1. 1 EssentialPostpartum and andNewborn Care Care MCH in Developing Countries January 24, 2008

2. 2 Session Objectives Describe the importance of postpartum care Describe the importance of postpartum care –Purpose, components, and timing of focused PP care Describe the importance of newborn care Describe the importance of newborn care –Purpose, components, and timing of newborn care Explain the importance of integrating the two Explain the importance of integrating the two

3. 3 Post Partum: Critical Period for the Mother More than a half of all maternal deaths occur within 24 hours of delivery. More than a half of all maternal deaths occur within 24 hours of delivery. Postpartum hemorrhage is the most important cause of these deaths Postpartum hemorrhage is the most important cause of these deaths 22.3% maternal deaths occur days 1-7 22.3% maternal deaths occur days 1-7 14.7 % maternal deaths days 8-14 14.7 % maternal deaths days 8-14 2.8% maternal deaths days 31-42 2.8% maternal deaths days 31-42

4. 4 Postpartum Death by Cause and Time (%) Hemorrhage: 90.6% 0-7 Days Hemorrhage: 90.6% 0-7 Days Sepsis: 78.3% 8-28 Days Sepsis: 78.3% 8-28 Days PIH Complications: 100% 0-7 Days PIH Complications: 100% 0-7 Days Direct Causes: 80.3% 0-7 Days Direct Causes: 80.3% 0-7 Days

5. 5 Postpartum care: when and where? Timing (WHO recommendation): Timing (WHO recommendation): –Six hours –Six days –Six weeks PP visits should occur PP visits should occur –In a private setting –Where essential equipment and supplies available –Emergency response system is in place (!)

6. 6 Essential Components of PPC 1) Detection and treatment of problems –Bleeding –Sepsis –Retained placenta –Eclampsia –Severe anemia

7. 7 2) Preventive measures, counseling –Vitamin A supplement –Early and exclusive breastfeeding and breast care –Family planning –Mother/newborn and family relations –Nutritional support –Danger signs for mother and baby –Newborn care –Concerns of mother

8. 8 Newborn Care: WHAT IS THE SITUATION OF THE NEWBORN? EVERY MINUTE of the day: 7 babies die in their first week of life 10 babies die in their first month of life 10 babies are stillborn

9. 9 Neonatal Mortality Approximately 4 million neonatal deaths occur each year (98% in developing countries) Approximately 4 million neonatal deaths occur each year (98% in developing countries) For every neonatal death another is stillbornFor every neonatal death another is stillborn (4 million) Accounts for ~two-thirds of deaths of infantsAccounts for ~two-thirds of deaths of infants Two-thirds occur in the first week of lifeTwo-thirds occur in the first week of life Two-thirds early neonatal deaths occur in the first 24 hoursTwo-thirds early neonatal deaths occur in the first 24 hours Accounts for four-tenths of deaths in children < 5 yrsAccounts for four-tenths of deaths in children < 5 yrs (Hyder et al, 2001) (Hyder et al, 2001)

10. 10 Relative Risk of Death per Month 0 5 10 15 20 25 30 35 Deaths per 1000 live births Average number of deaths per month in each period of a child’s life Newborn period 31 deaths per month Post-neonatal period (1-11months) 2 deaths per month Children (12-59 months) 1 death per month From: State of the Worlds Newborns 2001, State of the World’s Children 2001 WHO Publications

11. 11 Lifetime Risk of a Mother Experiencing a Neonatal Death (%) Africa21 Asia 9 Latin America/Caribbean 5 North America<1 Europe<1

12. 12 Perinatal and neonatal mortality rates are declining more slowly than other infant mortality Stillbirths/1000 births Deaths/1000 births -60 -40 -20 0 20 40 60 80 100 1983 1999 1983 1999 Post-neonatal mortality Late neonatal mortality Early neonatal mortality Stillbirths Developing Regions Developed Regions

13. 13 Causes of Newborn Deaths Pregnancy-related complications (e.g., complications of prematurity, congenital anomalies) 34% Delivery-related complications (e.g., asphyxia, birth injury) 29% Infectious diseases (e.g., neonatal tetanus, pneumonia, sepsis, meningitis, diarrhea) 32% WHO, 2001

14. 14 SEPSIS (septicemia, pneumonia, meningitis, diarrhea) 52% ASPHYXIA 20% PREMATURITY 15% Other 13% Causes of Neonatal Deaths in the Community (Bang AT, Lancet 1999;354:1955-61)(Bang AT, Lancet 1999;354:1955-61))

15. 15 How can a health worker or family member identify a sick newborn? Results of a recent multi-country study showed that most newborn illness can be predicted by observation for seven key danger signs: Results of a recent multi-country study showed that most newborn illness can be predicted by observation for seven key danger signs: –difficulty feeding –convulsions –movement only when stimulated –respirations of 60/minute or greater –severe chest indrawing –temperature of > 37.5 (C) –temperature of < 35.5 (C) (Clinical signs that predict severe illness….Lancet, Jan 12, 2008)

16. 16 Routine Newborn Care Labor & Delivery Care Antenatal Care Immediate Newborn Care IMMEDIATE CARE Drying & warming (wrapping) Assure adequate breathing Immediate, exclusive breastfeeding Cord care, prophylactic eye care, immunizations (BCG, OPV, Hep B?) ROUTINE CARE Exclusive breastfeeding Clean umbilical cord and skin care Maintenance of temperature Early postnatal visit Danger signs to watch for (jaundice, color changes, breathing change, etc.) Essential Care for Newborn Health

17. 17 Where should the focus be for perinatal/neonatal interventions? Globally most births occur at home Globally most births occur at home Most perinatal/neonatal deaths occur at home within the first week Most perinatal/neonatal deaths occur at home within the first week Sick babies are rarely identified by families or referred to health workers in time to prevent death Sick babies are rarely identified by families or referred to health workers in time to prevent death Few health facilities are available to provide essential neonatal care Few health facilities are available to provide essential neonatal care

18. 18 Integration of PP and NB Care: Immediate Postnatal Monitoring Monitor closely for the first 6 hours: Parameters for the new mother: Parameters for the new mother: –Pulse –Vaginal bleeding –Uterine firmness –Blood pressure (+/-) Parameters for the new baby: Parameters for the new baby: –respiratory rate, cry –warmth –bleeding from cord –breastfeeding

19. 19 Designing programs with a postpartum and newborn focus: Two clients (mother and baby) Two clients (mother and baby) Critical time for problems Critical time for problems Local variables that support or hinder PP/NB care Local variables that support or hinder PP/NB care –Access to care –Recognition of problems –Local customs/beliefs (postpartum seclusion, taboos, traditional beliefs) –Financial factors –Knowledge base of mother, family and provider

20. 20 A look at newborn care in Timor-Leste: A look at newborn care in Timor-Leste: