This blog was originally published by the EveryOne Campaign. Written by Devendra Tak.
The Aanganwadi Centre (for government-sponsored child-care and mother-care) in Uttar Pradesh’s Gangapur village in Varanasi district has probably never received such a frenzy of attention. A group of community-based women journalists from U.P. and Bihar have dropped in to check the status of child care, especially related to newborns. There are three children who are under treatment for Severe Acute Malnutrition (SAM) at this Centre, two of whom are present at the Centre at the time of the visit of these journalists representing Khabar Lahariya, a pioneering decade-old newspaper for communities with local news in local languages.
Kusum, the mother of Ankita (who was born prematurely and is suffering from Severe Acute Malnutrition), looks visibly relieved with the attention she is receiving and says that she is grateful for the support of Save the Children-led Karuna Project. The project reaches 100 villages in U.P. and Jharkhand in its fight for nutrition and child survival; and is made possible by donations from His Holiness the Dalai Lama. Amazingly, Kusum did not even know that she was pregnant till six months: by when she had missed out on essential care for herself and the yet-to-be-born Ankita. “As soon as we determined that she was pregnant, we got the Centre to support Kusum with counseling, additional nutrition, food supplements and other medical support, but it was probably a bit late,” informs Rakesh Choubey, nutrition counselor from the Karuna Project. He adds, “It is a real problem that expecting mothers are not brought to the Centres regularly for check-up during their pregnancy.”
The other child, Rhimjhim, who is over 1 year old now, moved from the SAM to MAM (Moderate Acute Malnutrition) status just a month ago. When questioned, Gulabchand, her father (a labourer at a brick kiln) puts the blame squarely on the fact that his wife was away at his in-laws (as is the tradition in these parts) for the delivery and initial months of the baby’s life for any slackness in taking Rhimjhim for regular health-checkups. “My wife and I are regularly visiting the Centre now to ensure that Rhimjhim recovers fully and stays healthy,” he says.
From SAM to MAM to OK – the journey of newborns in India is riddled with conundrums that can be likened to a game of Russian roulette in their race for survival. India has the highest number of newborn deaths, many of whom do not survive the very first day of their life. Over 300,000 children die in India on the 1st day of birth and more than 700,000 in their 1st month. More than half of these newborn deaths occur within the crucial first week of birth – and most of these deaths can be saved by simple and economical methods of preventive care that can be accessed by all young mothers and their newborns. Save the Children’s ‘Ending Newborn Deaths’ Report (launched on 25 February) undoubtedly offers more perspectives to help guide policy makers to make the right decisions, which becomes even more relevant in India when we are facing the possibility of a new government following the upcoming General Elections.
Shashi Kala, the local Auxiliary Nurse Midwife (ANM), provides an update on the Centre’s services: “We have an immunization camp every third Wednesday of the month. For children who are SAM or MAM we provide nutrition supplements twice a month.” Choubey adds that the Karuna Project even takes care of the transportation of affected children to the Centre or the Public Health Centre (located at the district headquarter), if that is required for children in a critical situation.
While the ANM mentions that there are several issues in running the Centre smoothly, she is grateful for the support of the Karuna Project and hopes that this will pave the way for sustainable methods to be adopted by the state administration once the Karuna Project ends its 3 year foray. One of her biggest grouses is that there are times when the regular funds from the government arrive much later than expected, leaving her and other staff and volunteers to cope with their own resources. “Health services have to go on without any break and that is what we attempt to provide,” she says proudly.
The National Rural Health Mission Implementation Framework mandates states to undertake district planning exercise, whereby local problems can be identified and addressed through systems by due allocation of budget. Hopefully, the district would take lessons from the processed adopted by the Karuna Project, which is now a year old. A comprehensive strategy of Block Operational Plan identifying convergence point among 8 departments -- which are key to ensuring nutrition security -- has made this intervention a successful one. The learning from this project will provide evidence for the Government to adopt policy changes while designing larger interventions on nutrition security.
Choubey affirms that much needs to be done to ensure systematic health care but feels that progress is being made. “Health workers are often criticized and even attacked when they are not able to do more than what is physically possible, but yet each one of us goes on knowing that saving every newborn more than makes up for the challenges that have to be overcome.” The Neonatal Mortality Rate graph is now showing a decline, and there are states where this has been very good, and the Government has the RMNCH+A Approach, and a slew of programme and guidelines have been developed and launched, to tackle the challenges of working in a culturally, economically, geographically and politically diverse nation as India.
Across India steady progress is being made to ensure the survival of newborns and of course there are gaps, many of them related to the issue of inequality, urban health issues and also the quality of service delivery but we can be hopeful that – with initiatives such as the Karuna Project chipping in – that our future generations may be secured.
A newborn with jaundice receives phototherapy treatment in a Firefly while its mother looks on at Okkalapa Teaching Hospital, Yangon, Myanmar. Photo: East Meets West
Jaundice is a killer. Not in the United States, where mortality and morbidity from severe jaundice is almost unknown, but in places like Myanmar and West Africa, where phototherapy—a simple and cost-effective light treatment—is largely unavailable.
Worldwide, 60% of newborns experience infant jaundice. Of those, one in ten will require treatment with phototherapy to prevent the possibility of serious complications, including kernicterus, a severe form of brain damage. Yet each year, 5.7 million jaundiced newborns in South Asia and Africa receive no phototherapy.
Phototherapy treatment, when available and properly administered, is amazingly effective. In a recent discussion with Dr. Priscilla Joe, Medical Director of the Neonatal Intensive Care Unit at Children’s Hospital Oakland and medical consultant to international development organization East Meets West, she noted that newborn brain injury from jaundice is so rare in the United States that the U.S. National Quality Forum lists it as a “never event,” or, in other words, “The kind of preventable and tragic outcome that should never happen in a healthcare setting. Period.”
Globally, however, 6 to 10% of all newborn mortality--according to expert estimates--can be attributed to jaundice and complications caused by jaundice. The situation in a country like Myanmar, for instance, stands in stark contrast with the excellent outcomes in the United States.
Most hospitals in Myanmar lack a safe, robust, and inexpensive device to deliver phototherapy. An urban hospital in Yangon may have a donated phototherapy machine, but often it sits unused—broken or lacking parts that are too expensive to replace. A functioning machine intended to treat one newborn is commonly used to treat multiple sick babies simultaneously, exposing some to too little healing light and all to an increased risk of infection. If this sub-optimal treatment fails, the only intervention remaining is a blood “exchange transfusion,” with the attendant risk to the infant of transfusion reaction, blood clots, infection and shock.
January 2014 saw a welcome change at 22 hospitals in Myanmar, as international development organization East Meets West coordinated the delivery of specially designed, engineered and manufactured phototherapy machines that address these challenges. The device, called the Firefly, is the product of an innovative collaboration among East Meets West, industrial design firm Design that Matters, and medical device manufacturer MTTS Asia. (This design partnership is described in detail in “The East Meets West Foundation I: Expanding Organizational Capacity,” published by the Stanford Center for Innovation in Global Health, Innovation Insight Series, June 2012.) EMW’s Breath of Life neonatal care program ensures that the machines are accompanied by trainings for clinicians and nurses in topics including machine use; early identification and management of jaundice; and parent education. Warranties, technical support, and manuals in the Burmese language all contribute to ease of use and proper maintenance of the machines.
So in January, clinicians at North Okkalapa Teaching Hospital in Yangon were able to quickly and correctly diagnose Ms. Ye Ye’s newborn with severe jaundice. The infant was then treated in a Firefly-- with just the right amount of light coming from above and below--and the newborn’s condition was monitored by nurses who had received training in using the machine and managing jaundice. A healthy baby and relieved mom left the hospital just a few days later.
These newly installed Firefly phototherapy machines are expected to treat over 1,000 newborns per year and to have a profound impact on the speedy care of newborn jaundice, the near-elimination of the need for exchange transfusions and a reduction in kernicterus in these hospitals.
East Meets West will conduct rigorous measurement and evaluation to track the effectiveness of the machines and the support provided by Breath of Life. As demonstrated results attract additional funding for Firefly deployment, more hospitals will have the equipment and training they need. The day may still be far off when brain damage or death caused by severe jaundice becomes a “never event” in Myanmar, but the Firefly illuminates a path forward.
New mother Nakintu wraps her two-day-old preterm baby
boy for Kangaroo Mother Care at Kiwoko Hospital, Nakaseke
district, Uganda. Photo: Ian P. Hurley/Save the Children
Should the Ugandan government spend more resources on incubators to save premature babies rather than encouraging mothers of premature babies to use the less expensive health strategy of Kangaroo Mother Care? Patrick Aliganyira of Save the Children Uganda offers his views below in a recent commentary in the Kampala-based newspaper, New Vision.
Photo: Jonathan Hymes/Save the Children
Mamie, thirty two, begins her three hour walk home after giving birth to her son Darius the day before at the clinic in Peterstown, Margibi county, Liberia. Pregnant women and mothers in some rural parts of Liberia have to walk up to eight hours to reach the nearest health clinic. Maternal waiting homes, some supported by international partners including Save the Children, provide pregnant women like Mamie with a place to stay in their final week before delivery.
“Equity needs to be the heart of what we are doing. We need to be doing more to reach the most vulnerable communities and ensure that members in the communities have access to better newborn and child care.”
These words by UNICEF Representative Sheldon Yett rang out at a recent workshop held for community health workers, county health directors, senior health ministry officials and programme staff in Monrovia, Liberia.
This diverse group of public health practitioners were there to learn about the new UNICEF handbook for newborn and child health and how they could implement some of its recommended practices in their own communities. Importantly, infection prevention and management along with Kangaroo Mother Care were part of the discussion. Neonatal infections now account for 28 percent of all newborn deaths in Liberia.
In 2011, it is estimated that 13 percent of all the under five deaths in Liberia occured on the day a baby was born. Stregthening the quality and impact of newborn care is thus very important for helping to reduce mortality and morbidity. One of the county health directors in attendance said that the handbook will be important for strengthening Integrated Community Case Managment (iCCM) interventions.
With the annual rate of newborn mortality reduction moving from 1.64 percent from 1990-2000 to 4.02 percent from 2000-2012, Liberia is certainly making progress. We must keep in mind, and use as motivation, that newborn mortality now accounts for a larger percentage of under five deaths than it did in 1990. Last summer's commitment to A Promise Renewed was an important milestone for attention and resources for newborn and child health. Based on the excitement and commitment of all those at the workshop, this momentum has not waned and has brought even more involvement across the country to address this issue.
Photo by: Cameron Taylor
“Every system is perfectly designed to achieve exactly the results it achieves.” USAID Applying Science to Strengthen and Improve Systems (ASSIST) Deputy Director Dr. Kathleen Hill shared this quote from W. Edwards Deming with an audience of more than 40 leading experts in technology, health care, and international development that gathered on January 31st in Washington, D.C. for an m/eHealth Health System Strengthening technical working group meeting. The Bridging the Gaps: Leveraging m/eHealth to Achieve Strong Health Systems and High Quality Care in Low-Resource Settings technical meeting considered a working framework developed by the USAID ASSIST project and discussed how m/eHealth solutions can bridge common quality and systems gaps in low-resource settings to augment system strengthening and quality improvement efforts to achieve better health outcomes.
As a gender specialist working for WI-HER LLC, Women Influencing Health, Education and Rule of Law, on the ASSIST project, my interest in m/eHealth is twofold: first, I am examining how technology can be leveraged to transform traditional gender norms to improve health outcomes for women, men, girls and boys. My second interest is in mitigating the negative impact that m/eHealth interventions can potentially have on gender relations. One of the biggest takeaways from the meeting for me was the idea that technology is often developed and packaged as a solution before the problem and its root cause are defined. There can be a lack of discussion and consensus about what the problem is, what response is required to solve the problem and close the gap, and to what extent m/e technology can aid in that. It’s important that the technology solutions benefit the women, men, newborns and children they are meant to serve.
An example is the push in recent years to target women through mHealth interventions, sometimes without sufficiently analyzing whether the problem warrants a response which includes mHealth and targets women exclusively. If the problem identified, for example, is that neonatal mortality is very high, and it is observed that very few mothers in the community receive antenatal care (ANC) or deliver with skilled providers, an mHealth project might provide mobile phones to pregnant women and girls or communicate with expecting mothers through their cellphones to tell them about the importance of seeking care throughout their pregnancy. The reasoning behind this makes sense: mothers who do not receive high-quality ANC and childbirth care are more likely, along with their newborns, to suffer serious consequences of childbirth complications such as pre-eclampsia. But if one of the root causes of pregnant women not attending ANC visits is because the power and decision-making dynamics in households limit women’s and girls’ ability to make health-related decisions, and male partners do not appreciate the value and therefore do not want their partners to attend ANC visits, then the mHealth intervention would not be as effective as it could be. In some cases the receipt of text instruction that challenges a male partner’s authority in the home may even put the woman or girl at risk.
A more appropriate solution which utilizes mHealth would be to design an intervention that also sends messages to male partners about the importance of ANC, appointment reminders for their partners and promoting their participation in education and counseling sessions. This gender-sensitive mHealth intervention would be more likely to lead to increased use of ANC services and skilled delivery care by pregnant women and help to contribute to improved outcomes for mothers and newborns if the quality of care is high. This highlights the importance of m/ehealth projects incorporating a gender analysis and strategies to implement gender-sensitive interventions into the project.
The most moving and powerful part of the meeting was listening to Dr. Hill share the heartbreaking story of Mariama. Mariama is a pregnant woman who arrives at a local clinic with symptoms of pre-eclampsia, and faces a number of health care quality gaps which cause her to not get the treatment she needs: from lack of appropriate diagnosis and transportation to the hospital, a lack of triage to receive care promptly and then finally when she delivers her preterm son Bulakai, who is alive but not breathing and the health care team is unable to locate a bag and mask to resuscitate him. Dr. Hill used storytelling to make this hypothetical case study come alive for all of the meeting participants. Dr. Hill then linked the loss of the life of Bulakai to a system and quality failure which could have been prevented in part by integrating m/e health into MNCH quality improvement efforts.
The “Bridging the Gaps” meeting highlighted the importance of leveraging m/eHealth solutions as part of broader health system strengthening and QI efforts to achieve better health outcomes for women, men, newborns and children. Specifically, experts in the field discussed strategies for leveraging m/eHealth to strengthen essential health system functions related to service delivery and real time care, workforce, commodities and supply chain, and data and information systems in low-resource settings and identified many areas for participant collaboration. The meeting offered a very useful platform for collaboration and learning and the expectation is that m/eHealth HSS/QI technical working meetings such as this will continue in the future.
The Bridging the Gaps: Leveraging m/eHealth to Achieve Strong Health Systems and High Quality Care in Low-Resource Settings technical meeting was jointly organized by the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project managed by University Research Co., LLC (URC) with support from the U.S. Agency for International Development (USAID) Office of Health Systems. For more information about USAID ASSIST’s work to leverage technology to improve systems, please contact Allison Foster at email@example.com.
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