Addressing Critical Knowledge Gaps in Newborn Health

Blog

By Steve Hodgins on April 23, 2014

When we think about the value of immunizations, normally we think about preventing serious childhood illnesses. For example, many countries have made serious efforts to push up coverage for measles immunization, through their routine services as well as through special campaigns.

But immunizations and the newborn: what’s the connection? There are several significant links. 

April 23 - 30, 2014, marks World Immunization Week. This year's theme, "Are you up-to-date," focuses on making sure everyone knows which vaccines are available to them, and how they can vaccinate themselves and their family members. Mothers who are vaccinated are less likely to transmit dangerous diseases to their newborn babies, and vaccinations given in the first 24-hours of life can dramatically reduce a newborn's risk of dying from certain preventable diseases. 

Until recently, tetanus was a major cause of newborn deaths around the world. Many countries have made big improvements in the proportion of pregnant women that are adequately immunized against tetanus, which has resulted in making deaths from newborn tetanus largely a problem of the past. According to UNICEF, 34 countries have achieved “elimination” of maternal and neonatal tetanus. Bangladesh, Burundi, Egypt, Ghana, Mozambique, Rwanda, Turkey, Uganda and South Africa are among them. However, there are a number of countries where tetanus is still a public health problem, and even in countries that have achieved high coverage there needs to be continued attention to maintaining high tetanus toxoid coverage, including in countries where “elimination” has been achieved.

Second, the very early newborn period– the first day of life – provides a critically important window of opportunity for providing vaccines that can prevent disease and death later in life. For instance, in many areas in Africa and Asia, where 10% or more of women of reproductive age carry the hepatitis B virus, giving the hepatitis B vaccine at birth can dramatically reduce risk of transmission to the newborn.

Finally, immunization contacts at 4 to 6 weeks after birth can serve as important opportunities to emphasize protective practices that reduce the likelihood of life-threatening illness later in infancy – for example, exclusive breast-feeding through the first 6 months of life.   Success in reducing vaccine-preventable mortality has been dramatic, but it cannot be taken for granted. While national vaccination coverage in some countries now exceeds 80 percent, overall national coverage is not the only important metric. Before being exposed to disease, women and newborns must be reached in every region and sub-population of every country with the right vaccines and high-quality services in a safe, timely, effective, and affordable manner, so that they return to complete all their doses. 

By Vince Blaser on April 18, 2014

WASHINGTION, DC – At the close of a week where I witnessed one of the first plastic surgeons in Bangladesh captivate Capitol Hill with accounts of saving lives of women and children accidentally or deliberately burned in his country and pleas to support deployment of more frontline health workers to prevent those burns, I sat in the World Bank listening to major power brokers in global health policy discussing what can and might be in 2030. I wondered: will we look back at this time as a key moment in a powerful and sustained drive toward ensuring every person has access to quality health services, or will weak support of health workers continue to entrap at least 1 billion people with little to no access?

It’s easy to be a sceptic and pick the latter, but in the last decade working in global health I’ve already seen such sea changes happen. From slashing early annual childhood deaths in half since 1990 to having an AIDS-free generation within our sights – the combination of strong advocacy, political will and investment from public donors, and private sector commitment has been a powerful force to save and improve the lives of millions in this century.

But with the target date to achieve the health Millennium Development Goals (4, 5 and 6) approaching next year, where does the focus need to go to make the most impact? The World Bank made its view clear Friday – the focus should move squarely to ensuring that by 2030, everyone has access to health services that do not push them or keep them in poverty under the framework of universal health coverage (UHC).

This expansion of access to services from maternal care to malaria prevention simply cannot happen without major efforts to strengthen the health workforce to deliver services. The World Health Organization and the Global Health Workforce Alliance recently reported that 7.2 million more doctors, nurses and midwives than are currently serving are needed for everyone to have access to essential, lifesaving health services – a gap which could reach 12.9 million by 2035 if we keep with the status quo.

World Health Worker Week – during which leaders and advocates came together both in person and on social media to pay tribute to those who serve to make our lives healthy and prosperous – brought to the fore just how necessary it is to strengthen the global health workforce, especially on the frontlines of care.

The video above was provided by the Frontline Health Workers Coalition and outlines the importance of health workers to delivery life-saving interventions. 

From the inspirational stories shared by the health workers honored by The REAL Awards in Washington, to advocates in Malawi visiting health workers and taking their concerns to their government, to story after story virtually shared of how a frontline health worker safely delivered a newborn to a healthy mom, administered a lifesaving vaccine, or provided knowledge on how to keep a child from dying from malaria or pneumonia – World Health Worker Week left no doubt on the impact frontline health workers have in delivering the health outcomes we seek. United States Agency for International Development global health chief Dr. Ariel Pablos-Mendez stated it this way in an opinion piece: the health workforce gap “presents a major development challenge and barrier to meeting the health goals of ending preventable child and maternal deaths and reaching an AIDS-free generation.”

So, how do we do it? The Frontline Health Workers Coalition, Global Health Workforce Alliance and Health Workforce Advocacy Initiative in a joint World Health Worker Week statement wrote that we can start by “strong and swift implementation” of the 83 concrete commitments to support the Recife Declaration on Human Resources for Health, “backed by sufficient resources and clear health workforce targets included within the post-2015 global development framework.” IntraHealth International President and CEO Pape Gaye in an opinion piece outlined five key steps to ensure health workers are centered in the world’s post-2015 commitments.

I am optimistic that in 15 years when we’re knocking at the door of the 2030 date discussed Friday at the World Bank, we will see many more frontline health workers like Anniekie Nkhumeleni and her team of community health workers Lwamondo, South Africa, delivering services and referrals across the gamut of health issues. If that happens, we should also be knocking at the door of fulfilling the ideals encapsulated by the MDGs of healthy mothers, newborns and families the world over.

Vince Blaser is Deputy Director of the Frontline Health Workers Coalition, an alliance of United States-based organizations working together to urge greater and more strategic U.S. investment in frontline health workers in developing countries as a cost-effective way to save lives and foster a healthier, safer and more prosperous world.

By Ian Hurley on April 17, 2014
Jordan, Syria
Middle East

Photo: Hedinn Halldorsson/Save the Children

Ibtisam, a Syrian refugee, and her newborn baby, Dala'a, in Za'atari refugee camp, Jordan.  Save the Children Jordan runs two centres in Za'atari refugee camp where around 150 women visit every day. 

The centres are open 6 days a week and are women and children centers only. Save's Nutritional educators and councellors have gone from tent to tent and caravan to caravan to introduce their services to mothers or pregnant mothers. Ibtisam escaped Syria with her husband and sisters.

Dala'a weighed 3,85 kg at birth, which is a normal curve. According to Isra'a, Save the Children Jordan's nutrition expert who is also Ibtisam's counselor, the nutritional value of the food and the rations being served in the camp is OK but the simplicity of it and the same meals over and over again result in people getting fed up. Isra'a is currently seeing Ibtisam and her daughter once a week. Dala'a was born in a French Field Hospital in Za'atari refugee camp.

"We are doing fine. When I was in labour I thought of all those that I have lost, all those that have been killed, who kept asking me when my little Dala'a would enter this world, when she would come to life. I closed my eyes and saw them all there in front of me. Immediately after Dala'a was born, I couldn't take care of her, I didn't have the energy, I couldn't take care of my daughter. But the following day I had gathered my strength and could see her. Now, I am so happy I can't even describe my feelings with words."

Based on the latest estimates from the United Nations High Commissioner for Refugees, there are just over 104,000 people living in the Za'atari Refugee Camp. UNICEF, UNFPA, IFH/NHF are administering reproductive services at the camp. MSF, JHAS, UNHCR and UNICEF along with Save the Children are also providing nutritional services. A variety of other organizations are providing health-related services. 

In arecent article in The Independent, Amin Awad, the head of UNHCR, stated that the situation for Syrian refugees is not improving. He says that some governments are failing to live up to the finanical commitments they agreed to help refugees. Many of these refugees have fled Syria and are now living in Jordan, Turkey, Iraq and Lebanon. 

At Za'atari though, we can look to stories of hope like that of Ibtisam's safe pregnancy and birth of Dala'a and have it serve as a rallying cry to redouble efforts to help those most affected by the conflict. 

By Nynke Van Den Broek on April 16, 2014
Malawi
Africa

Photo: Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine

Although significant progress has been made in the past decades to reduce child mortality worldwide, the rates of decline for neonatal mortality are happening at a slower pace. Figures from the World Health Organisation (WHO) suggest that prematurity accounted for 17% of the 6.9 million under-five deaths worldwide in 2011; it also accounted for one-third of all neonatal deaths. Consequently, strategies for tackling preterm birth have remained important keys to unlock global child mortality challenges.

Apart from being responsible for a significant number of under-five and neonatal deaths, for survivors, preterm birth has also been associated with an increased risk of childhood problems including stunting, increased morbidity and developmental delay as published in a recent study from Malawi.

A good understanding of the factors associated with preterm birth is essential in devising strategies for reducing morbidity and mortality associated with preterm birth.

Another recently published study from Malawi found a significant association between preterm birth and a history of previous preterm and persistent malaria (despite prophylactic anti-malarial treatment). Similarly, mothers under the age of 20 and anaemia were reported to be associated with early preterm birth.

In contrast, weight gain had a protective effect against preterm delivery. Importantly, this study did not find a statistically significant association between HIV infection and preterm birth.

Because there are very few studies that demonstrate statistically significant reduction in preterm births as a result of preventive measures, attention has now shifted towards interventions to improve survival of preterm babies.

In a systematic review of ‘approximately’ 2000 interventional studies, Barros et al identified 11 interventions to improve survival of preterm babies in low- and middle-income countries. These include four interventions to be provided during pregnancy and at the time of birth: prophylactic steroids, antibiotics for premature rupture of membranes, vitamin K supplementation at delivery and delayed cord clamping.

The other seven interventions are: case management of neonatal sepsis and pneumonia, room air for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome.

At this point, it is important to mention that, as highlighted in the Every Newborn Action Plan, interventions put in place around the time of delivery have the greatest effect on reducing neonatal mortality.

In our experience at the Centre for Maternal and Newborn Health (CMNH) at Liverpool School of Tropical Medicine (LSTM), it is crucial to improve knowledge and skills of health care workers to provide essential maternal and newborn care at and around the time of birth. This improves both coverage and quality of maternal and newborn health services.

The CMNH, in collaboration with the Royal College of Obstetricians and Gynaecologists (RCOG) and the Department of Making Pregnancy Safer at WHO Geneva, has developed a short competency based ‘skills and drills’ training package for health care providers.

The package is being delivered through the ‘Making it Happen’ (MiH) programme, and it focuses on the signal functions of emergency obstetric and early newborn care. With the support of UK Department for International Development (DFID), the programme has been rolled out in 12 African and Asian countries.

Finally, as with all interventions, it is important to bear in mind the resource constraints in most developing countries where preterm babies have the least chance of survival. What could be your most significant barrier(s) to implementing some of the strategies mentioned above?

 
This blog was written by Professor Nynke van den Broek, co-author of Factors Associated with Preterm, Early Preterm and Late Preterm Birth in Malawi. Professor Nynke van den Broek is a professor in sexual and reproductive health, an honorary consultant obstetrician gynaecologist and the head of the Centre for Maternal and Newborn Health at the Liverpool School of Tropical Medicine. 
By Pragya Vats on April 15, 2014
India
Asia


Photo: CJ Clarke/Save the Children

This blog was originally published by the EVERY ONE Campaign. Written by Pragya Vats.

Reshma, 20, lives in a slum cluster in New Delhi. Her first pregnancy ended in her child dying, due to complications during the birth. She did not have assistance from a trained birth attendant: her baby was delivered by an untrained midwife at home, and was stillborn.

“My daughter's head got stuck," Reshma says. "She couldn’t get out. She suffocated inside and died right there. How do I feel? If a mother loses her child, how does she feel? For nine months I carried her in the womb and I couldn’t save her.”

That's one child every 20 seconds: the highest rate anywhere in the world. More than 300,000 babies die each year on the first day they enter the world. These deaths are very far from inevitable. Half of India’s women give birth without skilled birth attendants, which puts both mother and child at risk.

Like parents everywhere in the world, Indian mothers wish for their children to be safe, happy and healthy. It’s what they all want for their children. And it’s not too much to ask. Why is life still a lottery for children who are poor?

There is a lot to be done to make India a safer and healthier place for a mother or a newborn. We have the resources and the knowhow and we can save these precious lives.

India’s economic growth is phenomenal. Its future is bright. So why is the nation failing its children? Many Indians are demanding an answer to this question.

Just like a child, a nation can’t grow big and strong without a nurturing start, and in a country’s case, that nourishment is healthy children. If we are to lead as a nation we must invest in our children and hence in the country’s future.

When I meet mothers like Reshma and hear their stories, it reminds me that so many of us are lucky enough to take it for granted that we will have trained help to give birth to our children, just as our mothers did to give birth to us. The right to life is fundamental and should be universal; unless we all agree on that, solutions to these problems will remain elusive for years to come.

India is gearing up for elections; and this time, they will not be business as usual. We must demand answers from our political representatives and hold them accountable so they keep their commitments over the next five years.