NATIONAL NEWBORN STAKEHOLDERS MEETING

Transcription

1 NATIONAL NEWBORN STAKEHOLDERS MEETING 28 th to 30 th JULY 2015 ACCRA, GHANA 1

2 Table of Contents ACKNOWLEGMENTS... 4 ACRONYMS AND ABBREVIATIONS... 5 KEY DEFINITIONS... 6 EXECUTIVE SUMMARY... 7 THE PROCESS EXECUTIVE FORUM OBJECTIVES: WELCOME ADDRESS STATEMENTS BY PARTNERS KEY MESSAGES FROM SPEAKERS WHAT IS HAPPENING WITH OUR PRETERM AND LOW BIRTH WEIGHT NEWBORNS? THE NEWBORN HEALTH STRATEGY: PROGRESS SO FAR INVESTING IN NEWBORN HEALTH: THE CASE FOR THE PRETERM AND LOW BIRTH WEIGHT BABY.. 21 CALL FOR SUPPORT KEYNOTE ADDRESS TECHNICAL SESSION SESSION 1: PROGRAMMES AND ACHIEVEMENTS UNDER THE NEWBORN STRATEGY SESSION 2: IMPLEMENTATION OF EVIDENCE BASED INTERVENTIONS RELATED TO CARE OF PRETERM AND LOW BIRTH WEIGHT NEWBORN WITHIN THE RMNCH STRATEGY SESSION 3: UNDERSTANDING KANGAROO MOTHER CARE: HISTORY, DEFINITION, EVIDENCE AND PROGRAMMATIC APPROACHES SESSION 4: KMC EXPERIENCES AND IMPLEMENTATION IN GHANA KEY OUTCOMES ANNEX ANNEX 1: Summary of progress with the Newborn Health Strategy ANNEX 2: Regional Progress and Next steps with the Newborn Health Strategy for ANNEX 3: Programmatic Approaches to KMC implementation ANNEX 4: Key Recommendations for KMC implementation ANNEX 5: Discussion Points ANNEX 6: Summary of strengths and challenges with regard to KMC (and newborn care) implementation identified in regional working groups

3 ANNEX 7: Regional KMC Implementation plans ANNEX 8: Agenda for the meeting ANNEX 9: Participants list ANNEX 10: References

4 ACKNOWLEGMENTS The Ministry of Health and Ghana Health Service acknowledge the financial and technical support received from Governments, UNICEF, PATH, WHO and other partners in the implementation of the National Newborn Strategy and Action Plan and the Fourth National Newborn Stakeholders Meeting in Accra. We would also like to thank the National Newborn Sub-Committee for their immense support in the planning and coordination of the Fourth National Newborn Stakeholders Meeting. Our sincere gratitude goes to all the chairpersons and speakers for their facilitation and insightful presentations. We are especially grateful to Dr. Anne-Marie Bergh for her technical expertise and support during the Kangaroo Mother Care session of the meeting. We are truly grateful to our newborn care champions for supporting the Reproductive and Child Health Unit of the Ghana Health Service in advocating for newborn health. We specially thank the staff of the Family Health Division of the Ghana Health Service for their hard work, dedication and support throughout the process of planning and organisation of this meeting. Finally, we are grateful to Dr. Priscilla Wobil for her guidance and technical support. As consultant for the meeting her insight and expertise in no small measure contributed to ensuring the richness of the technical content of the meeting. 4

5 ACRONYMS AND ABBREVIATIONS CHPS Community - based Health Planning and Services CoC DHIMS2 DHMT DHS ECEB EMBRACE GHS HBB HBPNC HIMS IMNCI IPC KATH KBTH KMC KNUST KSH LB LBW MASHAV MBFFI MBU MCI MDG Continuum of Care District Health Information Management System District Health Management Team Demographic Health Survey Essential Care for Every Baby Ensure Mothers and Babies Regular Access to Care Ghana Health Service Helping Babies Breathe Home Based Postnatal Care Health Information Management System Integrated Management of Neonatal and Childhood Infection Prevention and Control Komfo Anokye Teaching Hospital Korle-bu Teaching Hospital Kangaroo Mother Care Kwame Nkrumah University of Science and Technology Kumasi South Hospital Live Births Low Birth Weight Israeli Centre for International Cooperation, Ministry of Foreign Affairs Mother Baby Friendly Facility Initiative Mother and Baby Unit Millennium Cities Initiative Millennium Development Goals 5

6 MEBCI MMDAs MOH NICU NMR PATH PNC QI RCC RCH RHMT RMNCH SANDS SGH SWOT UNICEF USAID WHO Making Every Baby Count Initiative Metropolitan, Municipal and District Assemblies Ministry of Health Neonatal Intensive Care Unit Neonatal Mortality Rate Program for Appropriate Technology in Health Postnatal Care Quality Improvement Regional Coordinating Council Reproductive and Child Health Regional Health Management Team Reproductive Maternal, Neonatal and Child Health Stillbirth And Neonatal Death Study Suntreso Government Hospital Strengths, Weaknesses, Opportunities and Threats United Nations Children s Fund United States Agency for International Development World Health Organization KEY DEFINITIONS Low birth weight Newborn death Preterm baby Weight of less than 2,500 gm, irrespective of gestational age Death within 28 days of birth of any live born baby regardless of weight or gestational age A baby born less than 37 completed weeks of pregnancy 6

7 EXECUTIVE SUMMARY INTRODUCTION Proven high impact interventions provided along the continuum of care have the potential to save nearly 3 million newborn lives every year. The vision of the Every Newborn Action Plan is to have a world in which there are NO PREVENTABLE DEATHS of newborns or stillbirths, where every pregnancy is wanted, every birth celebrated, and women, babies and children survive, thrive and reach their full potential (1). The Every Newborn target of a national Neonatal Mortality Rate (NMR) of 10 or less per 1000 live births (LB) is achievable by The question is whether we are willing to commit fully to the course of saving every newborn. We must bear in mind that a single newborn death is a 100% loss to a mother and family, and the repercussions of such a loss are indescribable. Obviously a lot is being done in Ghana to improve newborn survival, but the pace is slow, and if we continue at this rate it will take Ghana over 100 years to attain a NMR of 3/1000 LB(1). The newborns cannot wait, they will continue to be born and we must be ready to make the right decisions actions to keep them alive and healthy. The target of the National Newborn Strategy is to reduce the number of neonatal deaths by 5% every year from 32/1000 LB in 2011 to 21/1000 LB in 2018; and reduce institutional neonatal mortality by at least 35% by The day of birth which is supposed to be a day of rejoicing, is the time of greatest risk of death and disability, with more than 1 million newborns dying. Per contra, this same day is a time when we can achieve the biggest impact, saving 3 million newborn lives per year with a triple return on our investments. The three main causes of newborn deaths are preterm birth complications, intrapartum complications including birth asphyxia and neonatal infections, and 71% of these newborn deaths can be prevented without intensive care(2). Eighty percent of newborn deaths occur in small babies of which two-thirds are preterm, and according to the Born Too Soon report (2, 3), prematurity is the number one cause of under five mortality. Preterm births are increasing all over the world with unacceptably high rates of mortality. We have the knowledge and tools to end needless deaths among babies born too soon and too small. Donors, policymakers and governments must make newborn health a priority and ensure adequate investment to improve quality care for every newborn. 7

8 BACKGROUND Ghana joins countries worldwide in a deep commitment to protecting mothers and infants during pregnancy, birth and the first weeks of life. Recognizing that NMR in Ghana remains high 29/1000 LB, the Ministry of Health (MOH) and the Ghana Health Service (GHS) developed the Ghana National Newborn Health Strategy and Action Plan(4). The plan is an integrated, comprehensive, and data driven road map to measurably improve services and care for newborns by It is guided by 14 key strategies targeted at developing and implementing newborn health policies, capacity building of health workers, health system strengthening, increasing health financing, and intensifying monitoring and evaluation mechanisms. Following the launch of this strategy and action plan, the MOH/GHS with support from various bilateral and multilateral agencies is implementing key interventions of the action plan. At the national level, the Newborn Sub-Committee is actively coordinating, advocating, mobilising resources and monitoring the implementation of the strategy. With support from partners, GHS has organised three National Newborn Stakeholders Meetings in July 2012, July 2013 and July The Newborn executive forum was organised as part of the Committing to Child Survival: A Promise Renewed launch in Ghana. The Ministry of Health (MOH) and Ghana Health Service (GHS) under the coordination of the National Newborn Sub-Committee held the fourth Newborn Stakeholders Meeting in Accra, from the 28 th to the 30 th of July, 2015 under the theme Born Too Soon, Born Too Small, Help Us Live. The executive forum held on 28 th July 2015, targeted government officials, partners, donors, business organisations, United Nations Systems, international and local agencies, the media, MOH and GHS officials at national and regional levels, professionals in academia and newborn champions. The meeting drew over 140 participants with two main objectives. 1. Review the progress of implementation of the Newborn Strategy since Educate and advocate for support to improve care of the preterm and low birth weight newborn. The technical session took place from 29 th to 30 th November A major part of the agenda was dedicated to orienting participants on KMC and planning for its implementation in Ghana. The objectives of this session were to focus attention on improving evidence-based quality care for preterm/low birth weight newborns with particular emphasis on KMC introduction and expansion in Ghana. 8

9 The executive forum was moderated by Dr. Gifty Anti a Newborn care ambassador and chaired by Dr. Victor Ngongala, Chief - Health and Nutrition Section, UNICEF. KEY MESSAGES Commitment from Government The Honourable Minister for Health, Dr. Alex Segbefia in his keynote address stated that Ghana is signatory to global goals to end preventable child deaths, and he reaffirmed government s support and commitment to newborn care as the nation redoubles its efforts to accelerate a decline in neonatal mortality. National Progress with the Newborn Health Strategy According to the National Child Health Coordinator Dr. Isabella Sagoe-Moses, considerable progress has been made over the past year. Ten Regional focal persons for newborn care have been appointed to coordinate newborn care activities. Capacity of facility-based health workers in Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) has been scaled up. Key newborn indicators have been identified and included in the District Health Information Management System (DHIMS2). A Mother and Baby Friendly Facility Initiative (MBFFI) is also being introduced to improve quality of care during the intrapartum and early neonatal period within the framework of the National Newborn Strategy. However, more partners are needed to take effective interventions to scale and more government funding is needed for sustainability. At the Executive Forum, a number of stakeholders and newborn care champions called for support to accelerate quality health care services for newborns in Ghana... if we could all come together and prevent Ebola from coming to Ghana, I strongly believe that together we can save our newborns. WE CAN DO IT! I implore all of you to contribute to support the newborn care programme. Honourable Mavis Ama Frimpong, Deputy Regional Minister for Eastern Region & Newborn Care Ambassador What is happening with our preterm and low birth weight newborns? Ghana ranks 25 th in the world in terms of number of preterm births 14.5% of all deliveries are preterm 9

10 Prematurity accounts for 7,200 neonatal deaths every year What can be done to save our preterm/low birth weight newborns? Despite all these alarming figures, evidence has shown that preterm/lbw newborns can be saved with low cost interventions along the continuum of care. Some of these interventions include family planning, antenatal corticosteroids for preterm labour, essential care such as resuscitation, early and exclusive breastfeeding, and extra care for the preterm/lbw newborn including KMC. Beyond survival Caring for a preterm baby can be very stressful for mothers. Preterm babies are at increased risk of lifelong problems and disabilities such as visual impairment and learning difficulties, and need long term follow up. At the community level, preterm birth myths and misconceptions still exist, and it is necessary to take into account the sociocultural beliefs and practices surrounding preterm birth, and constantly provide a supportive environment for mothers. Psychosocial support for parents in particular should also be an integral part of the preterm/lbw follow up programme. Kangaroo Mother Care standard of care for preterm and LBW newborns KMC is a programme for preterm/lbw babies consisting of three components - prolonged skin to skin contact, early and exclusive breastfeeding and early discharge and follow up. At the 2013 KMC acceleration meeting in Istanbul, newborn stakeholders reached a consensus that, based on available evidence, KMC should be adopted and accelerated as standard of care as an essential intervention for preterm newborns. Success was defined as augmented and sustained global and national level action to achieve 50% coverage of KMC among preterm newborns by the year 2020 as a part of an integrated RMNCH package(5). With universal coverage, KMC could prevent close to 531,000 preterm deaths every year by 2025(6). To effectively implement and scale up KMC in Ghana, participants worked in groups to brainstorm on the facilitators, challenges and possible solutions to KMC implementation within their regions, using the WHO Health System Building blocks. 10

11 Recommendations for KMC implementation Dr. Anne-Marie Bergh, a Senior Researcher at the Medical Research Center, University of Pretoria, South Africa shared various programmatic approaches to KMC implementation. One key approach that has been used extensively in Africa is the stages of change approach (Figure 1). STAGES OF CHANGE 5. Integrate into routine practice 4. Implement Evidence of practice 3. Prepare to implement Taking ownership 2. Commit to implement Adopt the concept 1. Create awareness Get acquainted with KMC Know the problem (survival) STAGE 6. Sustain new practice PROGRESS MARKERS year audit evidence - Staff development ***** - Evidence of all three components of KMC - Policies and other written documents ***** - Babies in KMC position - Patient records - Staff orientation ***** - Mobilisation of resources (human, space & equipment) ***** - Conscious decision to implement ***** - Awareness by management Figure 1:Stages of change approach with progress markers, Courtesy Anne-Marie Bergh KEY RECOMMENDATIONS FOR IMPROVING CARE OF PRETERM AND LBW NEWBORNS IN GHANA National level 1. Intensify and scale up competency-based training modules for critical staff involved in newborn care with particular focus on the preterm/lbw newborn. 2. Develop or adapt KMC guidelines with clear indications for KMC services at various levels of the health care delivery system 3. Advocate for more investment in newborn care and KMC through public-private partnerships. Regional level 1. Build stronger collaborations between paediatricians, obstetricians and midwives at all levels of the health care delivery system. 11

12 2. Increase availability and accessibility to newborn care and KMC services in every region. 3. Improve data collection and track preterm/lbw morbidity and mortality outcomes. we are all reminding ourselves of our promise and the commitment to do our best in protecting the smallest of Ghanaians from needless illnesses and death. Nora Maresh, Family Health Team Lead USAID 12

13 THE PROCESS The National Newborn Sub-Committee chaired by the National Child Health Coordinator was formed in 2012 to help facilitate, coordinate and oversee development and updating of policies, standards, guidelines, indicators for monitoring and evaluation and financing mechanisms related to Newborn health. In line with the responsibilities of the Newborn Sub-Committee, members were tasked to facilitate the planning and execution of the fourth newborn stakeholders meeting in Since the launch of the Newborn Strategy and Action Plan in 2014, it was decided that at each annual stakeholders meeting, one of the three major causes of newborn deaths will be selected as the main focus of the meeting. Since complications of prematurity accounted for the highest number of neonatal deaths and being the number one cause of under five deaths globally, Care of the preterm and low birth weight newborn was selected as the topic for discussion at this year s meeting. The committee brainstormed and carefully selected the theme for the meeting Born Too Soon, Born Too Small: Help Us Live! A concept note was developed which contained the summary of the proposed agenda for the 3-day Newborn stakeholders meeting, it included the following: An executive forum on the first day was targeted at partners, donors, health professionals in academia, business organisations, newborn champions, the media and government officials, with the objective of educating and advocating for support for the preterm and low birth weight newborn. The second objective was to review progress with the Newborn strategy since The technical session was to take place on day 2 and 3, with one full day dedicated to KMC to set the stage for KMC introduction and expansion in Ghana. A National Consultant was appointed to provide support to develop the agenda, assist the Sub- Committee to plan and execute the programme and submit a written report at the end of the meeting. A smaller group planning team was formed to support the National consultant. They included staff from the Reproductive and Child Health Unit, PATH Ghana, UNICEF and the National Child Health Coordinator. A series of meetings were held at the Ghana Health Service Headquarters in Accra, with a number of correspondences and Skype meetings. Questionnaires on Regional Newborn Care Action Plans and implementations plans for were adapted from the previous year and sent to the 10 Regional Focal Persons for Newborn care to complete and submit to the National Child Health Coordinator. 13

14 The agenda for the meeting was finalised and invitation letters were sent out a month prior to the meeting to all stakeholders, both local and international. EXECUTIVE FORUM The Executive Forum of the Fourth Newborn Stakeholders Meeting of the Ghana Health Service and the Ministry of Health was held in Accra, Ghana, July 28, 2015 at the Miklin Hotel. The meeting drew over 140 participants made up of newborn care ambassadors, government officials, media practitioners, lecturers, public health physicians, researchers, policy makers, health managers, administrators, general nurses, paediatric nurses, midwives, medical officers and specialist paediatricians. Participants came from all the 10 regions of Ghana, South Africa and the United States of America. Participants represented the government, development partners, United Nations Systems, nongovernmental organisations, private sector, international agencies, research institutions, academia, health institutions including Teaching hospitals, Quasi government hospitals, Regional hospitals and District hospitals, and the National Headquarters of the Ghana Health Service. H.E Claudia Turbay Quintero, Colombian Ambassador to Ghana, Dr. Gloria Quansah-Asare-Deputy Director General GHS, Dr. Patrick Aboagye-Director Family Health Division GHS, Dr. Alex Segbefia-Hon. Minister for Health, Dr. Victor Ngongala, UNICEF-Chief of Health and Nutrition, Nora Maresh, Family Health Team Lead USAID Ghana, Hon. Mavis Ama Frimpong, Deputy Regional Minister Eastern Region/Newborn Care Ambassador The meeting started at 9:00am with an opening prayer by one of the participants. The meeting was chaired by Dr. Victor Ngongala, UNICEF Chief of Health and Nutrition Section, and the Master of 14

15 ceremonies was Dr. Gifty Anti, a former media practitioner, the Chief Executive Officer of GDA Concepts and a Newborn care ambassador. OBJECTIVES: 1. To raise awareness about the importance of improving care for preterm and low birth weight babies so that they survive and thrive 2. To advocate for resources to improve the care of preterm and low birth weight newborns along the continuum of care 3. Review progress on the implementation of the Newborn Health Strategy WELCOME ADDRESS Dr. Patrick Aboagye, Director of Family Health Division of the Ghana Health Service (GHS) gave the welcome address on behalf the Director General of the Ghana Health Service. Since 2012, the GHS in collaboration with partners have been organising annual newborn stakeholder meetings aimed at raising awareness and focusing attention on the newborn. According to the 2014 Demographic Health Survey report (DHS)(7), under five mortality is down to 60% from about 150% in the 1990s. However, 40% of all under five deaths occur within the newborn period, hence the increased attention and focus on the newborn. Ghana would have to account for her stewardship of the Newborn Action plan in 2018, and therefore entreated all stakeholders to commit to take action to reduce preventable newborn deaths particularly among those born too soon and too small. STATEMENTS BY PARTNERS United Nations Systems UNICEF, WHO Dr. Victor Ngongala, UNICEF-Ghana made a statement on behalf of the United Nations Systems supporting the Health Sector. The number of newborn lives being lost 29,000 every year, is a huge economical loss for Ghana considering the cost of antenatal care, delivery services, maternity leave and breastfeeding hours. Ghana did not meet the target for Millennium Development Goal (MDG) 4, but we have made some 15

16 progress in reducing under five mortality. There is evidence that we can change the trends, but what we need is commitment, resources that have been equitably distributed nationwide, support at all levels and accountable managers who will take the interventions to scale, he said. Improving the quality of care during the intrapartum and early newborn period is critical to save the lives of Ghanaian mothers and their newborns. USAID Statement by Nora Maresh, Family Health Team Lead on behalf of USAID We are here today because we are all reminding ourselves of our promise and the commitment to do our best in protecting the smallest of Ghanaians from needless illnesses and death, she said. There is substantial evidence that two-thirds of newborn deaths can be prevented using low cost interventions. USAID is pleased to support the efforts of the Government of Ghana and their leadership in answering the moral imperative which is ending preventable child deaths within a generation. She concluded her statement with a quote by the President of the United States of America This is our first task caring for our children. It s our first job. If we don t get that right, we don t get anything right. That s how, as a society, we will be judged. PATH Dr. Goldy Mazia, Newborn Advisor for PATH, Washington DC, made a statement on behalf of PATH Ghana. The MEBCI (Making Every Baby Count Initiative) project being implemented by PATH, is supporting the Newborn Strategy of the MOH/GHS in four regions in Ghana Brong-Ahafo Region, Eastern region, Volta region and Ashanti region (figure 2). The support is not only in the implementation of evidence-based interventions to reduce newborn morbidity and mortality, but also at the National level giving input to guidelines and tools. Ghana has pioneered a lot of evidence based interventions and already is showing lessons learned that we can share with the world. 16

17 Figure 2: Map of Ghana 17

18 KEY MESSAGES FROM SPEAKERS WHAT IS HAPPENING WITH OUR PRETERM AND LOW BIRTH WEIGHT NEWBORNS? By Dr. Gyikua Plange-Rhule - Lawyer, Senior Specialist Paediatrician, Senior Lecturer-Kwame Nkrumah University of Science and Technology (KNUST)/Komfo Anokye Teaching Hospital (KATH) Ghana ranks 25 th in the world in terms of the number of preterm births(8) (Figure 3). The increase in the number of facilities providing assisted conception in Ghana, could also account for the rise in premature births in Ghana. Prematurity accounts for 14.5% of all deliveries in Ghana, and compared to babies born term, preterm babies are 25 times more likely to die in the first month of life(9, 10). The knowledge and skill of the health care provider largely affects the quality of care and survival of the preterm newborn Being a preterm mother herself, she shared some of the distressing moments mothers go through particularly with feeding, while caring for their preterm babies. I am a mother of a preterm baby and my daughter is all grown up 28 years old and a lawyer. But I still remember how really distressing it is when they are born. The nurses would ask for breastmilk, and you express and express and nothing comes. And I remember the very first milk I expressed looked watery and I sent it to the nurses and they said, No! your breastmilk is not good, throw it away, and don t bother to express anymore. Breastfeeding myths still exist in communities. Results from the NEWHINTS trial in Kintampo(11), in 2007, revealed that mothers believe that breast milk must look like tinned milk, and must go from the breast to the baby otherwise it is not good. We need to constantly provide a supportive environment for mothers and take into account the sociocultural beliefs and practices surrounding preterm birth. Mortality from prematurity is unacceptably high, and we need to focus attention on how to reduce preterm births. It is also important to keep in mind that most preterm babies become healthy adults if they are managed well as newborns. 18

19 Figure 3: Born too soon The Global Action Report on Preterm birth 2010 THE NEWBORN HEALTH STRATEGY: PROGRESS SO FAR Dr. Isabella Sagoe-Moses, the National Child Health Coordinator made this presentation on behalf of the National Newborn Sub Committee. A number of newborn interventions were already ongoing in Ghana before the launch of the Newborn Strategy in Having a separate newborn health strategy will help maintain a better focus on the newborn and serve as a guide for the health sector, the government, development partners and all 19

20 stakeholders, Dr. Sagoe-Moses told conference participants, adding that the strategy has two main goals and thirteen strategic objectives. In order to address the major causes of newborn deaths, the strategy has FOUR MAIN INTERVENTION PACKAGES: 1. Basic essential newborn care 2. Management of adverse intra-partum events (including birth asphyxia) 3. Care of the preterm/low birth weight/growth restricted baby 4. Management of neonatal infections/sick newborn SUMMARY OF PROGRESS (see details in Table 2, under ANNEX 1) 10 Regional Newborn focal persons have been appointed Helping Babies Breath (HBB) is already in use in-country and Essential Care for Every Baby (ECEB) training materials have been adapted and in use Newborn Indicators identified for inclusion in the District Information Management System (DHIMS2) Scorecard for Reproductive Maternal Newborn and Child Health (RMNCH) developed List of essential equipment for newborn care at various levels developed Newborn section included in peer review tool for health facilities Newborn issues included in national integrated supervisory tool Advocacy and communication strategy developed Despite the fact that considerable progress has been made, challenges of inadequate staff versus work load at various levels, inadequate infrastructure in health facilities, difficulties in implementing the newborn strategy to scale and inadequate flow of government funds still persist. We need more partners to take effective interventions to scale and more government funding to ensure sustainability of our newborn care programmes. Dr. Isabella Sagoe-Moses 20

21 INVESTING IN NEWBORN HEALTH: THE CASE FOR THE PRETERM AND LOW BIRTH WEIGHT BABY Dr. Yaa Adoma Fokuo, Specialist Paediatrician, Dormaa Presbyterian Hospital, Brong-Ahafo Region In July 2015, a newspaper article showed 3,514 excited university students looking splendid in their graduation gowns and ready to conquer the world. If 112 students out of these 3,514 graduates were to die, it would be breaking news. But that is how many newborns we lose 29/1000 LB. So why are newborn deaths not an issue but accepted as normal? We forget that newborns actually have more potential than these graduates for potential can only be lost as you grow. The interventions to save our newborns are not expensive or difficult to do so why then are we losing so many of our newborns? It is not a matter of funding or equipment or even human resource. It is simply a matter of priority. Do we use our funding to build mothers hostels knowing that the small baby will be on admission for a long period and the mum cannot continue to lie on the bare floor for a month? Do we not use our funding to take care of administrative issues and lucrative adult oriented ventures at the expense of the small baby? Do we not choose fuelling our hospital cars over purchasing oxygen for the small baby who might have breathing problems as a result of his immature lungs? Do we have small baby sized equipment or we just make do with adult sized equipment? Culturally, we don t name newborns early because they might die. And when they die, we say loftily to the mum, you will get pregnant again as if the baby never mattered at all nameless he dies and no one notes his passing. Investing in newborn health and survival helps achieve health and development goals and honours newborns human rights(12, 13). It makes economic sense because healthier households spend less savings on healthcare and the value of a nation is measured by how it takes care of its most vulnerable population. What then must be done since it is clear that we need to invest in the health of the LBW and preterm baby? We need the political will to ensure that the health of every newborn is guarded as jealously as any other treasure of the state. 21

22 We need the media to help raise awareness that though he is small, he matters to us culturally, socially, financially and in every way imaginable. We need the private sector to partner with government in building mothers hostels and creating a place for the newborn in every single hospital in the country to keep them warm and alive. At the end of the day when all has been said and done, the real question is not: is this achievable, or is this viable financially, or is this doable, or is it even ethical? The real question is: DO WE WANT TO DO IT? CALL FOR SUPPORT A number of stakeholders and newborn care champions called for support to accelerate quality health care services for newborns in Ghana. You may not have money, but we all have voices and we can speak on behalf of the newborn on the radio, on television... You may not have to give a mother money, but you can give your love, your time and your commitment. Thousands and thousands of babies are said to be born dead when they were actually born alive. Some of them were born too small, and they could not handle them. Ladies and gentlemen, we can invest in innovations and research. Our partners have done a lot, but are we going to continuously rely on partners? Each one of us is an advocate, we should all call for support wherever we find ourselves, and if we are determined, together as a country we can help every newborn survive and develop well. Together we can! Dr. Linda Vanotoo - Regional Director for Health, Greater Accra Region. I am here to join the call, an urgent call to action. We must take opportunity whenever we have the microphone to advocate for the newborn. I am taking it upon myself to do a monthly call to check on the number of preterm babies surviving in my region and advocate for support in parliament. For me I know there is hope, because in the era of HIV in Ghana, we all sat and worked together and HIV prevalence dropped. I believe that if we could all come together and prevent Ebola from coming to Ghana, I strongly believe that together we will be able to save our newborns. We can do it! I implore all of you to contribute to support the newborn care programme. God bless you all. Honourable Mavis Ama Frimpong, Deputy Regional Minister for the Eastern Region and Newborn Care Ambassador 22

23 We need action now! We set dates and timelines and we don t meet them, probably apart from elections. We made so much noise about MDG 4 and 5, and 2015 is here and we did not achieve the targets. I think we need to do something now especially those of us in civil society and the various nongovernmental organisations (NGOs). We need to take the bull by the horn and do something about newborn health. Maybe we need to politicize newborn health and get the media to put the information out. We need to make noise, we need to demand. At the launch of the 10 th anniversary of the Women s Manifesto last year, we said Women demanding, still demanding, and yes, we are still demanding that something more should be done for the newborn. It is a partnership, it s not just about women - it s about men and women. I want to agree with my colleague ambassador, that if we could fight Ebola, then we can fight to put an end to needless deaths of newborns in Ghana. Motherhood is beautiful, so let s help to make it really beautiful. Gifty Anti, Chief Executive Officer-GDA Concepts, Host of The Standpoint on Ghana Television and Newborn Care Ambassador Colombia supports Kangaroo Mother Care implementation in Ghana Kangaroo Mother Care (KMC) started in Colombia. I believe that the KMC programme is about showing love to mothers and babies, she said, and we have to strengthen that vision of love by improving KMC for all preterm and low birth weight newborns. In October 2014, she made a passing visit to one of the MEBCI workshops organised by PATH in Accra, and a request was made for support to expand KMC in Ghana. The Colombian government has approved a proposal to support the implementation and expansion of KMC in Ghana. This includes sponsorship for an off-site three month training in KMC for three health professionals from Ghana this year, and technical support for the setting up of centers of excellence for KMC training and implementation in Ghana. The Ghana Health Service and the Ministry of Health are grateful to the Government of Colombia for their support and collaboration. Claudia Turbay, Colombian Ambassador to Ghana KEYNOTE ADDRESS The Honourable Minister for Health, Dr. Alex Segbefia, delivered the keynote address. Also a proud father of a preterm child, his daughter was born at 28 weeks and for two weeks they thought they were going to lose her, his daughter survived and has graduated in Law and Business and has started working. The topic of prematurity and low birth weight which we are 23

24 discussing here today is very important because it can affect any of us in different ways. The theme for this conference, Born too soon, born too small, help us live! is very appropriate and all of us present here today should commit to nurture these small babies so that they live, the Minister said. Although Ghana has seen a decline in under five mortality and infant mortality, neonatal mortality has remained stagnant. Ghana s neonatal mortality rate of 29/1000 live births is a serious blot on our development ethics, and we have to halt these preventable deaths because every life counts(7). He assured us that child health has and will always remain on the list of priorities for the government. A number of development partners and other stakeholders have shown commitment in working together with government to achieve the goals and objectives of the Newborn strategy to improve newborn survival and health in Ghana. Every newborn, every child and every pregnant woman in our community has the right to live. He emphasized that, it is our moral and ethical responsibility to ensure that newborns survive because they represent the builders of the future of Ghana. It is therefore in our interest that we invest in newborns because when we invest in our newborns we are investing in the foundations for growth, development and progress for Ghana. TECHNICAL SESSION The Technical Session of the Newborn Stakeholders Meeting took place from the afternoon of 28 th July to 30 th July Objectives of the session 1. Review programmes and achievements under the Newborn Strategy 2. Highlight evidence based interventions related to the care of the preterm and low birth weight newborn along the continuum of care 3. Standardize KMC and set the stage for strengthening and scaling up KMC in Ghana 4. Share best practices and lessons learned from the above strategies and interventions related to KMC and care of the preterm/low birth weight newborn 5. Develop annual national and regional action plans with timeframe and available resources for accelerating KMC in Ghana 24

25 SESSION 1: PROGRAMMES AND ACHIEVEMENTS UNDER THE NEWBORN STRATEGY 1. PROVEN INTERVENTIONS FOR IMPROVING THE QUALITY OF NEWBORN CARE Dr. Hari Banskota from UNICEF presented some key proven interventions that can improve quality of newborn care in line with the Every Newborn Action Plan. The three main causes of newborn deaths all have effective and feasible interventions (Table 1). 71% of newborn deaths are preventable and actionable now without intensive care. Investing in quality care at birth results in a triple return, is highly cost effective and achieves high impact results. Table 1: Proven interventions targeting the major causes of newborn deaths Preterm birth Antenatal corticosteroids, preterm labor management Essential newborn care + Kangaroo mother care Birth complications (and intrapartum stillbirths) Antenatal corticosteroids, preterm labor management Essential newborn care + Kangaroo mother care Neonatal infections Essential newborn care especially early and exclusive breastfeeding, handwashing, chlorhexidine where appropriate Case management of neonatal sepsis with antibiotics 2. RESEARCH A. EVIDENCE-BASED NEWBORN CARE IN GHANA: LESSONS FROM THE NAVRONGO HEALTH RESEARCH CENTRE - Dr. Cheryl Moyer (Director - GlobalREACH programme, University of Michigan) shared results from the Stillbirth and Neonatal Death Study (SANDS), on behalf of the Research Team. Key findings Stillbirth rate: 23/1000, Early neonatal mortality rate: 16/1000, Neonatal mortality rate: 24/1000(14) Grandmothers are influential for infant feeding and other newborn care practices(15) Community members know recommendations for breastfeeding and clean delivery, but they do not always follow it(15, 16) Maltreatment in facilities during labour and delivery is a barrier for care seeking(17, 18) The community prefers traditional providers because they have a better understanding and appreciation for local customs(19) 25

26 SANDS highlighted the gaps in understanding the important role of social and cultural factors that affect neonatal outcomes along the continuum of care. New Project at the Navrongo Research Center PREMAND (Preventing maternal and neonatal deaths in Ghana) is a USAID-Ghanafunded project that builds upon lessons from SANDS. It will focus on using social autopsy and spatial visualization to foster locally relevant solutions for maternal and neonatal deaths and near-misses. No intervention will reach its maximum potential for success without acknowledging and accounting for regional, tribal, community, and familial differences in attitudes, beliefs, norms, and cultural traditions surrounding pregnancy, delivery, and newborn care Dr. Cheryl Moyer B. GHANA EMBRACE IMPLEMENTATION RESEARCH: Dr. Abraham Hodgson, Director of Reasearch, Research Unit, Ghana Health Service (Member of Research Team) In 2012, the Japanese government in conjunction with Ghana government launched the Ghana EMBRACE Implementation Research (20) at three study sites: Health and Demographic Surveillance System sites at Navrongo, Kintampo and Dodowa. EMBRACE simply means Ensure Mothers and Babies Regular Access to Care. Sixty-seven percent (67%) of neonatal deaths can be prevented if the Maternal Newborn and Child Health (MNCH) continuum of care process is completed. On the contrary, the EMBRACE team prior to the study, identified a lot of breaks along the continuum of care (CoC) for mothers and newborns, with only 8% of women completing the CoC process (Figure 4). The CoC includes pre pregnancy care, at least four antenatal visits, delivery assisted by skilled birth attendants, postnatal care within 48 hours, at 7 days and 6 weeks. The aim of EMBRACE project: 1. To develop a pathway to create feasible and sustainable packages of interventions to improve MNCH outcomes and to test such packages in rural settings. 2. To disseminate the findings and lessons learnt to the wider global health community. 26

27 Figure 4: Coverage of continuum of care related service indicators at the three study sites Preliminary findings between October and December 2014 Very high potential of adoptability with over 5000 CoC cards distributed Sharp increase in the number of women staying in the facility for 24 hours, and received postnatal care (PNC) within 48 hours of delivery Comment from a mother: When I properly follow the CoC card and do good behavior, I can get a gold star. I want to get all gold stars 3. QUALITY IMPROVEMENT (QI) INITIATIVES IN THE BRONG-AHAFO REGION: Dr. Paulina Appiah, Newborn focal person for Brong-Ahafo Region, Paediatrician, Sunyani Municipal Hospital) Under the MEBCI project sponsored by PATH, a Rapid health facility assessment was conducted in 2014 to serve as a baseline to monitor and evaluate project outcomes. Achievements Currently, three newborn care areas have been created in three District hospitals, adding on to the existing 7 within the Region 138 (27%) providers have received training in HBB, ECEB and IPC (see details in Table 3). The facilities have also institutionalized practice sessions and drills in HBB and ECEB. Facilities have provided sterile cot sheets for deliveries. 27

28 Challenges Despite these achievements there have been a few challenges such as late referrals from Health centers and Maternity homes. Unfortunately, these facilities are not included in the MEBCI training. Difficulty in getting drugs and supplies for newborn care eg. Vitamin K1 Poor quality of newborn data being captured and erratic flow of funds for newborn care in the region. HBB training session in Brong-Ahafo Region 4. HOME BASED POSTNATAL CARE (HBPNC) IN THE UPPER EAST REGION: Rofina Asunu, Deputy Director of Nursing services, Upper East Region In 2012 UNICEF supported the region to roll out newborn care activities with particular focus on HBPNC. Frontline staff mostly Community Health Officers and Community Health Nurses were trained in HBPNC. They were all provided with job aids and other logistics such as home visiting booklets and bags, thermometers, spring weighing scales and many others. A Community Health Officer conducting a HBPNC visit 28

29 Challenges Inadequate transport and fuel Inconsistent addresses Lack of standard home visiting register Weather conditions especially during rainy season hamper home visits High staff attrition rates Difficulty in sustaining volunteer enthusiasm Harmful traditional beliefs and practices still persist Successes PNC registration increased from 8,400 in 2013 to 11,900 in 2015 Number of babies visited increased from 2,500 in 2013 to 9,700 in 2015 Number of sick babies treated increased from 0 in 2013 to 33 in 2015 Number of mothers counseled increased from 2,500 in 2013 to 9,600 in 2015 SESSION 2: IMPLEMENTATION OF EVIDENCE BASED INTERVENTIONS RELATED TO CARE OF PRETERM AND LOW BIRTH WEIGHT NEWBORN WITHIN THE RMNCH STRATEGY KEY MESSAGES FROM SPEAKERS ANTEPARTUM AND INTRAPARTUM CARE Dr. Michael Yeboah, Senior Obstetrician Gynaecologist, KATH, Kumasi Key points The obstetric care of the preterm fetus focuses on the prevention or delay of a preterm birth. Of key importance is the identification of predisposing factors and their elimination. Prediction of the risk of a preterm birth is possible, and those with significant risk can be managed with cerclage or progesterone(21, 22). In cases of threatened preterm birth, an attempt at aborting uterine contractions is essential so that fetal health may be enhanced using steroids with or without magnesium sulphate(23, 24). Delivery of preterm babies below 34 weeks is safer without vacuum extraction and safer with caesarean section if it is a breech presentation(23). 29

30 Corticosteroids: With 95% universal coverage, 41% of preterm deaths would be prevented by 2025 and 444,000 babies would be saved(6). ESSENTIAL AND EXTRA CARE FOR THE PRETERM AND LOW BIRTH WEIGHT NEWBORN Dr. Mame Yaa Nyarko, Senior Specialist Paediatrician, Princess Marie Louis Hospital, Accra More than one in 10 of all babies born around the world are preterm. All newborns are vulnerable, but preterm babies are much more vulnerable. According to the Born Too Soon report(3), with simple measures such as providing warmth, preventing infections by hand washing, appropriate feeding including exclusive breastfeeding and support for feeding, many preventable deaths among preterm and LBW babies can be avoided. Kangaroo Mother Care though a simple intervention, is crucial for improving preterm and low birth weight (LBW) outcomes and is also cost saving. Training health care providers to identify danger signs early and refer to the next level for appropriate management will help reduce long term complications among preterm and LBW babies. LONG TERM CARE AND FOLLOW UP OF THE PRETERM BABY WITH COMPLICATIONS Dr. Bola Ozoya, Specialist Paediatrician, Korlebu Teaching Hospital (KBTH), Accra A planned follow up programme is an integral part of the care of every preterm and LBW baby after discharge from hospital. The objectives of the follow up programme (25, 26) are to Conduct a comprehensive evaluation of the preterm baby and recognise the need for early intervention Identify and treat medical complications early Identify neuro-developmental disability early and refer to appropriate specialists Provide parental counseling and support An effective follow up programme needs a multidisciplinary team of health care providers (Doctors, Public health nurses, Nutritionists, Physiotherapists etc) with linkages to support groups such as KMC support groups and breastfeeding support groups within the community(25, 26). 30

31 follow up Dr. Bola Ozoya, first from the right, counseling parents of a preterm baby at Every premature baby needs long term follow up care but this care must be individualized. Babies born too soon and too small certainly need our help to live to enable them attain their full potential and enjoy their lives and make a positive contribution to society. Dr. Bola Ozoya PSYCHOSOCIAL SUPPORT FOR MOTHERS AND FAMILIES OF PRETERM AND LBW NEWBORNS - Dr. Kwabena Kusi Mensah, Senior Resident, Department of Psychiatry-KATH Studies have shown that continuous untreated depression is a high risk factor for preterm birth(27, 28). When an infant is born prematurely a mother may not be as emotionally or physiologically prepared for childbirth as she would have been had the pregnancy gone to term. The premature birth may represent an interruption in the natural process of the mother's bonding with her child and could be more egothreatening to mothers. Research has shown that in the first week after birth parents of preterm infants cried more, felt more helpless, were more worried about future pregnancies and their ability to cope, and wanted to talk to hospital staff a lot more(29). Psychosocial support should start early in pregnancy and must be provided at every stage of the continuum of care programme. Providing information, answering questions from the family and providing avenues where specific challenges can be addressed can provide relief to parents and boost their confidence(29). Parents will then be empowered to provide optimal care, love and support for their preterm babies, and ensure that they survive and thrive. Sometimes a kind word to a distressed soul does more good for more people than all the medicine in the world. Dr. Kwabena Kusi Mensah 31

32 SESSION 3: UNDERSTANDING KANGAROO MOTHER CARE: HISTORY, DEFINITION, EVIDENCE AND PROGRAMMATIC APPROACHES KEY MESSAGES FROM SPEAKERS The session was chaired by Dr. Gyikua Plange-Rhule GLOBAL HISTORY AND CONTEXT OF KMC - Dr. Goldy Mazia, Senior Newborn Health Advisor, PATH, Washington Kangaroo Mother Care (KMC) was initiated by Dr. Edgar Rey Sanabria in Bogota- Colombia in 1978 at a time when there was a shortage of incubators in his hospital. KMC has become a more humanized and less costly modality of care in both developed and developing countries(30). It has been taught globally by the Colombian Kangaroo Foundation for the past 25 years and also by the Medical Research Council Unit for Maternal and Infant Health Care Strategies, University of Pretoria, South Africa. WHO, USAID, UNICEF, Save the Children, and countries such as South Africa are strongly contributing to dissemination and scale-up. In 1981, WHO started calling attention to the KMC programme in Bogota. In 1996, the first international conference on KMC was held in Italy where the International KMC Network was formed. Since then 9 additional international meetings have taken place to share research and implementation experiences. WHO endorsed KMC in 2003 confirming that KMC is more than an alternative to incubator care, and has shown to be effective for thermal control, breastfeeding and bonding in all newborn infants(31). In May 2012, WHO published the Born Too Soon report that strongly recommended KMC as one of the most effective ways to save preterm babies. The report cited a systematic review of several randomized controlled trials that showed a significant reduction in neonatal mortality by 51% compared to incubator care among babies weighing less than 2000g(2, 3, 8, 9). More recent evidence from a Cochrane Review in 2014 concluded that continuous KMC reduced the risk of death among preterm babies by 40% at discharge or 40 weeks corrected age(32). In October 2013, newborn experts and stakeholders met in Istanbul, Turkey to discuss how to accelerate KMC implementation globally. Based on available evidence, the consensus reached which was also backed by WHO stated that: 32

33 KMC should be adopted and accelerated as STANDARD OF CARE as an essential intervention for preterm newborns. We have defined success as the increased and sustained action to achieve 50% coverage of KMC for premature babies at the national and global levels by 2020 as part of an integrated reproductive, maternal, newborn, and child health package(5). CURRENT KMC LANDSCAPE: DEFINITION AND EVIDENCE Dr. Naana Wireko-Brobby, Specialist Paediatrician, KATH Kangaroo Mother Care is not only skin to skin contact between a mother and baby. KMC has three main components: Kangaroo position (placing a baby in skin to skin contact in between the mother s breast), Kangaroo nutrition (exclusive breastfeeding and feeding expressed breastmilk) and Kangaroo follow up (early discharge and follow up)(31, 33). Preliminary evidence from studies in Colombia has shown better brain function among adolescents born preterm that were managed with KMC(34). A systematic review demonstrated a reduction in nosocomial infections and hospital stay, and an increase in weight gain and exclusive breastfeeding among LBW newborns receiving KMC(32). Study in Ghana reported that 70% of mothers said KMC was easy to practice, 72% said they would recommend KMC to other mothers, 96% said it was beneficial to their babies and 99.5% said continued to practice KMC at home(35). Key definitions(31, 33) Skin to skin contact Skin to skin contact is recommended for every baby. It is simply placing a baby in skin to skin contact with the mother immediately after delivery for a least one hour to ensure warmth and early initiation of breastfeeding. It is also recommended for transporting sick newborns to a health facility. Kangaroo Mother Care (KMC) KMC is the early, prolonged, and continuous skin to skin contact between mother (or substitute) and baby, both in hospital and after early discharge, with support for positioning, feeding (ideally exclusive breastfeeding), prevention and management of infections and follow up care. The duration for continuous KMC should be at least 20 hours. 33

34 Intermittent KMC Intermittent KMC refers to recurrent but not continuous skin to skin contact between mother and baby for few hours in the day. It is practiced when the mother is unable or unwilling to practice continuous KMC. Post discharge KMC Post discharge KMC is when the mother and baby are discharged from the facility because the baby is feeding well, growing and stable, and the mother or caregiver demonstrates competency in caring for the baby on her own. KMC is continued at home with an agreedupon schedule for follow up visits at the hospital, outreach clinic or at home to monitor the health of the baby. PROGRAMMATIC APPROACHES TO KMC INTRODUCTION AND EXPANSION Dr. Anne-Marie Bergh, Senior Research Officer, Medical Research Council Unit for Maternal and Infant Health Care Strategies, University of Pretoria, South Africa KMC introduction in Ghana KMC was introduced in Ghana in 2007 in Kumasi, and in 2008 KBTH also started implementing KMC. UNICEF in 2008, introduced KMC in four regions in Ghana. In the same year, four doctors and nurses from KBTH and KATH were sponsored by Saving Newborn Lives/Save the Children to attend a KMC orientation workshop in South Africa. They returned as champions to establish their facilities as centres of excellence. Despite the fact that KMC was introduced in Ghana eight years ago, KMC is still not well known. The reasons could have been due to lack of country ownership. Recommendations following implementation were not taken up, there were no long-term plans for supportive supervision and follow-up, drivers retired or left the service, changes in leadership at different levels of the health system, and it is not clear how the final regional reports were disseminated or used. All the same, KATH and KBTH have continued to provide KMC services to date, and two additional facilities in Kumasi have also started implementing KMC. Approaches to the introduction, expansion and scale-up of KMC There are four main approaches with two focus areas: 34

35 Pathways to implementation 1. Big bang or staggered approach (Table 4) 2. Pedestal approach Tools for programme planning, execution and evaluation 3. Stages of change approach 4. Systems approach Knowledge of KMC does not imply there is a policy. A policy or the existence of KMC guidelines does not imply that it is implemented. Implementation of KMC does not guarantee sustainability. Anne-Marie Bergh SESSION 4: KMC EXPERIENCES AND IMPLEMENTATION IN GHANA The session was chaired by Dr. Kwasi Yeboah-Awudzi, Public Health Physician & Director - Kumasi Metropolitan Health Directorate. PERSPECTIVES FROM KORLEBU TEACHING HOSPITAL (KBTH), ACCRA by Dr. Joan Woode, Specialist Paediatrician, KBTH History In 2008, one Paediatrician and nurse attended a KMC orientation training in South Africa sponsored by Save the Children KMC unit established in April 2008 Began as a 4-bed unit, expanded into an 8 bed KMC unit Initiative was driven by a doctor, the Head of the Neonatal Intensive Care Unit (NICU) There was buy-in from the Head of Department of Child Health and matron-in-charge of NICU at the time and her deputy Preparation towards implementation Bottom-up approach KMC guidelines were developed Space identified at the NICU Basic equipment such as weighing scales and thermometers were obtained from the NICU 35

36 The nurse-in-charge surveyed the hospital from department to department and got beds, mattresses and chairs for the KMC unit. Bathing and toilet facilities available There was no initial funding A few staff were transferred from the NICU to man the KMC unit Implementation of KMC All babies less than 2.0kg and who are stable are eligible for KMC. There are three methods of KMC practice at KBTH. Mothers use a special wrap to tie the baby in KMC position. In-house continuous KMC: Mothers are admitted to the KMC unit for continuous KMC Daytime KMC: Due to lack of space and beds, mothers practice KMC continuously until evening, go home and return the following morning to continue KMC. Intermittent KMC: KMC is done for several minutes or few hours at the NICU Staffing: There are two dedicated nurses at the KMC unit responsible for the care of the mother and baby. Doctors review the patients on a daily basis. Discharge and follow up: Patients are discharged based on discharge criteria and enrolled into the follow up programme. Occurs at the NICU clinic, held once weekly Special arrangements are made for babies discharged home small <1.2kg early review within a week on NICU Ophthalmology review and hearing assessment are done for all preterm babies. Those with complications are referred for specialist care Challenges High case load: preterm babies account for nearly 50% of admissions and one out of five are very low birth weight Lack of space (only 25% of babies <1.5kg do in-house continuous KMC) Reluctance of mothers and families to practice day time continuous KMC due to the stress of going in and out of hospital. Successes Between 2009 and 2014, 795 babies <1.5kg were admitted for continuous KMC approximately 133 per year 36

37 Case fatality rate of 0.02%, more than 99% survived Number of brought-in-dead preterms significantly reduced after KMC implementation PERSPECTIVES FROM KOMFO ANOKYE TEACHING HOSPITAL (KATH), KUMASI by Mrs. Christiana Acquah, Senior Nursing Officer, KATH. History KMC started in 2007 following a Neonatal emergency nursing training programme which included a full day workshop on KMC for doctors, nurses and midwives in Kumasi. The KMC workshop was facilitated by Karen Davy, a nurse practitioner from South Africa. Programme was sponsored by the Millennium Cities Initiative (MCI), MASHAV (Israeli Centre for International Cooperation, Ministry of Foreign Affairs) and Soroka Medical Center, Israel, in collaboration with the Kumasi Metropolitan Health Directorate and KATH. The initiative at KATH was driven by the nurse manager for the Mother and Baby Unit (MBU) and a Paediatrician at the unit. Preparation towards implementation No available space for a KMC unit No funding Had to reorganise newborn care services at the MBU which has three wards. Designated one ward solely for preterm and LBW newborns Staffing: Pulled dedicated staff from within the MBU and assigned them to the LBW unit to run a 24 hour shift (2 nurses and 1 doctor per shift) Developed guidelines for KMC Implementation of KMC Moved all preterm and LBW newborns to the LBW unit in Bed capacity, but with an average daily ward state of 40 babies The LBW unit provides conventional care and intermittent KMC Intermittent KMC is practiced for 1 2 hours twice a day (morning and afternoon) Mothers use their own cloth to tie the baby in KMC position Mothers sit in the corridor of the unit and practice KMC 37

38 Initially preterm LBW babies weighing 1.5 kg and stable were transferred to Kumasi South and Suntreso Government Hospitals for continuous KMC. But since 2012, the transfers have stopped because the two facilities now admit many cases from their facility with a lot of referrals. Discharge and follow up: LBW newborns weighing < 1.5 kg are followed up on alternate days at MBU LBW newborns weighing > 1.5 kg come for weekly visits until they are between 2.5 kg and 3.0 kg. Follow up continues at the specialist clinic and care is individualised Challenges The set-up of the unit does not allow for continuous KMC Continuous increase in the number of admissions out numbering the unit s bed capacity for mothers and babieshigh case load with a nurse-patient ratio of 1:20 Mothers get tired easily I would love to do kangaroo more often but I can t, I get tired of sitting. Comment by a mother Bathing and toilet facilities not available Successes It allows my baby to sleep well and feed more. Comment by a mother Paediatricians from KATH provided technical support for the initial training, set up and running of the MBUs at Kumasi South and Suntreso Government hospitals. Currently the units are fully functional with three permanent paediatricians and nursing staff. Trained over 500 nurses and midwives in KMC with support from Millennium Cities Initiative and Women s Health to Wealth. KATH management has finally and officially allocated more space in the hospital to the MBU and part of this space will be used as a KMC ward. 38

39 PERSPECTIVES FROM A REGIONAL/DISTRICT HOSPITAL, KUMASI by Dr. Rita Fosu-Yeboah, Specialist Paediatrician, Kumasi South Hospital, Kumasi and Abenaa Akuamoah-Boateng, former West Africa Director for MCI, CEO of Women s Health to Wealth. Every facility that delivers babies should have a dedicated space for newborn care and I think it is unethical if you don t have anything in place to take care of Newborn emergencies and Kanagaroo Mother Care. Abenaa Akuamoah-Boateng History KMC started in 2008 at the Regional hospital Kumasi South Hospital (KSH) and in 2009 at one of the District Hospitals Suntreso Government Hospital (SGH) all in Kumasi. This was after the Kumasi Neonatal emergency nursing care training in A 10 member KMC steering committee was set up to champion KMC. Members were nurse-in charges from various facilities within the Kumasi metropolis. MASHAV Israel built an MBU at SGH, and renovated a section of a Maternity block at KSH for an MBU, between 2008 and The objective was to help decongest the MBU at KATH and provide a unit for continuous KMC. Preparing to implement Series of meetings between the Ashanti Regional Health Directorate, Kumasi Metropolitan Health Directorate and KATH to discuss operational and technical issues of the collaboration Guidelines and protocols were developed by Paediatricians at KATH and Soroka Medical Center, Israel. Staffing: Nursing staff from the two hospitals were assigned to the MBU, and Paediatricians and residents from KATH reviewed the patients on a daily basis Basic equipments such as ventilation bags were provided my MASHAV and MCI, and hospital supplies were procured by the facilities. Currently Women s Health to Wealth is supporting the facilities with newborn care training and equipment. Implementation of KMC The MBU has three wards a postnatal ward for mothers and their sick newborns, a special care ward and a Kangaroo Mother Care ward. 39

40 KSH has 16 beds and 20 cots, SGH has 15 beds and 12 cots KMC is practiced continuously Discharge and Follow up: LBW babies come for alternate day visits until they weigh 2.0 kg, and then weekly follow up visits at the MBU until they attain a weight of kg. They are referred to the Child Welfare Clinic to continue the follow up. Challenges Low awareness about the practice of KMC among mothers Lack of catering services in facilities and a dedicated eating place Inadequate laboratory services and inadequate supply of newborn drug formulations Poor management of pain especially among caesarean section mothers Lack of family support on discharge Lost to follow-up on discharge Rotation policy and transfer of nurses has led to a massive decrease in the number of trained nurses only one of the initial staff trained in 2007 is still on the MBU Increased number of admissions with increasing LBW babies Successes KMC mothers have become peer educators on the ward KSH has served as a KMC training centre for midwives and nurses from Ashanti and Brong-Ahafo region Over 80% of all LBW newborns admitted received KMC 40

41 Lessons A good incentive for health care providers that has worked is consciously and regularly recognizing, acknowledging and appreciating every team member Providing facilitative and supportive supervision and timely feedback needed for action at facility level is vital for quality newborn care A PARENT S EXPERIENCE WITH KMC by Mr. & Mrs. Sackey I am a mother from KBTH KMC unit. KMC has helped us a lot. Infact we have learnt a lot and KMC has boost our confidence to take care of our baby, a 0.9 kg baby. The nurses and doctors were all available to help us Mrs. Sackey (mother) you can imagine, we leave our daughter at the NICU and go home. I could not sleep very well. When we were told our baby was ready for full KMC we were so happy because we knew that our baby will soon be discharged from hospital. And within one week we saw that her weight gain had improved. So what you see today is the product of KMC a healthy and good looking baby girl. Mr. Sackey (Father) KEY OUTCOMES 1. Awareness about the care of preterm/lbw newborns and KMC created. 2. Executive forum broadcasted on National television and other television stations as a major news item. 3. Call for support and investment in the preterm and LBW newborn successfully done 4. Progress of implementation of the Newborn Health Strategy between 2014 and 2015 reviewed 41