1. AMTSL and ENC at birth Goldy Mazia & Indira Narayanan BASICS PPH Working Group Meeting Washington DC March 20,2008

2. Outline of Presentation Burden of deaths in the early newborn period and the need to address it Key programmatic priorities for addressing newborn health and integration with maternal care Linking AMTSL and ENC at birth

3. To achieve MDG 4 neonatal deaths must be addressed 0 50 100 150 Global mortality per 1000 births 1960198020002020 Year Under-5 mortality rate Present trend MDG 1-60 mo. mortality < 1 mo. mortality (NMR) Why Focus on Newborns?

4. The Lancet Series- Newborn Survival, 2005 Direct Causes of Neonatal Mortality: Global Estimates

5. 4 Million Newborn Deaths - When? Up to 50% of neonatal deaths are in the first 24 hours 75% of neonatal deaths are in the first week – 3 million deaths Time when most babies die is when coverage of quality care is lowest

6. Source: WHO estimates 2000 Skilled Birth Attendants and NMR

7. Mere presence of a skilled birth attendant is not sufficient Quality of care and an enabling or supportive environment are important –Skills/expertise (for both mother and baby) using rational, appropriate interventions –Supportive supervision of staff –Adequate appropriate drugs, equipment and supplies of suitable sizes and strengths with good maintenance –Appropriate referral center/system including appropriate transport Pre-service education must also improve

8. Home to hospital continuum of care Pre-pregnancy to post partum Prevention to treatment - priority sepsis and asphyxia Where funds are limited: –Prioritize key interventions with subsequent phasing in of other components –Link with partners leveraging additional support Continuum of Care is Important Newbornhealth Inf./Childhealth Schoolhealth Adol.health Maternalhealth

9. Key Essential Newborn Care Components linked with maternal care AntenatalBirthPostpartum Minimum 4 visits Tetanus toxoid, iron & folate (+ pre-preg), iodized salt, birth preparedness, counseling for breastfeeding, detection and treatment of STIs and HIV/AIDS, referral for maternal danger signs Skilled birth attendance, clean delivery practices, AMTSL, basic ENC (temperature maintenance, cord & eye care, early and exclusive breastfeeding), identification and treatment for danger signs, resuscitation, extra care for LBW/premature babies, PMTCT Assessment before discharge, early visit,1st within 3 days, basic ENC; vitamin A for mother; detection and treatment for danger signs and minor problems; PMTCT

10. Essential Maternal and Newborn Care Other Essential Interventions Family planning Immunization Special care for LBW Iron folate Prophylactic Eye care Facility-Based Minimum Package Minimum Package Birth preparedness Tetanus toxoid Partograph Infection prevention Active mgt of 3 rd stage of labor Newborn resuscitation Cord care Thermal care Immediate & excl breastfeeding Infection treatment Minimum Package Birth preparedness Tetanus toxoid Partograph Infection prevention Active mgt of 3 rd stage of labor Newborn resuscitation Cord care Thermal care Immediate & excl breastfeeding Infection treatment Context-Specific Package Intermittent presumptive treatment for malaria Prevention of Mother-to-Child Transmission of HIV Syphilis detection and treatment Iodine Adequate nutrition Basic EmOC

11. USAID/BASICS/POPPHI: Integration of AMTSL and ENC Receive and dry the baby, discard wet linen Baby cries well Place baby on mother’s abdomen Dry and cover with dry cloth Inform mother about baby & AMTSL; administer oxytocin Clamp cord when pulsations stop/2-3 min. after the birth Apply controlled cord traction + uterine massage 1.) Keep required items for mother & baby close by, load oxytocin in syringe 2.) Inform mother what is being planned at her level of understanding Cry not heard Dry and wrap in fresh dry linen exposing chest. Keep warm. Assess breathing Breathing well Not breathing/gasping/ breathing very slow Cut cord; resuscitation and AMTSL or if no assistance, physiological management of 3rd stage Start AMTSL – Get help to observe baby Monitoring + rest of routine care of mother & baby Eye prophylaxis; tie the cord; warmth (skin-to-skin); initiate breastfeeding

12. Integrating AMTSL and ENC at Birth: Challenges It is at the same time of AMTSL that the newborn requires care immediately after birth Integrated care may present as a “conflict of interests” where there is only one attendant A trained second attendant should be available for AMTSL in case the newborn requires special attention (i.e. asphyxia requiring resuscitation).

13. Care of the Newborn at Birth - Monitoring Assess the baby with the mother (as a part of AMTSL): Every 15 minutes for first 2 hours Every 30 minutes during the third hour Every hour from hours 3 to 6 after birth Breathing Regular breathing (30-50/min) No difficulty (nasal flaring, grunting, chest in-drawing) Color Lips and tongue, palms and soles should be pink Blue palms and soles might mean the baby is cold Temperature Normal axillary temperature is 36.5 0 to 37.5 0 C Promote skin-to-skin to keep the baby warm Umbilical cord Check for bleeding/oozing; retie if needed

14. Dominican Republic- Clean Delivery Practices In 3 Hospitals

15. Swaziland -Temperature maintenance at birth

16. Swaziland - Breastfeeding in first hour (interviews of mothers)

17. Through Prioritization; phasing in of activities/interventions with continued expansion Support to construct a strong, cost-effective, VISIBLE newborn strategy to link with maternal and child health programs Addressing inequities, sustainability, scale and adequate coverage with adequate interventions Ultimate Goal is to Achieve the MDGs