Addressing Critical Knowledge Gaps in Newborn Health


By Patrick Aliganyira on September 30, 2014

Photo: Mother Practicing Kangaroo Mother Care in Mulago National Referral Hospital, Save the Children

This blog was co-authored by Patrick Aliganyira and Kate Kerber from Save the Children

Prematurity and its complications remain the leading cause of deaths in children below the age of five years according to the new estimates. In Uganda, preterm birth complications alone contribute 38% of all deaths of babies younger than one month of age. This is the situation even when we know what can be done to prevent majority of these deaths. One of the highest impact interventions for newborn survival and health is kangaroo mother care (KMC). This low-tech and cost-effective intervention a mothers serve as human "incubators" for their newborns. Even in well-resourced settings where intensive care is available, KMC is considered gold-standard care for stable small babies. Despite convincing evidence, KMC uptake is low and only a very small proportion of newborns who could benefit from KMC receive it.

In the recent publication of the evaluation of progress of implementation of KMC intervention in Uganda, only 4 regions (Central 1, Central 2, East-Central and Southwest) plus the City of Kampala were identified as having facilities providing KMC services.

(Photo on Left: Districts with health facilities providing Kangaroo Mother Care Services - 2012) In addition to the equity gaps that are clearly indicated by the geographical distribution of KMC coverage, the effectiveness and quality of services is still in question as is the level of institutionalization (including ownership and sustainability) in the health facilities where it has been introduced.

This year represents a turning point and the call for a renewed attention to preterm babies and scaling up interventions with the level of quality that can save lives. In November, 17th – 19th the 10th KMC international conference will be held in the neighborhood, in Kigali Rwanda. The 17th November also happens the World Prematurity Day commemorations and around the same dates, Uganda will be celebrating the first anniversary for “A Promise Renewed” since the launch of the integrated RMNCH sharpened plan. This represents an opportunity to revisit our focus on the biggest of cause children’s deaths.

Current estimates of coverage show only 10% of all babies that need to receive Kangaroo Mother Care. Progress has been made but much more is needed if we are to dent the curve for newborn mortality in Uganda. Getting from national readiness achieved over the past decade to ensuring translation of this national readiness to effective delivery of Kangaroo Mother Care is the divide that needs to be addressed.

The barriers to sustained KMC include - lack of awareness and information, the feeling that KMC is lesser than incubator care, lack of champions, rotating staff with KMC skills out of neonatal care confines, and unsupportive management. KMC needs to be a priority and not “another” intervention for saving lives of newborn babies. KMC information, education and delivery should be integrated along the continuum of reproductive, maternal, newborn and child health and in all platforms of service delivery (Community and Health Facility). This is also a key message of the current government focus in the integrated RMNCH plan, 2013 – 2017. This is also further emphasized in Uganda’s commitment to the UN Secretary General’s Every Woman Every Child Initiative and the Born Too Soon Movement in November, 2012.

Urgent attention to reducing deaths in children below five years converges to the same need for renewed attention to increasing reach for all babies born too soon. We need to build champions who share knowledge and skills by working closely with professional associations, ministries of health, and traditional leaders who can work with local providers and families to overcome barriers. We also need to be accountable and continue to measure and report our progress using robust metrics and indicators. In doing so, we will achieve a better future for all of Uganda’s families but especially for those born too soon.

Visit the Pan African Medical Journal to view the article: Helping small babies survive: an evaluation of facility-based Kangaroo Mother Care implementation progress in Uganda

By Kathryn Millar on September 29, 2014

This post is part of the Maternal and Newborn Health 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. 

Dr. Jorge Hermida, presenter at the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting, addressed global leaders on promising approaches to integration of care. In his presentation, Dr. Hermida proposed a global paradigm shift for health care and reviewed the success of a quality assurance project. This project implemented quality improvement (QI) teams, which constituted a variety of health worker cadres and healed a both horizontally and vertically fragmented system. We had a chance to ask Dr. Hermida a few questions. His answers help us better understand the needed paradigm shift, steps to healing health systems, and what is needed to sustain successful programs.

Promising Approaches to integration of care - panel discussion from Maternal Health Task Force on Vimeo.

Q: In your presentation you presented a paradigm shift of “Best Practices” to “Implementation Effectiveness.” Can you expound on this shift?

A: The current paradigm has been, so far, one where the effort of international organizations has been focused in recommending countries and health systems what are the “best” interventions they need to put in place. The actual process of making it happen in the reality of those health systems has not been a priority.

A new paradigm—much needed—that I call “implementation effectiveness” is to focus most of the efforts of international organizations and country health systems in understanding the process of actually implementing those best practices, including what are the main barriers and facilitating factors and what are the best ways to achieve large scale implementation with an acceptable level of quality. This approach refers too to integration of maternal and newborn care.

Q: The QI integrated teams you spoke of are wonderful and seem to be very effective. What were the factors that made these teams successful?

A: QI teams are an operational mechanism to continuously measure and improve access and quality of health care at the local level. They exist and thrive as much as there is in place a process to improve the quality of care in a health care system or hospital or health center. Among the many factors that support these teams, a strong leadership towards improving access and quality of care is essential.

QI teams represent a radical change in the way health care is managed at the operational level, much different from the hierarchical and authoritative, top-down, doctor-based common existing reality to make decisions on how care is organized. QI teams are collaborative among professional cadres, use data to base their decisions, use evidence to approach improvement on access and quality, and their work is patient-centered.

Q: You mentioned the health systems of Cotopaxi and how they were both vertically and horizontally fragmented. What were the key activities for transforming this health system as you did in the ASSIST project?

A: Prior to our project, Ecuador had existing national policies mandating the construction of a national health care system that integrates public and private institutions. However, there were few experiences on how to make it happen. Our project—which collaborated with the Ecuador Ministry of Health (MOH)—brought to the same table the different actors in the Cotopaxi province—traditional TBAs, MOH facilities, Social Security facilities, NGOs who had been working separately—and facilitated building a common vision of an integrated network.

This common vision aimed at reducing maternal and newborn mortality through increasing access to and quality of care and focusing on high-impact, evidence based maternal and newborn care. Increasing access meant reaching remote rural mothers and newborns by linking TBAs to the formal health care network and increasing the offer of essential care at district and provincial hospitals to 24 hours, seven days a week, among other changes. It also meant supporting communities to have mechanisms to transport emergencies to the nearest hospital, as well as strengthening the referral mechanisms among TBAs, health centers, district and provincial hospitals. Increasing the quality of care meant working with health care personnel organized in QI teams to introduce high-impact, evidence-based obstetric and newborn best practices; implement monitoring indicators of quality of care; detect deficiencies; and constantly improve care.

Q: What do you think are the most critical factors moving forward to ensure sustainability of this project?

A: The most important factor leading to the sustainability of the model is the MOH ownership of the initial demonstration process. It was also very important to carefully align at all times the objectives of the project with those larger ones that guide the action of the national government and in particular the MOH. Then the MOH needed to develop its capacity not only to understand the model but also to operate it. This was achieved through a constant insistence on working with the MOH on every decision and operational activity.

This may sometimes seem to slow down the pace of action of a project, but it certainly pays back at the end when the MOH has developed their own experts and advocates for the principles that guided the operations of the project. There is a need to obtain clear-cut results that are meaningful to the MOH and national government objectives and to show how the results of the project contribute to the larger aims of the country and the MOH. As long as these factors are clear, the chances for sustainability will exist.

By Graciela Salvador-Davila on September 26, 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. The blog was originally published on the MHTF Blog

Ninety-nine percent of all maternal and newborn deaths in the world occur in low- and middle-income countries. That inequity is unacceptable. Furthermore, 46% of all maternal deaths occur during the time of labor and the day of birth. In a tragic alignment, as much as 45% of all newborn deaths occur within the first 24 hours of a child’s life. The parallels between the timing of maternal and newborn deaths is no accident. Both women and their babies are in dire need of high-quality, skilled care. Following are four key steps toward improved integration of maternal and newborn care.

1. The mother-newborn dyad is inextricable. Program design, service provider training, and public and private sector funding mechanisms must be crafted in acknowledgment of the mother-baby pair. Sadly, current efforts to address health needs of these two groups are often conducted in siloes. This compartmentalization of care is reflected in the unfortunate persistence of high neonatal mortality rates in contrast to recent reductions in maternal mortality. In spite of recent gains, high rates of maternal mortality persist in certain regions of the globe. In order to cover the final mile and begin to tackle the challenge of neonatal mortality, programs and health systems must take into account the inter-reliance of a mother and her newborn.

2. A high-quality, robust continuum of care is the only way the world will meet its goals of reducing maternal and neonatal mortality and morbidity. A strong mother-baby focused continuum of care begins with comprehensive access to contraception since meeting the developing world’s unmet need for  contraception would prevent an additional 79,000 maternal deaths and more than 1.1 million infant deaths each year. Furthermore, it is essential that the continuum of care includes access to skilled health care workers at all levels of the health systems, from community to hospitals. It is also essential that all clients have access to life-saving commodities such as oxytocin to prevent postpartum hemorrhage and ART to prevent mother-to-child transmission of HIV. Pathfinder International’s Clinical and Community Action model for addressing post-partum hemorrhage has demonstrated the value of a robust continuum of care approach, resulting in significant reductions in associated deaths. Pathfinder International’s model builds on the Three Delays Model while encouraging stronger health systems that ensure a provider’s ability to be equipped with up-to-date knowledge and skills as well as a women’s ability to access respectful, high-quality care for herself and her family.

3. Community engagement: Women do not become mothers nor are babies born in isolation. Entire communities—especially partners, fathers, aunties, and grandmothers—play a role. Many of the most common complications affecting women and newborns must be addressed through preventative behavior change at the community-level and through quality improvement in the services offered at traditional health facilities. By engaging an entire community, it becomes possible to not only increase uptake of priority health services and behaviors, but to engender change in beliefs and behaviors essential to maternal and newborn health.

4. Advocacy: At all levels of society, it is essential to mobilize resources and attract political support for integration of maternal and newborn care. Furthermore, advocacy is key to prioritizing quality of care in all health system services. Quality of care goes far beyond dissemination and application of evidence-based technical guidelines, although that is imperative. As we move toward high-quality integrated maternal and newborn care, we must also ensure community-based conversations and ownership; empowered midwives armed with livesaving competencies; and family-centered, respectful care.

By Liya Kebede on September 25, 2014
Equity, Scale-up

Video above: recording of the Simple Ways to Change Lives panel from the Social Good Summit. This blog was originally posted on the Huffington Post and was co-authored by Liya Kebede, Founder of the Liya Kebede Foundation and Carolyn Miles, President & CEO Save the Children US.

As children, we were fascinated when our school teachers rolled out the maps showing different parts of the world. Even today, as we've each traveled the world in our respective roles, maps still hold a certain fascination and urgency to go beyond where we've been -- to move forward. So you can imagine how we feel about a roadmap that places the health and survival of newborns and mothers at the very center of the political agenda.

This year, the global health community won a huge victory in the battle to reduce health risks for millions of mothers and newborns with the passage of the Every Newborn Action Plan. In agreeing to this plan, governments around the world have embraced an ambitious set of actions to ensure all mothers and their newborns -- no matter where they live -- can reach and receive quality care from a trained and skilled health worker during pregnancy, childbirth and the early days of life. These actions are a lifeline for millions of families and a path to strong and healthy communities.

In our last year before the Millennium Development Goals deadline, we've also seen a huge drop in the numbers of children under five dying, from nearly 12 million in 1990 to 6.3 million today. On our recent trips to Ethiopia, we both got to see what that statistic looks like in reality. Instead of dying from malaria and malnutrition, more children today are getting a healthy start and are thriving in their schools, learning to become the next generation of doctors and teachers and leaders.

The road is still long. Globally, 40 million mothers give birth alone every year. In Ethiopia, 90 percent of mothers are still giving birth at home, and the country continues to face major health challenges so that their newborns survive their first month. Of the one million newborns that die each year, 88,000 are from Ethiopia, making it one of the top ten countries with the highest number of newborn deaths.

It's these high rates of deaths among newborns in Ethiopia and globally that keep us fighting for access to better care. As the MDG deadline looms ahead of us, we need to redouble our efforts to end preventable newborn deaths if we are to meet those targets.

This week, as world leaders gather in New York for the opening of the UN General Assembly where they will discuss a new set of development targets for a post MDG world, we will be encouraging them to stay focused and committed on actions to improve maternal and newborn health. At the Social Good Summit on Sunday, we shared what we've learned alongside two heroes in the fight to reach more women and children: UNFPA Executive Director Dr. Babatunde Osotimehin and Victoria Shaba, a leading midwife for Save the Children in Malawi.

The success around child survival in Ethiopia as well as countries like Malawi, Nepal and Bangladesh proves that the Millenium Development Goals can work if we commit to putting the health of our mothers and children first. With less than 500 days left, we can be hopeful that together, we will save the lives of millions of mothers and their children.

Watch the Mashable I Social Good Summit Webcast

By Newton Isaac on September 24, 2014

This blog was written by Newton Isaac, World Vision India's Director of Government Relations. It was originally published by World Vision. Photo by World Vision.

“Unless health becomes accessible like other rights guaranteed by the constitution, children will remain outside the periphery of all health services and entitlement. World Vision India believes that universal healthcare access is key to realization of the Right to Health for all people.” said Dr. Vijay Edward, Director – Health, World Vision India.

India has drastically reduced maternal and under-five child mortality over the past two decades. However, progress to reduce newborn deaths and stillbirths has been much slower. India has one of the highest burdens of neonatal mortality and stillbirths in the world, with 750,000 babies dying each year within their first month of life. This represents 56% of all deaths of children under five years in India. Most of these deaths are preventable with the knowledge and effective interventions that are available today.
Today, the Government of India is launching India’s Newborn Action Plan (INAP) in response to the country’s unacceptable high burden of newborn mortality. #INAP represents India’s renewed commitment to end preventable newborn deaths and stillbirths and reduce maternal deaths, based on the latest evidence on effective, life-saving interventions.

World Vision India welcomes the launch of the INAP and offers its support as a key partner to the government in the implementation of this crucial initiative across the country. We work in over 6200 urban, rural and tribal communities, spread across 163 districts in 25 states, and impacting the lives of more than 26 lakh (2.6 million) children.

There is great potential to save lives through expanding coverage of targeted, low cost interventions, in alignment with the Every Newborn Action Plan (ENAP) endorsed at the World Health Assembly in May 2014. India’s Newborn Action Plan is guided by the principles of integration, equity, gender, quality of care, convergence, accountability and partnerships and builds on six pillars of intervention packages, including: preconception and antenatal care; care during labour and child birth; immediate new born care; care of healthy newborns; care of small and sick newborn and care beyond newborn survival.
Through a comprehensive framework for implementation, monitoring and evaluation and clear targets, all stakeholders will work together to scale up the proposed interventions in order to reach the goals of a “Single Digit” neonatal mortality rate and a “Single Digit” Stillbirth rate by 2030, in line with the global #EveryNewborn targets. India’s current neonatal mortality rate is 29 per 1,000 live births and stillbirth rate is 22 per 1,000 live births, so there is a great deal of progress to be made.

On 9th September, World Vision India together with Indian Child Abuse Neglect & Child Labour (ICANCL), Indian Academy of Pediatrics Delhi (IACLAN), India Alliance for Child Rights and All India Institute of Medical Sciences (AIIMS) hosted a consultation on the ‘Right to Health’ to create awareness on child health and child rights. During this event, World Vision highlighted the unacceptable disparities in newborn survival between different socio-economic groups and between States in India. Many miss out on life-saving health services because they live in locations without access to care or since they belong to communities that are discriminated against. Scheduled Castes and Tribes, particularly those living in less developed States, are the most disadvantaged of all groups. Neonatal mortality rates vary from 49 deaths per 1,000 live births in Uttar Pradesh to 8 deaths per 1,000 deaths in Kerala.

World Vision India has called for the Government of India to strengthen its focus on the most vulnerable mothers and babies in the implementation of the INAP, and to ensure equitable access to universal, quality health services free at the point of use, address social determinants of health, and ensure that every child and mother is counted through expanding and improving health management information systems and civil registration and vital statistics. It is also critical that the government engages both civil society and communities in the planning, monitoring and quality assurance of health services.
India’s triumph over polio has proven that it is possible to reach even the most hard-to-reach and vulnerable children with life-saving health interventions despite demographic, economic, and socio-cultural challenges. The great possibility, and simultaneously the key challenge, for India is to now ensure that INAP is implemented so that it translates into measurable improvements in the survival and health of India’s most vulnerable children, towards the target of ending preventable newborn deaths and stillbirths.