Development of A Referral System Using Kangaroo Mother Care (KMC) Intervention for Low Birth Weight Babies

Transcription

1 Development of A Referral System Using Kangaroo Mother Care (KMC) Intervention for Low Birth Weight Babies PEER-USAID FACULTY OF PUBLIC HEALTH UNIVERSITAS INDONESIA HADI PRATOMO AND TEAM AIPI MEETING JAKARTA, 18 MAY 2017

2 Background KMC is one of proven low cost methods in improving the condition of low birth weight babies. Babies with KMC had lower lengths of hospitalization, higher proportion who were exclusively breastfed, decrease in incubator use, and lower antibiotic use (Broughton, 2013). It reduces the need for expensive equipment such as incubators and also highly skilled medical personnel à can be applied in low-resource settings (Cattaneo, 1998). Implementation of KMC still low, even in low resources setting countries. Lack of knowledge and confidence in KMC method among health personnels à prevent its uptake in health facilities (Dalal, 2014; Chan, 2016).

3 KMC Definition: A universally available and biologically sound method of care for all newborns but in particular for premature babies with 3 components: Skin-to-skin contact, Exclusive breastfeeding, and Support to mother-infant dyad m

4 Integrated packages to reduce newborn deaths Clinical care Skilled obstetric and immediate newborn care (hygiene, warmth, breastfeeding) & resuscitation Emergency obstetric care to manage complications such as obstructed labour and hemorrhage Antibiotics for preterm rupture of membranes # Corticosteroids for preterm labour # Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies including Kangaroo Mother Care Outreach services Family-community Folic acid # Family Planning Antenatal Focused 4-visit antenatal package including tetanus immunisation, detection & management of syphilis, other infections, 8 % pre-eclampsia, etc Malaria (6 intermittent 9%) presumptive therapy* reduction of NMR Detection and treatment of bacteriuria # Counseling and preparation for newborn care and breastfeeding, emergency preparedness Intrapartum 27 % (18 35%) reduction of NMR Clean delivery by traditional birth attendant (if no skilled attendant is available) Simple early newborn care Postnatal Postnatal care to support healthy practices Early detection and referral of complications 29 % (17 39%) reduction of NMR Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care Extra care of low birth weight babies Case management for pneumonia 10-30% NMR reduction 15-32% NMR reduction Pre- pregnancy Pregnancy Birth Neonatal period Infancy 4 # For health systems with higher coverage and capacity

5 KMC is not the only public health intervention to have slow uptake, but it is time to "bend the curve" for KMC 75 Skilled birth attendancemeasured starting HepB Vaccine from starting from ARV's measured approval in NNRTI Initiative in Safe Motherhood 1987 measured 1 starting from 1981 ORS measured starting 50 approval in from Bangladesh rollout in Exclusive breastfeeding measured starting from Baby-Friendly 25 Hospital Initiative in 0 % coverage of health intervention in low and middle income countries Coverage (%) I t Introduction d ti fof intervention Years from availability of intervention KMC (illustrative) Originally introduced in Colombia in Skilled birth attendance and breastfeeding are ancient intervention. Introduction of SBA is measured from 1987, when the Safe Motherhood Initiative was launched. Exclusive breastfeeding measured from 1992, when Baby- Friendly Hospital Initiative was launched. 2. Average of 49 countries reporting ORS rates , weighted by population under 15 years old 4. NRTIs were first approved in NNRTIs were approved in 1997 while PIs were approved in Source: WHO/UNICEF; World Bank; Mahy et al., 2010); BCG analysis 2012 Bill & Melinda Gates Foundation 14

6 Goal and Objectives Goal : To improve the survival of the LBWI (Low Birth Weight Infants) using the KMC (Kangaroo Mother Care) Objectives : To address LBWI problems, especially those weighing grams To improve its referral system using KMC as a means of transporting from hospital to community To promote the sustainability of the KMC for increasing its survival as well as reduction of both mortality and morbidity of the newborn.

7 Methods The study will consist of qualitative (formative research) and quantitative approaches. The purposes of qualitative research: to obtain an effective, acceptable and sustainable intervention. To fine tune the proposed intervention adjusted to the existing condition. A quantitative study will follow.

8 Purpose of study: The purposes of quantitative study (before and after intervention) : To obtain and compare baseline and endlines situation regarding newborn outcomes. To compare outcomes in the two district hospitals (preferably, hospitals within EMAS project in West Java will be selected) INTERVENTION: The intervention will consist : training and refresher training on breastfeeding and KMC practices, including KMC as the means of transporting the baby. The target : health personnel at hospital and community levels, as well as cadres, the mothers and families.

9 Population and Sample Primary target population à families with LBWI born in hospital setting (over a period of 6 months) Location à North Jakarta and Karawang District, West Java STUDY IMPLENTATION PLAN:

10 Year-1 Year-2 Year-3 FORMATIVE RESEARCH BASELINE ASSESSMENTS INTERVENTION 3 months + Supervision 1 month IMPLEMENTATIO N & FOLLOW UP ENDLINE ASSESSMENTS FINAL RESULTS Recruitment of sample Recruitment of sample 6 months retrospective + 6 months prospective Qualitative study with respondents: DHO Hospital management Pediatrician, midwives and nurses at hospitals GPs, midwives and nurses at 1st level health facilities Quantitative Study with study population: 220 Infants with birthweight < 2,200 gram who were born or admitted to the study-hospitals within 6 months prior to commencement of baseline data collection Hospital data on : Number of staff trained and oriented on PMK services Supplies an dequipment for caring LBWI and PMK services Implementation study with study population: 70 Infants (subset of 220 infants in quantitative study assessment) with birth-weight < 2,200 gram who were born or admitted to the study-hospitals will be follow-up at home maximum 1 months or graduate. Quantitative study with study population: 220 Infants with birth-weight <2,200 gram who were born or admitted to the study-hospitals after completion of PMK and PMK Referral Training for hospitals and 1 st level health providers. Qualitative study with respondents: Pediatrician, midwives and nurses at hospitals GPs, midwives and nurses at 1st level health facilities and community level

11 Conceptual Framework

12 Conceptual Framework Input Process Output Outcome Baseline Health Personnel (KAP, Training) Infrastructure: Policy (Hospital and DHO) Human Resources (Hospital and DHO) Equipment (Hospital) Recording and Reporting Training modules (KMC and Lactation Hospital willing to update/modify its policy on KMC referral (based on developed model) Health personnel with adequate knowledge Health personnel able to provide counseling on KMC to mother with LBW babies Advocacy Meeting to update policy to support KMC and referral Draft of policy change or SOP Modified and updated module Competency of health personnel in: KMC Lactation Referral Policy updated/in place/available Quality and quantity(functioning) of supplies: Room Cost HR Equipment

13 Input Process Output Outcome Health indicators: Neonatal Health Birth weight Significant weight gain Infant mortality Survival improved Morbidity Morbidity decreased % baby with complication % baby treated in NICU % baby treated with Incubator % Baby treated with Infant warmer Record of temperature KMC Practice How many KMC intermittent and continue Coverage of KMC Practiced by premature babies Data on KMC baby based on weight How many in born and referral with KMC Start of KMC (in days or age) Lactation practice Breastfeeding after discharge Counseling

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15 BASELINE STUDY 1. To obtain information on the quality of KMC to baby with LBW prior intervention 2. To obtain information on the outcome of baby with KMC prior intervention

16 Study Design 1. Mother and baby data Source: medical record extracted into questionnaire Target: 220 babies in each hospital Inclusion criteria: Baby with birth weight <2200 gram Exclusion criteria: baby with APGAR score < 3, baby treated in NICU, medical record missing 2. Health Personnel KAP Survey Target: health personnel in hospital and community (Puskesmas) 3. Infrastructure Survey Using checklistto identify infrastructure for KMC

17 Preliminary Findings from Baseline

18 Summary of Data Collection Activity Survey KAP (Knowledge, Attitude, Practice) Tenaga kesehatan mengisi kuesioner KAP Source of Data Dinkes Karawang (n = 150) Ka PKM (50 org), Dokter PKM (50 org), Bikor (50 org) RSUD Karawang (n=64) Perinatologi (22), Bersalin (13), Rawat Gabung (26), Tumbang dan ANC (3) Sudinkes Jakarta Utara (n = 49) Bidan PJ RB (10), Bidan IBI (6), BPM (12), KPLDH (14), Bidan Koordinator (2), Staff Sudinkes (5) Pengumpulan data rekam medis Peng-input-an register di RS (Juni-Des 2015) RSUD Koja (n =65) Perinatologi (29), Bersalin (15), Rawat Gabung (21) RSUD Karawang : 193 sampel RSUD Koja : 111 sampel RSUD Karawang Register Perinatologi, Register Ruang Bersalin RSUD Koja Register Perinatologi, Register Ruang Bersalin, Register Rawat Gabung

19 Baby recruitment RSUD Karawang RSUD Koja Total persalinan Juni Des 2015 N = 2559 Total persalinan Juni Des 2015 N = 3041 Bayi dengan berat lahir < 2200 gram N = 345 Bayi dengan berat lahir < 2200 gram N = 287 Sortir berdasarkan kriteria insklusi dan eksklusi Sortir berdasarkan kriteria insklusi dan eksklusi Sampel N = 193 Berat lahir gram, n = gram, n= gram, n= 78 Berat lahir gram, n = gram, n = gram, n= 43 Sampel N = 111

20 Medical Record Baseline Results Tabel 1. Characteristics of baby RSUD Karawang Neonatal n = 111 Mean Med characteristics (%) (Std dev) (min-maks) Infant Sex Male 94 (48,7) 42 (37,8) RSUD Koja n=193 (%) Mean (Std dev) Med (min-maks) Female 98 (50,8) 68 (61,3) No record 1 (0,5) 1 (0,9) Birth at admission in perinatal ward (grams) 1867,20 (276,11) 1945 ( ) < (0) 1 (0,9) (13,5) 8 (7,2) (46,1) 59 (53,2) (40,4) 43 (38,7) 1856,26 (277,63) 1900 ( )

21 Characteristic based on complications Hipotermia Infeksi Neonatal Hipoglikemia Jaundice Anemia Sepsis Pneumonia Asfiksia HMD/RDS Apnea RSUD Karawang RSUD Koja

22 Treatment received in hospital KARAWANG HOSPITAL KOJA HOSPITAL Incubator KMC Incubator and KMC

23 Implementation of KMC in hospital Policy on KMC Baby with KMC RSUD Karawang No SOP on KMC (not specific on the eligibility criteria) 24 babies (22 in born) à source: register in 7 months (Jun-Dec 2015) 66 babies à source: medical record RSUD Koja SOP was made (and legalized through SK of director) after baseline conducted, and suggestion to include KMC clothes in BPJS package 42 babies (14 in born) à source: SPM book in 7 months (Jun-Dec 2015) 39 babies à source: medical record Average age of KMC initiation 8-9 days days Average of hospitalization days 9 days 14 days Discharge without permission 62,2% 8,1%

24 Characteristics of baby with KMC RSUD Karawang (n = 66) RSUD Koja (n = 39) Age of mother < 20 years 6 (9.8) 7 (25.9) years 43 (70.5) 15 (55.6) > 35 years 12 (19.7) 5 (18.5) Parity < 3 45 (73.8) 21 (77.8) Ø3 16 (26.2) 5 (18.5) Referral status Referral baby 2 (3.03) 10 (25.6) In born baby 64 (96.7) 29 (74.4)

25 Characteristics of baby with KMC (cont ) BW/BW at admission (gram) RSUD Karawang (n = 66) RSUD Koja (n = 39) N (%) N (%) (19.7) 7 (17.9) (45.5) 30 (76.9) (34.8) 2 (5.1) Gestational age < 37 week 53 (89.8) 22 (91.7) week 6 (10.2) 2 (8.3) Baby Weight Changes During Treatment Increase 18 (34.0) 22 (62.9) Decrease 35 (66.0) 11 (31.4) No changes 0 (0) 2 (5.7)

26 Birth Weight Changes of Baby with KMC RSUD Karawang RSUD Koja Increase of birth weight 18 (34%) 22 (62,9 %) Mean (Std.Dev) 134,7 (112,8) 250,5 (274,1) Med (Min-Maks) 67,5 (5-330) 175 ( ) Decrease of birth weight 35 (66%) 11 (31,4%) Mean (Std.Dev) -119 (79,5) -105,4 (113,1) Med (Min-Maks) -105 (-5 sd 310) -70 (-10 sd -380) No changes 0 (0) 2 (5,7%)

27 Health Personnel KAP Survey

28 Room Number of respondents for KAP Survey RSUD Karawang RSUD Koja Perinatology Nurse 8 29 Midwife 14 0 Perinatology Total Delivery ward Midwife (total) Rooming in Nurse 2 9 Midwife Rooming in Total ANC and growth Clinic Nurse 2 - Midwife 1 - ANC Clinic Total 3 -

29 Score on Knowledge and Benefit of KMC Knowledge Benefit Average Median Min-Max Average Median Min-Max RSUD Karawang (n=64) Total Perinatology (n=22) Delivery ward (n=13) Rooming in (n=26) ANC (n=3) RSUD Koja (n= 65) Avera ge Knowledge Benefit Median Min-Max Average Median Min-Max Total Perinatology(n=29) Delivery (VK) (n=15) Rooming in (n=21)

30 Activities on January May Preparation for training in KMC for Karawang & Koja Hospital 2. Dissemination of Baseline Result to MoH and other stakeholders (Karawang DHO, Koja hospital, WHO, UNICEF, Professional Organization) 3. Development of community KMC Training modules 4. KMC Training for 2 hospitals 5. Training of Trainer in Karawang and Koja Hospital 6. Supportive supervision at Koja & Karawang Hospital from Sardjito Hospital Jogyakarta 7. KMC Training for community health personnel in North Jakarta (Koja) area 8. Assessment and development of KMC Media 9. Study tour for management and clinicians Sarjito and Da Nang hospitals

31 PROJECT EVENTS 20 events were held during January until March 2017 Participated by 673 females and 106 males Outreach and Collaboration An informal visit was made to Gunung Jati General Hospital, Cirebon, West Java (January 18, 2017). Collaboration was also made with the Indonesian Midwife Association (IMA/IBI) chapter of North Jakarta and Karawang district. On March 31, 2017 a special discussion was made in which two private companies namely PT Perina Medika Edutama and PT Sijari Emas on ICT issues of referral of maternal and newborn emergencies.

32 Technical Research Presentation Technical presentation was made on January 17, 2017 in which the PEER KMC research team organized dissemination of KMC baseline to stakeholders namely Ministry of Health (Director of Family Health). Team also presented project s technical presentation to both hospital in Karawang and Koja (January 26 in Karawang Hospital and February 2 in Koja Hospital). International KMC workshop (Trieste, Italy), November 13-16, 2016 International Meeting on Public Health, Jakarta, February 6-8, 2017 International KMC seminar, Da Nang, May 12, 2017

33 Potential Development Impact KMC Training for health personnel Our training for health personnel on KMC has been participated by more than 210 health personnel in hospital and 197 health personnel in the community in both areas (Karawang district and North Jakarta municipality) Pilot test of referral system In our activities, we tried to pilot testing of a relatively new model of referral of low birth weight infants (LBWIs) discharged from the hospitals to primary health care personnel.

34 Policy change In Koja hospital The Director and management of Koja hospital has been decided to change their Strategic Plan documents to include KMC in their annual strategic plan for hospital services. In Karawang Hospital The supports are in form of planning for additional special room for KMC and other infrastructure such as KMC clothes and involvement of Obstetric unit in implementing KMC practices since antenatal care. The hospital also formed 5 teams to be responsible in practicing KMC in the hospital, consist of pediatricians, obstetricians, nurses, midwives, and management.

35 Future Plans Finalization instruments of KMC implementation and Monitoring and Evaluation both in the hospital and community Preparation for data collection and Implementation of KMC We plan to do external and internal M&E to both hospitals in each of wards that are included in the study (i.e.: ANC clinic, Delivery, Perinatal, NICU, and Rooming-in Ward). The M&E is planned to be done 3 times during the 6-7 months data collection. Establishing a continuum of care mechanism for small infants using KMC methods as mode of transferring infant back home, and continue to practice KMC until the baby is graduated from KMC (reached weight of 2,500 gram on 40 weeks).

36 Plan for follow up to the community

37 Baby <2200 gr received KMC Baby discharged Baby at home received KMC and supervise by HC staff (n = 70 baby) Discharged of criteria: - Weight: 1800 g / return to birth weight > 1800 g - Vital signs stable - Weight increase 15 gr/kg/day for 2-3 days - Able to suck/direct breastfeeding or with cup feeding Return to HC for immunization Health Center Supervision Accompanied by HC staff Hospital staff provide information on patients to HC staff 2 nd control to hospital At home, baby continue received KMC 1 st control to hospital Refer to Type A hospital for eyes, hearing, neurology and growth screening

38 Quality Research for Quality KMC!