicators to use now for what and more detail on ENAP metrics definitions • Review excel, welcome to send questions or ideas to Harriet Rees-Forman [email protected] (on behalf of Matthews Mathai & Joy Lawn) • Discussion opportunities at Newborn indicators Technical Working Group in DC next week (18th) if you will be there • Upcoming WHO ENAP meeting report and BMC paper

.2 Metrics Improvement Plan • Ideas for improvement or other inputs please contact Harriet Rees-Forman

We have the potential to transform survival and health for EVERY newborn EVERY mother including for the world’s poorest families – Acting on the plan depends on better data

www.lancet.com/series/everynewborn @joylawn #EveryNewborn