The Components of Essential Newborn Care - basics

BRIEFPerinatal/NeonatalThe Components ofEssential Newborn CareIndira Narayanan, Mandy Rose, Dilberth Cordero,Silvana Faillace, and Tina Sanghvi

AbstractEssential newborn care (ENC) is a comprehensive strategy designed to improve the health of newborns throughinterventions before conception, during pregnancy, at and soon after birth, and in the postnatal period. This briefdescribes the components of ENC, criteria for prioritizing them, and strategies used in operationalizing them.Implementation of ENC will have a positive impact on neonatal and infant mortality.Recommended CitationIndira Narayanan, Mandy Rose, Dilberth Cordero, Silvana Faillace, and Tina Sanghvi. The Components of EssentialNewborn Care. Published by the Basics Support for Institutionalizing Child Survival Project (BASICS II) for the UnitedStates Agency for International Development. Arlington, Virginia, June 2004.Photo Credit: BASICS IIBASICS IIBASICS II is a global child survival project funded by the Office of Health and Nutrition of the Bureau for GlobalHealth of the U.S. Agency for International Development (USAID). BASICS II is conducted by the Partnership forChild Health Care, Inc., under contract no. HRN-C-00-99-00007-00. Partners are the Academy for EducationalDevelopment, John Snow, Inc., and Management Sciences for Health. Subcontractors include Emory University, TheJohns Hopkins University, The Manoff Group, Inc., the Program for Appropriate Technology in Health, Save theChildren Federation, Inc., and TSL.This document does not represent the views or opinion of USAID. It may be reproduced if credit isproperly given.BASICS II1600 Wilson Boulevard, Suite 300Arlington, Virginia 22209 USATel: 703-312-6800Fax: 703-312-6900E-mail address: infoctr@basics.orgWebsite: www.basics.orgUSAIDU.S. Agency for International DevelopmentOffice of Health and NutritionBureau for Global HealthWebsite: www.usaid.gov/pop_health/

The Components of EssentialNewborn CareIndira Narayanan, Mandy Rose, Dilberth Cordero,Silvana Faillace, and Tina SanghviCare provided during the perinatal andneonatal periods (Figure 1) is critical toensuring the health of mother and baby.Maternal health and newborn health areinextricably linked; this brief primarily addressesthe needs of the newborn infant and some selectedmaternal issues that influence birth outcome.Essential newborn care (ENC) is acomprehensive strategy designed to improve thehealth of newborns through interventions beforeconception, during pregnancy, at and soon afterbirth, and in the postnatal period.These issues need to be addressed in anappropriate manner at the facility and communitylevels to ensure a continuum of care.ComponentsThe components of ENC are summarized inFigure 2 and described in greater detail in Table 1.Depending on their mandates, private voluntaryand other organizations may facilitate or provideENC services or simply promote them throughcommunication and social mobilization strategies.Essential Newborn CareENC comprises:(a) Basic preventive newborn caresuch as care before and duringpregnancy, clean deliverypractices, temperaturemaintenance, eye and cord care,and early and exclusivebreastfeeding on demand dayand night;(b) Early detection of problems ordanger signs (with priority forsepsis and birth asphyxia) andappropriate referral and careseeking.This may also be a partof (a) and (c); and(c) Treatment of key problems suchas sepsis and birth asphyxia.Figure 1. Definition of the Perinatal and Neonatal PeriodsPregnancyPerinatal periodEarlyneonatalperiod22 weeks 6 completedBirthdaysLateneonatalperiodNewborn period27 completeddaysThe Components of Essential Newborn Care3

Figure 2. Essential Newborn Care Components: The “What”Maternal issuesPromotion or provision of servicesCloselinkBaby issuesPromotion or provision of servicesPreventive maternal components(Essential obstetric care)1. Essential preventive care2. Recognition of danger signs and referralPreventive baby components(Essential newborn care)1. Essential preventive care2. Recognition of danger signs and referralManagement of complications(Emergency obstetric care)1. Recognition of danger signs and referral2. Treatment of problemsManagement of complications(Essential newborn care)1. Recognition of danger signs and referral2. Treatment of problems (with prioritygiven to sepsis and birth asphyxia)Before conception Pregnancy At birth Postnatal periodPrioritization of ComponentsTable 1 outlines a large number of componentsfor optimal newborn health. However, it may notbe feasible to implement all componentssimultaneously. Components should be prioritizedaccording to local needs, and implemented in aphased manner or by linking with suitablepartners. Criteria for selection of components tobe implemented in initial and subsequent phasesinclude:■■Existing infant and neonatal mortality rates.Generally, as infant mortality decreases,neonatal mortality as a proportion of infantmortality increases. With lower infantmortality rates, countries and organizationsare more likely to be ready to implement anincreased number of components forimproving newborn health;Resources that are available or that can beleveraged;■■■■■Likelihood for sustainability and for taking toscale;Acceptability with and interest of partners,including the Ministry of Health, aftersuitable advocacy;Existing programs into which newborn healthcomponents and strategies can be linked;Proportion of facility and home deliveries,and available care providers; andExisting infrastructure and quality ofservices.Implementation of Essential Newborn CareIn general, it is easier to select ENC interventionsto implement (the “what”) than to operationalizethem (the “how”). Some approaches that havebeen used include:■■Advocacy (at all levels and at every stage);Situational analysis of key issues within thecountry or area;4The Components of Essential Newborn Care

Table 1. Improving Newborn Health: The Essential Newborn Care ComponentsBeforeConceptionAntenatal PeriodAt and Soon after Birth (Up toabout Six Hours)Postnatal Period■ Adequate care ofthe female child,including nutrition,education, andhealth care.■ Immunization,including tetanustoxoid.■ Folatesupplementation.■ Birth spacing.■ Prevention ofsexuallytransmittedinfections (STIs).■ Avoidance ofsubstance abuse,includingavoidance ofsmoking andalcohol use.■ At least four visits with an emphasis on goalorientedor focused antenatal care.■ Tetanus toxoid.■ Iron and folate.■ Adequate nutritious diet.■ Extra rest.■ Consumption of iodized salt by the family.■ In areas where malaria is endemic:– Mother (later with the baby) sleeps underan insecticide-treated bednet; and– Mother takes intermittent presumptivetherapy.■ Detection and treatment of STIs such as syphilisand gonorrhea.■ Interventions for HIV/AIDS, including voluntarycounseling and testing.■ Birth preparedness:– Determination of place of delivery with thehealth care provider;– If home delivery: (a) adequate linen, washedand sun-dried—at least five pieces of clothfor delivery (may include a plastic sheet forthe mother); (b) clean new blade kept in itswrapper until the moment of use; and (c)clean cord ties. All these items should bekept in a clean container;– Setting aside of or arrangements to getmoney for going to a facility for planneddelivery or for emergencies in the motherand baby; and– Identification of the facility andtransportation to be used in case of anemergency.■ Early detection of problems or emergencies inthe mother and appropriate referral to and careseekingat a suitable facility.■ Treatment of problems in the mother.■ Skilled birth attendant following cleandelivery practices and supported byan enabling environment (skills,supplies, and suitable referralfacilities).■ Application of principles of theprevention of mother-to-childtransmission (PMTCT) of HIV/AIDSstrategy to the baby and the careprovider.■ Detection of problems andemergencies in the mother andappropriate referral and care-seeking.■ Treatment of problems in the mother.■ Essential preventive care of the baby:– Cleanliness and prevention ofinfection;– Temperature maintenance;– Eye care;– Cord care;– Early initiation of breastfeeding(within one hour) without prelactealfeeds, and advice forsubsequent, frequent exclusivebreastfeeding on demand day andnight; and– Extra care for the low birthweightbaby.■ Resuscitation at site of babies who donot breathe properly at birth.■ Detection and referral and appropriatecare-seeking for babies with dangersigns.■ Consultation(s) with mother and baby early in the first week, atleast once before day 3, and followed up as required.■ Continued essential preventive newborn care, includingsupport for exclusive breastfeeding on demand, temperaturemaintenance, cord care, etc.■ Continued application of inputs for PMTCT activities, includingfeeding and other support such as antiretroviral therapy,counseling, and nutrition.■ Postnatal vitamin A for the mother and continued use of ironand folate and intermittent therapy for malaria (where malariais endemic), according to recommendations of the Ministry ofHealth.■ Counseling for nutrition, family planning, and prevention andtreatment of STIs.■ Detection of danger signs and appropriate referral and careseeking.*The first four or five signs are more commonly used,especially in the community:– Poor sucking or not sucking;– Inactivity or lethargy—often denoted by families as“loose-limbed” in several languages;– Fever or hypothermia;– Respiratory distress;– Convulsions;– Vomiting;– Abdominal distension;– Severe umbilical infection (redness or swelling of the skinsurrounding the base of the cord or a foul smell); a slightpus discharge may often be considered a minor infectionthat can be treated locally;– Jaundice reaching the palms and soles;– Extensive pustules or skin infection; and– Swollen eyelids with pus discharge.■ Detection of minor problems, local treatment where necessary,and follow-up including referral, if needed, for:– Conjunctivitis;– Minor umbilical infection;– Pyoderma or skin infection;– Thrush; and– Jaundice.*Organizations or programs have selected different signs and varying numbers of signs; however, the fewer the danger signs, the easier it is for health workers to recall themand inform families if they occur. This prioritization of danger signs is useful, particularly for those working at peripheral centers and in communities.The Components of Essential Newborn Care 5

■■■■■■Use of existing programs, resources, and careproviders;Collaboration, coordination, and consensusbuildingwith partners;Health system strengthening:– Competency-based capacity-building;– Improvement of pre-service education;– Supervision;– Drugs and supplies; and an– Improved referral/counter-referral system.Community-based interventions:– Capacity-building of community healthworkers and volunteers includingtraditional birth attendants;– Supervision of community health workersand volunteers;– Provision of supplies; and– Social mobilization includingparticipation from community-basedorganizations.Multi-channel communication for appropriatebehavior at all levels, including targeting ofpolicymakers, community leaders, and careproviders at facility and community levels.Linkage with or coordination between groups,strategies, and sites, such as a link between■communities, facilities, and public and privatesectors for a continuum of care; andMonitoring and evaluation as part of an ENCprogram, with emphasis on the use of data toidentify gaps and implement adaptations.ConclusionIn brief, key strategies to improve newborn healthinclude:■■■Prioritization of ENC interventions accordingto local requirements, with gradual phasing-inof interventions not initially included;Integration of ENC with existing maternaland child survival programs in a way thatmaintains clear visibility of newborn healthissues in order to attain the necessary impacton neonatal morbidity and mortality; andImplementation that addresses at inceptionkey issues such as sustainability and scale.Strategies like these will have a greater impacton neonatal mortality rates and, in turn, on infantmortality rates, which will represent an importantstep toward achieving the MillenniumDevelopment Goals.Acknowledgment. The authors wish to thank the BASICS II Strategic Experience Transfer (SET) team for their assistance inpreparing this document.6The Components of Essential Newborn Care

ReferencesBang, A. T., R. Bang, S. Baitule, M. Deshmukh, and H. Reddy. 2002. Burden of morbidities and the unmetneed for health care in rural neonates: A prospective observational study in Ghadchiroli, India. IndPediatr. 38:952–65.BASICS II (Basic Support for Institutionalizing Child Survival), PAHO (Pan American HealthOrganization). 2004. Selected annotated bibliography on newborn health: Evidence-based informationfor developing country programs including public health aspects. Arlington, Va.: BASICS II.BASICS (Basic Support for Institutionalizing Child Survival)/USAID (United States Agency forInternational Development), UNICEF (United Nations Children's Fund), WHO (World HealthOrganization). 2004. Nutrition essentials: A guide for health managers. Revised edition printed byBASICS II.Bhutta, Z. A., G. L. Darmstadt, and E. I. Ransom. 2003. Using evidence to save newborn lives. Policyperspectives on newborn health. Washington, D.C.: Save the Children, Population Reference Bureau.USAID (United States Agency for International Development). 2003. Immunization essentials: A practicalfield guide. Washington, D.C.: USAID.WHO (World Health Organization). 1996. Essential newborn care: Report of a technical working group.WHO/FRH/MSM/96.13. Geneva: WHO.The Components of Essential Newborn Care 7