This blog was originally published by the EVERY ONE Campaign. Written by Tanu Anand.
Living poorly and yet having everything taken away from you by a natural disaster can be deemed impossible. Throw a newborn birth into the mix and you have Mrs. Erlina Wati, who tells us a story of how she succeeded in giving birth to a healthy boy on 26 December 2004 despite running for her life from the Tsunami.
Erlina Wati’s family comprises of four members, and at that time she was pregnant with her third child. Her husband worked as a full-time driver and her daughters were still in pre-school age when the tsunami struck their village and took everything they owned with it.
At 8am, Erlina was at home with her daughters when she experienced a slight tremor which she didn't pay too much attention to. Soon after, a strong earthquake shook her entire home which caused her and her family to evacuate outside of their house. By then, everyone in her village had left their homes and she wasn't sure if her neighbours were safe and sound.
Soon after, she noticed people running inland and towards the hills and scurrying for the top. Something did not feel right and within minutes, her neighbourhood was getting flooded and the water was rising steadily and increasingly. Panic ensued but with the help of bystanders, she was able to evacuate into a small building that acted as a makeshift shelter. By 8:15am, Erlina’s water broke and her labour process unexpectedly began. What is usually a happy moment turned into despair and worry for Erlina.
“I thought I was going to die. There was no medicine. I don’t know how my baby would have lived. I prayed to Allah (God) and left it up to him.”
Prior to the disaster, many community members claimed that the term “tsunami” was unheard of and this experience was described to be a phenomenon which led to many assuming that this was the “end of the world”.
With the help of others at the makeshift evacuation centre and a piece of sarong (cloth used to wrap around one’s body or waist), Erlina was able to give birth to Rizqil, her third child. The next step was to ensure his survival. The next 5 months proved to be the hardest. Erlina was unable to produce proper milk and without the access to midwives and health facilities, Rizqil and his mother recovered in harsh and unsanitary conditions.
Ten years on, Erlina tells us: “…change is really now everywhere. There are more and more buildings (development) and they are getting taller. The sports centre I work in as an instructor is also getting more luxurious. I have never seen this kind of infrastructure before.”
But the big question is - are the communities better prepared for a disaster? Erlina explains: “There are sirens now in place near the seaside and anything more than 5 on the richter scale will set it off. There are evacuation buildings that are in place near the coastal communities as well. These systems were never in place before the Tsunami happened.”
The tsunami response made an important contribution to the upgrading of infrastructure and capacity building of health staff which have contributed to an improvement in services and in both Aceh Province and Sri Lanka the health service is now better prepared to respond to disasters.
A community health worker from Aceh province explains the current situation: “One of the blessings of the tsunami was that many of the survivors were able to improve their situation; before the disaster, people rented boats but after it they were given their own; before, they were staying in a small hut but after they received a house.”
A senior health centre staff member in Aceh province tells us that, "Before the tsunami we weren’t open 24 hours and had far fewer facilities…In addition to a larger staff and more facilities, we have also received training from Save the Children and feel more confident in the skills that we have. We now have twice as many patients as we had before the tsunami.”
Save the Children's report - Tsunami ten years on: Stories of Change - captures the change through the eyes and voices of affected communities in Sri Lanka and Indonesia (Aceh province).
Clinical and administrative leaders from hospitals empaneled by the Aarogyasri Health Care Trust participate in a question and answer session at the project launch. Photo: ACCESS Health International
We began a journey on August 28, with the formal launch of the Safe Care, Saving Lives project. Safe Care, Saving Lives is a quality collaborative designed to reduce neonatal morbidity and mortality in public and private hospitals across Andhra Pradesh and Telangana. Over the past four weeks, our journey has transformed, quite literally, into an odyssey. Three groups from the ACCESS Health project team set out to visit hospitals that had applied to participate in the first phase of the project. The goals of these visits were to understand the willingness and drive of each hospital to be a part of the project and to ensure that the clinical and administrative teams at each hospital understand their roles and responsibilities. Each visit was designed as a series of discussions with the administrative staff and with the clinical staff in the labor rooms and the neonatal intensive care units.
The ACCESS Health team – Dr. Satyanarayana Bhamidipati, Dr. Santhosh Kumar Kraleti, Dr. Sreeraj Sasi, Sujata Rao, Dr. Vivek Gupta, Dr. Manish Singh, Gayatri Emani, Dr. Sandesh Sibhinath, and Dr. Anunaya Jain – clocked in just over five thousand kilometers (more than 3,100 miles) of travel. We visited eleven hospitals in Andhra Pradesh and eighteen hospitals in Telangana to discover the reality of what it means to provide maternal and child care in urban, semi-urban, and rural settings in the two states.
Of the twenty nine hospitals we visited, we selected twenty five hospitals for phase one of the project. The hospitals selected for phase one incorporate a good mix of private and public, teaching and non-teaching, large and small, and urban and rural hospitals across the two states.
At the end of these visits, we asked the members of the ACCESS Health team to reflect upon their most memorable, inspiring, and disheartening moments during these visits. We also asked them if they felt that change was truly possible at each of the hospitals. Here are their responses:
Satyanarayana Bhamidipati: My biggest realization after these trips was the importance of perspective. The staff members working in the hospitals need to change their attitude and adopt a deeper sense of accountability for reducing newborn deaths. There is strong evidence in published literature that working in teams achieves the best outcomes in challenging healthcare environments. However, we still continue to work in silos. Most hospitals still do not have assigned teams that can handle resuscitation or infection control activities for neonatal care. If our project can ensure only that the neonatal intensive care units and the labor rooms form teams to deliver care within standard protocols – the improvement would be huge. Yes, resources are scarce. Yes, there is lack of infrastructure. But a neonatal intensive care unit is the reflection of the team that leads it. Resources and infrastructure alone do not guarantee good quality care.
Sujata Rao: The quote that inspired me most during these visits came from a neonatologist who said, “We are investing time on training these nurses extensively. Yes, we are empowering them, but we do this more for ourselves. We do this so we can sleep peacefully every night and know that today, we saved one more life.” There are many people within the system who believe that what they do now is the only way to do things. Many are caught up within the administrative obstacles and believe that putting in effort for quality improvement is futile. To them, I would ask, “Do you want to change? Yes? Then that is the only thing required to start change.” Willingness and attitude are the central pillars on which our project will succeed or fail. You need only look to your neighbors: hospitals where physicians and surgeons work twenty four hours a day, seven days a week, 365 days a year to ensure zero maternal and neonatal mortality. We witnessed many such shining examples during our hospital visits. I hope that the joint learning that results from this project will inspire everyone who says, “This is not possible.”
Vivek Gupta: Given where we are now, the scope for change is tremendous. We met amazing doctors, nurses, and administrators who ooze motivation, despite the resource and infrastructure constraints that surround them. The attitude of healthcare providers determines the quality of care, not the infrastructure and resources. The mentoring visits that our clinical and quality improvement experts will make to the each of the hospitals will be the most important aspect of the project. The staff members at the hospitals are only looking for a direction and for appropriate guidance. If we give them these, improvement is definitely possible. “Never neglect an opportunity for improvement” is a mantra I heard during the visits. It would be a great motto for everyone participating in this project.
Manish Singh: During one of the visits, someone said, “Man is but a product of his thoughts; what he thinks, he becomes.” This statement was exemplified on many occasions for me. Wherever the hospital teams had accepted their reality, outcomes were poor. At hospitals where doctors, nurses, and administrators wanted to change their reality, lives were saved. In the end, improvement will be a compound equation that includes equal parts of attitude, skill, and monitoring.
Sreeraj Sasi: One of the things that inspires me most about this project is the fact that both public and private hospitals are part of the solution. Private hospitals are often viewed as being willing to do anything and everything to ensure that their reputations are not tarnished, even driving patients away or refusing to admit babies with complications. It was absolutely amazing to see many private hospitals say, “We admit all cases and take them as a challenge toward achieving better outcomes.” The thing that hit me the most was the sheer volume of patients being cared for in large public hospitals, and the chaos and confusion that ensue from the sheer lack of resources. But we witnessed some shining examples of leadership during our visits. We saw dedicated individuals build model systems of care, despite being plagued by resource crunches and fund shortages. So yes, improvement is possible – if the hospitals are motivated to look into their system and are eventually held accountable to bring the required changes to improve quality and outcomes.
Gayatri Emani: Improvement is not a function of just asking for more. It flows from the willingness to change and the approach that individuals, teams, and systems take toward problems. I was inspired to see healthcare providers stand up and question their own practices. They compared and contrasted their own work with evidence based practices and made changes to improve. We have all witnessed disheartening situations – situations where doctors and nurses give up on sick children or where mothers refuse to accept the benefits of antenatal care – but I do believe that change is possible. “Did you wash your hands today?” Even if we start asking ourselves simple questions like this, outcomes can change dramatically.
Santhosh Kumar Kraleti: I was most struck by the staff at one particular public hospital. The staff was inspired by the vision of a district collector. They were making concerted efforts to achieve accreditation for their hospital from the National Accreditation Board for Hospitals and Healthcare Providers. Because of their hard work, they had driven down maternal and infant mortality rates in the hospital. And they achieved these improvements despite high volumes, constrained resources, and a remote location. A true leader is one who is humble enough to admit his mistakes. We saw examples of these true leaders time and time again. We saw shining beacons of excellence, individuals who were more interested in hearing about potential opportunities for change than to receive praise for their achievements so far. It was a truly humbling experience to witness their work. Given the support that we have from the administration and our partners in the Aarogyasri Health Care Trust, I have no doubt that we will be able to achieve the change that we set out to.
Sandesh Sibhinath: The sheer volume of work at some of the hospitals was simply overwhelming. We saw twelve laboring patients rushed into the delivery ward within a span of fifteen minutes. And this happens every fifteen minutes, every day of every month of every year. Nurses are the backbone of any newborn care program. It was heartening to listen to nurses who said, “Where there is a will, there is always a way.” You could see the excitement in the eyes of these nurses when they spoke about saving lives of underweight, premature, and truly sick babies. Their excitement was contagious. It made me sit up and ask myself, “What did I do today, and what can I do tomorrow?” These four weeks have taught us a lot. The visits impressed upon us the acute need for change. They also reaffirmed that change is possible – thanks to the multitude of individuals who have dedicated their entire careers, most evenings and many nights, to ensuring that babies survive, even in the most dire of circumstances. The most important lesson was the importance of stepping out of the box, from time to time. You have to take a step back and see things in perspective. Sometimes a bird’s eye view is better than a microscope. It is not important to have working warmers; it’s more important to keep the babies warm. It is not important to have wash basins; it’s more important to have clean hands before touching babies.
It is only when individuals, teams, and systems understand the true aims of quality care that change will happen. This trip was only the first step in a long journey, a journey that we all feel privileged to be a part of.
The Council of International Neonatal Nurses (COINN) and the Global Engagement Institute (GEI) have teamed up to launch the "Engage for Healthy Newborns" (EHN) campaign, a unique high-impact global engagement model to inspire health professionals and institutions from around the world to Engage for Healthy Newborns in Africa and Asia.
Many countries especially in the developing world fall short of achieving Millennium Development Goal 4 – a reduction of child mortality by two thirds from 1990 to 2015. According to The Lancet’s Every Newborn series, 3 of the 6 million annual, global maternal and newborn deaths and stillbirths are preventable with just three proven interventions: newborn resuscitation, kangaroo mother care and breastfeeding.
Building workforce capacity of those rendering newborn care is essential to decrease mortality, especially in low-resource countries. And evidence-based curricula such as Helping Babies Breathe® (HBB) are readily available – but not consistently taught.
The EHN Campaign
In collaboration with health ministries, universities, hospitals and civil society partners at the destinations, EHN sends Travel & Teach delegations of 12 international health professionals and an experienced master trainer to countries like Rwanda, Tanzania, Papua New Guinea and Vietnam. Participants have the opportunity to upgrade their own professional knowledge, skills and intercultural competence while making significant contributions to the development of capacity of local health professionals, institutions and systems.
On the ground, they first take a Helping Babies Breathe (HBB) Master Trainer course and an intercultural workshop together with a group of local counterparts, before pairing up to teach HBB to local health professionals under the supervision of the master trainer. The typical duration of the trips is 11 days.
The result is a unique self-financing model. Each visiting delegation is entirely paid for through the participants’ contributions to their costs of attendance or through sponsorships. And the impact goes far beyond the main goal of developing local workforce capacity: Both international and local participants also benefit from opportunities to enhance their emotional and cultural intelligence, and to foster global understanding, professional exchange and friendships.
At a glance
- Intervention goal: Development of neonatal resuscitation and essential care workforce capacity
- Intervention objectives (2015): To train 120 international and 120 local health professionals as HBB/HBS instructors who then train 1,200 local care givers as HBB/HBS providers
- Intervention curricula: Helping Babies Breathe (HBB), Helping Babies Survive (HBS)
- Initial intervention countries: Rwanda, Tanzania, Papua New Guinea, Vietnam
- Intervention website: www.engage4healthynewborns.org
Midwife Watta Borbor helps T-Girl, 24, breastfeed her baby at a Save the Children supported clinic in Peterstown, Margibi county, Liberia. T-Girl is an inpatient at a new Maternal Waiting Home built by Save the Children at Peterstown clinic. Pregnant women and mothers in some rural areas in Liberia have to walk up to eight hours to reach the nearest health clinic. The Maternal Waiting Home provides pregnant women with a place to stay, at the clinic, in their final week before delivery to ensure they get the proper professional care they need. Photo: Jonathan Hyams/Save the Children
On December 25, as millions across the world come together to celebrate the holiday season with family and friends, an estimated 800 mothers and 7,500 newborns will die in labor, childbirth or from complications in the first month, almost all of them with little public notice. And these numbers do not include the more than 7,000 stillbirths that also occur every day.
More than 95 percent of these deaths take place in poor countries where such deaths are so commonplace that in some regions babies often go unnamed until they survive the first month of life.
This staggering death toll of mothers and babies -- at least two-thirds of whom could be saved with adequate care -- represents one of the greatest health challenges of the 21st century.
While recent success in treating pneumonia, diarrhea and malaria, among other diseases, has spurred significant progress in reducing the deaths of children who survive the first month of life, there has been less progress in saving mothers and newborns. Babies dying within the first month of life now account for 44 percent of all deaths of children under age 5. In some countries babies account for nearly 60 percent of child deaths.
We can do better, especially considering the huge inequities involved. In Africa, for example, a newborn's risk of dying is 5 times greater than in Europe, and a woman's risk of dying in pregnancy and childbirth is 30 times higher. Even in countries that have made progress in saving maternal and newborn lives, there are often major disparities in death rates of mothers and newborns among a country's wealthiest and poorest populations.
We know what are causing these deaths. More than 40 percent of maternal deaths, newborn deaths and stillbirths occur around the time of birth. Babies that are born too small or too soon are at the greatest risk. Other babies cannot breathe at birth and die of asphyxiation while others develop deadly infections. Solutions as basic as an inexpensive antiseptic to protect the umbilical cord from infection or a bag and mask resuscitation device to help babies breathe have the potential of saving hundreds of thousands of lives. Old norms and customs around child birth also continue to claim countless lives. In some areas, mothers are allowed to bleed to death based on the misconception that "bad blood" from the mother needs to be purged.
To put a halt to these needless deaths, 194 countries endorsed the Every Newborn Action Plan at the World Health Assembly in 2014. This action plan is part of the UN Secretary General's Every Woman, Every Child initiative and A Promise Renewed -- both of which seek to accelerate progress for ending preventable maternal, newborn and child deaths. A broad range of experts, activists and government officials -- representing the interests of reproductive, maternal, child and adolescent health -- have agreed to work together to save the lives of mothers and their babies, with a special focus on Africa and South Asia, where the majority of these deaths take place.
An important component of the action plan is identifying effective ways to support country efforts to end preventable maternal and newborn deaths. The Ministries of Health in many countries, including India, Ethiopia, Uganda, Ghana and others, already have adopted new policies to make it easier for health workers to save newborn and maternal lives. The next big step -- and this is already happening in many countries -- is to put these new policies into practice and scale up proven interventions in ways that will have impact country-wide.
This is not an easy or simple undertaking. Health systems in many countries are weak, and the demand for services is huge. But with increased attention and focus on mothers and newborns, 2015 could well be a turning point in ensuring that more new parents in the future can celebrate this time of year with joy rather than sadness and loss.
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.
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The Healthy Newborn Network Blog provides timely information and insights from the global newborn health field and seeks to promote dialogue on important newborn health issues. The blog is a platform for the HNN Editors and guest contributors to post commentaries on current happenings in the newborn health field. The content of each post and comments expressed on the HNN blog are those of the individual contributors and do not necessarily represent the views and opinion of the HNN or its Partner Organizations. >>Read a note on leaving comments
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