Neonatal Survival in Ghana – Challenges and Way forward

1. Neonatal Survival in Ghana – Challenges and Way forward 3rd Annual Scientific Conference College of Health Sciences, KNUST, Kumasi 27th August 2010 E.O.D Addo-YoboMB ChB DTCH MSc MWACP FGCP Consultant Paediatrician, SMS-KNUST/KATH Kumasi

2. Outline • Where we are with regard to MD4 • Contribution of Neonatal mortality in achieving MDG4 • Teaching Hospital perspective on Neonatal mortality • Key Challenges for improving Neonatal mortality • Recommendations for improving Neonatal mortality in Ghana • Conclusions

3. Introduction • Welfare of the state depends on the status of reproductive and child health • Maternal and Child Health Indices are basic indicators of a country’s socio-economic situation quality of life • The child health indices are useful in population projections as well as monitoring and evaluating population and health programmes and policies. • Characteristics of childhood mortality such as age patterns and socio-economic and demographic differentials are useful in addressing factors that have positive or negative impacts on child survival • Analysis of mortality measures is useful in identifying promising directions for health programmes and improving child survival efforts in Ghana.

4. MDG4 • Reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate. • Indicators • Under-5 mortality rate • Infant mortality rate • Proportion of 1 year old children immunised against measles • Reduced family size/ spacing • Baby friendly health initiatives The developing world is generally not on track to meet the MDG target for under-five mortality.

5. Infant mortality trends • Improvements in Infant mortality have stalled largely because of difficulties in reducing neonatal mortality • If Maternal mortality rates are increasing (214 in1993)  560 in 2008) in Ghana, neonatal mortality rates are unlikely to be doing any better.

6. MDG Target • Neonatal deaths regularly constitute about 60 -70% of Infant deaths and 30-40% of U5 deaths over the last 20 years

7. Limitations with surveys • Information gathered form birth history recall – hence recall bias • The most common problems • misreporting of age at death, • misreporting of dates of birth, • event underreporting (of both the birth and death of a child • True figures on neonatal mortality rates may be higher. (e.g Ghanaian cultural practices that do not allow neonatal deaths to be recognised/counted) • Lack of strong national data on neonatal morbidity and mortality from health institutions

8. GeneraL FACTS ABOUT neonatal mortality IN DEVELOPING COUNTRIES • Key determinants • Prematurity • Asphyxia • LBW • Sepsis • Malformations/congenital abnormalities • “Each of the four DHS surveys found that the neonatal mortality rate after a birth interval of less than 24 months (13% of births in the 10 years preceding the 2003 GDHS) was between 2·6 and 4·2 times the rate after a birth interval of 24 months or more”. • Underlying factors: • Poverty • Poor neonatal care – >40% babies delivered without skilled attendance in Ghana • Under-resources health care facilities • Inadequate neonatal care skills • Paucity of specific information about neonatal morbidity and mortality for action • Cultural practices

9. We do not seem to have good control on Neonatal mortality yet!

11. characteristics of mother-baby unit admissions: 2006-9 – kath(SB Nguah et al, 2010. MBU Mortality audit 2006-9: Unpublished) 25,906 admissions of children under 3 months over 4 years • <12 % are under weight (<1.5kg) at birth • >85% were less than one week old • 60-80% delivered at KATH – proportions declining in recent years, with a decline in admission of children born at KATH • 65-70% were delivered by Spontaneous vaginal delivery • Only 5-10% had normal Apgar Scores (8-10) in First minute and 30-35% at 5th Minute • A good proportion of neonatal admissions are normal weight babies from spontaneous vaginal deliveries who require resuscitation at birth.They may be foetally distressed or poorly resuscitated at birth, or both

12. Preliminary MBU Mortality audit statistics

13. Risk factors for neonatal mortality kath – 2006-9

14. Inferences • Early (first week) neonatal deaths contribute significantly to infant mortality • There is significant mortality among normal weight babies although low birth weight babies also contribute • Babies born in facilities with good obstetric and neonatal care service (KATH) are less likely to be admitted • Delayed obstetric interventions and possibly resuscitation challenges may be contributing significantly to neonatal mortality in the hospital (?and outside) • Males and females died equally • Birth Weight <1kg had 90% mortality (<2% total admissions)

15. Key Challenges • Delivery (supervision and action) and Neonatal Resuscitation • Birth Asphyxia (20-40% KATH neonatal deaths) • Neonatal sepsis • (Prematurity) • Neonatal care challenges • Keeping baby warm • Hypoglycaemia:delayed, inappropriate feeding • Birth Injuries • Infection control/Cord care • Early recognition of problems/Delayed referrals • Poor regard for neonates • Poor neonatal record keeping/referrals • Poor neonatal care facilities • Few trained neonatal care givers – many general clinical care givers are challenged by neonatal diagnoses and neonatal care • Emerging challenges abuse of antibiotics with under-dosing and incomplete regimens – emerging pressure on few affordable antibiotics available

16. OPERATIONAL CHALLENGES No real changes in approach to neonatal care in the past 20 years (…until recently) Departmental approach to service delivery:Paediatrician has the skills, Obstetrician does the job Paediatrician attendance to delivery – ideal but hardly possible now Reluctance of trained doctor to practice paediatrics (neonatal care) in districts Lack of specially trained paediatric nursing staff Birth attendant’s responsibility bias – towards maternal health Bedside dilemmas –who to save, mother or baby - One-man station Lopsided supervision of skills – neonatal resuscitation skills wane Poor awareness/feedback about neonatal outcomes Biased training needs assessment (until most recently) Tug of war for nursing staff (midwives) between Child Health and OB-Gyn Inadequate/under-utilized resuscitation equipment Care becomes more and more technical and labour-intensive as we try to save the very ill and LBW e.g. Oxygen delivery, Intubation, Intravenous access, Ventilation, Antibiotics, Neonatal Monitoring. (who to train)

17. Way forward -1 The needed improvements in reducing U5 mortality (MDG4) will largely be achieved by major improvements in Neonatal Mortality Significant improvements in neonatal mortality can be achieved to a large extent by addressing causes and management birth asphyxia and neonatal sepsis. This is linked to maternal care: Birth asphyxia and Neonatal sepsis can be controlled by equipping delivery attendants with Neonatal Resuscitation skills and skills for identification of risk factors for peri-natal morbidity and mortality, infection control and treatment of common infections Need to address obstetric risk factors for birth asphyxia and sepsis concurrently: Prolonged labour, Risk deliveries, Early obstetric referrals, Early interventions;Neonatal resuscitation, Infections control and Management, Early referrals and appropriately-equipped referral Centres.

18. Way forward -2 Short term issues: • Training on neonatal resuscitation, safe deliveries, infection prevention and control • Early neonatal monitoring: Mandatory first week neonatal assessments - as national policy

19. Way forward -3 Long Term: • Strengthening Child health and neonatal care Units in all regional and district hospitals nationwide to support lover levels of child health care dedicated staff, basic Equipment, training and re-training, appropriate documentation to facilitate follow-up Technical issues involved – Neonatal assessment, drugs, intubation • Develop Paediatric (Neonatal) Nursing training programmes to address local challenges • Training of paediatricians should remain a national priority until every district has a trained paediatrician • Strong national strategy for distribution of trained obstetricians and paediatricians needed: Ideally every district should have a paediatrician and obstetrician • Relevant CPD programmes for child health practitioners • Birth spacing and FP • More research on neonatal issues, adaptation of technologies for improves care (e.g. skamgoa)

20. Conclusions • Ghana may be on target for most of the MDGs but we are unlikely to achieve our goals unless we significantly reduce Neonatal mortality • Proposed target:80% districts with paediatrician or trained paediatric nurse by 2020 • Promotion of Birth Spacing cannot be forgotten

21. I will survive ! Thank you