Addressing Critical Knowledge Gaps in Newborn Health

Blog

By Sanni Kujala on January 27, 2015
Rwanda, Uganda
Africa

Swedish Organization for Global Health (S.O.G.H.) is a registered non-profit based in Stockholm, Sweden. The non-profit was founded by a group of Public Health Master's students at the world-renowned medical university, Karolinska Institute (KI). 

Our mission is to develop evidence-based public health projects in low-income countries, with a focus on maternal, newborn and reproductive health.

S.O.G.H. currently has partners in Uganda and Rwanda, whom we work with to develop projects that address some of the most important public health issues in the countries.

In Sweden, we encourage students interested in a career in global health to get involved in fundraising activities and volunteering in the project countries.  

What We Do  

We are currently running a maternal and newborn health project – the Maama Project – together with Uganda Development and Health Associates.   

Through enlisting the help of local community health workers, we want to increase antenatal care attendance and health facility births in our project area in Maina (in the Mayuge district in Uganda), as well as reduce the risk of infections for mothers and newborns after birth by providing them with clean birth kits.


One of our community health workers talking to pregnant women about the benefits of antenatal care, giving birth in a health facility and using the clean birth kit.

Our partnerships with the local NGOs allow more students from KI to gain practical experience in global health by working for our organization and our partner NGOs.  

Our KI Education

Sanni Kujala is the program director and co-founder of S.O.G.H., and a student in the Public Health Sciences KI program. In an interview, she shares that her education at KI has helped her in her NGO work.

"My education has helped me to look at development projects from an evidence-based standpoint," she says. "Courses in data collection and intervention evaluations have been especially helpful in planning how and when we collect data in order to evaluate how well our peoject is working and what kind of difference we are making."

Meeting with UDHA and S.O.G.H. members together with community leaders and community health workers — in Mayuge, Uganda.

Our Progress

S.O.G.H.'s Maama Project has been designed to align with the strategic objectives of the Every Newborn Action Plan that was launched in June 2014 by WHO and Unicef. 

A pilot has been running in four villages in Maina Parish since August 2014. 

The initial results from the pilot are encouraging: the average number of antenatal visits to the local health clinic have increased by 104% (from 35 to 72). Moreover, the proportion of women who complete all four recommended antenatal visits has gone up from 12% to 75%.

In the long term, we are aiming to expand our work to more countries. 

We are also designing a sexual health education program for secondary school students. The project is directed towards 14-18 year old secondary schools students, in collaboration with HDI (Health Development Initiative) in Rubavu district, Rwanda.

Connect With Us  

We welcome everyone who is interested in volunteering with us! Feel free to reach out to us via our website, or through social media on TwitterInstagramLinkedIn, and Facebook.

By Ian Hurley on January 23, 2015
Liberia
Africa


Photo: Magda Rakita/Save the Children 

Baby Gift, 3 weeks old, is examined by certified midwife Alice at a health clinic in White Plains, Montserrado County Liberia. Note that this photo was taken prior to the Ebola virus outbreak.

The Ebola outbreak that begin in West Africa in March of 2014 has had devastating consequences for communities, families and the people in Liberia, Sierra Leone and Guinea. Thousands of men, women and children have died and health systems have taken a major blow. The Centers for Disease Control and Prevention stated that in November 50 percent of the reported cases of the Ebola virus in Liberia were in Montserrado County, where the above photograph was taken. Montserrado includes the capital Monrovia but also many rural areas like White Plains. 

That same month the CDC issued recommendations for how a newborn baby should be breastfed in the context of Ebola. The statement noted that:

Although Ebola virus has been detected in breast milk1, it is not known whether Ebola virus can be transmitted from mothers to their infants through breastfeeding. However, given what is known about the transmission of Ebola virus, regardless of breastfeeding status, infants whose mothers are infected with EVD are already at high risk of acquiring the virus infection through close contact with the mother, and are at high risk of death overall2. Therefore, when safe replacements to breastfeeding and infant care exist, mothers with probable or confirmed Ebola should not have close contact with their infants (including breastfeeding).

The overall impact of the Ebola outbreak will have on the region's health systems is still not fully known. Pregnant women and new mothers in particular may be less likely to seek care as to not become infected and pass the virus onto their baby. We can be sure though that with a lack of fully staffed and supplied health facilities, pregnant women and newborns are at an increased risk of complications and death. Thankfully, the number of Ebola cases has come down in Liberia, but there is a sustained need to ensure that pregnant women and newborns are able to access lifesaving care as the emergency response continues. 

 

1. Bausch et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. Journal of Infectious Diseases 2007;196:S142-7.

2. Bulletin of the World Health Organization, Ebola Haemorrhagic Fever in Zaire 1976 56 (2): 271-291 (1978)

By Pallavi Dhakal on January 22, 2015
Nepal
Asia

This blog was originally published by the EVERY ONE Campaign. Written by Pallavi Dhakal.

Save the Children, under the guidance of the Government of Nepal, leads a consortium of seven partners on the Suaahara program. The USAID-funded Suaahara is a five year (2011-2016) program aiming to reduce national stunting from 41 percent to 27 percent through the concentration of activities in 41 of the most vulnerable districts of Nepal.

Suaahara meaning “good nutrition” in Nepali is a uniquely designed, multi-sector community-based nutrition program focused on reducing undernutrition among women and children during the critical 1000 days (period from conception to a child’s second birthday) and their families. According to the global recommendations Government of Nepal has prioritized 1,000 days as primary targets to improve nutrition.

Malnutrition remains a serious obstacle to child survival, growth and development in Nepal – 41 % children under five are stunted, 11% are wasted and 29% are underweight. Diarrhea and other morbidity conditions related to poor sanitation and hygiene continue to be major cause of childhood malnutrition including illness and death.

The Suaahara program is focused at the household level to address multiple causes of malnutrition and is in line with the National Multi-Sector Nutrition Plan of Action. It uses integrated approach (nutrition specific intervention, agriculture, Water, Sanitation and Hygiene (WASH), and health service promotion) to tackle malnutrition at the household level. It focuses on changing behavior by promoting actions and practices that are easily doable (e.g., adding animal protein such as egg or a piece of liver to porridge to make it nutritious, maintaining properly-managed backyard poultry and/or vegetable garden for access to nutritious food, washing hands with soap prior to preparing food and feeding, using toilet and boiling drinking water, going for regular ante-natal checkups and more).

Transformation of a young mother from knowing little to becoming a role model

When Rita Tilija from Myagdi district in the west attended the training by USAID-funded Suaahara program for the first time, she was already three months pregnant. “I was surprised to learn that children needed to be exclusively breastfed for six months without even giving water,” says Rita.


Photo: Pallavi Dhakal/Save the Children

The integrated nutrition program, Suaahara, trained Rita to recognize the importance of yellow and green vegetables and diverse diet, proper hygiene and sanitation, regular health check-ups and imparted valuable skills on homestead farming and poultry management. She also received five young chicks and diverse vegetables seeds to start farming at home. “I didn’t know anything about agriculture and today I am teaching mothers how to make raise beds to improve cultivation and increase their access to nutritious vegetables at home,” smiles Rita.

Delivering better health

35-year-old Malla Devi Joshi was already in labour when she arrived at the Deulekh Primary Health Center in Bajhang. Auxiliary nurse midwife (ANM) Shyamkala Panthee rushed to meet Malla and escorted her to the delivery room. Soon thereafter, Malla gave birth to her fourth child— the first to be born in a health facility.


Photo: Rachel Machefsky/Suaahara, JHUCCP

Women come from far and wide to the Deulekh Primary Health Center. Before Suaahara began organizing Health Mothers’ Group meetings for pregnant women and new mothers in Bajhang District, many women did not understand the importance of delivering in a health facility, and instead delivered at home. Suaahara also contributed to improving the quality of services provided in the health center by training the auxiliary nurse midwives (ANMs), like Shyamkala, on skilled birth attendance, as well as on nutrition and family planning counseling. The Health Post In-Charge, Hem Raj Bhatta says, “There has been a huge increase in the number of institutional deliveries and antenatal checkups made by women in this community over the past few years The number of patients we see has grown from 20 -30 in one day to 50 -60 in one day.”

Transforming community's nutritional behaviour

In the remote Kaluketi village of the far-west corner of Bajhang district in Nepal, the Joshi family – traditionally forbidden to eat eggs or meat – is going against their custom for the health of their family. Suaahara works to improve nutrition and health status through an integrated approach that includes communication activities to change behavior such as Bahun individuals’ abstinence from consuming animal source foods rich in nutrients.

“Before we became involved in the Suaahara Program,” Deepak Raj Joshi says, “we never even heard the sound of chickens.” Today, Deepak Raj and his wife, Dhan Laxmi, own seven large chickens. They feed their 17-month-old son, Parshuram, eggs and meat frequently. Dhan Laxmi Devi, who breastfeeds Parshuram in addition to giving him nutritious solid foods, also regularly eats eggs and meat.

Almost immediately, the Joshis saw the benefits of their unpopular decision. Deepak says, “Our second baby looks bigger and healthier than our first did.” Dhan Laxmi adds, “He is also smarter and has never suffered from a serious illness.”


Photo: Rachel Machefsky/Suaahara, JHUCCP

Impact and accolades

Dr. Patrick Webb, Dean for academic affairs of the Friedman School of Nutrition Science and Policy at Tufts University called Suaahara “the most cutting-edge nutrition program in the world”. He says, “As a global nutrition community, we now know the critical importance of integrated projects to achieve maximum effectiveness. Suaahara does this, and that is why it’s showing impressive initial results.”

Since its beginning in 2011, Suaahara has already increased the prevalence of exclusive breastfeeding of children under six months of age by 18 percentage points – from 46 percent to 64 percent. At the same time, the prevalence of children 6-23 months receiving a minimum acceptable diet has improved from 36 percent to 54 percent in the project’s initial 25 districts.

By Leith Greenslade on January 21, 2015
Africa, Asia

The nutrition of women and their children can be improved by reaching them through their employers. Photo: Munir Uz Zaman/AFP

This blog was originally published in The Guardian's Global Development Professionals Network. Written by Leith Greenslade.

What if nutrition efforts focused on the places where large populations of teenage girls and young women are most likely to congregate – their workplaces? As more and more young women stream into the labour market in countries with the greatest nutrition challenges, there is an opportunity to reach hundreds of millions of women with education about nutrition. And better still, there is a chance to improve their diets by providing nutritious foods at work.

Traditionally, the route to reaching pregnant women has been through the health sector, which has usually meant waiting until a woman shows up at a clinic and struggles to deliver her baby, or returns later with a baby so close to death that the facility responds to the emergency, and not always with success. Poor nutrition in pregnancy is contributing to the estimated 290,000 maternal deaths and 2.8m newborn deaths that occur globally each year, and to the estimated 160 million children who are stunted – a lifelong condition that causes physical and mental delays, depressed educational performance and earnings, and an increased risk of developing chronic diseases like hypertension, type 2 diabetes, and cardiovascular disease.

In Vietnam, the Alive & Thrive project has been working with local employer Canon since 2012 to support pregnant women and new mothers among its 24,000 employees. The benefits package encourages breastfeeding and good nutrition with an extra month of paid maternity leave prior to delivery in addition to the mandated six months after delivery, extra 15-minute work breaks for nursing mothers, breastfeeding facilities on site (a dedicated room with breast pumps, refrigeration, towel, steriliser and educational materials) and a $7.50 (£5) monthly allowance for employees with children under one year old. Alive & Thrive has increased the exclusive breastfeeding rate from 19 to 63% in the project sites in just three years.

Another project in Bangladesh is working with local employers to bring fortified foods and micronutrient supplements to 40,000 women garment workers alongside better prenatal care, breastfeeding support, childcare, water, sanitation and hygiene in the target factories. As a country with high female labour force participation (57%), with millions of women employed in garment factories in urban areas and 40% of women delivering their first babies before they turn 18, Bangladesh is an ideal candidate for work-based nutrition and breastfeeding support programmes that improve the health of young mothers.

We need to see many more programmes like these in other countries with large populations of poorly nourished women, including India, China, Pakistan, Indonesia, Ethiopia, Nigeria, the Philippines, and the Democratic Republic of Congo.

The Scaling Up Nutrition (SUN) movement is focusing on encouraging large-scale employers to make commitments to workplace nutrition programmes that target maternal health and support for breastfeeding mothers. More than half of the 51 companies that have signed up to the SUN movement’s business network have made such commitments. To guide them, SUN has produced a toolkit which lays out the basics of an effective workplace nutrition policy including improved maternity leave, breastfeeding support and vitamin-fortified (especially iron and calcium) high-protein, energy foods in workplace kitchens and canteens.

Ultimately it is the largest employers of women of reproductive age in the countries with the worst nutrition performance that can have the greatest impact on reducing nutrition-related deaths and disability among women and children. Those employers have the power to stop the vicious cycle of malnourished young women giving birth to low birth weight babies who become stunted children, grow up to be malnourished teens, giving birth to low birth weight babies. The stakes are high enough to warrant some bold and large scale investments.

Leith Greenslade is vice chair at the MDG Health Alliance. Follow @MDGHealthEnvoy on Twitter.

By Atul Gawande on January 16, 2015
India
Asia

Birth attendants on the frontline of childbirth delivery in India’s public hospitals work under challenging circumstances. One on one coaching is the core of a childbirth safety improvement trial involving these health care workers in the northern state of Uttar Pradesh. Source: PSI/Ariadne Labs

This blog was originally published in Impatient Optimists. Written by Atul Gawande, Vishwajeet Kumar, Ruth Landy and Mariam Claeson.

“The mother and her newborn are safe in my hands!” Ishrawati, a birth attendant at a remote health center in northern India, is feeling confident, and in many ways that’s surprising.

Like millions of mostly female health workers delivering babies in the world’s poorest communities, Ishrawati works under conditions of chronic scarcity. No heating in her facility during freezing winters; no air conditioning in the sweltering summers. No running water in the delivery room much of the time. Outmoded equipment and regular stock outs of medicines. Severe understaffing combined with patchy supervision.

The result: a preventable tragedy where a woman still dies every two minutes from causes related to pregnancy or childbirth and 2.9 million infants don’t survive their first month of life.

If Ishrawati is nonetheless gaining confidence under these daunting circumstances, it’s at least partly because of the coaching she’s received as a participant in the BetterBirth Program. It’s a pioneering research program we’re conducting in 120 public health facilities across rural districts of Uttar Pradesh, one of India’s most disadvantaged states. The stakes are high - if we are successful, it could be a game changer for maternal and newborn survival worldwide.

Our BetterBirth trial has adopted the WHO Safe Childbirth Checklist as its basic protocol, since it focuses on key lifesaving practices that cannot be forgotten or skipped from the moment a woman arrives in labor until she leaves for home with her newborn baby. In practice, this requires the delivery team to briefly pause in the flow of care and confirm they have taken basic steps, such as washing their hands with soap, taking the mother’s blood pressure, keeping mom and baby in skin to skin contact after birth to maintain the newborn’s body temperature, and so on.

 
The WHO Safe Childbirth Checklist focuses on improving care at four moments when mother and baby are in greatest danger. Source: Ariadne Labs

It’s hard to follow a checklist, we knew going into the trial, because it involves both individual and systemic behavior change. There are barriers to overcome to execute even the simplest step, and those barriers differ from place to place. Staff may not wash hands in one place because they don’t know it’s important; in another, because they don’t have sinks or running water in the delivery rooms; and in another, because they simply have not made it their habit and no one cares.

Our observation—and our gamble—is that the last phrase is the critical one: if no one cares when someone takes the trouble to do things right, nothing changes. And the overwhelming message to the people who work at the frontlines of care around the world is that no one notices excellence and no one cares. Burnout and discouragement among health care workers around the world is high.

Our BetterBirth trial is tackling these challenges head on in facilities such as Ishrawati’s. Classroom training won’t solve these problems, we realized. So we're training peers—nurses and doctors—to work onsite with birth attendants and hospital leaders to introduce the checklist and simple metrics of adherence to good practice and to coach them in using these aids to gradually close gaps in care.

These systematic efforts and a granular focus on daily problem solving are beginning to bear fruit. Though it’s early days, we’ve begun to see changes in childbirth practices in the pilot facilities where we are working. In one facility, the nurses figured out to ask the sweepers to bring a fresh basin of water and soap when they clean the room. In another, the medical-officer-in-charge recognized that he could order an alcohol hand sanitizer.

Use of technologies are essential to good outcomes, from oxytocin injections to stop maternal hemorrhage after delivery to baby masks for resuscitating newborns. Indian government leadership is also making a crucial difference, aided by our committed partners.

 
The BetterBirth trial involves a major data collection effort in rural Uttar Pradesh. These data collectors gather information on birth outcomes in call centers and community settings. Source: PSI/Ariadne Labs

In the end, though, we think it’s coaching done with empathy that is the true killer app catalyzing improved safe childbirth practices in the over-burdened health centers of Uttar Pradesh. Because the technologies are often unstocked, unused, or wrongly deployed, and it’s only the people on the ground who can change that. Human beings talking to human beings is still how the world’s standards change.

Can this approach succeed at large scale? We’re finding out. Scaling up requires training people who can be a sales force for these concepts and strengthen the connections between the different levels of the health system.

We will report on the findings of the Better Birth trial as they emerge. With quality of care rising as a global health priority, we are eager to learn from Ishrawati and her nurse midwife colleagues as they model that essential agenda.

We invite you to comment below and share this post on Twitter with a message such as this one: Saving #everynewborn: it takes a sales force