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Helping Babies Breathe Program
in Tanzania
Georgina Msemo (MD, Mmed Paed)
Global Newborn Health ConferenceSouth Africa, 16th April 2013
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Background Country Context
Population size 44.9 million (census 2012)
Under five: 7.74 mill
Infant: 1.65 mill
Women of child bearing age 10.4 mill
Live births:1.8mill
Tanzania is divided administratively into:
30 regions (25 Mainland; 5 Zanzibar)
142 LGAs ( Local government authorities)
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Maternal, Newborn and Child Health
Country commitments /targets
MDG 5- reduce maternal mortality rate to
193/100,000 live births by 2015
MDG 4- reduce U5 mortality to 54/ 1000 live
births
MKUKUTA and Election Manifesto reducematernal mortality rate to 264/100,000 live
births and U5MR to 79/1000 by 2010
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Background- Country situation
Situation in 2004/5
DHS 2004/5 showed no improvement in
reduction of maternal and neonatal
mortality
24% Reduction in under-five mortality and
31% reduction in infant mortality (1999-2004)
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National DHS 2004/5 showed child survival gains
162
141136 147
112
91 9287
99
68
3237.9
40.432
145
54.3
0
20
40
60
80
100
120
140
160
180
1990 1992 1996 1999 2004 2009 2015
Mortality(nq0)
Under-five
Infant
Neonatal
MDG Target
An improvement of 24% in under 5 mortality represents
39,200 fewer child deaths per year in Tanzania
-24%
-31%
Source: URT Measure DHS
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Country effort to attain MDG 4
1. Continue with child health interventions atscale:
IMCI (used research for advocacy to scale up)
- Case management Quality of Care at Hospital level
Immunization (through campaign and outreach, nowGAVI HSS opportunity to scale up )
Vitamin A supplementation
Malaria interventions Long Lasting Insecticide Treated Nets (LLINs), Access to Malaria
Treatment
Management of Diarrhoea (ORS/Zinc)
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Country effort to attain MDG 4
2. Strengthen Newborn care by dealing with
major killers of neonates mainly:
Infections-28%
Premature complications-27%
Birth asphyxia- 26%
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Efforts to strengthen newborn
care
Newborn health desk office established in theMinistry of Health-Newborn programming
Adaptation/Review IMCI guidelines at all
levels to include the newborn in the first weekof life-Neonatal Infections
Establishment of Kangaroo mother care
services- Low birth weight babies Newborn Resuscitation program-Reducing
birth asphyxia related mortality
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Birth Asphyxia on "Tanzania's
HBB program."
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HBB-Background
49% of women and their babies do not receive
skilled care during birth (DHS 2010)
The first day at birth especially the first hour is
critical for a newborn survival
Proper monitoring of labour, appropriate
newborns resuscitation are interventions to
reduce newborn deaths
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HBB-Background
Limited resuscitation skills and knowledgeamong service providers.
The number of skilled providers present at
delivery was 15 years
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HBB-Background
High level Political commitment:
His Excellency President Jakaya Kikwete
Statement made in Sept 2007 during 62nd session
UN General Assembly- countries are the MDGtimeline while targets set are not there yet
In 2008 during the Launch of MNCH Roadmap2008-2015 and Deliver now Campaign for
women and children and He wanted to have scaled interventions that are
proved to work rather than pilots
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Components of HBB
The program has:
An intervention component (training)
A research component The Primary Goal- to reduce Birth Asphyxia
related mortality by 50%
A Secondary Goal- to reduce stillbirth deathsby 25%.
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Intervention component
Educational material developed by the AAP
(later translated into Swahili), Neonatalie
model and resuscitation equipment were used
Cascade model approach to train health
providers throughout the country
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Cascade training approach
10,000+
1332
145
40 MasterTrainers
Zonal/Regional
DistrictTrainers
Service
providers
Serviceproviders
Service
providers
Service
Provider
Districttrainers
DistrictTrainers
Zonal/Regional
Zonal/Regional
Zonal/Regional
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Continuing cascade training andrefresher training
Trained providers and trainers:
Continue to provide on job training to other
service providers
Refresher training in the facilities where they
are working.
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National data acquisition and reporting
Each facility reports all births and theiroutcome using existing reporting format.
Weekly notification reporting of all newborn
death. Data compile at health facility on monthly
basis.
Districts /Region compile both a quarterly
report and annual report. Central level receive bi-annually reports from
regions using existing reporting system.
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Master trainers 40 trained in September/October 2009
(WHO support)
Zonal trainers 126 trained in October-December 2009
(WHO support) District trainers 592 trained in December 2009-
December 2012 (UNICEF support)
Service providers 1987 trained up to December support
from some CCHPs (UN JP2 and Laerdal Foundationsupport)
Status of training to date
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Research components
Research sites were 8 ( Eastern Zone -3 and
collaborating institutions; Northern zone -3;
Lake zone -2)
A data collection form with core elements and
desired elements was used
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Program monitoring
Data committee reviews and assesses the
status of implementation
Steering committee ensures the running of
the program
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Variable Pre HBB Post HBB
Number/Total Number (rate/1000)
Risk Reduction
(95% CI)
Neonatal Deaths 24h 107/7969 (13.4) 552/77369 (7.1) 0.53( 0.43-0.65)*
Stillbirths 155/8124(19.0) 1131/78500 (14.4) 0.76(0.64-0.90) **
Perinatal Deaths 262/8124(32.2) 1683/ 78500(21.6) 0.67(0.59-0.76)*
* p < 0.0001, ** p=0.001.
Summary of Neonatal Deaths, Stillbirth Ratesand Perinatal Deaths
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Results Conclusion
HBB implementation is associated with:
HBB implementation was associated with a significant reduction inboth early neonatal deaths within 24 hours and rates of FSB
HBB uses a basic intervention approach readily applicable at all
deliveries.
These findings should serve as a call to action for other resource-limited countries striving to meet Millennium Development Goal
Published in the February 2013 edition Journal of the American Academy ofPediatrics
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Challenges for the current HBB
program
Inadequate supportive supervision to the
sites
Inadequate funds to roll-out cascade
trainings
Inadequate skilled providers
Ensuring availability and maintenance of
equipment
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Scale up plan
Used research findings to acquire CIFF
support- three year program (2012-2015)
Scale up neonatal resuscitation training to
remaining service providers
Improve facility readiness by providing
resuscitation equipment and training
materials
Establish mentorship program for MNCH
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Sustainability Plan
HBB program fully owned by the Ministry
Steps have been taken to ensure newborn resuscitationtraining takes hold in all areas of the medical system.
The HBB curriculum is being introduced into the pre-service midwifery curriculumMidwifery instructors from more than half of the nursing schoolshave already been trained in HBB to be able to train the nextgeneration of service providers.
Districts have already begun to budget for HBB trainingand supervision in their annual budgets
National clinical mentoring system to be developed.
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Acknowledgements
Global Task Force on Resuscitation
Tore Laerdal and the Laerdal Foundation
American Academy of Paediatrics
UN Agency UNICEF and WHO
Children Investment Foundation Fund
SNL/SC- Newborn health programming initiatives
Jeff Pearlman- Weil cornel University
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Asanteni Sana