Addressing Critical Knowledge Gaps in Newborn Health

Making community case management work for newborns – lessons from Uganda

A paper published this week in the American Journal of Tropical Medicine and Hygiene highlights efforts in Uganda to incorporate newborn care into the national integrated Community Case Management (iCCM) program that is being scaled up by government together with partners like Malaria Consortium, UNICEF, Healthy Child Uganda and International Rescue Committee. Uganda has made substantial progress in reducing child mortality with under-five mortality dropping from 178 per 1000 live births in 1990 to 90 in 2011. The leading causes of child deaths are neonatal causes (26%); pneumonia (17%); malaria (13%); and diarrhea (10%).

Uganda’s village health strategy renewed

In order to address these causes of death and to reflect the need for improved primary health care, in 2006 Uganda revitalized its Village Health Team (VHT) program. The VHT consists of 5-6 community volunteers who provide maternal, newborn, and child services. In 2010, the Ministry of Health committed to scaling upiCCMfor children under-five. VHT members are trained to assess and treat malaria (ACTs), pneumonia (amoxicillin), diarrhea (ORS and zinc) for children 2-59 months. Preventive newborn careis also included in the iCCM package including postnatal home visits, danger signs recognition, and assisting referral. Learning from the Uganda Newborn Study (UNEST) was incorporated into the basic VHT training as well as the add-on iCCM training (see box for details). However, iCCM clinical practice sessions do not include a newborn example and newborn content is not covered in the post-training assessment.

Aspects of newborn care covered in Uganda’s basic training for Village Health Team members

  • Emphasize the importance of facility deliveries
  • Record births that take place at home
  • Identify and record newborn danger signs (difficulty breathing, weakness, fever, difficulty feeding, umbilical cord is red or discharging pus, convulsions, and vomiting)
  • Encourage routine postnatal checks at the health facility at 6 hours, 6 days and 6 weeks after birth
  • For babies born at home, practice immediate essential newborn care (dry the baby, wrap the baby, ensure breastfeeding is initiated, check for danger signs every hour and refer if needed)
  • Make home visits to the newborn after delivery on days 1, 3 and 7
  • Advise the mother and the family on healthy newborn and maternal practices including early and exclusive breastfeeding, thermal care, clean and dry cord care, immunizations, and skin-to-skin care and extra breastfeeding support for small babies 

Newborn care review provided during iCCM training

(2 hours on the final day of the 6-day iCCM training)

  • Initiate breast feeding soon after delivery within 1 hour and breastfeed exclusively
  • Delay the first bath, wrap baby in warm clothing to prevent low body temperature
  • Recognize very small babies and give extra care
  • Mothers and other caregivers should always wash hands before breast feeding or  handling the baby
  • Check on the cord regularly and ensure it is clean and dry
  • Follow up of newborn in the community by the VHT member
  • Make home visits to the newborn after delivery on days 1, 3 and 7
  • VHT should take opportunities such as child health days to actively look for sick newborns

Integration of newborn care within iCCM

In order to assess the effectiveness of the integration of newborn care within iCCM, interviews and focus group discussions were conducted with Village Health Team members, facility-based health workers, and caregivers in 3 mid-western districts of Uganda with full scale implementation.  

The linkage between the health facilities and VHT members is strong. Health facility staff are responsible for training, supervising, and providing medications to VHT members:

“When we receive their medicine we call them to come pick it and they refer patients to us. Basically we work hand in hand with the VHT members.’’ - Health worker interview.

VHT members trained in iCCM unanimously reported referring sick newborns to facilities:

“During the training, we were told not to treat the newborns at all; we just refer them to the health workers in the health units.”  - VHT, focus group discussion

Whilenearly all of the VHT members could list some danger signs they did not identify the most important signs of severe newborn illness. Two-thirds of VHT members mentioned promoting exclusive breastfeeding but less than half mentioned counseling on importance of keeping baby warm, hygienic care practices or inquiring about birth weight.

Overall iCCM is perceived as beneficial, but caregivers, VHT members, and health workers want to do more for sick babies at facilities and in communities. When VHTs do identify and refer sick newborns, it is imperative that the health facilities are equipped and staffed to provide appropriate care:

“It is like we do not have a program for the newborns here. Even if we go to the health facility there are no drugs.” – Caregiver, focus group discussion

“The program is not good concerning newborns because we cannot treat them.” – VHT, focus group discussion

More to be done

Uganda has been one of the first countries to incorporate newborn care into their national iCCM package and their experience is important for other settings considering service integration across the continuum of care. The benefits of iCCM for older children are well known and iCCM also has potential to improve newborn survival in communities where it is being implemented. In order to build on this important program, additional research is needed to assess the ability of VHT members trained in the basic package as well as iCCM to correctly identify newborn danger signs. Barriers to compliance with referrals and the quality of newborn treatment at facilities should be examined to determine the bottlenecks in linking care between communities and health facilities.

iCCM supplement launch

The supplement of over 20 papers reviewing evidence from implementation research has been launched this week at the 61st Annual Meeting of American Society of Tropical Medicine and Hygiene. On November 14, 2012 there was a special session on scaling up iCCM for children in low-resource settings.  This symposium presented some of the most recent results of research on iCCM including findings from large-scale programs in challenging, low-resource settings, new data on the potential effectiveness of teaming different cadres of community-based health workers, engaging the private sector in iCCM activities and an evaluation of the potential integration of newborn care into iCCM.

> Read the full paper