1. Care seeking for newborn
illness: A changing
paradigm?
Steve Wall
Save the Children
CORE Meeting
Baltimore
April 25, 2013

2. 0
20
40
60
80
1990 1995 2000 2005 2010 2015 2020 2025 2030 2035
Source: UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report 2011;
UNICEF, Required Acceleration for Child Mortality Reduction beyond 2015, 2012; team analysis
SNL/Save the Children team analysis for NMR projection for Call for Action meeting
MortalityRate(deaths/1000births)
20
35
Accelerated U5MR ARR = 5.1%
Current U5MR ARR = 2.2%
* ARR = annual rate of reduction
MDG 4 target =
34 U5MR
Global Progress for child survival
U5MR and NMR decline 1990-2010, projected to 2035
15
Current NMR ARR = 1.8%
If 1-59 month mortality accelerates further but neonatal mortality continues on
same trend then with
2 million child deaths in 2035, 1.5 million may be neonatal.

3. Why are we focused on newborn survival?
Three killers –
prematurity, asphy
xia, and infections
- account for 81%
of all neonatal
deaths3.1 million
Sources: CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010. UNICEF, State of the World's Children, 2011.
Causes of death in children under-five in developing countries –
Newborn deaths are almost half of all deaths of children under
five

4. REGION Neonatal mortality rate
Average annual change
1990-2010
Africa 1.3%
East Med 1.6%
Southeast Asia 2.2%
Western Pacific 4.2%
Americas 3.6%
Europe 3.6%
Maternal mortality ratio = 4.2%
1- 59 month mortality rate = 3%
Neonatal mortality rate = 1.8%
All 3 measures show increased progress since 2000
Source: Lawn J,E. et al. 2012. Newborn survival: a multi-country analysis of a decade of change. Health Policy and Planning.
27(Suppl. 3): iii6-ii28. Data sources: Oestergaard et al 2011 PLoS, UNICEF 2012 www.childinfo.org
2165
2085
Mortality average annual rate of reduction
WHEN WILL REGIONS REDUCE NMR TO
CURRENT RATE OF HIGH INCOME
COUNTRIES
(3 per 1000)?

5. Care seeking for NBs: Our Original Assumptions
• Home-based management of sick
newborns is effective and saves lives
• Care seeking from qualified providers
outside the home is low, influenced by
entrenched cultural beliefs and practices.
– Seclusion, contamination
– Evil eye
– Traditional beliefs about illness and remedies
– Lack of trust in “western” medicine

6. • Case identification in Projahnmo (Bangladesh)
coincided with the days of scheduled post-natal
home visits “active” case detection
seemed needed
Baqui et al. BMJ, 2009.
 Family acceptance of referral to facilities:
 Bangladesh – ~ 1/3
 Pakistan – 20%
Baqui et al. Lancet. 2008; Zaidi et al. XXX.
Evidence “confirming” these assumptions

7. More recent evidence and program experience
• Nepal:
• MINI – FCHVs counseled family, who notified
FCHVs of suspected newborn illness
• FCHVs identified signs of PSBI, treated with
cotrimoxazole and referred to gov‟t CHW for
injectable gentamicin
• CHW provided 7 days of gentamicin
• Initially at home; but families became willing to go to
health posts/centers for gentamicin
 MINI model incorporated into 10-district pilot of
Community-Base Newborn Care Program (CB
NCP)
 Recent CB NCP data show families infrequently
contact FCHVs, but tend to directly seek care at
health posts/centers

8. More recent evidence and program experience - 2
• Ethiopia
• COMBINE (cRCT) introduced NBS management
(amoxicillin + gentamicin x 7 days) by Health
Extension Workers (HEW) at Health Posts
• Expectation of “active case detection” by
volunteers and HEWs
• Initially, very low case identification in intervention
areas.
• Qualitative research identified barriers –
cultural/religious taboos against taking newborns
outside the home; lack of knowledge of newborn
illness, treatment, and availability of such
treatment at HPs.
• Project worked with community/religious
leaders, volunteers to provide information.
• Increased care seeking for sick newborns was
largely „self-referral‟

9. COMBINE care seeking for NB illness
Table 1: Expected births & care-seeking
For newborn illness
2011 2012
Q3 Q4 Q1 Q2 July
Intervention Expected No. of births 2711 2395 2123 2468 880
No. (%) seen at HP 8 (0.3) 28 (1) 131 (6.2) 170 (7.0) 54 (6.1)
No. (%) seen at HC 0 (0) 8 (0.33) 102 (4.8) 38 (1.5) 12 (1.6)
Control Expected No. of births 2731 2394 2068 2419 894
No. (%) seen at HP
5 (0.18) 6 (0.25) 16 (0.75) 7 (0.28) 8 (0.91)
No. (%) seen at HC
3 (0.1) 5 (0.2) 42 (2) 31 (1.3) 13 (1.5)

10. Implications
• Families ARE willing to seek care for NB
illness (from qualified providers) outside
the home.
– Taboos can be overcome (rapidly ?) if
families/communities have knowledge about
preventable newborn deaths, need for early
care seeking, and availability of services
– Services must be reliable (set times for health
worker at HP, medicines in stock)

11. Issues/Questions
• Is care seeking timely enough for effective
treatment? Any prior care seeking from
unqualified providers?
• Can community participation and CHW
role(s) help “facilitate” care seeking?
• How different might this care seeking
pattern be in different regions or different
country contexts (eg, need for formative
research and pilots)?
• How rapidly can community norms be
changed and will these changes be
sustained?

12. Additional questions for discussion?
• In some countries
(eg, India, Pakistan), care seeking for
newborn illness may be mostly from
private providers (many unqualified). How
to address this challenge?
• What is care seeking pattern for sick
newborns in the first week of life, and how
can this be increased?
– First week NBS is more lethal
condition, requires early identification and
treatment, and is more prevalent than later
neonatal NBS.

13. Further considerations
• Roles of CHWs (SNL 2 experiences) in
changing household practices and care
seeking
• Role of community mobilization in
changing expectations &
norms, household practices and care
seeking, and care quality

14. Learning from
implementation of
community-based
maternal & newborn health
programs:
The role of CHWs
Deborah Sitrin
Save the Children
CORE Group Meeting
Baltimore
April 25, 2013

15. SNL2 Vision
To have reduced global
neonatal mortality by
providing catalytic
assistance to develop, and
implement, effective
evidence-based newborn
care interventions at scale.

16. Guatemala
Bolivia
Indonesia
Vietnam
Bangladesh
Nepal
India
Pakistan
Afghanistan
SNL2: Where?
South Africa
Mozambique
Malawi
Tanzania
Uganda
Ethiopia
Ghana
Mali
Nigeria
60% of the world‟s 3.1 million neonatal
deaths
18 countries
•Africa: 9
•Asia: 7
•Latin America: 2
Global & Regional

17. Description of programs
Program elements:
• Home visits by Community Health Workers during pregnancy & after birth to:
Encourage ANC and facility delivery
Promote optimal care practices for newborn and mother
Counsel families to identify danger signs and seek care
Identify sick newborns and refer to facilities (+ pre-referral oral antibiotic in
Nepal only)
• Facility strengthening (varied)
• Community engagement (varied)
Data from pilot districts in 4 countries:
• Malawi
• Uganda
• Nepal
• Bangladesh

18. Community workers conducting home visits
Differences across programs:
• Population catchment size
• Gender
• Education level
• Salaried government
employee vs. volunteer
• Incentives
• How workers are recruited
• Residency
• Time in community
• Length of pre-service training
Similarities across programs:
• Length of training in
maternal newborn health
package
• Content of counseling on
newborn care practices
• Made home visits during
pregnancy and soon after
birth
LESSON: Delivery platforms vary substantially and delivery
systems can change.

19. Implementation Questions
1. How many women and newborns received home visits?
2. What did CHWs do for newborns during visits?
3. How many families sought timely and appropriate care
when their newborns had danger signs?
4. What was the role of CHWs in identifying and referring
newborns with danger signs?
5. What have we learned about increasing uptake of
healthy newborn care practices?

20. Percent of mothers/babies receiving home visits
FINDINGS:
• Low in Malawi, higher in
Bangladesh and Nepal
• More received pregnancy
visits than postnatal visits
• If a postnatal visit was
received, it was usually within
3 days after birth
LESSON: Percent receiving home visits varied substantially
and we need to consider what each community platform
can handle.
0
20
40
60
80
100
Nepal
(N=615)
Bangladesh
(N=398)
Malawi
(N=900)
1 or more home visits during pregnancy
1st postnatal home visit 0-3 days after birth
1st postnatal home visit 4-7 days after birth
Percentage of mothers/newborns that
received home visits
Data from interviews with mothers with a live birth in previous 12 months

21. What was done for newborns during postnatal home
visits within 3 days after birth
FINDINGS:
• Nearly all newborns that received an early postnatal home visit had
at least one key function done
• Weighing baby low in Nepal, but FCHVs only instructed to weigh
babies not previously weighed at facility
0
20
40
60
80
100
Checked cord Breastfeeding supportChecked temperature Weighed baby All 4 functions
Nepal
(N=307)
Malawi
(N=95)
Percentage of newborns that received a postnatal home visit ≤3 days after birth and signal functions were
performed by CHW
LESSON: When postnatal visits are done, CHWs performed
key tasks. BUT need to monitor quality.
Data from interviews with mothers with a live birth in previous 12 months

22. Care-seeking for newborns with danger signs
Malawi Uganda Nepal Bangladesh
Endline Endline Baseline Endline Baseline Endline
NB with danger sign 23.4% 50.0% 21.4% 28.8% 52.3% 40.7%
Care-seeking for those with a danger sign:
Sought care (any source) 82.9% 94.2% 85.8% 98.9% 82.0% 88.3%
Sought care <=24 hours at
a facility (public or private)
41.2% 48.3% 36.6% 67.8% NC 20.4%
FINDINGS:
High levels of care-seeking
• High in all countries (baseline & endline, intervention & comparison areas)
Yet fewer newborns taken to a facility within 24 hours after onset of
danger signs
• % newborns with danger signs taken to a facility within 24 hours increased in
Nepal, was moderate in Malawi and Uganda, low in Bangladesh
Data from interviews with mothers with a live birth in the previous 12 months

23. Care-seeking for newborns with danger signs
LESSONS:
 Families will leave the home and seek care.
 Need to address delays in seeking care from a facility within 24
hours after onset of illness. Noting we found high levels of
newborns with danger signs. Difficulty in relying on survey data –
mothers may not accurately recall or report illnesses.
 Need to ensure families are accessing appropriate care. Use of
private facilities and pharmacies/drug shops high in Nepal,
Bangladesh, and Uganda. We saw decreases in Nepal but no change
in Bangladesh (no baseline information from Uganda or Malawi).

24. Access to full course of treatment for newborn sepsis
MALAWI
NEPAL
1 facility per
300,000 people
1 facility per
7,000 people
LESSON: Community-based
programs may create
demand, but treatment needs
to be available closer to home

25. Role of CHWs in referring sick newborns
FINDINGS:
CHWs have good understanding
of newborn danger signs and
appropriate care
• >95% of CHWs in Malawi and Nepal
could name 3+ newborn danger signs
BUT low volumes of CHW
referrals of newborns with danger
signs
• Many newborn not visited by CHWs
within the first week after birth
• Families going straight to facilities
when newborn has danger sign
• Issues with CHWs not getting
required supplies/equipment
Data from interviews with mothers with a live birth in
previous 12 months
0
20
40
60
80
100
Nepal
(N=615)
Bangladesh
(N=398)
Malawi
(N=900)
1 or more home visits during pregnancy
1st postnatal home visit 0-3 days after birth
1st postnatal home visit 4-7 days after birth
Percentage of mothers/newborns that
received home visits

26. Role of CHWs in referring sick newborns
LESSONS:
 Need appropriate expectations for the role of CHWs in identification
and referral: Focusing on increasing family-initiated care-seeking may
be more important and more feasible than detection by CHWs.
 Examine role of CHW in follow-up and treatment completion: May be
feasible and effective to involve CHWs in follow-up of sick newborns.
Counter-referral systems are needed to implement follow-up.
 Strengthen monitoring of referrals and outcomes: Weak systems to
track referrals and referral outcomes.

27. Uptake of 4 key newborn care practices
0
20
40
60
80
100
Malawi* Nepal* Bangladesh Uganda*
Baseline Endline
Immediate breastfeeding
0
20
40
60
80
100
Malawi* Nepal* Bangladesh* Uganda*
Baseline Endline
Bathing delayed ≥6 hours
0
20
40
60
80
100
Malawi Nepal Bangladesh Uganda
Baseline Endline
Skin-to-skin contact
0
20
40
60
80
100
Malawi Nepal* Bangladesh* Uganda*
Baseline Endline
Nothing applied to cord after cutting
*Statistically significant at p<0.05
Data from interviews with mothers with a live birth in previous 12 months

28. Newborn care practices
FINDINGS:
• Practices improved over time with a few exceptions (immediate breastfeeding in
Bangladesh, applying nothing to cord in Malawi and Uganda)
• Practices increased in both intervention and comparison areas, though endline
rates often higher in interventions areas. (Note: comparison area data only
available in Bangladesh and Uganda.)
• Newborn care practices associated with receipt of home visits from CHW during
pregnancy (except in Uganda)
– Only statistically significant if mother received 3+ home visits during pregnancy
LESSON: Home visits during pregnancy are an opportunity to improve
newborn care practices and programs able to reach large numbers of
women during pregnancy. BUT may be difficult to achieve 3+ visits.

29. Mobilizing communities for sustainable change in newborn
health expectations, care giving practices, and care seeking
Angie Brasington, Save the
Children
CORE Group SPRING MEETING
April 25, 2013
Mobilizing communities for improved maternal & newborn
health:
lessons and questions
Angie Brasington,
Save the Children
CORE Group
SPRING MEETING
April 25, 2013

30. Outline:
 CORE Group Newborn Health Survey
 CM for Newborn Health – what are we learning?
 Questions that need exploration

31. Carolyn Kruger, Ph.D.
Sr. Advisor MNCH
PCI
CORE Group co-chair: Safe motherhood &
reproductive Health Working Group
CORE Group
Newborn Health Survey Results

32. USAID Priority Countries:
Supporting Newborn Care
Belize
Dominican Republic
Guatemala
Mexico
Nicaragua
Colombia
Ecuador
Peru
Ethiopia
Kenya
Senegal
South Sudan
Mali
India

33. Newborn Health Areas Supported
(18 Organizations)
Number of organizations
16
16
15
15
12
12
12
11
10
10
9
9
8
7
6
5
3
2
2
1

34. Cross-Cutting Approaches
• CHW capacity building - 100%
• Behavior change/communication - 78%
• Community mobilization - 70%
• Community health system strengthening - 70%
• Care groups - 50%
• mHealth approaches - 48%
• Mass communication - 42%
• C-IMCI/CCM - 38%

35. Innovative Strategies
• mHealth reminders on assessment of mothers and newborns
• Mobile job aids - counseling messages
• Newborn screening on birth defects
• Preconception care
• Casa Materna birthing home model
• Community Kangaroo Mother Care
• CHW capacity to recognize danger signs
• Involving fathers during pregnancy, delivery and PP care
• EBF among adolescent mothers using text messaging and support groups

36. Mobilizing Communities…..

37. Community-based Activities
=
Community Mobilization
• Day celebrations, competitions, use of action cards to stimulate
group dialogue are all examples of behavior change strategies.
• The process of stimulating a community to identify, plan and
implement strategies and activities to achieve an agreed upon
goal is community mobilization.
• CM often incorporates participatory behavior change
strategies, however
• BC strategies can be effective without CM, so why…..
Mobilizing Communities…..

38. 1. We have evidence it works:
WEWE problems
So, why mobilize communities?
Costello et al, Effect of a participatory intervention with women’s groups on birth outcomes
in Nepal: cluster-randomized controlled trial. Lancet 2004; 364: 970 – 979.
Baqui et al, Effect of community-based newborn-care intervention package implemented
through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-
randomized controlled trial. Lancet 2008; 371: 1936–44.
Kumar et al, Effect of community-based behaviour change management on neonatal
mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomized controlled trial. Lancet
2008; 372: 1151–62.
Costello et al, Effect of a participatory intervention with women's groups on birth outcomes
and maternal depression in Jharkhand and Orissa, India: a cluster-randomized controlled
trial. Lancet 2010; 375: 1182-1192

39. 2. The principles behind CM fit with our mission and context:
• Decentralization and democratization require increased
community level decision-making --- CM is an entry point for civil
society strengthening and democracy building.
• CM builds mechanisms and systems to sustain improvements in
individuals’, families’ and communities’ well-being.
• Communities can apply political pressure to improve services.
• CM can strengthen community members’ capacity to address the
underlying causes of poor health.f problems
So, why mobilize communities?

40. LESSONS:
 Men want to be involved
 Communities are able and
willing to contribute
resources
 Communities are changing
rapidly
 Communities take action:
emergency transport
systems and funds, advocacy
for satellite clinics and
staff, pregnancy surveillance.
What have we learned from communities lately?

41. Challenges and lessons
LESSONS:
 Need appropriate expectations
for the role of CHWs: MOH
staff who are closest to the
community are already thinly
stretched.
• Should CHWs lead or only
support CM efforts?
• Can existing community
leaders, volunteers or members
of civil society organizations
feed input from communities to
the health system?
• ‘Sharing the burden lightens the
load’

42. Challenges and lessons
LESSONS:
 Community mobilization competes with many other priorities
(clinical training, infrastructure development) within a resource
limited environment.
• Make every effort to integrate CM into broader national health
strategies, especially when existing MOH policy calls for strong community
engagement.
• When communities, CHWs and program managers experience results, the
relative value of CM is compelling and support is more likely.

43. Challenges and lessons
LESSONS:
 Community mobilization takes time.
• Simplify the process as much as possible before you start and refine
further as you roll out.
• As staff becomes more confident and skilled , CM processes speed up.
Good training is essential.
• CM successes build momentum and can lead to organic expansion.
• Communities and groups with prior experience organizing to solve
problems can move more quickly.

44. Challenges and lessons
LESSONS:
 Community mobilization at scale takes thoughtful planning.
It can be done when:
• Designed with scale in mind
• Effective training materials and guides are produced to support the
process
• Financial and political support is available
• Partners are interested in adopting the approach
• Systems are in place to support capacity-building of program teams
(including monitoring and evaluation, training and ongoing technical
assistance)

45. So how can we ensure communities are
engaged?
Questions:
Why are communities consistently left out of the Household to
Hospital Continuum of Care (HHCC)?
What do we as PVOs/INGOs require to inspire and equip more
partners to engage communities for improved MNH?
• More evidence on ‘how’ CM works?
• More advocacy?