To save lives of moms and babies and improve care in low-income settings, frontline workers need periodic coaching to master using the Safe Childbirth checklist. Here, a nurse (sitting) and her two coaches, part of a large trial now underway in northern India. Source: Ariadne Labs
Imagine this. You’re a staff nurse at a rural hospital in Uttar Pradesh, one of India’s poorest states, and you’re responsible for deliveries at the busy facility. The other staff nurse didn’t show up, and you have no doctor onsite for backup, a common occurrence. You have six women in recovery, one woman with the baby crowning, and multiple other responsibilities tugging at you. You had a training course in safe birth practices, but the list of things you were expected to do was more than you could memorize. And no one ever explained how you were supposed to pull all of it off in the chaos of a real birth center anyway.
Then the baby is born, and she’s blue. She’s not breathing. Your heart starts racing. It comes back to you that you were supposed to have a bag mask ready for resuscitation of the newborn. But now what are you supposed to do?
Scenarios like this play out every day in India, and across the developing world. Every year, almost 300,000 women die giving birth and one million newborns don’t survive their first day, because quality maternity and newborn care is in such short supply in low-income settings. Most of these deaths are preventable – but how?
A multi-year research program is underway to address that challenge in 120 public hospitals across Uttar Pradesh. The BetterBirth trial aims to rigorously test whether practical changes in health workers’ behavior – applying WHO’s Safe Childbirth checklist - can actually reduce major harm and save lives when they are most in danger.
The checklist idea was originally developed by the aviation world to help pilots ensure basics weren’t forgotten, to reduce complexity, and foster teamwork. The Safe Childbirth Checklist we’re testing in Uttar Pradesh aims to achieve the same goal. It’s a user-friendly distillation of best practices such as handwashing, taking the woman’s blood pressure, and having all your critical life-saving materials available at the bedside including key medications, a sterile blade, a suction bulb—and a bag mask for resuscitation.
If our major stress test in real time of an innovative childbirth safety program is effective, it could provide us with a model which could be replicated globally – a game changer for maternal and newborn survival, in other words. Our partners include the government of India, WHO and Population Services International, as well as the Community Empowerment Lab in Uttar Pradesh, the state government.
What happens in India matters greatly worldwide. It’s the world’s largest democracy. It also has the largest number of maternal and newborn deaths. The Indian government is addressing that challenge head on, with the recent launch of the India Newborn Action Plan (INAP), the country’s first nationwide commitment to save newborn lives.
“The vision of the India Newborn Action Plan is a world with no preventable deaths of newborns or stillbirths,” said Dr Rakesh Kumar, Joint Secretary, RMNCH-A, Ministry of Health and Family Welfare, Government of India.
It’s our job with the BetterBirth trial to translate these high-level policy goals into measurable reductions in maternal and newborn deaths on the ground. We know it isn’t enough to get women to deliver their babies in health care institutions rather than at home. To save the lives of mothers and babies, you have to improve the quality of care. And that's really hard to do.
“Addressing gaps in newborn health is the single most important thing we can do to reduce child mortality in India and worldwide. It is also one of the most important things India can do to ensure health equity – in particular for women and children,” Melinda Gates, co-chair of the Bill & Melinda Gates Foundation, said recently in Delhi at the India Newborn Action Plan launch. “We’re committed to supporting Indian leadership in advancing appropriate new technologies to achieve the greatest impact. The WHO Safe Childbirth Checklist in Uttar Pradesh is an astonishingly simple and powerful idea for improving the quality of care.”
To achieve this, our trial is heavily focused on coaching nurses who are the backbone of staff delivering babies in Uttar Pradesh health facilities. We’ve found that nurses mentoring other nurses is most effective.
What will motivate these staff nurses to change practices on the job under working conditions requiring daily heroism? Can strengthening nurses’ abilities actually reinforce the system itself? What are we learning through this process?
Watch this space. We’ll be exploring these questions in upcoming blog posts on the BetterBirth trial. We invite you to comment and share on Twitter with a message such as this one:
The safe childbirth #checklist: a game changer for #EveryNewborn #INAP
This post is part of the Maternal and Newborn Integration Blog Series, which shares themes of and reactions to the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting. This blog was originally published by the Maternal Health Task Force.
- The need for pain medication during labor
- The rate of prolonged labor, labor complications, episiotomies, caesarean sections, low apgar scores, lack of exclusive breastfeeding, and severe postpartum depression
- The risk of newborn sepsis
In addition, global experts identified key areas to address when implementing integration to improve health outcomes for both the mother and newborn. The themes included strengthening service delivery points, preventing “content-free contact,” and understanding context and health systems in order to implement integration.
Recognizing and addressing disrespect and abuse are essential for evaluating context and strengthening service delivery points to improve maternal health outcomes. Lastly, disrespect and abuse may prevent a woman from seeking skilled care, which means she and her newborn are both exposed to unskilled care, or no care at all.
Increasingly, worldwide, more women are delivering in facilities, where they have safer births with trained providers. And while this is good news, statistics on respectful maternity care (RMC) reveal that the care women receive at the facility is one of the biggest drivers—or obstacles—to the type of treatment they’ll choose.
According to Diana Bowser and Kathleen Hill, “examples of disrespect and abuse (D&A) include subtle humiliation of women, discrimination against certain sub-groups of women, overt humiliation, abandonment of care and physical and verbal abuse during childbirth.” The causes of D&A during maternity care can vary – beginning at the community level with a lack of engagement or financial barriers, and extending to individual providers, who may lack training or have personal biases. But the result is often tragically the same: too many women deliver at home and with untrained providers because they fear the D&A that may accompany a facility birth.
In some cases, policy makers, program managers, and care providers are unaware of the D&A that is experienced in their own settings or the settings for which they are responsible. In other cases, people entrusted with the care of women and their newborns may recognize a need for RMC, but may feel ill-equipped to address it.
In response to these needs, USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) launched a Respectful Maternity Care Toolkit in 2013 to provide the necessary tools to these actors to begin implementing RMC in their area of work or influence. With these combined tools, users can help to change and develop attitudes within themselves and among their colleagues and other stakeholders in the care of women and their newborns – and, ultimately, reduce this underutilization of skilled birth care.
For providers, improving RMC can be as simple as addressing patients by name, using understandable language, and conducting examinations privately. It involves sympathy: looking for signs of anger, stress, fatigue and pain. To a fearful patient, it is critical to explain any actions being taken, and to provide reassurance.
But to truly remove D&A from all care, we must gain acceptance at the highest levels: among policymakers and program managers, clinicians, and other groups and institutions who affect the work done every day by providers on the ground. These stakeholders must hold providers accountable by establishing processes for registering complaints and effectively enforcing policies.
As Bowser and Hill point out, “A central factor at the core of addressing disrespectful care at birth is the unequal relationship between the skilled provider and the woman giving birth.” To even this playing field, medical personnel must be held responsible for D&A and even the most marginalized women—those who are illiterate or of an ethnic minority—must be able to assert their complaints without fear of redress.
As we continue marking the final days to the Millennium Development Goals, we know that MDG 5—improving maternal health—can only be met if more women choose safer, facility-based births. RMC is not a checklist, an intervention, or a dialogue that is spoken: it is an attitude that permeates each word, action, thought, and non-verbal communication involved in the care of women during pregnancy, childbirth, and the postnatal period. Let us ensure women receive this basic human dignity during one of the most vulnerable times in their lives.
Photo: The Bill & Melinda Gates Foundation
It is well-recognized that gender inequalities exist around the world. Evidence has also mounted showing that the marginalization and neglect of the needs, roles and potential of women and girls are key factors limiting advances in human health and development outcomes for all – women, men, boys and girls.
Moreover, strong associations have been identified between addressing inequalities and enhancing women and girls’ empowerment and agency, and improved health and development outcomes across sectors ranging from agriculture to family planning and maternal newborn and child health and nutrition. Investing in women’s and girls’ empowerment is a smart investment for overall development as well as a matter of social justice. And many global health organizations are recognizing these facts and acting on them to magnify the impact they are able to achieve.
In this week’s issue of the prestigious magazine Science, Melinda Gates weaves together her personal experience and journey of learning that has resulted in her call for our foundation to address gender issues more intentionally in our work. Drawing from the latest evidence as well as extensive observations and conversations with women in low and middle countries, she recognizes that it is a matter of social justice when women – half of the world’s population – are marginalized, lacking in agency and voice, and unable to share in control of income or assets or influence decisions in their homes and communities.
Addressing gender inequalities is the right thing to do, as a fundamental right of women and girls to equal opportunity to live a healthy and productive life. She also argues that gender equality is key for achieving impact across multiple health and development sectors. It is the smart thing to do too.
It’s important to measure the impact of health and development programs, not only on sector outcomes such as modern contraceptive prevalence rate, prevalence of stunting, immunization rates, or access to digital financial services, but also on gender outcomes – things such as equitable decision-making power, personal safety, mobility, and equitable interpersonal relations in the home which promote women’s individual dignity and safety. These outcomes reflect empowerment of women and girls not only as a fundamentally important end in and of themselves. They also are the ingredients that enable women and girls to be engines of change in their communities, thus creating a virtuous cycle of enhanced gender equality and women’s empowerment and improved health and economic and social development for households, communities and nations. Thus, to ignore gender in health and development programming – to be blind to gender inequalities and therefore to do nothing intentional to address them – leads to missed opportunities to enhance the lives and potential of women and girls as well as men and boys, and leads to lost health and development impact as well. It’s poor stewardship. What’s more, being gender blind or unintentional is a roll of the dice. Impact of health and development programs may be lost, but women and girls could also be harmed. The potential for gender-based violence is real, for example, when women begin to gain access to financial resources through increased agricultural productivity, or family planning services, or, as highlighted by Malala, when girls gain access to education.
As a learning organization, Melinda Gates calls upon our programs to move beyond the existing evidence to help accelerate discovery of how to most effectively and intentionally identify and address gender inequalities. We also need to do more to develop better measures of the impact of interventions to enhance women’s and girls’ empowerment and agency. Combining interventions in health and development (for example, improved supply chain logistics for contraceptives) with interventions that address an existing gender gap (e.g., facilitating conversations between men and women, leading to more collaborative decision-making about family planning) might lead to enhanced sector outcomes (for example increased modern contraceptive prevalence rate) and gender outcomes. These actions may improve outcomes in other sectors too, for example improved child nutritional status. Aspects of agency such as equitable influence and control over assets and decision-making power have positive associations with outcomes across multiple sectors. Many organizations have worked for years to identify effective ways to address gender inequalities and empower women and girls. It’s time for the foundation to join forces with these important and ground-breaking efforts, be more intentional about addressing gender inequalities, and scale up approaches that we know work, in context-relevant ways, within existing health and development programs.
Additional research and rigorous evaluation are also needed to investigate how addressing gender inequalities and promoting women’s and girls’ empowerment will enhance the ability to achieve impact in different sectors, and how sector and gender outcomes can influence each other. Furthermore, there is a gap in our knowledge of the existence and measurement of gender inequalities and the cost-effectiveness of approaches to address them in different contexts. Innovation, integration and better data and measurement are needed in this space. We don’t have all the answers today but we have a plan and call to action to get smarter about each of these issues over time.
This is the journey of learning that Melinda Gates is calling the foundation to, and CEO Sue Desmond-Hellmann will be leading going forward. This is what we intend to deliver. Many of our program teams have been working intentionally to address gender issues, but we recognize that we can do more. We will be making additional investments in the near future, for example in a new Grand Challenge that will be launched in early October. It’s an exciting evolution in our organization. Most importantly, it’s a change that will position us to more effectively engage with partner organizations working to enable women and girls around the globe to improve their well-being and that of their families, societies and our world.
Dr. Rifat Atun of the Harvard School of Public Health speaks on one of the opening panels during the Integration of Maternal & Newborn Health Care meeting in Boston. Photo: Ian Hurley/Save the Children
Join us over the next two weeks as the Maternal and Newborn Integration Blog Series unfolds. This blog series will dive into the details of the meeting discussions and action items. In addition, meeting participants and speakers will share their reactions to maternal and newborn integration from a variety of perspectives. You can also view this series on the Maternal Health Task Force's blog.
On September 9th and 10th, the Maternal Health Task Force and Save the Children’s Saving Newborn Lives program convened experts in Boston to discuss maternal and newborn health integration. The meeting, “Integration of Maternal and Newborn Health Care: In Pursuit of Quality,” hosted about 50 global leaders—researchers, program implementers and funders—in maternal and newborn health to accomplish the following three objectives:
- Review the knowledge base on integration of maternal and newborn health care and the promising approaches, models and tools that exist for moving this agenda forward
- Identify the barriers to and opportunities for integrating maternal and newborn care across the continuum
- Develop a list of actions the global maternal and newborn health communities can take to ensure greater programmatic coherence and effectiveness
Biologically, maternal and newborn health are inseparable; yet, programmatic, research, and funding efforts often address the health of mothers and newborns separately. This persistent divide between maternal and newborn health training, programs, service delivery, monitoring, and quality improvement systems limits effectiveness and efficiency to improve outcomes. In order to improve both maternal and newborn health outcomes, ensuring the woman’s health before and during pregnancy is critical.
Reviewing the Knowledge Base
Participants work in small groups during the Integration on Maternal & Newborn Health Care meeting. Photo: Ian Hurley/Save the Children
The meeting focused on a variety of themes as global experts led presentations and gathered for small group work to discuss next steps for integration of maternal and newborn health care. While little research thus far has been specifically devoted to maternal and newborn integration, it was shown that great inequity exists among maternal and newborn health interventions and that while about 90% of women receive at least one antenatal care visit, only slightly more than half deliver with a skilled attendant at birth, and about 40% receive postnatal care. These disparities along the continuum of care helped meeting participants identify service delivery points in need of strengthening and optimization to ensure the health of both the mother and newborn. Given the limited knowledge base, leaders were encouraged to strengthen the evidence by engaging in research to identify both the costs, and potential risks of integration.
Opportunities and Barriers for Integration
Overarching themes that emerged while evaluating integration at the meeting included optimization of service delivery points to prevent “content free contact” and the need for efforts to be context specific. There was broad consensus that programmatic and policy efforts for integration need to recognize and reflect the local environment and the capacity of the health system. The meeting concluded that integration should not be viewed as an intervention in and of itself, but rather as a method of reevaluating and designing health systems to effectively provide better maternal and newborn health care, ensure better outcomes, and incur less cost. In approaching integration in the future, it was made clear that some of the most important factors for integration include assessing and understanding contextual factors, as well as anticipating what the woman, family, and health care workers need and want.
Case studies were presented from Ecuador, Nigeria, and the Saving Mothers Giving Life program. Each presenter evaluated approaches for integrating health systems, programmatic strategies, and service delivery in order to optimize maternal and newborn health outcomes. These case studies provided potential models for maternal and newborn health integration in future programmatic efforts.
Actions for Greater Programmatic Coherence
Lastly, and perhaps most importantly, small groups presented action items and next steps to strengthen the evidence for integration and promote integrated care so that no mother or newborn is neglected in programmatic efforts. These action items were created for three levels: facility and service delivery; national policy and programming; and technical partners and donors.
Proposed action items include improving and redesigning health workforce training; ensuring quality improvement; integrating health information systems; aligning global maternal and newborn health initiatives; integrating advocacy tools for maternal and newborn health care; and unifying measurement frameworks.
Nurses and midwives in Pakistanís Sindh province attend a Jhpiego-supported training on Helping Babies Breathe, a program designed to address birth asphyxia and reduce newborn deaths. Photo: Jhpiego
Pakistani nurse revives infant with Helping Babies Breathe techniques
Khairpur, Pakistan–The 36-year-old woman arrived at the Lady Wellington Hospital in labor, exhausted and anxious that her baby would not survive. Abida, the mother of one previous child, had a history of miscarriages and failed pregnancies.
“It was a prolonged labor at home. … The staff performed a vaginal examination and found that she was 10 centimeters dilated but the baby was in distress,” recalls Tasleem Mirani, the only nurse in the labor ward that morning. “I quickly assessed her condition and … prepared her for delivery.”
As Abida gave a last push, “there it was, a tiny baby girl, quite a bundle of joy, except she was pale and almost lifeless,” says Mirani.
The nurse recognized the problem immediately–birth asphyxia, a leading cause of newborn deaths worldwide. Mirani knew she had 60 seconds to resuscitate the newborn before the condition would cause irreparable harm or death. She was among 121 nurses and midwives from Sindh province who had participated in an innovative newborn resuscitation program supported by the U.S. Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego. Helping Babies Breathe (HBB) is an evidence-based program designed to teach resuscitation techniques to midwives in healthcare facilities that lack sufficient health professionals.
Under HBB, the quality of care administered within the first 60 seconds of a baby’s life– “The Golden Minute”–can determine whether or not the newborn will survive.
Although preventable, birth asphyxia contributes to 920,000 newborn deaths a year, approximately 28 percent of the estimated 3.3 million babies who die within the first month of life, according to the Ending Newborn Deaths: Ensuring Every Baby Survives report published by Save the Children, an MCHIP partner. It can lead to serious neurological conditions ranging from cerebral palsy and mental retardation to epilepsy. In Pakistan, approximately 280,000 newborns die at birth, due in part to limited access to skilled birth attendants.
Once Mirani noticed the ashen color of Abida’s baby girl, she sprang into action. She lifted the baby off Abida’s stomach, where she had been placed as part of skin-to-skin contact and mother-to-child bonding, and rubbed the infant’s back.
She used a sucker bulb to remove any mucus clogging the baby’s airways. When that did not help, Mirani cut the umbilical cord and rushed the baby to the labor room’s HBB table, where an Ambu bag — a manual resuscitator — and pictorial instruction chart were waiting.
As the nurse pumped the Ambu bag, the tiny baby girl’s skin began to turn pink and she cried out with life. An exultant Mirani returned the baby to her mother to keep the infant warm. “I was so proud when I gave the crying baby to her mother for skin-to-skin care,” she recalls.
And Abida was overjoyed, knowing that her small family had a new addition–a healthy girl.
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The Healthy Newborn Network Blog provides timely information and insights from the global newborn health field and seeks to promote dialogue on important newborn health issues. The blog is a platform for the HNN Editors and guest contributors to post commentaries on current happenings in the newborn health field. The content of each post and comments expressed on the HNN blog are those of the individual contributors and do not necessarily represent the views and opinion of the HNN or its Partner Organizations. >>Read a note on leaving comments
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