Addressing Critical Knowledge Gaps in Newborn Health

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By Sanjana Shrestha on August 18, 2014
Nepal
Asia

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.

By Steve Hodgins on August 18, 2014

This blog was originally published by the Maternal Health Task Force as part of their  “Continuum of Care” blog series. 

What some propose

Most maternal and newborn deaths happen around the time of labor and delivery, so program effort should focus on ensuring delivery with a skilled birth attendant.

Why it is wrong

By this logic, if our concern were deaths due to heart attacks and stroke, we would be arguing to concentrate effort on ambulance, emergency room, and ICU services, rather than an approach that would also give attention to underlying causes, e.g. smoking, obesity, and hypertension.

Is it true that there’s little impact from ANC?

That all depends on what happens during the ANC visit. If there is little attention to appropriate content, there’s little reason to expect much benefit. But if getting ANC means that pregnant women in malarious areas sleep under treated nets and receive intermittent presumptive treatment, risk of bad pregnancy outcomes can be significantly reduced. Likewise, particularly in settings where many deliveries still happen at home in unhygienic conditions, the otherwise devastating risk of newborn tetanus can be largely eliminated if the mother receives tetanus toxoid during pregnancy. The impact doesn’t stop there. Anemia and associated fetal growth restriction can be much reduced by iron-folate supplementation. Delivery in a health facility and timely care-seeking for complications during pregnancy, or at the time of childbirth, can be increased if appropriate counseling is given during ANC. Similarly, the probability of adoption of key newborn care practices—like early initiation and exclusive breastfeeding—can be increased through good ANC counseling.

If ANC can make such a difference, why doesn’t it get more attention?

The short answer: history. Until about 20 years ago, the emphasis in ANC efforts was on “risk stratification”. The idea was that ANC would be used to identify pregnant women at higher risk, e.g. teen mothers, women who’d had many pregnancies, and women with past histories of complications of pregnancy or childbirth. These women were then to be referred to higher level health facilities for care. As a strategy, however, this didn’t work. Most of those identified as “high risk” ended up having normal deliveries and most of those developing complications had been classified as low risk. This has contributed to the perception that ANC is not useful.

In the late 1990s, a multi-country study showed that on most endpoints an abbreviated 4-visit protocol gave comparable results to a more conventional protocol, entailing a larger number of visits (although subsequent analysis actually showed a higher risk of perinatal mortality under the 4-visit protocol). An antenatal package based on the protocol used in the study was then promoted, under the rubric of “focused ANC”. This did include guidelines on timing and content of the visits. However, what was monitored was the proportion of women getting 4 or more ANC visits, not the content of those visits. Not surprisingly, then, it has been number of visits received that has been the main focus of program effort.

Currently, the World Health Organization is doing a thorough review of ANC and is expected to develop new guidelines. The time is right to bring new attention to ANC.

How can we do a better job on ANC?

There are specific elements of ANC which have good evidence for reducing risk. Many are quite simple and can be provided by peripheral level health workers like auxiliary nurse midwives. They can be provided through health posts and outreach services. But it is the actual content or substance of care that provides benefit, not merely having contact with a health worker. Program focus needs to be on actual content. On the principle that “what gets measured gets attention,” we need to make the content of care the focus of our routine monitoring.

Bottom line

ANC can make a big difference—but contact alone will not do it. Having succeeded in getting the pregnant woman in the front door, now we need to ensure she gets what she needs.

By Sarah Dwyer on August 14, 2014
Uganda
Africa

This blog was originally posted on the Maternal Health Task Force's blog. This post was part of their “Supporting the Human in Human Resources” blog series co-hosted by the Maternal Health Task Force and Jacaranda Health.

“Things were really a bit appalling.”

That’s what conditions at her rural health center felt like to Habiba Shaban Agong, a senior nursing officer and midwife in Uganda.

She says she loves her profession. “In midwifery I do a lot,” she adds proudly. “I help mothers in carrying out their pregnancies. During deliveries I help them to conduct live babies—to make a better future.” But it pained her that her facility was not able to deliver the high quality of services the community deserved.

Habiba Shaban Agong (Carol Bales, courtesy of CapacityPlus/IntraHealth International)

For starters, there were not nearly enough health workers to meet the demand. Each department had only “about one human resource working day and night,” Habiba says. “They get exhausted, and that can hinder service delivery.”

And there were other challenges. The facility was not well maintained, water was unreliable, waste was not segregated. There wasn’t adequate equipment in the wards. Beds were broken and too few in number, and mattresses were torn. “As a patient, you wouldn’t like to stay in a dirty environment,” Habiba points out. Many staff arrived late or did not show up at all.

The district health officer recognized Habiba’s potential. “He thought I was one of the health workers who could go for training in leadership and management,” she says.

Habiba joined several others to form Dokolo District’s team in the Human Resources for Health Leadership and Management Program, intended to strengthen Uganda’s decentralized health systems. Two USAID-supported projects led by IntraHealth International—the Uganda Capacity Program and the global CapacityPlus project—delivered the program in partnership with the Uganda Ministry of Health.

Teams from 19 priority districts were guided in identifying challenges, selecting priorities, developing action plans, and implementing the plans at their sites. Everyone came together for three one-week workshops over a six-month period and supplemented this work with field assignments. Instructors provided coaching support between workshops, and participants built skills in such areas as health workforce planning, recruitment, deployment, performance management, retention, teamwork, and advocacy.

“When I came back,” Habiba recounts, “I made some changes.” The following were a few of the changes:

  1. Infection control measures were implemented.
  2. A system for segregating waste was set up.
  3. A new incinerator was purchased.
  4. Facility maintenance improved.
  5. Habiba’s supervision became more supportive, and discussions with staff helped decrease tardiness and absenteeism.
  6. Small rewards, such as a chicken, are regularly given to selected staff to demonstrate appreciation and increase their motivation.

Habiba Shaban Agong and a client with newborn twins (Sarah Dwyer, courtesy of CapacityPlus/IntraHealth International)

Prenatal and antenatal visits are increasing, and the number of deliveries is going up. “We used to get only about five or ten patients (per month) who delivered in our facilities,” says Habiba, “but last month we got more than 60 deliveries!” And child mortality is decreasing. “In the pediatric ward, during the last three months we have not observed any death at all.”

Habiba is also happy that the Ministry of Health’s successful advocacy convinced Parliament to allocate $20 million to recruit more health workers. Dokolo District benefitted by getting 36 new health workers and raising its staffing level from 49% to 84%. The district rose in the national rankings for health service delivery, from 57th to 11th in the country.

Empowered health workers can improve maternal and child health, one facility at a time. To read other participants’ perspectives and learn about recommendations for adapting the leadership and management program to other contexts, read the related publication. Meet Habiba in a short video, “That’s Improvement!”: Uganda Focuses on Health Workers.

By Possible Health on August 11, 2014
Nepal
Asia

When a Hospital Isn't Enough from Possible on Vimeo.

This blog was originally published by Girls' Globe. Written by Possible.  

In rural Nepal, pregnancy is referred to as a “gamble with death.”

Rupa nearly lost the gamble. She was born in her own home, but her mother warned her of the dangers of home births. Rupa, like so many other pregnant women, wanted to give birth in a safe healthcare facility near her home.


Photo: Possible

When she went into labor, she immediately journeyed to the nearest clinic. There was only one midwife present and part way through her delivery the nurse suspected complications.

Rupa knew she needed additional help. Rupa is from a district called Mellekh, which is a two-hour drive over rough roads to our hospital in Bayalpata—a drive that is impossible to make during the monsoon season because of the road conditions. Rupa called for an ambulance. Possible’s ambulance driver came to pick her up and bring her to our hospital in time to safely deliver a baby boy.

Rupa’s story has a happy ending. She gave birth to a beautiful baby boy after an intense labor and the imperative help of two of our midwives. Mothers who are fortunate to be close to a hospital can also experience safe and healthy deliveries. Without having trained staff and professional services, the baby could have died. At Possible’s hospital hub in rural Nepal, the number of births taking place within the facility has grown over 900% since 2010. We believe a hospital is not enough.

What pregnant women really need, in a region with one of the highest maternal mortality rates in the world, is access to safe birthing centers closer to their homes and support throughout their pregnancies. Which is why Possible exists, and why we have pioneered an approach called Durable Healthcare that puts safe births at the center of our integrated model. It is also why the percentage of women delivering in health facilities is one of our six Key Performance Indicators.

We solve the problems of pregnant mothers like Rupa by having female community health workers provide training and referral support in villages. The health workers coordinate with local community governments to transform clinics into safe birthing centers and link clinics to a central hospital with ambulances for emergency deliveries.

This model is supported financially through a partnership with the Nepali government’s Safe Motherhood Program, where both pregnant mothers and Possible receive payments for attending prenatal care visits and delivering in a health facility. It is a model of safe births that works fully for pregnant women, not partially—a model that ensures all mothers can have a happy ending like Rupa.

This post is from one of Girls' Globe partners. Possible, is a healthcare company that delivers high-quality, low-cost healthcare to the world’s poor. 

By Ian Hurley on August 8, 2014
Malawi, Nepal, Nigeria, Uganda


Innovators share their projects at The Saving Lives at Birth DevelopmentXChange 2014. Photo: Ian P. Hurley/Save the Children

“Innovation is the highway, impact is the destination.” Grand Challenges Canada CEO Dr. Peter Singer echoed this statement while speaking to newborn and maternal health innovators at the Saving Lives at Birth DevelopmentXChange 2014 in Washington, DC.

31 seed grantees, 40 seed grant finalists, 10 transition grantees and 11 transition grant finalists were on hand to present their projects at the morning marketplace and to see what new grantees would be getting support under the fourth round of funding at the afternoon forum. Organizers received over 500 applications from 60 countries for the fourth round. 


Rice University's BreatheAlert, a high-performance , low-cost method to reduce death due to apnea of prematurity is demonstrated at the 2014 DevelopmentXChange. Photo: Ian P. Hurley/Save the Children

The Saving Lives at Birth partnership was launched in 2011 by the U.S. Agency for International Development (USAID), the Bill & Melinda Gates Foundation, the Government of Norway, Grand Challenges Canada, and the U.K. Department for International Development (DFID). It was founded to seek out innovative approaches to address the more than 1.6 million newborn deaths, 1.2 million stillbirths and 150,000 maternal deaths that occur within the first 48 hours of life. To date, they have funded 59 potentially game-changing innovations that have come from academics, students, faith leaders, businesses, universities and more.

An example of one of those innovative projects is chlorhexidine for umbilical cord care in Nepal by JSI Research & Training Institute, Inc. It was a first round grantee in 2011. With over 60% of women giving birth at home, newborn infections are now the third-leading cause of newborn deaths in Nepal. The antiseptic gel, which costs roughly 23 cents and is made locally in Nepal, helps to prevent that infection. It has since been scaled-up in 45 of the country’s 75 districts. Dr. Leena Khanal, Project Manager of the Chlorhexidine Navi Care Program said that chlorhexidine has helped to save 2700 newborn lives as a result of the Saving Lives at Birth grant.


USAID Administrator Dr. Rajiv Shah gives welcoming remarks at the 
Saving Lives at Birth Forum. Photo: Ian P. Hurley/Save the Children 

The afternoon’s forum event was highlighted by USAID Administrator Raj Shah’s talk with Dr. Paul Famer, Co-Founder of Partners in Health about innovation and the need for health equity. Several innovator projects including the now famous Odon Device, the Augmented Infant Resuscitator (AIR) from Uganda, Rice 360’s bubble CPAP device from Malawi, and a project by DPRC aimed at further empowering Islamic scholars in Northern Nigeria to promote MNCH among local health providers were presented.


Dr. Susan Wandera Kayizzi, Deputy Country Director for Amref Health Africa in Uganda, talks about the WE CARE Solar Suitcase at the 2014 DevelopmentXChange. The innovation is a transition grantee. Photo: Ian P. Hurley/Save the Children

The 30 Round 4 award nominees were then introduced and came up to the stage to accept their award, filling it up almost to capacity in the process. It consisted of 26 seed grants and 4 transition-to-scale grants. This year’s awardees cut across newborn and maternal health and showcased groundbreaking ways to help improve the chances for newborn and maternal health survival during the most critical time of life.

The Healthy Newborn Network was among the partners at the Development XChange. Over the next few weeks, we will be featuring a series of blogs from the innovators themselves.