Addressing Critical Knowledge Gaps in Newborn Health

Blog

By Harriet Othieno on October 20, 2014
Uganda
Africa

On 18th July, I was part of a team from Save the Children and Mukono district that visited Mukono HCIV to provide support supervision to health workers whom Save the Children had trained in the Helping Babies Breathe Plus (HBB+) package.

When we arrived at the health centre, we met Norah Nakimuli, a Nursing Officer and registered midwife, moving quickly to the HBB+ corner, a newborn baby in her arms. We followed her to see what was going on, and she explained, “This baby has just been delivered in the theater and I have been resuscitating it.”

Norah puts the baby on oxygen

Norah said that the baby’s mother, 30-year-old Margaret Kizza of Seeta Bukerere, had been admitted at 3:00am that morning with labour-like pains which had begun the previous day. This was her fourth pregnancy. Although Margaret’s condition was generally good and she was in active labour, the fetal heart rate was low. At 5:30am, her membranes ruptured with meconium-stained liquior grade 2 and signs of face-to-pubis presentation. The doctor was informed and he ordered an emergency cesarean section.

After the operation, Norah received the baby, who failed to breathe. She wrapped and rushed it to the resuscitation corner in the theater. She positioned it well, cleared the airway using the penguin sucker and dried and rubbed its back. In spite of all this, the baby was still not breathing.

“While praying in my heart, I got hold of the ambu bag and started ventilation as I had learned in the HBB+ training,” says Norah. “Immediately the baby sneezed. The score was 3/10 at one minute, then advanced to 5/10 at five minutes and finally progressed to 7/10 at 10 minutes.” Norah was one of the participants in the HBB+ training that was conducted by Save the Children.

Norah says that all of this was done while maintaining warmth to the baby. The baby eventually started breathing and she transferred it to the labour ward for continuous monitoring as its mother recovered from general anesthesia.

“I felt very good because I saved the life of a baby who will be useful in this world,” said Norah. Margaret’s relatives were not around because she had come alone to the hospital, but Norah believed that they would be happy when they heard the story of the newborn’s survival.

She explained that Margaret would be kept in the health unit for three days on observation since she had undergone a caesarian birth. The doctor ordered antibiotics and dextrose 50% to be given to the baby and oxygen. Norah also gave the baby Vitamin K and tetracycline eye ointment.

By Severin Ritter von Xylander on October 17, 2014


Photo: Susan Warner/Save the Children 

This post is part of the Maternal and Newborn Health Integration Blog Series"Integration of Maternal and Newborn Health: In Pursuit of Quality technical meeting. 

The World Health Organization (WHO) welcomes the revitalized interest in integration of maternal and newborn health care as integration is the key to success for both improving maternal health and for ending preventable newborn deaths.

This is the very reason why WHO, together with UNICEF, UNFPA and the World Bank, have been promoting, already since 2000, Integrated Management of Pregnancy and Childbirth (IMPAC). This is the package of guidelines and tools, which respond to key areas of maternal and perinatal health programmes. IMPAC sets standards for integrated maternal and neonatal care. However, integration is not an end in itself, but should serve the purpose of improving quality and efficiency of health care services provided.

One important element of integration of health care services is that they should be centred around the mother-baby dyad, their needs and preferences. It is important that health care services are organized in a way that this will happen. For a normal pregnancy, childbirth and postnatal period this care can and should be provided by midwifery personnel with the necessary skills. Sometimes, however, the mother or the baby needs special attention and services that can only be provided by health care workers with specialized skills. But even in those cases, addressing the needs of the mother and the baby in an integrated way, remains key for success.

For example, early and exclusive breastfeeding is important for the survival, growth and development of the baby and should not be disrupted by separating the baby from her mother, if this is feasible – and in most cases this is feasible. So-called vertical health programmes, such as the expended programme of immunization (EPI) or the prevention of mother-to-child-transmission (PMTCT) have been successful in addressing certain public health priorities as they provide the necessary focus to make things happen. Sometimes they are perceived as disruptive, however, there are good examples how these programme interventions can be successfully integrated into maternal and newborn care services. Again, IMPAC provides guidance on how best to achieve this integration.

Finally, it will be important to promote a truly perinatal approach, which goes beyond highly specialized health care settings, but which will be based on the principles that only good pregnancy and childbirth care will lead to better neonatal outcomes. In conclusion, maternal and newborn health care should be as integrated as possible and as “vertical” as necessary to achieve high coverage and quality of health interventions for the mother and her baby. In the coming months WHO, UNICEF, UNFPA and partners will be working on a Every Mother Every Newborn initiative to improve the quality of integrated maternal and newborn care.

By Leith Greenslade on October 16, 2014
Africa, Asia


This newborn baby boy in Northern Nigeria was put to his mother's breast within 30 minutes of delivery to make sure he received the colostrum, the first milk a mother produces. It provides a newborn with important protection from bateria and infections. Photo: Lucia Zoro/Save the Children

We have known for a long time that breastfeeding can prevent the deaths of many babies.

Exclusive breastfeeding for the first 6 months can reduce child deaths by at least 800,000 each year - almost 15% of the total 6.3 million annual child deaths.

Breastfeeding within the first hour of birth has the potential to reduce newborn deaths by up to 560,000 - 20% of the total 2.8 million annual newborn deaths.

Babies who are not breastfed are particularly vulnerable to the leading killers of small children and are 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhea, compared to babies who are exclusively breastfed.

But despite this evidence rates of early and exclusive breastfeeding are very low (around 40%) and haven’t improved much since the early 1990s, despite more than 15 years of advocacy and investment.

It’s not that women don’t understand the value of breastfeeding. Surveys repeatedly show that new mothers across many countries know that breast is best for babies.

It’s not that we aren’t aware of the reasons that mothers don’t breastfeed. Surveys repeatedly show that new mothers are concerned that they don’t have enough milk or time; that they experience pain, exhaustion and rejection from their babies; that they feel awkward breastfeeding in public; that spouses are often unsupportive and that it’s just too hard to breastfeed and work. And don’t forget that although world health authorities recommend exclusive breast-feeding for 6 months most countries don’t offer maternity leave beyond three, and typically without pay.

It’s not that new mothers are hard to reach. With more women delivering their babies in facilities than ever before it has never been so easy to reach millions of mothers in the critical hours after delivery to help them initiate breastfeeding.

Our collective failure to do so has led to a realization that we need a new approach.

UNICEF’s landmark 2013 report, Breastfeeding on the Worldwide Agenda, outlines a powerful argument for change describing the current environment as “policy rich” but “implementation poor”.

At the same time, the Bill and Melinda Gates Foundation’s flagship breastfeeding investment - Alive & Thrive - is demonstrating that large increases in breastfeeding are possible with multi-sector action to shift attitudes among new mothers, the behavior of employers and the policies of governments. With this approach, the exclusive breastfeeding rate in the Vietnamese project sites has risen from 19 to 63% and across the Bangladesh sites from 49 to 83% in just three years.

And the countries that have achieved the greatest progress in reducing child mortality and achieving Millennium Development Goal 4 have all recorded exclusive rates of breastfeeding well above the global average including Rwanda (85%), Cambodia (74%), Malawi (70%), Bangladesh (64%), Nepal (70%), Eritrea (52%), Ethiopia (50%), Tanzania (50%) and Madagascar (51%).

Inspired by these successes and also by what we have learned in the areas of global health that have made the greatest gains though intense, sustained and collective public and private sector action, especially AIDS, malaria and vaccines, it is time for public-private partnerships to drive innovation, progress and deliver results in breastfeeding.

Partnerships that start with the needs of mothers and work backwards.

Partnerships with the goal of identifying and then removing one by one the major barriers and costs of early and exclusive breastfeeding as experienced by mothers.

Partnerships that are best practice and lift ambitions and inspire action in the countries with very low rates of breastfeeding and high numbers of newborn deaths.

Let’s start with Nigeria.

With the second highest number of child deaths in the world - 800,000 - and one of the lowest rates of early and exclusive breastfeeding - 23% and 15% - what happens in Nigeria will not only matter for a large number of Nigerian children but will also matter for the achievement of global health goals.

With Nigeria’s sharply rising population driven by a very high fertility rate (an average of 6 children per woman), the under 5 population is forecast to grow by 10 million in the next 15 years.

What happens in Nigeria increasingly influences the world.

We have the right ingredients for a strong public-private partnership in Nigeria - a federal government committed to saving one million lives by 2015, trusted local NGO partners like the Wellbeing Foundation, support from the global health community; mobilized networks including the 2,500 strong Global Breastfeeding Initiative; and corporations like McCann Health, Philips, Medela, Ameda and Hygeia fully engaged with an appetite for innovation.

A new public-private partnership can tap into the thriving innovation community that is starting to push the envelope on new breast-feeding supportive technologies. MIT’s Media Lab recently hosted a “Make the Breast Pump NOT Suck” Hackathon which produced the Batman-inspired (yes…) Mighty Mom Utility Belt - a fashionable, discrete, hands-free wearable pump that automatically logs and analyses personal data; Helping Hands - a sturdy, easy to clean, minimal parts, hands free compression bra designed by nursing moms; and PumpIO - an open software and hardware platform to make the breast pumping experience smarter, more data-rich and less isolating.

This is the tip of the iceberg of the innovation needed in the category of “breastfeeding supportive technologies”.

Every year more than 140 million new mothers face the decision whether or not to breastfeed and this population is growing fastest in the countries with the highest child mortality. There are 8 million new mothers every year in Nigeria alone.

As more and more of these mothers will come under increasing pressure to go back to work quickly as women’s labor force participation rates rise, new mothers will need intensive support, and even incentives and rewards to continue breastfeeding. If they don’t, we can expect breast-feeding rates to continue to flatline or more likely, to fall.

But we don’t accept this scenario. We know that most new mothers want to breastfeed. It’s the external environment that needs to change to enable mothers to fulfill their aspirations.

By Bina Valsangkar on October 15, 2014

This blog was co-authored by Bina Valsangkar, Stella Abwao, and Alyssa Om'Iniabohs. Photo Credit:Ida Neuman from Laerdal.

The American Academy of Pediatrics (AAP) has developed several newborn care modules under the Helping Babies Survive (HBS) series to assist healthcare providers everywhere, especially in low-resource settings, to deliver consistent, quality care for newborns. Essential Care for Every Baby (ECEB) is one module within the HBS package (ECEB, Helping Babies Breathe (HBB), and Care of the Small Baby). Learner workbooks and flipcharts are designed with an emphasis on clear and simple illustrations, case scenarios, checklists, and algorithms that direct the provider in caring for the newborn beginning immediately after birth. Consistent, user-friendly materials, is a key strength of ECEB and the HBS series.

ECEB responds to a need for a user-friendly training module to complement the existing WHO-UNICEF essential newborn care curriculum. The components of essential newborn care – ensuring warmth, immediate skin-to-skin care, early breastfeeding, umbilical cord care, eye care, Vitamin K administration, and immunization, are already incorporated into national guidelines, protocols and training materials. These components are routinely addressed in pre-service and in-service trainings for health care workers. ECEB does not necessarily aim to teach a new skill set to newborn care providers; rather, its purpose is to reinforce skills and build confidence. ECEB is not intended to replace existing in-country materials, but rather, complements what is already available. Countries have the option to adopt the ECEB materials or use them to augment their existing essential newborn care materials. ECEB takes what providers are already doing and helps them do it better.

The AAP is working with development partners and programs such as USAID/Maternal and Child Survival Program (MCSP) and Save the Children to introduce ECEB to health providers and policy-makers in countries with a high burden of newborn deaths. In May 2014, USAID’s Maternal and Child Health Integrated Program (MCHIP) and the Laerdal Global Health Foundation, in collaboration with the AAP and other partners, hosted a four-day regional workshop in Addis Ababa, Ethiopia to introduce and provide training for ECEB to participants from the Africa region. Countries already implementing HBB at scale shared their experiences and the potential use for ECEB. A total of 85 people attended the workshop, including ECEB trainers from AAP and represented countries, Ministry of Health representatives, national trainers, representatives of professional medical and midwifery associations, and implementing partners. A total of 55 participants from the following countries were trained as ECEB Master Trainers: Ethiopia, Ghana, Kenya, Liberia, Malawi, Nigeria, South Sudan, Tanzania, Uganda, Zambia, Zimbabwe and USA. After the workshop, participants are working with government and development and implementing partners to strategize how ECEB may become a part of newborn training. A similar ECEB workshop is planned for the Asia region in 2015.

ECEB and the HBS series have the potential to help countries realize their goals within the Every Newborn Action Plan and improve the quality of newborn care and neonatal outcomes.
 

By Bradley Wagenaar on October 13, 2014
Mozambique
Africa

The Lancet Global Health recently published the article Effects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique. In this blog, author Bradley Wagenaar shares insights from the study. Photo Credit: Suzanna Klaucke/Save the Children.

In Mozambique, when a child dies, chances are their death is not recorded in any official capacity. In part, this is because less than half of all children under-5 ever get birth certificates. Officially, they do not exist. If they die, in the eyes of the government, they never died because they never existed in the first place. Even if they were lucky enough to be registered, it is even less likely we will know why they died since less than seven percent of all deaths nationally are reported with their cause-of-death. What little information we do have about the causes and rates of child death come from large, infrequent, and expensive surveys, such as the Mozambican demographic and health survey where researchers physically go door-to-door and ask parents if they know of any children who died, and why.

In a recent article, a group of researchers from the Ministry of Health in Mozambique, the Mozambican National Institutes of Health, and Health Alliance International (HAI is a non-profit organization affiliated with the University of Washington, Seattle and focuses on improving public-sector health systems) used these large-scale population surveys to try to disentangle whether and which health system factors affect rates of child death in Mozambique. Since 90% of the population in Mozambique uses public-sector clinics run by the Ministry of Health that are available to everyone, usually free of charge, we focused on a few factors related to how critical health services are delivered in these facilities.

What we found was that Mozambique has made great strides in decreasing child death over the past decade – a 56% reduction from 2000 to 2010. We also found that three public-health-system factors seem to be most related to gains made in decreasing child death: (1) more women giving birth at public health facilities; (2) more qualified health workers at those facilities; and (3) ensuring there are enough public health facilities as population continues to grow.

What concerned us, however, was that these observed large decreases in the number of child deaths were not distributed equally across Mozambique. While mortality rates aggregated to the country level appear to have made these great reductions, at the provincial level (11 provinces in Mozambique, so ~2 million people per province) or district level (128 districts in Mozambique, so ~200,000 people per district), disparities in child death may actually be increasing.

There is an old adage, which appears to be borne out in some studies, that as the availability or quality of healthcare is improved, disparities in population health may increase in the short-term. This is because the people most likely to take advantage of new health care innovations are those who are more educated and already in better health. When these people access new services, their further separate themselves from the most disadvantaged; often reaching those who most need help is the hardest.

While some provinces in Mozambique showed decreases of up to 80% in neonatal mortality rate over the past decade, some provinces showed decreases as low as 5%. Even more concerning is that current designs of large-scale intermittent community surveys only allow analyses of child deaths to the provincial level in many countries. The differences in rates of death are not trivial. Comparing Provinces in Mozambique, some children are more than three times as likely to die in the first 30 days of life. Disparities in death rates across districts are likely significantly higher.

Alongside proven interventions such as investments in public-sector human resources for health, advocating for safe birth practices in health facilities, and health infrastructure improvements, urgent investments are needed in vital registration systems (births/deaths) and other ways to track district-level (or lower) health disparities. In an age of mobile technology and instant communication, the era of using community surveys to evaluate child deaths at the provincial level or higher should be over. The lack of data on health disparities or real-time statistics on child deaths impedes the development, targeting, and testing of novel innovations to save the lives of children and improve maternal and child health more generally.

We should all advocate for a world where, at the minimum, all children who tragically die before their fifth birthday have their birth, death, and cause-of-death recorded so that we can work to prevent these deaths for other unborn children.