Addressing Critical Knowledge Gaps in Newborn Health

Blog

By Kathryn Millar on September 23, 2014
Africa

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. The blog was originally published on the MHTF Blog. 

Around the world, countries are achieving Millennium Development Goal (MDG) 4 and 5—to reduce child and maternal mortality—yet we see little change in the number of newborns who die every year. This fact is one that Dr. Dunstan Bishanga, Chief of Party for USAID’s Maternal and Child Survival Program in Tanzania, emphasized at the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting last week when he said, “Looking at MDG 4 and 5,… there is no indicator for newborn, it is assumed that by improving, reducing under-five mortality rate and infant mortality rate you will definitely be addressing newborn health, but this may not be true.” This is a reality he has seen firsthand in his country of Tanzania.

In Tanzania, under-five mortality (U5MR) and infant mortality have decreased by 58% and 56%, respectively, from 1990 until 2010. Projections show Tanzania likely meeting MDG 4 by 2015 with a goal U5MR of 64 and an IMR of 38.

Yet, neonatal mortality—death in the first month of life—has only decreased by 32%, from 38 in 1991 to 26 per thousand live births in 2010. This makes neonatal mortality 32% of the U5MR and 51% of the IMR in 2010, compared to 20% and 33%, respectively, in 1990.

This stalled progress is likely due to low visibility and lack of measurement of neonatal health in the MDGs.

We have seen it in countries like Tanzania, and also in countries like Ethiopia, [MDG 4] has been attained with no progress on newborn health… so what does that tell us? It tells us that we don’t have valid indicators to measure newborn health progress. That’s why we are achieving MDG 4 without attaining the reductions in the targets for neonatal mortality.

Next Steps

Newborn health has often been an “orphan” topic, with neither the child health nor the maternal health community measuring and taking accountability for neonatal mortality. As these weaknesses have been realized, newborn health has taken a spotlight this year with The Every Newborn Action Plan endorsed by the World Health Assembly in May. This action plan lists five strategic objectives:

  1. Strengthen and invest in care during labour, birth and the first day and week of life
  2. Improve the quality of maternal and newborn care
  3. Reach every woman and every newborn; reduce inequities
  4. Harness the power of parents, families, and communities
  5. Count every newborn—measurement, programme-tracking and accountability

Inherent, then, in this plan is maternal and newborn health integration. Since the timing and delivery of key newborn health interventions often coincide with both the timing and delivery of maternal health interventions, speaking about maternal and newborn health simultaneously in strategy, implementation, monitoring, and evaluation is logical.

A Paradigm Shift

One way to make the global community accountable for newborn health is to change technical guidance from global entities, which have a tremendous impact on what is implemented at the country and community-level. Bishanga affirmed this impact when he said, “In countries like Tanzania where I come from, often they adapt global technical guidance, and [if] the people that get involved [in global policy] have a paradigm shift, then it is easier to make changes at the implementation level.”

So what might this global paradigm shift look like? Clearly measuring newborn health along with maternal health in the post-2015 development goals. Bishanga shared:

[In] the next phase you know, if it was possible, we need to really see that the newborn, even if it is an integral part of maternal and child health care, it needs to stand out and be measured clearly because that will lead even to the planning and implementation to have concrete and specific interventions that will be affecting the indicator for newborn health and neonatal mortality and enhance having a clear focus and attention to newborn health work.

Global Experts Paving the Way

Identifying a potential need and opportunity for improved maternal and newborn health, the Maternal Health Task Force and Save the Children’s Saving Newborn Lives convened experts at the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting to address this problem and others related to integration.

Dr. Bishanga attended and shared his reaction to the proceedings of the two-day meeting.

This was a great meeting, I like the fact that it has brought together people from different background; we have people from the field where the programming happens, we have people from donor community, we have people from policy level, from some ministries and the United [Nations] agencies. And I think also we have global experts in terms of maternal health and newborn health. Most of the time you find that these people meet in their own spheres; you have maternal health experts meeting on their own making strategies and newborn experts meeting on their own. But this kind of meeting brought them together. And the most impressive thing is that both groups appreciate… the need to have integrated care for the mother and the newborn. And that is where things start because these are the people that get involved in global policies, global technical documents and all that. If we have contemporated, and all of us do agree that we need this thing to happen in this way, then I believe that it will bring change.

By Niyi Osamiluyi on September 22, 2014
Nigeria
Africa

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. The blog was originally published on the MHTF Blog.

The main causes of newborn mortality are birth asphyxia, birth trauma, low birth weight, prematurity and infections. These accounts for 80% of deaths in the age group. While prematurity can spontaneously occur without any obvious predisposition or previous warning, a lack of obstetric and newborn care is often implicated in birth asphyxia, birth trauma and low birth weight – more especially in the developing countries.

This lack of care—which may occur at any stage of pregnancy, labor or delivery—may manifest as the absence of vital “skills”‎ on the part of the birth attendant or lack of low cost equipment/material such as a mucous extractor. This is why a significant amount of deaths resulting from such causes are labeled as “preventable.” Furthermore, the lack of skill may be manifested by the failure of the birth attendant to recognize the need for an emergency Caesarean.

It becomes evident ‎that if we can ensure antenatal care and the occurrence of delivery in a hospital—where there is likely to be ‘skill’ and low cost equipment—there may be an opportunity or greater possibility of preventing some of these avoidable deaths.

When we consider the commonest causes of maternal mortality—bleeding, obstructed labor, eclampsia, unsafe abortions and infection—obstetric care plays a major role in preventing deaths due to these causes.

In a developing country like Nigeria—where only 38% of deliveries are attended by a SBA and only 35.8% of deliveries occur in a health facility—interventions that will increase facility delivery and consequently newborn care are likely to reduce newborn death. While I agree that effort should be directed at improving facilities in the hospital, a greater problem is lack of demand for the utilization of these facilities. You will frequently find pregnant women registering in a hospital but not delivering there.

Why do majority of Nigerian women fail to use the services of a SBA? Why are Nigerian women not delivering in the hospital?

In my experience as a medical doctor practicing in rural Nigeria, I found out that ignorance was a major factor. I found out that ignorance often times played a greater role than poverty. You would find a patient that had visited a traditional birth attendant and probably spent three times what she would ordinarily spend in the hospital.

So how do we remove ignorance and enable a pregnant woman to make the decision to deliver in a hospital and thus increase the possibility of maternal and newborn survival? How do we deliver critical and relevant information that will lead to education? We can achieve this by delivering relevant and culturally appropriate information ‎through an existing channel that pervades across the rural and urban landscape. ‎This channel is the mobile phone. In our yet to be published work in delivering health education to expectant mothers via Short Message Service (SMS) in Nigeria, we found that greater than 95% of them had mobile phones. Those that didn’t have claimed it was missing or damaged.

I need to highlight that our work is not really about SMS or mobile technology; it is about the education of expectant mothers. Mobile just happens to be the route considering our environment.

In summary, education via SMS will lead to increased education, antenatal attendance and increased hospital delivery. When delivery occurs in a hospital, there is a greater chance of both the mother and newborn surviving.

By Mariam Claeson on September 19, 2014
India
Asia

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

This blog was originally posted by Impatient Optimist. The blog is co-authored by Mariam Claeson, Atul Gawande and Aparajita Ramakrishnan.

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
http://www.impatientoptimists.org/Posts/2014/09/Saving-lives-in-childbirth-do-we-have-a-game-changer

By Koki Agarwal on September 18, 2014

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.

Forward: In the following post, Dr. Agarwal speaks of an unfortunately common problem between health workers and mothers: disrespect and abuse. This problem and its solution—respectful maternity care—play a role not only in health outcomes for the mother, but for the baby as well. At the Integration of Maternal and Newborn Health technical meeting, Rima Jolivet and Jeff Smith reviewed research that showed emotional support during labor significantly decreases:

  • 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.

By Gary Darmstadt on September 17, 2014


Photo: The Bill & Melinda Gates Foundation

This blog was originally published in Impatient Optimists. Written by Gary Darmstadt

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.