TRACKING NEW BORN DISCHARGED FROM SCNU Dr. Gagan Gupta Health Specialist, UNICEF

Background……..

: IMR reduced by 11 points with out a single point drop in Neonatal Mortality Highest IMR in the Country at 67 per 1000 (SRS 2009)

Government Sector: Special Care was Non Existent

Key Strategy : Guna Model Continuum of Care from Community to Facility Community: -IMNCI -Immunization. -ORS & Zinc in Diarrhea. -ASHA for Social Mobilization -Maternal Death Audit Facility: -SCNU -NRC -Model Labour Rooms -24 x 7 Safe Delivery Centers at Sub - Block level -Staff trained in Skilled Birth attendance and Essential Newborn Care 24 x 7 Referral Transport Piloted in Guna in 2007,Replicated in Shivpuri being Scaled up State Wide

Strengthening Facility Based New Born Care To ensure Continuum of Care with IMNCI in community and SCNU at the Facility. First 2 Units established by UNICEF at Guna and Shivpuri. Establishment cost of each unit Rs. 45 Lakhs.( Civil work 25 lakh, Equipments 20 lakh) Running cost of pilot units and scale up entirely through NRHM. SCNU Shivpuri

Scale Up Under NRHM : SCNU Vidisha District Hospital

New-Born being treated at SCNU

Backed Up By….

Model Maternity wing at District Hospital ….. Model Labor Room : Shivpuri Maternity Ward : Shivpuri District Hospital

Free 24 x 7 Referral transport with Call Centre Saving Life on Wheels : 24 x 7

BTL SVP SNI SDH SA CDW BLG CTP KRG RSN MDL STN VDS DHR JBA PAN SJP KND DMH SHE SOP UJN RJG SDL DWS JBP HSB GUN RWA TKM NSP MDS KT N DDR AKN BHD IDR GLR MRN RTM ANP BRW UMR NMC HRD BHP BPL DTA 31 Functional 09 to start by 31 st January Status of Special Care New Born Units : M.P 10 under construction

What Happens After Discharge ??

Objective…. Determine survival at One year in babies discharged from SCNU To follow this cohort for Neurological Development Learn and put in place system for prospective follow up of discharged new born with Community – Facility linkages. Generate evidence for justifying continued investments of large funds on SCNU amongst other competing priorities

Methodology…. Study Area : SCNU Guna and Shivpuri - First 2 units in the State were established in these districts. - Presence of Call Centre, Block Coordinators for support Study Sample : All New Born discharged from SCNU since inception till 31 st December Guna : 1617 (14 th Dec – 31 st Dec.2008 ) Shivpuri : 557 (1 st July st December 2008)

Methodology…. Type of Study : Retrospective in 3 phases. - Phase 1 : Desk review, Data entry, Telephonic Tracking. - Phase 2 : Visit to community for verification - Phase 3 : Clinical evaluation for developmental assessment.

Follow up Stages..….. Phase 1 : Screening of Records Phase 2 : Verification by Home visit Phase 3 : Developmental Assessment

ADMISSIONS – FOR WHAT ?? N= 2681

FOLLOW UP FINDINGS DISTRICT SHIVPURI ISO : 9001 Certified Unit

TRACKING OUTCOME

SURVIVAL OUTCOME

TIME DISTRIBUTION Total deaths = 70

URBAN RURAL DISTRIBUTION Total deaths = 70

CASTE WISE DISTRIBUTION Total deaths = 70

WEIGHT ON ADMISSION Total deaths = 70

FOLLOW UP OUTCOME DISTRICT : GUNA ISO : 9001 Certified Unit

SURVIVAL OUTCOME

TIME DISTRIBUTION Total deaths = 183

WEIGHT ON ADMISSION Total deaths = 183

Phase 3 :Developmental Screening District Shivpuri (M.P.)

Developmental Screening : Protocols Neurodevelopmental, Visual and Hearing screening done Neurodevelopmental : Pathaks modification of Baroda Scale. Hearing : American Academy of Pediatrics criteria Visual : American Academy of Pediatrics guidelines

Developmental Screening… Head Circumference Screening for Visual Deficits

SUMMARY : FOLLOW UP OUTCOME Survival in New Born discharged after successful completion of treatment was 90% at 1 year of age Deaths were higher in new born who were discharged against medical advise and tertiary referrals. More than 60 % Deaths occurred in 1st month after discharge. Deaths were higher in excluded and rural population.

SUMMARY : FOLLOW UP OUTCOME Survival in < 1500 gram birth wt. was 61 % against 93% in > 2500gm. Deficits were seen in 11 % of Children who survived with Neurological deficit being commonest. SAM prevalence was unusually low on follow up.

LESSONS LEARNED…. Strong tracking system should be in place. Vital information on admission should be recorded (Postal Address,Mobile numbers) Need to develop follow up protocols with community and facility linkages. (Extending continuum of care) Local resources are best suited for follow up and tracking. (AWW, ASHA) First month after discharge is most critical with need to focus on very low birth wt babies < 2000 grams

Action Initiated :Tracking System…. SCNU Software developed and all vital information on admission / discharge recorded in it by data operator. On discharge Parents are counseled & provided contact of IMNCI worker along with a community follow up card. Data operator sends SMS to IMNCI trained worker to enroll the discharged child. SMS reminders are sent to Parents as well as worker on day of Follow up.

Community Follow up card

Actions Initiated : Tracking System IMNCI trained AWW to make Six home visits as per IMNCI schedule in first month. At least one home visit to be done by ANM SCNU follow up at 15 days, 1,3,6 & 12 months or in case of complications Status upgraded at the end of the day of visit.

Admission Entry Form

Entry after Treatment Outcome

Daily Follow - up List

SCNU Software Generated Graphs : 2010 DISTRICT SHIVPURI

SCNU Case Record Sheets & Monitoring Formats

Case Record File

Neonatal Admission Sheet

Discharge Card

SCNU Follow-up Statistics 2011 District Shivpuri (M.P.)

Facility Follow-up Statistics: , SCNU Shivpuri Total Facility Follow-up done since start : 2184

Community Follow-up Statistics, Shivpuri : 2011( Till Oct.)

Mainstreaming and Scaling Up…. Mainstreamed under NRHM for State wide use. Data operators sanctioned and on board in all units SCNU Software installed in all SCNUs across the State. Case Record sheets and SCNU stationary compatible with software developed and put in use Statewide Both Software and Case record sheets in line with GOI guidelines on FBNC Support to Other States : Orissa / Haryana / Uttaranchal / Andhra Pradesh / Maharashtra

Work Under Progress…… Mentoring visits to New Born corners & Stabilization units by SCNU / Maternity team

Work Under Progress…… Linkage of Software and Neonatal case sheets with Maternity records Setting up online monitoring system for centralized monitoring Neonatal transport system Early intervention clinic for limiting disability

Sharing Across States….. States being Supported : Haryana Andhra Pradesh Uttaranchal Tamilnadu Orissa Maharashtra

Justified Investment For Tomorrow… BABY 2 New Born Discharged from SCNU….

N = 42

TREATMENT OUTCOME STATUS UNCLEAR =2

N = 53

New Born Corners till Sub Block level …. 24 x 7 Sub Centre at Shivpuri