Breastfeeding: Nutrition Support and capacity building for premature and LBW babies Ute Feucht Paediatrician: Tshwane District Clinical Specialist Team 2nd World Breastfeeding Conference; 13 December 2016; Symposium: Strengthening Care and Support Systems

SAINC: Neonatal Care Improvement Essential Newborn Care Essential Maternal Care Essential Newborn Care Services: Neonatal Resuscitation at Birth Routine Care Inpatient Care for Sick and Small Newborns Standard Inpatient Neonatal Care (SIC) & KMC Neonatal High Care (HC) Intensive and highly specialized care (ICU)

Standard Inpatient care (SIC) Routine Care (RC) Standard Inpatient care (SIC) High Care (HC) Intensive Care (NICU) Most full term infants Most LBW >2kg Babies with: Low Apgars Congenital abnormalities LBW 1500-1999g Gestation 32-36w BW >4000g Meconium staining Wasting Possible infection Jaundice LBW <1500g Gestation <32w Encephalopathy Meconium aspiration Septicaemia/ meningitis Recurrent apnoea Moderate & severe respiratory distress Convulsions Severe jaundice Simple surgical problems Need for ventilation Complex surgical problems Persistent hypoglycaemia Cardiovascular problems Multisystem problems Requiring specialist interventions e.g. ambiguous genitalia Safe clean delivery Apgar score Basic newborn resuscitation Initiation of BF at birth and further support Emergency care before referral Vit K, eye care, cord care, measure, immunize Examination of newborn Baby of mother with HIV, TB or syphilis Skin-to-skin & KMC In addition to RC: Maintenance of thermo-neutral environment O2 administration & monitoring Glucose monitoring & correcting abnormalities IV fluid Tube feeding Bilirubin monitoring & phototherapy Drug administration In addition to RC & SIC: Cardio-respiratory monitoring O2 (>40% headbox) Nasal prong CPAP Short-term IPPV Blood transfusion Chest drain Exchange blood transfusion In addition to other NC: IPPV & advanced respiratory support TPN Arterial catheterization Therapeutic cooling Advanced neurological monitoring Sonar & Echocardiograph Sophisticated diagnostics Sub-specialist consult Surgical intervention

Levels of Neonatal care Level of care Level I Level II Level III Facility Clinic / MOU District hospital Regional Hospital Tertiary Hospital No of beds 4 / 1000 births in sub-district   4 / 1000 births / sub-district + 2 / 1000 births in district 2 / 1000 births in district + 0.5 / 1000 birth / province Neonatal care that should be delivered Routine care Initiating KMC KMC Standard inpatient (SIC) High care (HC) SIC HC Intensive care (Short term) Intensive care Ratio of beds / 10* KMC : SIC :HC: ICU KMC : SIC : HC 4 : 4 : 2 KMC : SIC: HC : ICU 4 : 3 : 2 : 1 KMC : SIC : HC : ICU 2 : 3 : 3 : 2

A focus on Neonatal care in Tshwane

Using a district approach MOU MOU MOU MOU MOU MOU MOU MOU MOU MOU

example: KMC Implementation Great strides in KMC implementation in terms of level of awareness of benefits Recent focus on expansion of KMC implementation & scale-up Often donor-funded development project, but what then? Two-edged sword Nothing happens without projects and/or funding Nothing happens after a project has ended How do we integrate implementations into routine care? DCSTs Role of supportive supervision

Stages of implementation Slide: Courtesy Dr AM Bergh

KMC wards as standard of care

INSTITUTIONAL-ISATION Health-system readiness Stakeholder readiness Stages of change QUALITY OF CARE Indicators in HMIS Standards for maternity & newborn services accreditation* Standards for quality maternal & newborn care** 6. Sustain new practice INSTITUTIONAL-ISATION 5. Integrate into routine practice 4. Implement COVERAGE Facility readiness Health-system readiness IMPLEMEN-TATION 3. Prepare to implement 2. Commit to implement Stakeholder readiness Create awareness PRE-IMPLEMEN-TATION Get acquainted * Facility level ** Individual level HMIS = Health Management Information System (Bergh et al, 2014)

KMC in action

Standardising the approach Clinical tools, like inpatient follow-up sheets Structured patient follow-up Links within health systems Training

Capacitating staff: Practical Issues to deal with Teenage mothers Multiple pregnancies Language barriers Unwanted pregnancies Postpartum blues & depression Smoking and substance abuse Competing demands on mothers Long-term oxygen therapy

After implementation: What is next? Shift focus to Clinical practice: Quality of care Supportive supervision Health systems strengthening Accountability Linkages between care provides Health programme integration Implementation research

Shift in focus Slide: Courtesy Dr AM Bergh

Mothers and infants are moving through the Health system Starting at antenatal care Midwives are absolutely crucial Consistent messaging Holistic care Health Programme integration

Thank You! Acknowledgements: Kalafong colleagues: Dr Elise van Rooyen, Ms Marlene Gilfillian, others MRC unit for Maternal and Infant Health Care Strategies: Dr AM Bergh Tshwane DCST Tshwane MCWH & Nutrition staff The many mothers and babies I have been privileged to work with over the years