Department of Health Sindh’s Maternal, newborn and Child Health Programme and UNICEF work plan 2012: Developing Newborn Care Policy, Strategy and Action Plan.
Pakistan Demographic and Health Survey (PDHS) 2006/7 reported high level of newborn mortality across all provinces of Pakistan, including Sindh. The major causes of death among under-five children are birth asphyxia (22 per cent), sepsis (14 per cent), pneumonia (13 per cent), diarrhoea (11 per cent), and prematurity (9 per cent). In 2009, Pakistan accounted for 6.9% of global newborn deaths and ranked 191 out of 193 countries in number of newborn deaths. With 225,450 total estimated annual newborn deaths, each day 618 Pakistani new-born die. The PDHS 2006/7 reported Newborn Mortality rate of Sindh is 53/1000 Live Birth. While there is no wealth quintile specific data on neonatal mortality for Sindh, neonatal mortality is 63/1000 among the poorest wealth quintile compared to 38/1000 among the wealthiest quintile nationally. Newborn mortality is high across all income quintiles and makes over half of all under-five deaths in all quintiles.
Nationally, estimated 61% of mothers reported ever receiving prenatal care from a skilled health provider. Use of prenatal care from a skilled provider is 92% among mothers from the richest quintile as compared to 36.9% from the poorest quintile. Estimated 36% of births have a skilled birth attendant (SBA). Though this in increase by 18% from the 18% SBA of late 90s), only 12% of mothers of the lowest wealth quintile give birth in a health facility as compared to 74% mothers of the highest quintile. Almost three out of five women do not have any postnatal checkup. Only 12 per cent of mothers of the lowest wealth quintile give birth in a health facility as compared to 74 per cent mothers of the highest quintile. Only 41 percent of mothers with no education report keeping aside money for emergency care as compared to 78 percent of those with higher education. Up to 56 per cent of women in the lowest wealth quintile do not deliver in a health facility because it cost too much. Almost three out of five women reported that they did not have any postnatal check-up. Overall, coverage of pre-natal care, skilled attendant at birth and post natal care interventions remain low and are lower among the poor, rural and illiterate.
While most newborns do not access skilled care and die at homes, neonatal mortality among hospital admitted newborn in Pakistan has been reported to be high and in the range of 9% to 39%. A study of newborn admission and mortality in a referral hospital in Bahawalpur, Punjab Province between 2005 and 2008 showed that 19.71% of the total children admitted were neonates, and mortality rate among those admitted was 15.62%. Over the three years period, overall child mortality among admitted children reduced but newborn mortality did not. The study reported 2,889 admission due to asphyxia, 3,029 due to sepsis and 1,482 due to prematurity. With the 15.62% mortality rate, out this total of 7400 newborn, in one hospital alone 1,156 would have died over a period of three years. High mortality rate among admitted newborn comes out consistently across all studies and the commonest causes of deaths are Asphyxia, Sepsis and pre-maturity, all of which have been proven to be treatable even by community health workers having requisite skills. Reports from tertiary care pediatric hospitals in Sindh suggest a very poor ratio between nurses and doctors with one facility reporting a situation where there were 07 nurses to 66 full-fledged doctors Plus 21 Post Graduate trainees. This illogical ratio of care provider deprives sick newborn of vital nursing care in health facilities, exposing them to risk of deaths. A situation analysis of 5 DHQ and 25 RHCs in 10 NPPI districts of Sindh showed round-the-clock staff availability ranging from 10% for Obstetrician and Nurses, 23% LHV and 37% WMO/MO and only 40% of facilities having staff with capacity to manage asphyxia. Only about 40% of clients reported trusting skills of the care providers and overall satisfaction with services.
Low birth weight (LBW) is a major contributor to newborn mortality and child mortality. Babies whose birth weight is less than 2.5 kilos have a 68 per cent greater risk of dying before their first birthday than those whose birth size is average or larger. Estimated 25.6 percent of newborn in Pakistan with have low-birth-weight (less than 2.5 kg), and are thus at risk of dying. In addition, it is a contributor to the inter-generational propagation of malnutrition. LBW reduction appeared as desired Health Policy outcome in National Health policy of 1990 and 2001 but there are no specific large scale interventions in place to address low birth weight.
Global evidence suggests that over 50% reductions in neonatal mortality can be achieved through an integrated, high coverage programme of universal outreach and family-community care (Darmstadt et al, 2005, Lancet). A community-based intervention package, principally delivered through Lady Health Workers in a rural district of Pakistan showed that stillbirths were reduced in intervention clusters (39·1 stillbirths per 1000 total births) compared with control (48·7 per 1000) and the neonatal mortality rate was 43·0 deaths per 1000 livebirths in intervention clusters compared with 49·1 per 1000 in control groups. A female facilitator supported action learning by women’s group in Nepal showed that neonatal mortality rate was 26·2 per 1000 (76 deaths per 2899 live births) in intervention clusters compared with 36·9 per 1000 (119 deaths per 3226 live births) in controls and the maternal mortality ratio was 69 per 100 000 (two deaths per 2899 live births) in intervention clusters compared with 341 per 100 000 (11 deaths per 3226 live births) in control clusters. In the context of Sindh, where, due to low levels of skilled birth attendants, post natal care and newborn care coverage, many newborn die at home without having had contact with health facilities, such community based interventions offer viable alternates. However, despite promising results there is little effort in scaling-up those models.
In low resources setting, such as highlighted above, interventions depending on lower level of technical skills and resources have shown good results. Meta-analysis of three Randomised Control Trials commencing Kangaroo Mother Care (KMC) in the first week of life showed a significant reduction in neonatal mortality compared with standard care; and KMC substantially reduced neonatal mortality amongst preterm babies (birth weight <2000 g) in hospital, and was highly effective in reducing severe morbidity, particularly from infection. A Sick Newborn Care Unit (SNCU), established in a district hospital in India, addressed the shortage of newborn care nurses by training local women with 10-12 years of school education as Newborn Aides. The study concluded that trained Newborn Aides may substantially alleviate human-resource constraint for SNCUs and Sick Newborn Stabilization units in smaller peripheral hospitals for care of sick newborns at an affordable cost. These models of KMC and of Newborn Aides offer potential options that can be explored to address the shortage of skilled care providers in health facilities in Sindh.
Prior to devolution, the Programme Documents of the Former National MNCH Programme and National Programme on Family Planning and Primary Health Care (NP-FP-PHC) defined programmes approach to address maternal and newborn health. However, the efforts to link these programme efforts to the horizonatl health system were inadequate and the thus the horizontal health system did not have a coherent direction. As a consequence efforts to address maternal and newborn health lacked coherence and convergence. These programmes and their supporting partners defined set of training materials and approaches to enhance care-providers skills in specific areas but no tangible efforts have been made to define approach across continuum of care until recently when the country adopted the global WHO, UNFPA, UNICEF and World Bank recommended Integrated Management of Pregnancy and Childbirth (IMPAC): Pregnancy Childbirth and Post Natal Care. This guideline defines approach to management of normal pregnancy, childbirth, essential newborn care and post natal care but the complementary guideline for managing a sick newborn titles “Managing Newborn Problems: a guide to doctors, nurses and midwives” is yet to be adopted. There is thus a need to define a coherent approach to address newborn care relevant to the context of devolution. Among others, the approach needs to consider a) defining policy statement for ensuring newborn survival, b) defining key approaches for reaching preventive, promotive and curative newborn care at all levels, c) adopting relevant guidelines and standards, d) defining needs and ways to develop and retain adequate human resources, e) defining how some of the cost of newborn care facility, staff and supplies can be incorporated into annual development budget of the province and districts. The intent to develop Newborn Survival Strategy and Action Plan is a way towards that coherently defined approach that all stakeholders working in newborn care in the province will commit to. Such a strategy and plan is not a stand-alone document but is an effort to ensure that critical aspect of newborn care are taken on by the sector reform agenda of the province. If and when provincial health sector strategy gets articulated, the Newborn Survival Strategy is expected to feed into and become subsidiary to it develop a comprehensive newborn survival strategy for the province to situate newborn care adequately in future health sector policy, strategy, plans and budgets. A overall scope and suggested outline for working is in in the attached document titled “Conceptual Outline for Newborn Survival Strategy Development”
 Pakistan Demographic and Health Survey 2006–2007
 Oestergaard et al, 2011, Neonatal Mortality Levels for 193 Countries in 2009 with trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities, PLoS Medicine , August 2011, Volume 8, Issue 8
 Mazhar A et al, 2011. Neonates- a neglected paediatric age group, Journal of Pakistan Medical Association, vol 61, No. 7, July 2011
 Arjumand and Associates, 2009, Situation Analysis of THQHs & DHQHs in 10 NPPI districts
 Pakistan Demographic and Health Survey 2006–2007
 Bhutta Z.A et al, 2011, Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial, The Lancet, Volume 377, Issue 9763, Pages 403 - 412, 29 January 2011
 Lawn et al, 2010, ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications, International Journal of Epidemiology 2010;39:i144–i154
Sen et al, 2007, Newborn Aides: An Innovative Approach in Sick Newborn Care at a District-level Special Care Unit, J HEALTH POPUL NUTR 2007 Dec;25(4):495-501 ISSN 1606-0997 , International Centre for diarrhoeal Diseases research, Bangladesh
Purpose of assignment:
The consultant/institution will work under the direction of Provincial Newborn Survival Strategy Working Committee, review relevant literature, policies and guidelines, facilitate the consultation process, document decisions and develop a comprehensive newborn survival strategy for the province to situate newborn care adequately in future health sector policy, strategy, plans and budgets. A overall scope and suggested outline for working is in in the attached document titled “Conceptual Outline for Newborn Survival Strategy Development”
Major tasks to be accomplished
1. Develop a budgeted work plan for the steering committee for developing, endorsing and disseminating the newborn survival strategy, present the process of the newborn Strategy development and the plan, get it endorsed by the steering committee and forward to UNICEF
2. Carry out situation analysis of newborn in Sindh through desk review of existing data, research and information available
3. Review a) existing global commitments, recommendations, guidelines and good practices and newborn care; b) policies and strategies of selected countries in the region; c) existing national and provincial policies and programme documents, including annual development budget of relevant sector to identify strengths, weaknesses, opportunities and threats and current programme, policy, programme and practice gaps
4. Present the findings of desk review (task 2, and 3 above) and DRAFT Newborn Survival Policy statement to steering committee, facilitate discussion, seek and incorporate views and prepare Newborn Survival Policy statement, which will guide the strategy and plan formulation
5. Develop outline of the DRAFT Newborn Survival Strategy and Plan , present it to the steering committee, incorporate suggestions and get their endorsement
6. Facilitate discussion within the steering committee to establish Task-Groups to work on relevant areas of the outline DRAFT Newborn Survival Strategy and Plan, co-opting experts as necessary to provide inputs. Facilitate work of each of the task-group, providing them relevant resource materials and support to complete their work and document the process and the inputs provided into each section by the group.
7. Collate and compile the work of the Task-Group set by the Committee to develop a draft Newborn Survival Strategy and budgeted plan.
8. Assist the Secretariat of the Newborn Survival Strategy Committee to present the draft Newborn Survival Strategy and plan to the steering committee, facilitate the process of discussion and obtain endorsement for wider dissemination.
9. Assist the steering committee to disseminate the Newborn Survival Strategy and Plan obtain comments, suggestion of stakeholders and finalize the document
1. Budgeted work plan for Newborn Survival Strategy Development Committee endorsed by the committee; along with Budget release forwarded to UNICEF through Secretary of Health (4 days).
2. Comprehensive report on the situation of newborn in Sindh(4 days)
3. A report identifying strengths, weaknesses, opportunities and threats of current programmes approach to newborn care in Sindh; policies, programme and practice gaps that need to be addressed; and good practices that could be adopted in the newborn care strategy and plan (5 days)
4. Provincial Newborn Survival Policy statement endorsed by the steering committee (4 days)
5. Newborn Survival Strategy and Plan outline endorsed by the steering committee (3 days)
6. Compiled work outputs of each task-group working on the outline DRAFT Newborn Survival Strategy (30 days)
7. Draft Newborn Survival Strategy and Plan (5 days)
8. Draft Newborn Survival Strategy and Plan endorsed by the steering committee (3 days)
9. End assignment report as specified below (4 days)
- · Three signed hard copies of the Newborn Survival Strategy and Plan
- · Electronic copy in editable format and PDF format
Time-Frame: Total 62 working days (holidays and weekends are not counted)
Cost, payment schedule and conditions:
· The cost will be based on budget proposal of the best evaluated proposal. Payments will be made as follows:
a. 10% of total value on submission of signed contract with a work-plan (deliverable-1)
b. 20% on completion of deliverable 2, 3, 4 and 5 specified above) 30% on completion of deliverable 6 and 7 specified above
c. 40 % of submission end assignment report with Three signed hard copies of the Newborn Survival Strategy and Plan along with electronic copy in editable format and PDF format
· The Provincial MNCH Programme will introduce the consultant with the steering committee and provide a work-space in the MNCH programme office
· The MNCH programme and UNICEF will jointly facilitate organization of the meetings of the steering committee, and the dissemination meeting, including photocopying/binding and sharing of the draft document with stakeholders, venue and other logistic arrangement.
· The consultant is expected to make schedule of the task group meetings, follow up the relevant members and arrange/facilitate the meeting. Venue for such task group meetings will be provided either in MNCH programme office or UNICEF Office
· All cost of computing, documentation, computing, communication, travel, and transportation, of the consultant will have to be borne by the consultant.
The District level stakeholders, where invited, dissemination meetings, work place for the team taking this assignment are the responsibility of the selected institution/firm and these should be factored in their proposals.
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