Better Cord Care Saves Babies’ Lives: Country Perspectives on Chlorhexidine Programming

On January 30, 2013 JSI was joined by PATH and Save the Children in hosting a special panel discussion on the implementation of chlorhexidine programming in three countries: Nepal, Nigeria, and Madagascar. The event, which was held at The Ronald Reagan Building in Washington, D.C., was moderated by USAID’s Neal Brandes. Participating in the discussion were JSI’s Leela Khanal and Nosa Orobaton, who spoke about their respective experiences in Nepal and Nigeria. Also on the panel were Trish Coffey of PATH and Steve Hodgins of Save the Children, who spoke about the planned implementation of chlorhexidine intervention in Madagascar through the USAID-funded MAHEFA project.

My name is carolyn heart i’m with jo sighs washington office and it’s a great pleasure to welcome you here this morning to this event which we are privileged to co-host with the chlorhexidine working group we are interested in hearing what the panelists have to say to us from the country perspectives i think we all have an appreciation that implementation is

A many-faceted puzzle or as neil just said to me conundrum and that will learn a lot from these guys about how that puzzle can be solved both us aid and nh were approached by researchers and others pointing out that there is some promise fork or hex even is an antiseptic to prevent both maternal newborn infections one of which was a trial in nepal where an ait

Platform for research actually had been a place where nih nested a trial showing promise of chlorhexidine the trial demonstrated a thirty-four percent reduction in newborn mortality the trials would have gotten nowhere if we hadn’t already concurrently been working on how do we deliver the product what are the different mechanisms public-private how do we engage

With industry what would convince government that’s really the conundrum for us how do we do this efficiently in nepal sixty-three percent of women give birth at home mostly in unhygienic conditions and forty-one percent of babies had some substance usually oil pointment turmeric or ash applied on their umbilical stump which can lead to infections four percent

Chlorhexidine a broad-spectrum antiseptic has been proven to be effective at preventing infection use of chlorhexidine for court care was piloted in 2008 based on the pilot results the ministry of health and population approved f nationwide scale up of the program by integrating it with other ongoing government programs as a part of saving lives at birth a grand

Challenge for development usaid awarded jsi rnt a grant to implement the chlorhexidine navi care program at the national level and the chlorhexidine has been already included as a part of a sincere new bern cure in the community-based newborn care packages and it is in the process of inclusion of a skilled birth attendant curriculum and pre-service curriculum and

We are hoping we could include that in the espn pre-service curriculum by end of 2013 we are using this tube individual tube for the baby now we are trying to introduce new bottle for the hospital and at the same time we have seen in the be like baby doll i use as a counseling to the community it was a whole big baby but it was hard to carry in the hard-to-reach

Area that’s what we are modifying with the half baby you have wavy i at least we can hold it and transferred easily to the community the work that we’re doing in nigeria is heavily driven by evidence you know it’s looking at the research what’s been published but but especially important is how do you translate what’s in how do you translate that when you sit down

In front of a politician to convey the same story i think that’s one of the successes that has emerged from sokoto state taking evidence from the lancets and so on and so forth and presenting it to a bureaucrat in a way that he’s fired up and it takes that message to the father’s places so what we have as a consequence is in sokoto states about 5 million people

All in not western fringe of nigeria approximately ninety-six percent of deliveries take place at home as you know you may know nigeria’s maternal mortality rate is very high in the 500s double that and you have what you have for sokoto state so it gives you a sense of just the fragility and the potential tragedy that we have out there sokoto state government

Took the balls to the horns and the thing that really are excited there was that they could actually be a pathfinder for the country as a whole and they relished that position and they have invested their resources and as we speak now 56,000 doses of clark sedin are now in country they’ve helped to train 2,400 community-based health workers they’ve overseen the

Design of community-based distribution system there are different factors related to product profile that can affect the supply and demand of the product for chlorhexidine is relatively simple you have a gel product and then you have a liquid product so those are the two main formulations right but you also might want to do a few little things to those so you might

Consider for example the way you’re presenting the product you might want to present the product in a spray bottle or you might want to present the product in a pre-moistened towelettes steve really likes to talk about or you might want to add color or you might want to add sent to the formulation so each one of those things is you think about it have an impact

On potentially user uptake or ease of distribution of the product or pricing of the product or even the regulatory path weight and then the other piece that i just wanted to mention is about establishing an affordable and available supply of product so you know there are different ways of doing that one way of doing that is through establishing local production

At the country level you could also have regional production you could also have global supply so for chlorhexidine from bilkul cord care which is a relatively simple product to make in fact countries may feel like oh you know we can do this at the country level this is easy and in fact countries may have the capability of doing that in and it will be fine some

Countries may feel like they can do it although they might not necessarily have the ability to assure the quality of the product this is a very exciting period for us right now with chlorhexidine we’ve got there’s probably at least a dozen countries that are either taking first steps and introducing chlorhexidine are actively discussing it as many of you know

The secretary general’s commission for life-saving commodities for women children’s health as prioritized chlorhexidine is one of its key commodities you’ve heard about the experience in nepal and nigeria the one other country that that’s moving ahead right now this is madagascar madagascar like our global technical working group it’s a multi partner effort

With important roles being played by by psi and a social marketing project by m chip-chip i go and buy a jsi bilateral we focus in the in the first stages on how are we going to buy the the core exiting that we need you know for our formative work or for piloting but from very early on we need to think about secure long-term funding arrangements at scale so

Leela mentioned that we’re now at the stage in nepal where the government is committing to buy all of the quarry exiting that’s going to be needed and we’re starting off very very well in sokoto where the government from the very beginning is committed to purchasing the cleric sedin we also need robust supply chain and if if we are if we have an existing supply

Chain that’s reasonably good then we can build on that and work with that but if we if we don’t have that to begin with we we we need to assure that need to build that we need to have service delivery strategies that take advantage of the existing channels finally on an ongoing basis like as a program is is being implemented at scale we need to have robust program

Performance management and that that means that we need to be monitoring key aspects of program performance especially coverage and we need to be equipping people kind of up and down the management chained to be using data that’s coming from their monitoring to continually improve performance of the program there are existing practices of applying something to the

Cord so in nepal you heard about the application of mustard seed oil and other substances well in madagascar there’s a very common practice of applying alcohol to the to the cord stump both for home deliveries as well as for health facility deliveries so we’re starting with an already existing feeling that you should be putting something on it and it’s important

To take those existing practices into account and to build from there we have a strong imperative to promote facility based care especially facility-based delivery there is still no substitute to it and we everything we’re doing even in even in in terms of promoting you know the use of misoprostol one is expressly intended to ultimately if the best if the birth

Nessa takes place away from the home that we make that happen as quickly and as soon as possible but there’s still a number of factors that still and you know compare women sometimes by choice but often not by choice to have the baby at home but and our goal is to save the mother and fun anti child as well i went nigeria twice the work with deceive and what was

The to participate in the un commission meeting at the same for the life-saving commodities at the same time we got opportunity to share on behalf of chlorhexidine working group meeting and we share the nepali experience it’s great that you know 50 countries you know know about for hexa dean from vocal cord care and maybe 50 countries have actually even attempted

To introduce it at some level in a pilot phase but if that’s as far as it goes it’s really not going to have a huge impact on mortality and what we really want to see is that so what we ultimately need to look at is what are the coverage rates at a population-based level chlorhexidine is it’s very cheap like it can be as cheap as a few cents per newborn we’ve got

Evidence that it’s that it’s efficacious and in high mortality settings where infection accounts for a large proportion of mortality you can avert a significant proportion of newborn deaths by using chlorhexidine it’s it’s easy to deliver so even in weak health systems there’s potential for achieving high coverage has to the best that is not harmful practices you

Know i think we called it the best buy in newborn health that’s available currently if you’re serious about health activism if you’re not writing an editorial on you know collects it in and newborn care then you’ve missed the boat you

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Better Cord Care Saves Babies' Lives: Country Perspectives on Chlorhexidine Programming By JSI