Mothers whose babies were born prematurely and who successfully went through Kangaroo Mother Care are photographed at the Mtwara District Hospital in Mtwara, Tanzania. Over the last year Save the Children has trained 392 health workers in the Lindi region of Tanzania, and provided them with the skills they need to stop preventable deaths associated with child birth and newborn babies. Lindi region is one of the Tanzania's poorest areas - where children and mothers die in higher numbers than anywhere else in the country. Under-five mortality rate in Lindi is as high as 117 per 1,000 live births. Children's health in this region is influenced by complex issues including remoteness, poor infrastructure such as roads and electricity, lack of education, inadequate planning and budgeting for health, lack of equipment and staff training as well as socio-cultural and religious beliefs. Photo: Jordi Matas/Save the Children
Despite the odds these mothers have helped to save their preterm babies and given them a chance to thrive. In addition to providing optimal thermal heating for a newborn, Kangaroo Mother Care promotes the mother-baby bond, helps to prevent infections and strengthens early initiation of breastfeeding. Read this report on Early Initiation of Breastfeeding by WHO, UNICEF and several other health organizations.
The Healthy Newborn Network also features comprehensive resources on Kangaroo Mother Care implementation and practice. These are especially useful for country level health professionals, program manangers and other MNCH practitioners who are looking to start or improve the performance of their own programs.
A midwife examines a pregnant woman in South Sudan. Photo: Kate Holt/Jhpiego
This blog was originally published in Impatient Optimists. Written by Lindsay Grenier.
Complications from prematurity are now the number one cause of death in children under five. While great strides have been made in reducing deaths from infectious causes—such as pneumonia, diarrhea and measles—progress has been slow in improving outcomes from preterm birth.
In developed countries, most pregnant women can rattle off their gestational age (GA) to the week, and their health practitioners estimate and record it to the day at every antenatal visit. It’s reflex for health care workers in these settings to find out the GA of a patient presenting in triage or on the labor ward as one of their first courses of action. This is because GA greatly impacts how maternal and newborn care providers team up to manage their patients and what treatment options they will consider.
By contrast, when USAID’s flagship Maternal and Child Health Program (MCHIP) began a research project in Cambodia aimed at increasing the use of dexamethasone in the management of preterm birth, staff discovered that many records didn’t include GA, and those that did estimated it to the month—not the week, let alone the day. We found this trend repeated in country after country when we looked: at worst, no GA; at best an entire month given.
Unlike their counterparts in developed countries, women in these settings rarely know their GA to the week, and their health care providers may or may not estimate and record it at all. This is in part because, until recently, they have had little reason to, as many of the interventions long in use in developed countries have been unavailable to them. Therefore, knowing a woman’s GA would not change their management plan. The baby would come when it would come, and there was little they could do to help prepare it for life prematurely.
However, as greater focus is being placed on addressing mortality in the neonatal period, that story is changing. National health systems and development partners are collaborating to improve quality of care for prematurity by strengthening the use of certain key interventions in the management of preterm birth—including antenatal corticosteroids (ACS) for fetal lung development; continuous positive airway pressure to support inflation of underdeveloped preterm baby lungs; magnesium sulphate for neuroprotection; and antibiotics in the case of preterm, prelabor rupture of membranes to prolong pregnancy.
These lifesaving interventions will enable maternal care providers to reduce the complications of prematurity in newborns in low-resource settings, just as their counterparts do in the developed world. In fact, MCHIP’s follow on project—the USAID-funded Maternal and Child Survival Program—is already leading an effort with the Survive and Thrive Global Development Alliance to create a clinical training package for the management of preterm birth under the Helping Babies Survive series.
Yet a critical element necessary for the correct use of interventions for preterm birth management is accurate GA estimation, as highlighted by findings from the recent  The authors found significantly higher mortality among infants given ACS and born with an estimated gestation ≥37 weeks. This study does not negate the previous 21 randomized controlled trials, which found a 30% reduction in neonatal mortality when steroids are given to women at risk of imminent preterm delivery between 24 and 34 weeks gestation; rather it points, in part, to the need for careful and improved gestational dating. When an intervention is beneficial at 34 weeks, and potentially harmful at 36 weeks, estimation of GA as “eight months” simply isn’t accurate enough.
(Please see the statement from the UN Commission of Life Saving Commodities ACS Working Group for more details regarding the ACT trial and the programmatic and research implications.)
When used appropriately, ACS are still one of the most beneficial interventions to improve mortality in premature infants. However, GA dating must be improved to ensure their judicious use. Improving GA dating worldwide requires:
- A clinical behavior shift among maternal and newborn health care providers to actively seek accurate GAs, and diligent recording of this information at each antenatal care visit (driven by the understanding that accuracy of dating is crucial for good clinical decision making in the effort to help save premature babies);
- Better dating techniques and/or algorithms to support providers in estimating GA with imperfect information (driven by a combination of clinical and implementation research);
- Judicious use of ultrasound to assist GA assessment when other techniques are not sufficient (driven by an understanding of the correct combination of clinical assessment and technology); and
- A cultural behavior shift among pregnant women to seek antenatal care earlier and to take careful note of the date of their last menstrual period (driven by the knowledge and belief that early care in pregnancy and accurate knowledge of their gestational age may help their baby survive).
As we turn the spotlight to prematurity, we must also focus on better dating. This will ensure our interventions reach those who need them most, while upholding the most central tenet in medicine: do no harm.
 The most commonly used antenatal corticosteroid
 Althabe et al. (Lancet, October 2014)
Although I am new to the Country Director position for Save the Children I have been very aware of the importance of the National Health Bill and the need to get it signed into law by the President. So when we learned that it had been signed on 9 December 2014 I there was great rejoicing within Save the Children. The new Act will provide new opportunities for the Government to deliver high quality primary health care services to Nigerians. Importantly, it will release funds from the Federal level down to the State level for primary health care.
The passing and signing of the National Health Bill has been a laborious and lengthy process – starting over 10 years ago. The Bill was first passed in May 2011 by the national Assembly and forwarded to the President’s office but it was returned unsigned 30 days later for amendments. It took another 3 years before it was again passed by the national Assembly in October 2014 and sent again to the President for signing.
The Save the Children Nigeria team, together with partner organizations, has been working tirelessly to get the Bill signed, not only under this President but also under the previous President. Many groups, both from within and outside the country have lobbied hard in support of the bill which finally bore fruit on 9th December. This achievement reflects the determination of activists to ensure that quality health care services are provided to Nigerians and in particular to children.
Now we have to make it happen. First, this means making sure money is released down to the States, and then that the States mobilize and use it. We will work closely with State officials to develop plans for the training of their staff and strengthening their health systems.
The recent National Newborn Health Conference, led by Government of Nigeria in October 2014, reflected the importance of the National Health Bill in addressing child mortality. While the Government has made some significant headway towards meeting the Millennium Development Goal 4 for reducing mortality for children under- five years, it has not made a similar progress in reducing te number of children who die in the first month of life. At the Conference the Government made a commitment to newborns and their mothers by launching the Call to Action to Save Newborn Lives. This calls for an end to all preventable maternal and newborn deaths and stillbirths by 2035. But can we, can those mothers and yet to be born children, wait another 20 years for this to happen? I don’t think so. Action is needed now and we all need to make a commitment to reduce these deaths significantly over the next 2 or so years.
To our partners, the signing of the Bill must provide significant encouragement to move forward and to keep pushing for good quality health services. Save the Children has had the privilege to work with a large network of organizations within the Maternal, Newborn and Child Health Coalition in lobbying for the Health Act over the past few years. We are all now delighted that it has finally been signed into law and that we can move forward together to improve the health of Nigeria’s children.
Photo: Parth Sanyal/Save the Children
“Scale up is a craft not a science”
- Quote from the IDEAS qualitative study of scale-up in Ethiopia, Nigeria and India
Working in the maternal and newborn health field, don’t we all want our work to benefit the health of as many women and babies as possible?
You may have an amazing innovation proven to improve the health of mothers and babies in your pilot implementation project. How do you get a national government to take notice and scale-up your innovation to benefit more women and babies?
Implementation projects need to use multiple methods
Unsurprisingly there is no ‘magic bullet’ approach. Implementation projects need to plan for scale-up from the start, use multiple methods - all requiring time, energy and resources – and work closely with other organisations and government to achieve scale-up.
Donors need to support scale-up
Donors need to support and fund implementers to catalyse scale-up so it is supported from the start of a project and implementaters have the resources to support scale-up work. When donors work on the ground brokering relationships with government and coordinating international organisations, scale-up is more likely.
Politics play a major role
But most importantly, the skill of achieving scale-up is a craft, not a science: support from a powerful government figure can be as important as having a good intervention and strong evidence. Country politics are very important to scale-up and implementers and donors need to work on building effective relationships with government officials.
These findings come from a paper I recently published (read a summary) based on 150 ‘qualitative interviews’ (meaning we asked respondents open ended questions and encouraged them talk in detail of about the issues they felt were important) with government, project implementers, UN agencies, expects from Ethiopia, Nigeria and Uttar Pradesh, India.
Based on this evidence, here are a few checklist tips implementers and donors can use to catalyse the scale-up of their successful innovations. We have also produced research briefs on this topic for Ethiopia, Northeast Nigeria and Uttar Pradesh, India.
Checklist: what implementers can do to catalyse scale-up
1. Design an innovation that is scalable
Designing an innovation to be scalable isn’t easy. It’s difficult to find a balance between innovations that are very effective but need a lot of money and time – and simpler, cheaper ones that governments can afford to scale-up. Ask yourself, is your innovation:
- Relevant to the needs and priorities of health workers and communities so they will accept it?
- Demonstrably effective?
- Simple for community health workers and communities to use?
- Adaptable to communities that may be different in terms of religion, wealth etc.?
2. Embed scale-up in your implementation project design
Dedicating staff, time and resources to scale-up as a central part of a project plan is important. Do research early in the project to help plan for scale-up. You may want to look at:
- The political context, e.g. what health issues does the government prioritise?
- The social context, e.g. what are the needs and priorities of communities and health workers within those communities?
- Other organisations. Are there other groups you can link with who will support your work?
3. Effectively advocate government for support
- Present strong quantitative evidence showing your innovation has a positive impact and is cost effective. Without this it’s unlikely a government with limited resources will agree to put resources in for scale-up.
- Use qualitative data to demonstrate operational lessons learned and how challenges were overcome.
- Communicate findings effectively so the government can make informed decisions. Ensure dialogue with government starts early and keeps going throughout the project (not just presenting evidence out of the blue) and try to present during the government’s decision making cycles when the evidence is more likely to be used.
4. Work closely with government and other organisations
- Get government buy-in. Make sure your innovation fits in with existing government policies and programmes and then build relationships with government officials who may be critical to getting overall government support and buy-in.
- Work with other organisations on projects, share information, and jointly communicate to government. Coordinate closely with other organisations to avoid a situation where there are lots of international organisations and implementers doing similar work in parallel – reinventing the wheel - then competing with each other for government attention.
Checklist: what donors can do to catalyse scale-up
1. Support and fund implementers to catalyse scale-up
Although donors want their innovations scaled up, work to achieve this is usually added on when a project ends. Supporting scale-up work from the start of a project and ensuring implementers have the resources they need to carry out the work will help to catalyse scale-up.
2. Be active on the ground
Broker relationships with government and help coordinate with other international organisations working in that particular country. Not all of innovations can and will be scaled-up but these checklist tips are based on in-depth qualitative evidence which I hope will help implementers and donors to get their successful innovations scaled up to benefit more women and newborns.
A premature baby in the pediatric ward at Yekatit Hospital in Addis Ababa, Ethiopia. The country made a commitment to integrate newborns into their child health strategy. Photo by Bill & Melinda Gates Foundation / CC BY-NC-ND
Recently, three countries with 40 percent of all newborn deaths and the world’s highest potential to save women and newborns — India, Nigeria and Ethiopia — committed to doing something brave, audacious and humbling. Thanks to a combination of strong evidence of what works, an enabling policy environment and an actionable framework, they committed to end preventable maternal newborn deaths and stillbirths by 2035.
Informed by compelling evidence pulled together by “The Lancet” Every Newborn Series, coupled with the World Health Assembly’s adoption of the Every Newborn Action Plan, endorsed by 194 countries, they responded to the call for action. Each country made commitments to action as part of their reproductive, maternal, newborn and child health development agenda and plan. They can make significant progress by increasing coverage of high-impact interventions particularly around the time of birth, serving as early models for how to go to scale, along with other front runners.
In September, India, the world’s largest democracy, took an important step towards preventing the death of women and newborns. The Indian government, along with national stakeholders, launched the Indian Newborn Action Plan focusing attention on maternal and newborn health as a top national health priority. Each year, India could save as many as 840,400 lives of mothers and newborns — more than any other country in the world — changing from business-as-usual to engaging key actors in a national movement for maternal and newborn survival.
Similarly, in October, the Nigerian government launched its “Call to Action to Save Newborn Lives” initiating the development of the Nigerian Every Newborn Action Plan. Activities outlined in the NENAP have the potential to save as many as 375,000 mothers, newborns and babies who are stillborn each year. It represents the nation’s most ambitious commitment to date for saving women and newborns, preventing stillbirths who are dying at alarming rates. Communities across the world and in the rest of Africa will be watching and learning as Nigeria tackles this formidable challenge.
Finally, just last month the government of Ethiopia, a country that has made excellent progress on improving maternal and newborn health services, particularly at the community level, made the commitment to integrate newborns into their child health strategy. Ethiopia could save as many as 76,800 mothers and newborns each year if it continues its aggressive efforts to develop and implement effective strategies to improve maternal and newborn health.
If countries as large and complex as India, Nigeria and Ethiopia can be successful, especially among their most marginalized and hard to reach communities — we will learn important lessons for how to scale for impact. It will take continuous strong leadership, quality services including facility-based births, skilled midwives, and engagement of families, communities and civil society to keep health providers accountable.
Each year around the world, 2.8 million newborns die within their first month and an additional 2.6 million are stillborn. Complications related to prematurity are now the leading killer of all children under-5. Proven interventions, such as essential newborn care (basic warmth, hygiene and the promotion of breast-feeding), neonatal resuscitation, kangaroo mother care for preterm babies and the prevention and treatment of infections, including clean cord care, are known and available in some settings but they are not reaching all of the women and newborns who need them.
As we move into 2015 and beyond, we find ourselves at the dawn of the sustainable development goals. As we move forward, we need to do better for the world’s mothers and newborns, starting by keeping them at the heart of our post-2015 health efforts. We need to reach women and their newborns with the high-impact interventions we know work. We need to overcome implementation barriers and continue to develop innovative tools for implementation and healthcare delivery in order to get to the hardest-to-reach communities.
And, as a global community, we must support government, local communities and civil society to seize critical opportunities, implement evidence-based plans, take action and ensure that the resources are available to deliver on commitments.
India, Nigeria and Ethiopia are to be commended for taking these steps toward ending preventable maternal newborn deaths and stillbirths.
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