Raeda, 33, recovers in a bed at Al Awda Hospital after giving birth to her firstborn, a daughter. Raeda lives in Jabalyia, northern Gaza Strip. Photo: Loulou d'Aki/Save the Children
The conflict has Gaza has caused the upheaval of the health system. For women and newborns it has been much more difficult to secure health services like antenatal and postnatal care, which are critical for survival and a health start to life.
The Palestinian Ministry of Health has reported that over 4500 babies have been born during the 29 days of active fighting before the first 72-hour ceasefire was agreed to. Amnesty International has also reported that health workers and hospitals have been deliberately attached during the fighting.
The needs of pregnant women and newborn babies are critical in the best of circumstances and in emergency and conflict settings there is an even greater need to prioritize and deliver care.
- World Vision: Maternal, Newborn and Child Health and Nutrition in Emergencies
- UNFPA: Providing Emergency Obstetric and Newborn Care
- Conflict and Health: Neonatal survival interventions in humanitarian emergencies: a survey of current practices and programs
- Al Jazeera: New life if born amid destruction
MESH-QI mentor conducting training on neonatal resuscitation at health center level
Partners In Health, in collaboration with the Rwandan Ministry of Health, implemented a program entitled Mentorship and Enhanced Supervision at Health Centers and Quality Improvement (MESH-QI) to address inefficiencies in current health center training and clinical practice of nurses. MESH-QI improves care delivery through:
- Decentralized pre-service training at the district level
- Building capacity of the existing district supervisory structure
- Initiation of a systems focus on clinical mentoring and coaching of health center teams
- Use of data for continuous quality improvement
Figure 1: Pillars of Mentorship, Enhanced Supervision and Quality Improvement Program
Current health center training for nurses consists of centralized pre-service training and limited in-service supervision. The pre-service training includes emergency obstetrics and newborn care (EmONC) and focused antenatal care (FANC), but periodic supervision visits by district hospital supervisors are largely consumed with data collection and reporting, with limited opportunities for on-site clinical mentoring and re-training.
To address this gap in training, MESH-QI mentors make routine intensive visits to health centers, lasting at least two days, in which they provide on-site case management observation; support for higher level problem-solving, diagnostic, and decision-making skills; lead case discussions; and address quality improvement issues (see Figure 1). By routinely capturing valuable data on nurses’ clinical skills, facility conditions, and clinical indicators, clinical supervisors also enhance the feedback loop for quality improvement.
Key lessons learned
Mentorship catalyzes translation of theory to practice
Clinicians expressed this as one of the positive aspects of MESH-QI interventions. Mentors use various adult learning techniques to support nurses to address the “knowledge-practice gap.” This facilitates the implementation of FANC at MESH-QI supported sites.
Mentorship improves clinicians’ confidence, motivation and adherence to MCH protocols
Prior to the implementation of MESH-QI, there were challenges in learning how to effectively integrate and utilize national protocols, guidelines, and tools. One nurse mentee mentioned: “They built my confidence not only in screening and case management, but also in general nursing care I provide every day. I feel proud of the work when I can handle even the complicated cases that I could not manage before… their support.”
Mentoring checklists enable evidence-based feedback and continuous QI
Using mentoring and coaching tools, such as checklists for case management, facility, and systems observations, enables mentors to provide objective and constructive feedback and regular monitoring of ANC delivery.
MESH-QI is an effective strategy to improve the quality of antenatal care
Figure 2: Quality of ANC Assessments at Baseline and Post-mentoring
With mentoring, uniform improvement was observed regardless of baseline EmONC/FANC-training status (Figure 2). This demonstrated that mentorship is a promising intervention to help improve the quality of FANC regardless of baseline training status. Mentoring, therefore, is particularly applicable to resource-limited healthcare settings facing human resources challenges. While EmONC and other didactic trainings are still costly—particularly in developing countries—on-site mentorship is an option to mitigate these challenges.
MESH-QI integrates in-service training and systems improvement into routine care delivery
In-service training bypasses the challenge of extracting nurses from their health centers to attend workshops in main cities, which could be hours away. Mentorship and coaching sessions take place at the health facility level, which avoids worsening staff shortages, an already significant challenge in resource-limited settings.
The MESH-QI approach is also proving successful in several other health domains, including neonatal care and integrated management of childhood illness (IMCI), by strengthening the entire spectrum of care for families. The Ministry of Health of Rwanda has a number of efforts underway to replicate and scale this mentorship approach.
To learn more about mentorship, enhanced supervision and quality improvement in Rwanda, please see the following:
- Description of the mentorship program in rural Rwanda
- Perceptions and acceptability of health care workers
- Mentorship and quality improvement strengthened the quality of pediatric care
- Integrated mentorship and quality improvement to improves antenatal care
Photo: Ayesha Vellani/Save the Children
World Breastfeeding Week 2014 was celebrated in August all over the world from the 1st to 7th. The week provided a platform to orient people on how about 800,000 under five child deaths can be prevented if all 0-23 month old infants are optimally breastfed.
Breastfeeding is beneficial both for mother and her children. Breastfed babies have lesser chances of asthma, childhood obesity, ear infections, eczema (atopic dermatitis), diarrhoea and vomiting, low respiratory infections, necrotizing enterocolitis (a disease that affects the gastrointestinal tract in pre-term infants), sudden infant death syndrome (SIDS) and Type 2 diabetes. While mothers who breastfeed their children have lesser chances of breast cancer; breastfeeding assist mothers in healing following childbirth and getting back to their pre-pregnancy weight quicker.
In more than 175 countries worldwide, breastfeeding advocates celebrated the theme 'Breastfeeding: A winning goal - for life’ highlighting that achieving the Millennium Development Goals (especially MDGs 4 and 5) requires more early, exclusive and continued breastfeeding.
EVERY ONE Pakistan commemorated the week with advocacy activities across the country. In Khyber Pakhtunkhwa province, a press briefing session was jointly organised by EVERY ONE and Child Rights Movement Khyber Pakhtunkhwa chapter at the Peshawar Press Club on August 7th. Then again on August 11th, EVERY ONE in collaboration with Child Rights Movement Khyber Pakhtunkhwa held an advocacy seminar for civil society organizations.
Both the events shared how Pakistan is the South Asian country with the lowest exclusive breastfeeding and highest bottle feeding rates. Over the last seven years, only a 0.6% increase has been seen in infants who are exclusively breastfed. According to the Demographic Health Survey, the overall percentage stood at 37.7 in 2012-13: Whereas, the percentage of bottle feeding rose from 32.1 in 2006-07 to 41% in 2012-13. Experts opined that the increasing trends in bottle feeding across the country were due to a lack of awareness.
In the province of Khyber Pakhtunkhwa, the percentage of exclusive breastfeeding is at 27%; percentage of infants ever breastfed is 96.5%; the timely initiation of breastfeeding is at 26.4%; while the continued breastfeeding rate at 12-25 months is 83.6% and at 20-23 months is 55%.
Civil society organisations at these advocacy events were urged to undertake strong lobbying in the form of social mobilization events, meetings with local body members, provincial legislators and the media to put pressure on the Government of Khyber Pakhtunkhwa to expedite legislation for breastfeeding similar to the other three provinces in Pakistan. The protection of children and their mothers from different diseases will be easily possible following the passage of Khyber Pakhtunkhwa Protection of Breastfeeding and Child Nutrition Bill.
Dr. Qaisar Ali, Deputy Director Reproductive Health/Nutrition stated: Except Khyber Pakhtunkhwa where legislation is still pending, all provinces have adopted/passed provincial laws for the protection and promotion breastfeeding. Due to the absence of provincial legislation in Khyber Pakhtunkhwa, the federal Protection of Breast-Feeding and Child Nutrition Ordinance 2002 is still applicable in the province. However, in the context of 18th Constitutional Amendment, Government of Khyber Pakhtunkhwa should introduce provincial legislation keeping in view the provincial realties. Recently, after two and a half year delay, the Khyber Pakhtunkhwa Protection of Breastfeeding and Child Nutrition Bill has been sent to the provincial cabinet for a final nod; however, political will is needed for approval of the bill.
CRM members also urged the implementation of the breastfeeding and marketing code, improved breastfeeding counselling by healthcare providers, and a revision of the undergraduate curriculum with a greater emphasis on good infant and young child feeding practices. The creation of baby-friendly health facilities, behaviour change strategies to promote breastfeeding, the development of effective messages and counselling of women at all education levels was also urged.
Early marriages, the poor status of women, repeated pregnancies, poor maternal nutrition, food restrictions in pregnancies due to taboos/myths, and poor antenatal care were a few of the reasons cited for the poor breastfeeding practices among women in Pakistan.
CRM members also provided information on the MDGs and how they related to breastfeeding and infant young child feeding (IYCF) to showcase the progress made so far and key gaps in breastfeeding and IYCF; to call attention for stepping up actions to protect, promote and support breastfeeding as key intervention in MDGs and in the post 2015 era; and, to stimulate interest among young people of both genders to see the relevance of breastfeeding in today’s changing world.
A documentary on the breastfeeding practices in Pakistan was also launched at the advocacy seminar. Save the Children has always been at the forefront in advocating children’s rights and by launching this impressive documentary, we once again registered our concerns on deaths among children which can be prevented by breastfeeding practices in children.
It is the basic right of an infant to be breastfeed for at least two years. Exclusive breastfeeding for at least 6 months can strengthen the immunity of a child. It gives our babies the healthiest start that will last a life time. The choice to breastfeed is an investment in our babies’ future!
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Countdown Coverage Writing Group. Fulfilling the Health Agenda for Women and Children: The 2014 Report. Countdown to 2015 (June, 2014).
- "Unfinished business, achievable goals"
- Nutrition: a building block for progress
- Coverage across the continuum of care, globally and at the country level
- Equity: no women and children left behind
- Determinants of coverage and equity — policies, systems and financing
- Data revolution and evolution: the foundation for accountability and progress
- The Countdown process—what we have learned so far
- Countdown speaks: priorities for the next 500 days and beyond
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Lakmi who is 22 years old and pregnant currently stays in an evacuation centre with sixty others.
Natural disasters can be devastating for anyone affected but for a pregnant woman, things are even more complicated.
Laxmi, 22, is pregnant. Her due date has come and gone. A huge landslide right in front of her village in Dhuskun VDC has also come and gone, claiming 156 lives and leaving large water-logged areas in the lower parts of her village, Dabi.
"I am on my 10th month," said Laxmi. Her mother-in-law, Devimaya, fears that Laxmi will go into labour anytime and if it happens at night, it will be very difficult for her to walk to the health facility that is two hours away. Laxmi's husband is not sure if they can afford to take her to the hospital right away and wait for the baby to be born. Currently unemployed, they do not have much cash with them. They have also heard rumours about prices going up in the nearby Barhabise market.
Flood caused by landslide disallows access to locals and submerges their homes.
Laxmi and her family have already spent five days in a primary school in their village where sixty other people are also sleeping at night. Everyone lives in fear that there might be another landslide or the lake might cause further flooding. With the landslide standing as a stark reminder that it will be a while before the community can feel normal again, there is a general feeling of uncertainty amongst the people there. Under these circumstances, a pregnant woman's concern about safe child birth and her wellbeing is easily pushed aside.
Laxmi's younger sister-in-law who is expecting a baby as well has gone to live with her parents in Barhabise. Laxmi says that her parents passed away so she does not have anyone to take care of her in her side of the family too. Her mother-in-law says," I wish I could send her to stay with someone at a time like this but there’s no one."
The rapid assessment team, led by Women and Child Development Office met Laxmi at the primary school where about 60 people were still taking shelter. The team advised Laxmi, her husband and mother-in-law about the risks the she might be facing if she had to give birth at home or complications arise while on her way to the hospital if she waits for the labour to start.
The landslide in Sindhupalchok that claimed 156 lives and displaced 478 people, has now put women like Laxmi at risk. There are 7 pregnant women in Dabi alone.
Anju Dhungel, Government's Women Development Officer in Sindhupalchok says, "Pregnant women have special concerns. They need access to health facility for safe birth and other health services after birth including nutritious food."
Update: As of 11th August, Laxmi and her husband are back at Dabi village with their newborn daughter. Though she is very happy to have delivered a healthy baby, the family has not moved backt o their home. They are living in the early childhood development center classroom in the same school.
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