1. 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

2. 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)

3. 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 g
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

4. 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

5. A focus on Neonatal care in Tshwane

6. Using a district approach
MOU
MOU
MOU
MOU
MOU
MOU
MOU
MOU
MOU
MOU

7. 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

8. Stages of implementation
Slide: Courtesy Dr AM Bergh

9. KMC wards as standard of care

10. 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)

11. KMC in action

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

13. 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

14. 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

15. Shift in focus
Slide: Courtesy Dr AM Bergh

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

21. 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