JOURNAL OF SCIENCE, Hue University, N 0 61, 2010

152

JOURNAL OF SCIENCE, Hue University, N 0 61, 2010 EVIDENCE FOR EFFECTIVENESS OF INTERVENTIONS IN NEWBORN CARE: HAS DISTRICT NEWBORN CARE UNIT ADDRESSED NEWBORN HEALTH PROBLEMS IN NHU THANH AND NGOC LAC HOSPITALS, THANH HOA PROVINCE, VIETNAM? SUMMARY Nguyen Van Hai Save the Children Introduction: The Vietnamese health care system faces many challenges in ensuring the survival of newborns with over 20,000 newborns still dying each year. The hierarchical health system is not able to provide quality newborn care services. For example, district hospitals and commune health centers are poorly equipped and have a lack of staff with adequate training in essential newborn care, and management of newborn complications. Household-level newborn care is provided through village health workers who lack standard communication materials, training, supervision and monitoring. Misconceptions about newborn care at birth and breastfeeding exist, especially in places with high rates of home births. Methods: This Operation Research (OR) study consists of a comprehensive newborn care intervention package which was introduced. The intervention included delivery care and postnatal care but more effort was focused on immediate postnatal care and management of newborn complications. The OR set four intermediate results (IRs): IR 1: Increased access and availability of newborn services and supplies; IR 2: Improved quality of newborn care at health facilities; IR 3: Enhanced community knowledge of newborn care practices and demand for newborn care services; IR 4: Promotion of an enabling policy environment for scaling up newborn care. This paper only covers facility-based interventions while other impacts will be reported at the end of the project. Results: After 1.5 years of intervention, the OR has helped to significantly reduce the neonatal mortality rate: 19.4%o (2006) to 14.4%o (2009) in Ngoc Lac, and 21.9%o (2006) to 8.5%o (2009) in Nhu Thanh. The referral rate of newborn complications and home birth rates also declined sharply in both districts. Conclusions: Neonatal deaths in Ngoc lac and Nhu Thanh districts of Thanh Hoa province can be averted with low cost interventions through the establishment of a district newborn care unit, and the health care system will benefit from having a functional district newborn care unit. Key words: neonatal death, district newborn care unit, facility-based intervention. 153

1. Introduction Vietnam is poised to achieve most, if not all, of its Millennium Development Goals. Vietnam has already met the target of reducing the under-five mortality rate to 18 per 1,000 live births by 2015. However, the Vietnamese health care system faces many challenges in ensuring the survival of newborns with over 20,000 newborn.deaths each year. Neonatal deaths account for over 70% of the infant mortality rate, and varies across 7 regions of Vietnam with the highest neonatal death rate occurring in the northern mountainous and the northern central coast regions. One of the determinants is poor access to newborn care in rural areas (geographic access, cultural barriers and quality of care), where twice as many newborns die than in urban settings. The hierarchical health system is not able to provide quality newborn care services. Both district hospitals and commune health centers are poorly equipped and staff lack adequate training in essential newborn care, and management of newborn complications such as neonatal resuscitation, thermal care, and infections. Few CHCs and district hospitals are capable of managing particular neonatal complications, and most cases are referred to higher level facilities. This often results in unnecessarily overloading provincial and central hospitals where only critical cases should be referred. Many people also often bypass health services at commune health stations and district hospitals and go directly to higher- level facilities, because they lack confidence in the competence of services provided at lower-level facilities. This may result in aggravating the condition of newborns during transportation, as they may not receive proper care for some manageable situations, such as attending to the newborn s body temperature. This situation also results in families spending more money, and increased human resources to care for the newborns in the hospital. There is a severe shortage of essential equipment for newborn care in all district hospitals. Only 21.9% of district hospitals are equipped with a set of appropriate newborn resuscitation equipment (UNFPA, 2003) while most commune health centers have no essential newborn resuscitation equipment. In fact, there is no unified neonatal care model for the provincial and district level, thus most of these facilities are facing difficulties in providing services for newborns, especially sick newborns. Consequently, there is a gap in newborn deaths caused by preventable conditions. At the household level, there are some misconceptions about newborn care at birth and breastfeeding, especially in places where the home birth rate is high. An annual report from the Thanh Hoa provincial center for reproductive health care indicates that its annual neonatal mortality rate is 4%, which is lower than other developed countries like Singapore, the Unites States and England (5%o). This means that the reported data is somehow underestimated. A baseline survey (2007) in Ngoc Lac and Nhu Thanh, Thanh Hoa indicates that the neonatal mortality rate in Ngoc Lac is 154

19.4%o, and Nhu Thanh 21.9%o. The home birth rate is 24% (Ngoc Lac) and 30% (Nhu Thanh) respectively. In short, Thanh Hoa similar to situation throughout Vietnam is facing huge challenges in addressing newborn health problems: lack of a functional newborn care system from community to district level; severe shortage of trained health workers in newborn care; absence of infrastructure, and appropriate equipment for newborn care at commune and district level; a high prevalence of home delivery; the community s knowledge of newborn care is limited, and misconceptions about newborn care at home, and lack of information about breastfeeding, especially in places where home delivery is high. 2. Methods Design: This is an operation research (OR) study with simple pre-and-post intervention comparison. However, this paper is only an abstract report from preliminary findings of the district newborn care unit within the comprehensive intervention package. Location: Thanh Hoa province is 157 km southward from Hanoi, with a natural land area of 11,106 km 2. The province possesses a diversified topography with 75% of its land are mountainous and midland area, 15% lowland and 10% coastal. It has a population of 3.7 million inhabitants living and working in 27 districts, towns and Thanh Hoa city, 636 communes and 7 ethnic groups including: Kinh, Muong, Thai, H Mong, Dao, Tho and Hoa. These ethnic groups reside mainly in mountainous and bordering districts. Nhu Thanh and Ngoc Lac districts were selected in the OR. These are mountainous districts with a total population of 226,663 people, and the total number of deliveries is nearly 3,000 per year. They have 39 communes and 474 villages. There are about 17 remote and especially disadvantaged communes. Below are key health indicators for Nhu Thanh and Ngoc Lac districts: Table 1. Key health indicators of Nhu Thanh and Ngoc Lac (2007) Source: *Reports from neonatal death screening in Thanh Hoa, March 2007 Indicators Nhu Thanh Ngoc Lac Population 85,227 141,436 Number of communes 17 22 Neonatal death rate (%o) 21.9* 19.4* Delivery in health facility (%) 70 76 Home delivery rate (%) 30 24 Number of delivery per year 1,078 1,876 155

3. Result 3.1. Results framework This OR consists of a comprehensive newborn care intervention package including delivery care and postnatal care, but more effort will be focused on immediate postnatal care and management of newborn complications. The project has set four intermediate results (IRs). IR 1: Increased access and availability of newborn services and supplies; IR 2: Improved quality of newborn care at health facilities; IR 3: Enhanced community knowledge of newborn care practices and demand for newborn care services; IR 4: Promotion of an enabling policy environment for scaling up of newborn care. The OR study will address the continuum of care from household-tohospital with interventions implemented by government staff and volunteers. The study is designed to demonstrate to policy makers, health managers, and authorities that quality newborn health care service can be provided with a small investment even in resource-poor settings. It will also show that quality services along with improved household practices will lead to improved newborn health outcomes. However, this paper will only refer to facility-based interventions (IR1 and IR2). The Results Framework is graphically shown below. Data collection: Data collection tools were designed carefully in order to capture all information about newborn care and newborn complications in two selected districts. Information collection relied on the government existing reporting system with village health workers in the community, CHC staff at the communal level and functional newborn care unit, and the district health center at the district level. However, this system was optimal because it provided designated data collectors with formatted registers and forms, which facilitated them to fill out and reconcile the data. To validate the intervention package, a Monitoring and Evaluation (M&E) Plan was designed. 156

SAVING NEWBORN LIVES (SNL) RESULTS FRAMEWORK Outputs Outcomes Impact Intermediate Result 1 Increased access to and availability of key services, equipment, and supplies for newborn health Goal: Improved newborn health and survival in Viet Nam SO: Improved use of key practices and services that protect and promote the health of newborns Intermediate Result 2 Increased quality of essential care and complication management for newborns Intermediate Result 3 Increased community- level understanding and acceptance of using healthy NBC practices Intermediate result 4 Strengthened enabling environment for newborn survival Provision of equipment for ENBC in CHCs and district hospitals Refresher training on ENBC for Pediatric Dept. of DHs Develop and distribute IEC materials on NBC Advocacy efforts to implement the scaling-up plan. Processes/Activities Set-up referral system Establish Newborn Care Unit at DH Refresher training on ENBC for midwives/ nurses at CHC, DHs Training courses on counseling, supportive supervision ToT courses on BCC for province and district trainers Roll-out BCC training courses for commune and village staff Scale-Up of OR intervention package. Develop nat. standards/ guidelines, action plan, and training manuals IEC materials availability at health facilities Service quality improvement (COPE) Inputs Operations Research to inform Scale-up Communications, Advocacy, Partnerships 157

INFORMATION FLOW AND DATA BASE SYSTEM FREQUENCY LEVEL Monthly Monthly Monthly Quarterly Obstetrics Obstetri Dept, DH cs Dept, DH Central Project Management Board (Save the Children MoH) Prov Prov Project Project Management Management Board (Provincial Health Board Department) (Provincial Health Department) General Planning Dept of DH and District Health Center Commune Health Centers NBC NBC Unit of DH Unit of DH VHW VHW VHW VHW Central Province District Commune Village Legend: Reporting to Supervision and giving feedback 158

3.2. Preliminary results The project was supposed to begin in January 2007 and finish in October, 2011. However, due to a delay in administrative procedure clearance with the local authorities and preparation for human resources (developing training manual and training of health workers at provincial, district and communal level) and purchase of essential equipment for district newborn care unit, actual service delivery began in June, 2008. The performance of district newborn care unit has actually improved health outcomes of newborns in the 2 intervention districts thanks to increased access to and availability of newborn care services. Two respective newborn care units in 2 district hospitals were established using the recommended standards in the National guideline for newborn care at different levels i.e. room space, infection control, a list of essential equipment for newborn care and integrated newborn care between the obstetric and pediatric specialty, and human resources. With a functional referral system (community to district), all newborns with complications in two districts were given care and transferred to either commune health centers (first point of contact) or the district newborn care unit for timely management and treatment. There was a big change in the number of newborn admissions to district hospital since the birth of the district newborn care unit October, 2008 (Table 2). Table 2. Situation of newborn complications at pre & post intervention periods Indicator # newborn admission to district newborn care unit Treatment outcomes Pre-intervention (2006) 159 Preliminary results (2008-2009) Ngoc Lac Nhu Thanh Ngoc Lac Nhu Thanh N/A N/A 867 215 Cured N/A N/A 767 178 Referred to higher level N/A N/A 79 32 Dead N/A N/A 13 2 Request to go home N/A N/A 34 3 Collaboration between pediatric and obstetric departments in newborn care have improved and been implemented in a systematic manner. Before intervention, most newborn health problems were handled by the obstetric department. However since then newborn care unit was established, located at the pediatric department. All deliveries suspected of difficulties had a joint consultation with obstetric and pediatric staff. If complications were predicted, the newborn health would be handled by well-trained

staff of the newborn care unit while the mother was cared by obstetric staff. If the complications became serious, the baby would be transferred to the well-equipped newborn care unit for treatment and follow-up. In addition, other supporting communications materials, e.g., brochures, booklets and posters of maternal and newborn care were provided to the district newborn care unit and obstetric department of the hospital. These materials will facilitate the hospital health workers to counsel and advice their patients or care takers about how to promote exclusive breastfeeding, how to recognize danger signs in infants, and what actions should be taken in particular clinical situations. There was a huge difference in neonatal death, referral rate and home delivery between pre-and-post intervention periods (Table 3). No 1 2 3 4 Table 3. Key indicators in newborn health status in Ngoc Lac and Nhu Thanh Key indicators Neonatal death - Ngoc Lac - Nhu Thanh Referral rate - Ngoc Lac - Nhu Thanh Home delivery - Ngoc Lac - Nhu Thanh Institution delivery - Ngoc Lac - Nhu Thanh Pre-intervention (2006) 19.4 21.9 95% (25%)* 98% (24%)* 23.9% 30% 76.1% 70% Preliminary results (2008-2009) 14.4 8.5 10.8% 14.2% 12.1% 7.7% 87.9% 92.4% After 1.5 years of intervention, the Operation research has helped to reduce significantly the neonatal mortality rate: 19.4%o (2006) to 14.4%o (2009) in Ngoc Lac, and 21.9%o (2006) to 8.5%o (2009) in Nhu Thanh. The referral rate of newborn complications and home delivery also declined sharply in both districts. The presence and operation of the district newborn care unit has brought about not only medical benefits but also non-medical benefits for local community, health care givers and managers. The district newborn care unit has helped fill the gap in the current health care delivery system. This observation is reflected in following aspects obtained from expert opinions: 160

Benefits for the health care provider Increase opportunities of investments in neonatal care and treatment Increase revenue for hospital from provision of newborn care services Improve professional skills in newborn care for health workers Regain the public s confidence in district health workers for treating difficult cases Take advantage of available human resources (took only 3 months for training) Avoid wasting human resources as there was no need to recruit new staff Benefits for the health sector Bridge linkages between the grassroots and higher levels in treatment of neonatal complications Reduce patient load of common neonatal diseases in provincial and national hospital. Other districts in the vicinity also benefit from the functioning newborn care unit. Help provide technical support for lower levels more efficiently because the district hospital is able (personnel, infrastructure and equipment) to provide Newborn care services are available for lower level. Help to improve management of all neonatal cases in the district through the information system at the newborn care unit. Create the availability of services to meet the people s need for health care. Benefits for community Place credit to hospital when seeking care Reduce non-medical costs (food, transportation, accommodation, etc ) and medical costs of bypassed patients at higher levels. Convenient for patients when seeking care in the district hospitals due to shorter distance travel between the hospital and their home. Care givers are provided with information about newborn care at home. Lives and health of the newborns are taken care because of available well-trained health workers. 161

Success story: Bravo for the Newborn Care Unit warmer! district) (Anecdote from Mrs. Quách Thị Thương in Rộc Môn village, Mậu Lân commune, Như Thanh Twenty-year old Quách Thị Thương, an ethic Mường, was in her 35 th week of pregnancy with twins when she felt severe abdominal pain. At around 8PM, her family took her from Rộc Môn village to the Mậu Lân Commune Health Centre by motorbike. It took them 30 minutes to reach the Commune Health Center. The commune health workers assessed her and identified signs that indicated she was likely to have a difficult and early delivery. The family then quickly transferred her to Như Thanh district hospital, one of two district hospitals in Thanh Hoa province with a specialized Newborn Care (NBC) unit. At about 11 PM that same night, she prematurely gave birth to two twin boys, Bùi Anh Tuấn, weighing 1,600 grams and Bùi Anh Tú, weighing 1,400 grams. Both boys were premature by several weeks and therefore had low birth weights. The doctors from the Obstetrics and Pediatric departments provided a detailed consultation and referred the twins to the NBC unit. Here, the doctors diagnosed them with pneumonia, and classified them as pre-term and with low birth weight; therefore they were prescribed with anti-biotic treatment for 5 days, and placed in the neonatal warmer to stabilize their body temperature. During this time, the doctors encouraged their mother to breastfeed them whenever it was appropriate. Breast milk is the ideal source of nutrition for infants in the first six months of life, and the NBC unit doctors promote and educate mothers about providing immediate and exclusive breastfeeding for newborns. When their conditions were stabilized, NBC unit nurses guided the mother and grandmother-inlaw to warm the babies with the Kangaroo method (Though they called it Kamaru!). The Kangaroo method of care (KMC) refers to using skin-to-skin contact as the principal means of warmth, rather than relying completely on an incubator machine. Many family members, grandfather, grandmother, and mother, took turns warming the twin boys, Tuan and Tu. The two boys stayed in the NBC unit for 10 days, and then the family requested to return home because of costs (food, travel, etc.). Once they reached home, the two boys were warmed by KMC, day and night, for another month. They were visited by the NBC Unit staff. The family also contacted the NBC unit staff to seek medical advice when they needed it. When they were 4 months old, they appeared very cute and healthy. Both boys were exclusively breastfed for the first 3 months after they were born. Thương looks very happy when talking about her babies: We thank doctors and nurses of the hospital very much because my boys were warmed by warmer there. Without it, we would have had to transfer our babies to Thanh Hoa. 162

4. Discussion This report was made to document preliminary results from the performance and operation of district newborn care unit. Overall, the performance of district newborn care unit has actually improved health outcomes of newborns in the two intervention districts. Before the intervention was made, there was no functioning newborn care unit at district level, thus all newborn health problems were handled by obstetric department (for delivery at district hospital). As most district health workers were not trained in newborn care and newborn complications management, almost all newborn complications were referred to either provincial or national hospital. About 89% (Ngoc Lac) of newborn complications was treated successfully, while it was 83% in Nhu Thanh. A salient point that should be discussed here is: Requests to go home (4% in Ngoc Lac and 1.4% in Nhu Thanh). These cases were too serious or the babies were too small and weak (pre-term birth), thus the newborn care unit was not able to save their lives. Going home meant that they would die at home. While the number of newborn admission to the district newborn care unit was restricted to deliveries in hospital and referral cases to the district hospital (facilitybased), neonatal death figures captured information from both health facility and community (reported by village health workers using the designed health information system). Given this reporting system, it is guaranteed that 100% of newborn deaths are captured in this system. The birth of the district newborn care unit has brought about not only medical benefits but also non-medical benefits. The linkage in newborn care across clinical levels has helped the health system to function more smoothly, helping reduce pressure of newborn care at higher levels. On one hand, the newborn care unit has created availability of services for the catchments area and vicinity. It also helps establish a teaching facility for a communal health center with low training costs as commune health staff don t have to travel long distance to learn neonatal care skills. On the other hand, local people find it convenient to seek care at the district hospital without having to pay for non-medical costs and other opportunities costs. Although we did not have information about revenue from newborn care services, both directors of district hospital reported that revenue from newborn care service provision was over 90% increased over the pre-intervention period, regardless of source of revenue. This was understandable because previously almost all newborns with complications were transferred to higher level, thus no service costs for newborn care incurred. 163

Limitations of the report This report has some limitations. Although the project has a comprehensive intervention package of newborn care covering facility-based and community-based intervention, this report merely touched on facility intervention while its impact might have come from community interventions, i.e., reduced home birth thanks to education and communication activities. There is no detailed analysis of newborn complications by disease category, and correlation between complications and place of delivery, socioeconomic status of the family, and other health determinants. This is an ongoing and longitudinal study, thus these preliminary results may not help come to confirmed conclusion of effective district newborn care unit. An intervention-control design could also help to conclude effective district newborn care unit and positive newborn health outcomes but the evaluation should be delayed until end of the project. 5. Conclusions The decision of locating a district newborn care unit in a pediatric department was rational as it facilitated a smooth workflow in the care and treatment for newborns within the district hospital setting. Neonatal deaths in Ngoc Lac and Nhu Thanh districts of Thanh Hoa province can be averted with low cost intervention through the establishment of district newborn care unit. The birth of the district newborn care unit has aimed at three targets: improved health care delivery system (reducing workload for higher level when they have to treat unnecessary cases referred from lower level); improved quality of care (doctors and nurses are confident in providing care for patients with positive health outcomes); and brought about huge non-health benefits for community (reducing medical and non-medical, and opportunity costs for local people. Overall, the performance of district NBC unit has actually improved health outcomes of newborns in 2 intervention districts, and brought about great benefits for the local community, health care providers and administrators. REFERENCES 1. Save the Children: Baseline household survey on newborn care in Nhu Thanh and Ngoc Lac district, Thanh Hoa province (2007) 2. Baseline survey report, UNFPA, 2003 3. Save the Children: Health facility and staff assessment in newborn care in Nhu Thanh and Ngoc Lac district, Thanh Hoa province (2007) 4. Ministry of Health: A situational analysis of newborn health and intervention in Vietnam (2006) 5. Save the Children: Screening of neonatal death in Ngoc Lac and Nhu Thanh, Thanh Hoa (2007) 6. UNICEF: The State of the World s Children 2009 (New York: United Nations Children s Fund) 164