1. Newborn care in Masindi and Kiryandongo districts Richard Mangwi Ayiasi Makerere University School of Public Health College of Health Sciences

2. Why this dissemination Give back Wider dissemination Decision-making Consensus building 2

3. Introduction Newborn death is major public health problem in Uganda and Masindi & Kiryandongo districts 29/1000 die before reaching one month old Causes are known-related temperature, breastfeeding, hygiene Interventions are cheap and effective Why are newborn babies still dying? 3

4. Solutions Comprehensive antenatal care Curative-malaria, HIV, Preventive-diet, education Skilled attendance at birth knowledge, permanence, continuity 4

5. Solutions Confidence in the system Accessible services – Available – Affordable – Acceptable 5

6. Objectives Part of doctoral degree Explore newborn care practices in the region/relation with ANC visits Determine the level of knowledge among health workers regarding newborn care Focus of prenatal education regarding newborn care 6

7. Our focus The service organization Provider knowledge Effect attending four/more antenatal consultations on newborn care 7

8. Methods-service organization Interviewed health workers, trainers, mothers, administrators and managers During October/December 2011 Questions asked – How is antenatal organized – What educational information do you receive from the health centre – Experiences with educational information offered at antenatal – Training and curriculum of health staff/recruitment/deployment 8

9. Methods 17 health workers 5 health trainers and administrators 30 women having babies five months or less 9

10. Main findings Little/no information regarding newborn care but Disease focus Not treating the patient as a patient Information is not targeted to suit individual women General health education Experiences during delivery were mixed 10

11. No/little information about newborn care “No, they don’t teach us anything concerning feeding, what to do during pregnancy or even how to look after the baby. They only tell me that I am negative (that is HIV). That is what they normally tell me” (adult mother) 11

12. Disease focus “At the hospital once you deliver, there is nothing else that they tell you. No, they don’t tell us to go back. They only tell us to take the baby for immunization after delivery that’s it” (adult mother), “Once the baby is out, the rest is your business. They do not tell anything else. And I don’t think they have that time. What are they supposed to tell us? They tell us to take children for immunizations” (adult mother). 12

13. Treating the patient as a patient “Ha, I was in the hospital, the nurse came and injected a patient without even touching her. It was like she was injecting a cow” (adult mother) 13

14. Patient as a patient “Ooh oh, can the nurse at Kiryandongo touch your baby. Their job is to get the baby out of your womb. Once that is done, they are finished. They do not tell you when to breastfeed, when to bathe, nothing Eeh! Nothing! Do you think those nurses tell you anything? Nothing, their job is to help you deliver and that’s it, nurses should be like mothers who know what childbirth means!”(adolescent mother) 14

15. Informal sources of information “I was told by my mother that I should stop (having sexual intercourse) when I was seven months pregnant, that when you sleep with a man in late pregnancy you will deliver a baby which is dirty with a bad skin” (adolescent mother) 15

16. Informal sources of information “Yes I was taking a little waragi; I took about a full glass once a week. I started when I got pregnant. I was told that a little waragi is good for the baby, it helps the skin of the baby to remain clean” (adolescent mother) 16

17. Suggestions Each individual should be treated uniquely Pay attention to basic educational information Consider the integration of HIV/AIDS and Malaria into routine antenatal care 17

18. Important questions How can each individual be treated differently when there is only one midwife at the station? How to integrate other programs like HIV & Malaria in antenatal care to offer comprehensive antenatal care including care for newborn? How to ensure that there is always one midwife available at health centre? How to ensure a positive birthing experience at the health centre? 18

19. Methods-provider knowledge Interviewed 183 health workers Midwives-40 General nurses-71 Nursing assistant-72 Period-October-December 2011 Both Masindi and Kiryandongo districts 19

20. Questions Related to antenatal care Immediate newborn care Managing infections Managing low birth-weight babies Recorded – Place of work – Years of service 20

21. Results PracticeLevel of knowledgeNumbersPercent Prenatal knowledge Adequate98/18353.5% Inadequate85/18346.5% Immediate newborn care Adequate85/18346.5% Inadequate98/18353.5% Infection Management Adequate13/1837.1% Inadequate170/18392.9% Low Birth- Weight adequate103/18356.3% Inadequate80/18345.7% 21

22. Proportion of health workers knowledgeable in Maternal and newborn care 22

23. Level of knowledge regarding infection management 23

24. Findings Low level of knowledge for all categories Least knowledge for infection management No difference in knowledge between nurses/nursing assistants/midwives No difference in hospital and health centre staff 24

25. Implications Major causes of neonatal death-infection & LBW-also least knowledge No difference between NA/Nurse/Mw-formal training/curriculum/selection No difference between HC & Hospital-referral and supervision! No difference in years of service-Experience! 25

26. Relationship between four/more ANC visits and newborn care To explore relationship between attending two groups: – Four/more antenatal visits with attending three/less Interviewed 923 women with babies five months or less Period October/December 2011 Place-Masindi & Kiryandongo districts 26

27. Aim of study Compare newborn care practices between the two groups-those that attended four/more with those that attended three/less ANC visits Newborn care practices- hygienic care for the cord, Providing warmth for the baby Newborn vaccination status 27

28. What do we expect Early drying and wrapping of the baby Delayed bathing over 24hrs to 3 days Initiation of breastfeeding within one hour No offer of other feeds/exclusive No application of substance on the cord 28

29. What do we expect Tie the cord with clean material Cut the cord with clean instrument Clean with salt and water only Baby vaccinated for Polio Zero/BCG 29

30. What did we find? PracticeNumberpercent Good Cord care202/92823.7% Poor Cord care708/92876.3% Good Warmth care57/9286.1% Poor warmth care871/92893.9% Good vaccination611/92865.8% Poor Vaccination317/92834.2% 30

31. Newborn care practices in Masindi & Kiryandongo districts 31

32. Results Delivering at the health centre improved warmth care, and vaccination status but NOT improved cord care-good news – Why? Application of substances on the cord (744/928=71.6%) done from home Secondary/Higher education improved cord care and vaccination status Therefore, Girls must remain in school longer and deliver in health facility when pregnant 32

33. Results No difference in practices between four/more visits with three/less visits Application of substances on cord to accelerate dropping of the stump & healing Early bathing of the baby-baby is dirty/crying too much 33

34. Results Delayed initiation of breastfeeding-baby is not crying therefore not hungry Provision of feeds other than breast milk-because there is no breast milk yet Poor practices also promoted by health workers- confirming minimal knowledge about newborn care 34

35. Implications Skewed focus of antenatal information- – newborn care is neglected; – main source of information remains cultural & informal networks Poor care practices go unabated-even 4 complete visits does not translate to better care practice Poor antenatal and birthing experiences-less likely to return for services Care not patient centered-antenatal is perceived to be irrelevant 35

36. Implications Less information among health workers-little/wrong information offered to women and families No difference in knowledge between more years and fewer years of service-no experiential/learning/continous medical education No difference between hospital staff and health centre staff-how can the referral system function; how can support supervision be conducted 36

37. Implications No difference between nurses/midwives and nursing assistants-is there a problem with the training, selection, curriculum? Poor practices-frequent sickness, strain on the health care system, supplies and health workers Increased OPD, inpatients, deaths-most preventable 37

38. Acknowledgements Participants in this study-Health workers, women, District officials (DHOs, MS, CHDs) District local governments Makerere School of Public Health/ITM Future Health systems Africa hub 38

39. Group work Three groups

40. Health workers, administrators and politicians Each of the three sectors will form a group Each sector will be given a set of questions Tasks: Real problems Strategic solutions Practical answers Within the means of local governments 40

41. Group one How can you increase the number of health workers to offer maternal and newborn health How can you ensure the availability of health workers at their duty stations What can we do to ensure that health workers treat patients in a dignified manner 41

42. Group two How can we increase the knowledge of health workers regarding prenatal and newborn health How can we ensure that maternal and newborn services are available at all times at the health centre and at the referral station How can we make communities to gain confidence and utilize maternal and newborn services 42

43. Group three How can we ensure an integrated antenatal services How can we ensure a whole range of antenatal services are offered at the health centre How can we ensure that women are actually receiving these services 43