Policy & Stakeholders
Continuum of care and integrated care
Improve reproductive maternal child and adolescent health
Contributed by Dr Vijay Kumar (SWACH), Dr Suresh Dalpath (NHM Haryana), Dr Saket Kumar (MD NHM Haryana)
Reduction of preventable maternal and child deaths as well as still births especially in India and other low and middle level developing countries will continue to be a priority as a part of efforts towards reaching sustainable development goals (SDG). The adoption of an integrated, continuum of care approach has a huge potential to not only achieve the mortality reduction goal but also have a host of other positive effects including reduction in malnutrition (which contributes to about half of under-fives deaths), attainment of full potential for productivity and reduction of adult onset chronic diseases that are becoming a huge burden on the countries and leading to premature deaths. It has been estimated that through 90% coverage, it will be possible to avert additional 149,000 maternal deaths, 849,000 still births and 1,515,000 child deaths. Meeting the unmet needs of family planning with a coverage of 90% would avert 28 million births. This would mean preventing 67 000 maternal deaths, 440 000 neonatal deaths, 473 000 child deaths, and 564 000 stillbirths from unintended pregnancies. Sustained advocacy is needed to commit annual increments of about US$6·2 billion in low-income countries, $12·4 billion in lower-middle-income countries, and $8·0 billion in upper-middle-income countries to obtain desirable coverages and aim at improved quality of care. The adoption of this approach is strategic to upgrade individual care as well as public health. The basic principles of continuum of care are highlighted in this communication. Coverage of key indicators during the continuum will be presented in another communication.
History and current status
In the 1970s, continuum of care was applied first in the context of provision of continuity of care to the elderly. This was then broadened in scope to individual patient care to improve their follow up. A large number of research papers were focused on palliative care, nursing and mental health. Around the same time, there was global consensus on primary health care and health for all. However, there were competing interest from priority programs like EPI, eradication of polio, control of tuberculosis and control of HIV/AIDS. This debate and competition for resources has not been resolved yet. Until 2002 only one paper highlighted public health and health promotion aspects of continuum of care. Even now there is a lot of stress on bio medical interventions but low emphasis on social determinants and family and community components. Further searches of more than 400 publications helped identify only 8 publications where the context appeared relevant. The policies, programs, and information systems that are needed to guide an eﬀective, integrated, population-level continuum of care have not been adequately addressed in the published work. This can be regarded as a major gap in building universal consensus on the adoption of an integrated approach to continuum of care.
Different life stages in the continuum of care
(Source: Joseph de Graft-Johnson,Kate Kerber, Anne Tinker,Susan Otchere,Indira Narayanan,Rumishael Shoo, Doyin Oluwole,Joy Lawn Opportunities for Africa’s Newborns – World Health Organization www.who.int/pmnch/media/publications/execsum.pdf pages 23-36 accessed December 2016)
The second important component of continuum of care is places of care giving and care provision. It comprises of (a) household and community care (b) outpatient and outreach services and (c) hospital and health facilities. These levels of care are linked through appropriate and safe referral and follow up of the sick. There should be good linkages in order to ensure seamless and synchronized provision of integrated care at all delivery points.
Places of care provision in the continuum
(Source: Joseph de Graft-Johnson,Kate Kerber, Anne Tinker,Susan Otchere,Indira Narayanan,Rumishael Shoo,Doyin Oluwole,Joy Lawn Opportunities for Africa’s Newborns – World Health Organization www.who.int/pmnch/media/publications/execsum.pdf pages 23-36 accessed December 2016).
Based on evidence, there are 8 packages and 190 interventions recommended for the implementation of continuum of care. The 8 packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. These packages are robust and comprehensive but continue to face implementation challenges. It is also important to recognize that synergistic connections between the three delivery approaches are necessary; since none of them is suﬃcient on its own.
The health of mothers, newborn babies, and children consists of sequential stages throughout the lifecycle. The success at each stage is dependent on the earlier stages. Planning and spacing of pregnancies and the health of the woman when she becomes pregnant determines her health and health of her rapidly developing fetus. Utilization of good quality antenatal care including appropriate management of high risk pregnancy determines place of child birth and the outcome of pregnancy. The quality of services rendered during child birth influences the use of services during post natal period. The utilization of services and family behavioral practices during childhood are determined by earlier experiences. Quality of services including skilled birth attendance and emergency obstetric services is a well-recognized intervention in the reduction of preventable maternal deaths, near misses, still births and neonatal deaths. Post-natal care is a big gap in the continuum of care that influences the survival, thriving and transformation. Exclusive breast feeding for the first 6 months followed by nutrient dense complimentary foods combined with care for early childhood development lays the foundation for lifelong good health and productivity. The health and development during adolescence depends on health and development during childhood, infancy and neonatal period respectively. In many ways, the outcomes are guided by cumulative experiences and interventions. It should be emphasized that the process of development and health occurs much the same way as the layering of a cake or the correct use of laying bricks, mortar, cement and steel for laying the foundations of a strong building.
Success of the program in terms of public health and individual care depends on the adoption of an integrated approach. Throughout different life stages and especially during antenatal period and the first two years, the integrated approach comprises of (a) nutrition (b) play and communication (c) prevention of accidents and injuries and (d) early and appropriate response to illness. Saving lives depends on high coverage and quality of integrated service-delivery packages throughout the continuum, with functional linkages between levels of care in the health system and amongst service-delivery packages, so that the care provided at each time and place contributes to the eﬀectiveness of all the intricately linked packages.
Within the continuum of life stages, there are critical and sensitive periods that require a special focus and have greater impact than others. For example child birth (although a period of short duration) is very dramatic and requires skilled care that is resource intensive and requires skilled birth attendance and emergency obstetric care. In contrast, a very effective intervention of early initiation of breast feeding and exclusive breast feeding requires mother’s commitment as well as support of the family, community and providers for its success. An intervention like fortified food (iodine, iron folic acid) or iodization of salt requires policy support for its success.
Although the continuum of care covers the entire life course, this communication is focused on pregnancy, childbirth, the postnatal period, and childhood. It does not cover the critical periods of adolescence, pre and peri conception periods and other stages of life even though these are also critical stages in life course. The implementation of continuum of care should be guided by the national policy, context and resources. It can be built in stages and expanded based on the availability of resources, social determinants of health and ongoing monitoring of the program. Since it may be difficult to implement the whole package due to numerous constraints, it is advisable to focus on critical and sensitive periods of life through selection of interventions based on the local situation as a starting point and build up incrementally matching resources. This would help to expand the scope of continuum of care and integrated approach progressively in an equitable manner. There is no doubt that all the components of continuum of care need more resources, and there is a yawning gap related to quality and equity for improved coverages of key interventions. Amongst the key life stages the neglected areas that deserve special focus are (a) post natal care (b) integrated family and community care in its own right (c) and care for early childhood development. The component of care for early child development even though evidence based, has received scant attention till date because of the preoccupation with mortality reduction.
Amongst the various interventions, child birth is probably the most dramatic and challenging. It is no doubt costly but it has the highest potential to save lives. It requires 24X7 services by trained, well supervised personnel and well equipped hospital or health centers. Low risk child birth also requires skilled birth attendance which does not come cheap. The other interventions in continuum of care are not as resource intensive as child birth services and can be delivered mostly on outpatient or outreach basis. However, the delivery of these services even though less resource intensive require the same rigor in terms of quality, coverage and equity as child birth care services to obtain favorable outcomes. The third category comprising of family and community care even though simple requires adoption of healthy behaviors and practices and demand for quality health care that is timely and appropriate. This has to be socially and culturally acceptable for its success and needs quality inputs from the family and the community health workers and those who work at the interface of the family and the facilities/outreach services. Unfortunately, the investments in India and most developing countries continue to be low.
There is no need for a “choice” between community care and clinical care – both are needed and should be synchronized. The facility is necessary to provide services, and the community is necessary for healthy home behaviors and demand for care. In the same way there is no need for a “choice” between ANC, childbirth care and PNC. Instead of competing calls for various packages or programs, the continuum of care focuses attention on high coverage of effective MNCH interventions and integration – a win-win for mothers, babies, and children and for health system strengthening. For the interventions in the continuum of care to succeed, there is a need for synergies between health care provision and participation of all the stakeholders.
Packages of continuum of care
- Reproductive health clinical-care package (facility based) Women of reproductive age might need clinical case management concerning problems of women during reproductive age (abortion, STI, HIV gynaecological problems). Unsafe abortions comprise of one of the prominent cause of maternal deaths. In India, termination of pregnancy is legal. It should be provided by trained provider in an equipped facility to reduce the risk of complications and deaths.
- Childbirth clinical-care package (facility based) consists of skilled attendance for normal low risk childbirth and emergency obstetric care in higher level facilities. Skilled care at birth and immediately after birth can determine the survival and health of both mothers and babies. The increasing rates of skilled attendance at birth have reduced home births in Haryana following intensification of efforts by NRHM. The challenge now is to improve the quality of services rendered at the time of child birth to help reduce maternal mortality, preventable still births and early neonatal mortality. This would also contribute to reduction in the occurrence of near misses and serious complications (hemorrhage, eclampsia, obstructed labor, sepsis or unsafe abortions). Besides improvement in quality of services rendered, it is important to facilitate early care seeking and safe transport in cases with complications.
- Newborn baby and child clinical-care package (facility and outpatient care) Levels of care rendered to sick newborn babies (management of asphyxia, premature and low birth weight babies, infections) in the facilities need improvement to reduce deaths in newborn within the first week of birth. It also includes provision of care during the continuum through integrated management of childhood illness (IMCI). This would require upgradation of capacity of facilities and of health care providers at all levels.
- Reproductive health package (outpatient and outreach services) can be used to deliver many interventions, including health education, contraception and family planning. These can improve both child and maternal health. Prevention, early detection, and management of STIs are crucial throughout the lifecycle, for both men and women. Reproductive health is closely tied to the education, nutrition, and health services that girls and women receive throughout their lives. Due to gender inequity in many states in India, many girls are underfed, undereducated, and experience gender-based violence. They marry young, and they have little power to make decisions such as the timing of their ﬁrst pregnancies or family planning. Even when reproductive health interventions are delivered, poor quality of services can hinder their use. Most women who present at family-planning clinics have already decided which contraceptive method to use; but there are unmet needs. In many settings, social marketing has made contraceptives more accessible but this approach has not been used on scale.
- Antenatal care package (outpatient and outreach service): All pregnant women need a minimum of four visits, at speciﬁc times with provision of evidence-based content. Essential components of a focused antenatal-care package include screening for and treatment of disorders (such as severe anaemia, abnormal presentation, hypertension, diabetes, STI, and other illnesses); provision of preventive interventions (such as micronutrient supplementation, tetanus immunisation and insecticide-treated bednets); and counselling about diet, hygiene and birth preparedness. Antenatal care has good coverage but to be effective, it needs quality and equity.
- Postnatal care package (outpatient and outreach services) Post-natal care is needed to reduce deaths of mothers, preventable still births and neonatal deaths, and to support adoption of healthy behaviors. Post-natal care is one of the most neglected areas in the continuum of care. The post-natal package includes 4 post natal visits comprising of visits in the ﬁrst days after birth (day 1,3,7 and 42). The number of visits should be increased when risk is high. These visits are meant to promote healthy behaviors, to identify complications, and to facilitate referral. Some mothers or babies will need extra support because of higher risk (preterm babies, sick mothers and sick babies). Delivery strategies for postnatal care should be context-speciﬁc. These should be structured and designed to improve family behavior and early care seeking in the event of an illness.
- Child health package (outpatient or outreach services) Immunizations have achieved high coverage though there are problems relating to equity. The progress in nutrition has not been able to match immunization even though it has far reaching implications. Exclusive breast feeding rates are improving though slowly. A weak area is the complimentary feeding starting at 6 months age, with energy dense foods and micronutrient supplementation. Success would depend on greater investments and improved outreach as well as appropriate family behavior. India is focusing on integrated management of newborn and childhood illness. To be effective, facility and community based IMNCI need to be implemented and coordinated.
- Family and community care package This package aims primarily to improve healthy home behaviours and to increase demand for outreach and clinical services. This package is a very important
Summary of packages included in the continuum of care
(Source: Joseph de Graft-Johnson,Kate Kerber, Anne Tinker,Susan Otchere,Indira Narayanan,Rumishael Shoo,Doyin Oluwole,Joy Lawn Opportunities for Africa’s Newborns – World Health Organization www.who.int/pmnch/media/publications/execsum.pdf pages 23-36 accessed December 2016)
Component of continuum of care. It includes simple measures like (a) hands washing and hygiene (b) exclusive breast feeding (c) seeking out for basic health care e.g. antenatal care, vaccination, child birth according to recommendations, (d) participation in feeding and micronutrient distribution programs, (e) early recognition of danger signs followed by appropriate care seeking from health facilities and hospitals. The package requires credible counseling and can be strengthened through (a) social marketing of products like contraceptives, ORS and zinc, sanitary napkins, insecticide treated bednets in malarious areas etc (b) supplementary feeding programs (c) participation in facilitated group meetings and (d) use of mobile technology to build capacity of families and communities.
The above 8 packages are robust and comprehensive. All of the above packages and also most of the 190 interventions are already included in the national policy. However, synergistic connections between the three delivery approaches are necessary; since none of them is suﬃcient on its own.
Policy and strategy considerations
Though initiated in the last century as primary health care and health for all, the efforts towards adoption of continuum of care have received a boost in pursuit of millennium development goals and the process is likely to be further accelerated in the years to come. India is a signatory to the SDG and it has already taken a lead through the adoption and roll out of RMNCH plus A strategy and is committed to universal health coverage. Progress in continuum of care will occur if there is (a) policy and strategy support (b) increase in investments incrementally (c) improved management of health system with a focus on skills development of providers and (d) engagement of stakeholders. The greatest returns will accrue when there is meaningful participation of families and communities and seamless integration with the services available.
Opportunities available for success of continuum of care
- Empowering women, families and communities to improve their own health through promotion of hygiene (frequent hands washing, safe disposal of excreta), exclusive breast feeding and appropriate complimentary feeding, timely care seeking and compliance with the advice given in outreach and home visit sessions.
- Availability of a variety of tools, including counselling cards, group facilitation guides, flipcharts, and training manuals, to support family and community interventions.
- Deploying well trained and supervised community workers who are a part of a system in which referral pathways are operational and quality care is available at the health facility. A combination of home visits (e.g. home postnatal care, breastfeeding) and services rendered by community health workers (e.g. treatment of diarrhea, pneumonia, malaria) can be used effectively. These workers when given the appropriate knowledge and skills, have proven their ability to detect and manage selected newborn and childhood illnesses such as pneumonia or sepsis or diarrhea or malaria. Besides improving case management, the CHWs can help improve good home care practices and recognize sick newborns for timely referral to a hospital.
- Care at the level of outreach and outpatient service delivery often serving as the first point of entry in the health care system and improves the survival of women and babies by forming the link between households and district hospitals by bringing services closer to home.
- Social marketing of specific products such as contraceptives, ORS, zinc, ITNs, or clean birth kits.
- Providing a mix of mostly antenatal and child health, with particular focus on growth monitoring and immunization services. Outreach services present opportunities for integration by adding early basic postnatal care for the mother and newborn. This can also help bring services closer to home for the clients. These services can reduce the pressure on overloaded facilities responsible for child birth through monitoring of labor outside the facility and safer transfer to the birthing facility. This is convenient, safe, less expensive and less traumatic for the client.
- At the primary care level, peripheral facilities and staff should be prepared to assist uncomplicated births and offer basic emergency obstetric and immediate newborn care such as hygiene, warmth, support for optimal feeding practices and resuscitation where needed. In addition, these facilities should be able to manage sick newborns and LBW babies (Kangaroo mother care (KMC) and refer where appropriate. Midwives and health workers can safely perform lifesaving procedures, including manual removal of the placenta, and diagnosis and management of the sick newborn.
- Opportunities through hospitals – At the top of the health care system is the district hospital, serving as a referral facility, which should deliver a core package of services with a prescribed set of staff. District hospitals should be equipped and supplied to provide emergency obstetric care to manage complications and emergency newborn care for all major newborn complications including birth asphyxia, preterm and very LBW babies, and sepsis. These hospitals provide treatment for severe conditions and manage complications.
Barriers to continuum of care
- Equity- reaching poor, rural, and remote populations who have the highest risks and yet the least access to care.
- Barriers to care extend beyond the health service and include issues such as financial and transport constraints especially relating to child birth and post-natal care.
- Human resource limitations, especially the lack of skilled attendants.
- Barriers related to family behavior, cultural practices and communication.
Care seeking and sociocultural determinants such as lack of gender equity in particular and the low status of women in households and communities also hinder women’s ability to seek care or take action when a complication occurs.
Innovations to be considered
- Mothers-to-mothers education and women’s groups: demonstrated to be of the most effective application of peer-to-peer education. Mothers are trained to advise other mothers and pregnant women on healthy living and care-seeking.
- Enhancing the health literacy and care-seeking among mothers: provision of relevant health information to pregnant women and new mothers using personalized text and/or voice messages that encourage them to visit local facilities for antenatal care and to immunize their children. Connecting remote populations with health providers: communication of patients with their health care providers via mobile phones to save travel time and to improve the efficiency of service delivery. Innovative use of mobile health and related information and communication technologies should be given priority.
- Creating incentives to use health services for women in the lowest quintile: introducing vouchers that can be used in place of cash to obtain services in health facilities contracted by the implementing organization or MOH. Removing financial barriers to health services: private providers redeem vouchers used by women to pay for anternatal and maternal services. This would help to reduce the burden of out of pocket expenses.
- Task shifting: delegation of tasks to less specialized health workers as a viable solution for improving coverage of essential services by making more efficient use of the human resources already available. One of the examples of task shifting is the use of CHWs to deliver basic health care interventions in the communities where health facilities do not exist or lack professional health care providers. The approach proved to be effective where CHWs have been provided with proper training, supervision and incentives.
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