Addressing Critical Knowledge Gaps in Newborn Health


By Rebecca Sheldon on July 24, 2014

Photo: MCHIP

This blog was originally published by MCHIP. Written by Rebecca Sheldon.

In recent years, Cambodia has received international praise for improvements in maternal and child health. The Ministry of Health (MOH), however, has recognized that tremendous challenges still persist in the area of newborn health. In particular, preterm birth—a live birth that occurs before 37 completed weeks of pregnancy—remains a prominent issue due to its direct link with high rates of mortality and morbidity among newborns. With the country’s preterm birthrate at 10.5%1 and a neonatal mortality rate of 27 deaths per 1,000 live births, Cambodia’s MOH has committed itself to improving newborn health and decreasing newborn mortality. 

This week, numerous officials from the Government of Cambodia, USAID, MCHIP and other stakeholders attended a national dissemination meeting in Phnom Penh to share the results of an MCHIP supported study that calls for increased coverage of antenatal corticosteroids (ACS) in the management of the country's preterms. ACS are one of the most effective interventions for improving preterm survival, reducing death by 31% by augmenting maturation of the premature fetus’  lungs.

Dr. Tung Rathavy and Dr. Keth Lysotha—Director and Deputy Directory, respectively, of the National Maternal Child Health Center (NMCHC)—were in attendance, along with USAID’s Sheri-Nouane Duncan-Jones (Director, Office of Public Health and Education), and USAID/Cambodia’s Robin Mardeusz (Maternal and Child Health Team Leader, Office of Public Health & Education).

The lessons learned from the intervention have substantial implications for reducing the country's newborn mortality. Directed by the MOH, NMCHC, and the sub-technical working group on maternal child health, the study sought to improve the quality of care given to pregnant women at risk of imminent preterm birth in six different Cambodian facilities. (Human Development Research Cambodia (HDRC) worked closely with NMCHC on local research, and MCHIP provided overall technical support).

Photo: MCHIP

The intervention called for increased coverage of dexamethasone—the most commonly found ACS—to these women in order to reduce complications of prematurity among preterm newborns. The drug is recommended for women with preterm labor, because it is known to improve health outcomes for premature newborns by reducing the chances of related complications if administered before birth. 

In just a short time (less than one year), the overall coverage rates of dexamethasone in the facilities across Cambodia dramatically increased from 34.9% at baseline to 86.1% at endline. Rapid increase in utilization even took place at facilities that had limited knowledge and use of the drug prior to the intervention. Dexamethasone is inexpensive and widely available in hospitals throughout Cambodia, so with increased guidelines and technical supervision, the neonatal intervention was able to produce substantial results even in the most limited facilities. 

Photo: MCHIP

These results are promising because they demonstrate that when strong technical leadership and clinical governance in facilities are combined, the ability of simple, evidence-based interventions—such as increasing the rate of administration of dexamethasone—can be effectively scaled up Cambodia. Providers could alter their behaviors and increase utilization because strong buy in from facilities and increased technical support created an environment that was conducive for implementing correct practices.

The dramatic increase in coverage of dexamethasone in such a short period of time is an incredibly encouraging outcome. With continued emphasis on stronger clinical guidelines and additional technical supervision, increases in the utilization of ACS could be replicated more extensively in other facilities within Cambodia. If the MOH sustains its commitment to scale-up the use of dexamethasone and other interventions for preterm birth, major progress towards reductions in neonatal mortality and morbidity are possible. 

By Elizabeth Atalay on July 23, 2014

This blog was originally published on World Moms Blog. Elizabeth Atalay traveled with the International Reporting Project on a New Media Fellowship to report on newborn health. This post was part of a series of stories from the ground. Read posts from fellows Jennifer James and Nicole Melancon.

We had just spent the night at the source of the Blue Nile River. Lake Tana sits in Bahir Dar, Ethiopia, and as our caravan of Land Cruisers wove through the countryside from Bahir Dar to Mosebo I took in deep gulping breaths of sweet fresh Ethiopian air. The lush colors of our surroundings looked to me like they had been enhanced in Photoshop in the way that everything seemed to pop. How could I feel this emotional connection to place that was never mine? A place I had never been?

Though this is my first time in Ethiopia, the verdant landscape brought me back to other rural parts of Africa I’d traveled through in my youth, similar topographies that had stayed with me ever since. This time I’d returned to the continent as a new media fellow with the International Reporting Project to report on newborn health. World Moms Blog Editor Nicole Melancon of ThirdEyeMom is a fellow on the trip as well, and last week wrote about our initial overview of maternal and newborn health in Ethiopia. Now we were heading to one of the villages housing a Health Post, which serves the local and surrounding population of approximately 3,500 people.

Mosebo Village is part of Save The Children’s Saving Newborn Lives program, and as such is looked to as a model village in the Ethiopian Government’s plan to reduce maternal and newborn mortality. Mosebo is a rural agrarian community that produces wheat, teff and corn. There I met seven-year-old Zina whose mother, Mebrate was about to give birth. Through our translator Mebrate estimated her age to be around 26, and told us that Zina was her first child. For economic reasons she and her husband had waited to have a second. When she had Zina, Mebrate had gone to her parent’s home to give birth, as women in Ethiopia often do. It is estimated that 80% of Ethiopian mothers will give birth in their home, often without a trained health care attendant. Towards the end of Mebrate’s first pregnancy she went to live with her parents as her family instructed, until after the baby was born. In that way her mother could help her deliver, could care for her and the baby, and feed her the traditional porridge after birth. Although there were no complications during her delivery, sadly, many young mothers giving birth at home are not as fortunate. The time period during and around birth are the most vulnerable for the lives of both the mothers and babies. The Saving Newborn Lives Program aims to reduce maternal and newborn mortality beginning with awareness programs and antenatal care on the local level at Health Posts like the one we visited in Mosebo.

We had met Tirgno and Fasika, the two Health Extension Workers at the Mosebo Health Post earlier that day as they showed us the two room interior, and explained their role in improving maternal and newborn health. They work to raise awareness in the community about the importance of antenatal care, and the potential dangers of giving birth at home for both mother and child. Newborn health is interdependent with maternal health, and the most prevalent causes of newborn mortality, infection, Asphyxiation, pre-maturity or low birth weight, and diarrhea can often be avoided with proper care. These days in Mosebo after receiving antenatal care at the Health Post women are then referred to the regional Health Center for deliveries.


Zina shyly smiled when we ask her how she felt about having a new sibling, she stood straight and tall listening intently as we asked her mother about the babies’ arrival. When Mebrate goes into labor this time, with her second child, she will embark on the walk along rural dirt roads for around an hour to the nearest Health Center to give birth.

Elizabeth Atalay was reporting from Ethiopia as a fellow with the International Reporting Project (IRP). This is a promotion of the original post written for World Moms Blog. You can follow all IRP reports by World Moms Elizabeth Atalay & Nicole Melancon at #EthiopiaNewborns

By Nicole Melancon on July 22, 2014

This blog was originally published on ONE. ONE Mom Nicole Melancon traveled with the International Reporting Project on a New Media Fellowship to report on newborn health. This post was a continuation of the ONE series of stories from the ground. This post was part of a series of stories from the ground. Read posts from fellows Jennifer James and Elizabeth Atalay. 

Reaching Mosebo village, about 42 kilometers outside of Bahir Dar in rural Ethiopia is not for the faint at heart. It requires a land cruiser, patience, and a bit of adventure to cover the hour and a half drive on bumpy, muddy roads to reach Mosebo and see how over 90% of Ethiopians live. If it starts to rain, as it frequently does during Ethiopia’s three month rainy season, the road becomes dangerous and impassable.

I visited Mosebo village as a International Reporting Project Fellow to learn more about the miraculous success Ethiopia has made by reducing child mortality rates and the work that needs to still be done in reducing newborn deaths, particularly within the first 28 days of life which are the most dangerous days to be alive.

Per Save the Children’s “Ending Newborn Deaths Report”, every year one million babies die on their first and only day of life, accounting for 44% of all deaths for children under the age of five. Nearly two million more children will die within their first month. Four out of five of these deaths are due to preventable, treatable causes such as preterm birth, infections and complications during childbirth.

We arrived at Mosebo village to the sounds of children cheering and herders curious, gentle smiles. At the village, we were introduced to Tirigno Alenerw and Fasika Menge, two of Ethiopia’s 34,000 trained Health Extension Workers, who work at the Health Post located in Mosebo.

Mosebo is a model village run by Save the Children’s Saving Newborn Lives Program and represents the best case scenario for health care coverage and services for Ethiopia’s rural people.

The Mosebo Health Post covers 3,700 patients in the community which encompasses an area of up to an hour and a half on foot each direction. The Health Post has morning office hours from 8-10 am where Tirigno and Fasika see patients for a wide variety of services such as family planning, pre and post natal care, vaccinations, treatment of minor health issues, and education and consultation on health issues.

The rest of the day is spent on foot visiting patients in other villages at their home. Tirigno and Fasika also consult expectant mothers about the importance of delivering in a hospital, exclusive breastfeeding, and family planning. They contribute the lower maternal, child and newborn deaths to their services and over the six years they have worked within the community there have been no maternal deaths.

We had the chance to meet Fasika Dores and her nine-day old baby. Her baby is her fourth child, and has not been named yet which is common in Ethiopia given the high newborn mortality rates. However Fasika and her husband Minwiyelet plan on naming their child Ketema which means “city” in Amharic as he was their first child born at a hospital in a city.

As a nation, it is estimated that 80-90% of women still give birth at home without a trained assistant in Ethiopia, which significantly contributes to Ethiopia’s high newborn and maternal deaths. In Mosebo, 50% of the women now give birth at a hospital thanks to the advice and work of the Health Extension Workers.

Although maternal mortality rates have decreased, the rates are still way too high, and newborn mortality rates have shown little progress. Getting more villages like Mosebo and training Health Extension Workers as midwives would significantly reduce maternal and newborn mortality rates in Ethiopia.

As we left Mosebo village, the children ran after our cars smiling and waving goodbye. It was a happy place, and all we can hope is that more villages will have access to better maternal, child and newborn care.

ONE Moms Elizabeth Atalay and Nicole Melancon are both traveling as IRP Fellows in Ethiopia. You can find out more about their journey and ways to follow here.

By Ivonne Gómez Pasquier on July 21, 2014

In June, the USAID ASSIST-supported Salud Materno Infantil (Maternal and Infant Health) Kangaroo Mother Care (KMC) Community of Practice hosted its second virtual discussion forum in Spanish on "Experiences in startup and early consolidation of Kangaroo Mother Care (KMC) activities in hospitals in Latin America: favorable aspects, constraints and lessons learned.” As a pediatrician and director of the USAID ASSIST Project in Nicaragua, I was honored to moderate the forum.

During the nine days of this forum, from June 16th through the 25th, participants from Bolivia, Colombia, Ecuador, El Salvador, Guatemala, Mexico, Nicaragua, Paraguay and the Dominican Republic shared valuable experiences and insights about the successes and challenges to implementing KMC programs in their respective countries, and shared innovative ways in which challenges were overcome.

Themes discussed during the virtual forum included the importance of having a well-trained team that is committed to KMC and ensuring that there is buy-in and support from hospital management. Involving all personnel at the hospital with more emphasis on the staff working in maternal and newborn health was revealed as a best practice, as was the importance of promoting the scientific evidence about the benefits of KMC for newborns among medical staff so as to overcome pushback from staff who don’t fully understand its importance and feasibility.

The conversation also addressed the limitations to expanding KMC in Latin America, including lack of adequate financial and human resources and infrastructure. Forum participants mentioned creative ideas to increase support from the Ministry of Health, civil society, and NGOs, international organizations and medical societies. Among the most pertinent lessons learned included the importance of working with hospital management to implement guidelines, track indicators, and to ensure that relevant information, including the benefits of KMC, is shared with mothers, families, and the community and that parents are supported to perform KMC.

We also shared results from cost effectiveness studies of KMC in Nicaragua and Ecuador, which show that KMC actually saves money for hospitals that implement it. As hospitals realize KMC improves health outcomes for premature newborns and is cost effective, they will be more open and excited to implement KMC.

Thiago de Oliveira, pictured with his daughter, Agate Victoria, who was born at 6 months’ gestation, Rocha Faria State Hospital in Campo Grande, Brazil. Photo credit: Edna Galvão. View full article.

A summary of the steps to introduce KMC to a health facility was also shared and discussed. Discussions also include guidelines, indicators and URC’s experience with respect to the application of KMC for premature and underweight babies in four countries in Latin America.

Discussions also included the importance of couples’ counseling as a much more effective method to achieving enrollment and retention in the KMC program than targeting pregnant women alone. Husbands often hold decision-making power within families in Latin America, and from a gender perspective, it’s important to educate fathers about the importance of KMC, so that they are aware of its benefits and support their wives to use the KMC method. Promoting fathers’ participation in KMC, at the discretion of the mother, can relieve mothers from some of the pressure of being the sole partner to carry out the skin-to-skin contact and can strengthen the bond between father and child, which can set the tone for the rest of the child’s life.

This was my first experience moderating a virtual forum, and it afforded me the opportunity to interact with health care professionals from all across Latin America. Some had general questions, others asked for help to resolve a specific problem, while some participants simply wanted to share the KMC context in their country. In reflecting on the forum, it is clear that we all face similar issues and challenges across Latin America. We can help and support each other and learn from our failures and successes.

The virtual forums and webinars hosted by our USAID ASSIST KMC community of practice team are critical because they offer a user-friendly platform for health professionals working in KMC to connect with one another at no cost, to share learning, best practices, and what doesn’t work about implementing and expanding KMC in Latin America. Forum participants echoed this sentiment, acknowledging the utility of the forum as a place to experiences between countries, strengthening their links and allowing each one to learn from others, in effect collectively strengthening all of our KMC work.

For more information about the KMC Community of Practice, visit the USAID ASSIST-supported Salud Materno Infantil (maternal and infant health) Spanish language website or join our upcoming webinar, “Scientific Evidence and Recent Developments that support the benefits of the KMC method” which will be held on July 22nd. For more information about Kangaroo Mother Care and its implementation, visit the Healthy Newborn Network’s KMC Information Page.

By Alexandra Shaphren on July 18, 2014

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L. Bartlett, E. Weissman, R. Gubin, et al. The Impact and Cost of Scaling up Midwifery and Obstetrics in 58 Low- and Middle-Income Countries. PLoS ONE (June, 2014).
Background and Methods: To guide achievement of the Millennium Development Goals, we used the Lives Saved Tool to provide a novel simulation of potential maternal, fetal, and newborn lives and costs saved by scaling up midwifery and obstetrics services, including family planning, in 58 low- and middle-income countries. Typical midwifery and obstetrics interventions were scaled to either 60% of the national population (modest coverage) or 99% (universal coverage).
Findings: Under even a modest scale-up, midwifery services including family planning reduce maternal, fetal, and neonatal deaths by 34%. Increasing midwifery alone or integrated with obstetrics is more cost-effective than scaling up obstetrics alone; when family planning was included, the midwifery model was almost twice as cost-effective as the obstetrics model, at $2,200 versus $4,200 per death averted. The most effective strategy was the most comprehensive: increasing midwives, obstetricians, and family planning could prevent 69% of total deaths under universal scale-up, yielding a cost per death prevented of just $2,100. Within this analysis, the interventions which midwifery and obstetrics are poised to deliver most effectively are different, with midwifery benefits delivered across the continuum of pre-pregnancy, prenatal, labor and delivery, and postpartum-postnatal care, and obstetrics benefits focused mostly on delivery. Including family planning within each scope of practice reduced the number of likely births, and thus deaths, and increased the cost-effectiveness of the entire package (e.g., a 52% reduction in deaths with midwifery and obstetrics increased to 69% when family planning was added; cost decreased from $4,000 to $2,100 per death averted).
Conclusions: This analysis suggests that scaling up midwifery and obstetrics could bring many countries closer to achieving mortality reductions. Midwives alone can achieve remarkable mortality reductions, particularly when they also perform family planning services - the greatest return on investment occurs with the scale-up of midwives and obstetricians together.
Background: There is renewed interest in stillbirth prevention for lower-middle income countries. Early initiation of and properly timed antenatal care (ANC) is thought to reduce the risk of many adverse birth outcomes. To this end we examined if timing of the first ANC visit influences the risk of stillbirth.
Methods: We conducted an analysis of a retrospective cohort of women (n = 34,671) with singleton births in a public perinatal service in Cape Town, South Africa. The main exposure was the gestational age at the first ANC visit. Bivariable analyses examining maternal characteristics by stillbirth status and gestational age at the first ANC visit, were conducted. Logistic regression, adjusting for maternal characteristics, was conducted to determine the risk of stillbirth.
Results: Of the 34,671 women who initiated ANC, 27,713 women (80%) were retained until delivery. The population stillbirth rate was 4.3 per 1000 births. The adjusted models indicated there was no effect of gestational age at first ANC visit on stillbirth outcomes when analyzed as a continuous variable (aOR 1.01; 95% CI: 0.99-1.04) or in trimesters (2nd Trimester aOR 0.78, 95% CI: 0.39-1.59; 3rd Trimester OR 1.03, 95% CI: 0.50-2.13, both with 1st Trimester as reference category). The findings were unchanged in sensitivity analyses of unobserved outcomes in non-retained women.
Conclusion: The timing of a woman’s first ANC visit may not be an important determinant of stillbirths in isolation. Further research is required to examine how quality of care, incorporating established, effective biomedical interventions, influences outcomes in this setting.
Background: Kangaroo Mother Care is an intervention that can help reduce neonatal mortality rate in Malawi but it has not been rolled out to all health facilities. Understanding the mothers׳ experience would help strategise when scaling-up this intervention.
Objective: to review experiences of mothers Kangaroo Mother Care at two hospitals of Bwaila and Zomba.
Design: quantitative, descriptive using open interviews.
Setting: two central hospitals in Malawi.
Participants: 113 mothers that were in the Kangaroo Mother Care unit and those that had come for follow-up two weeks after discharge before the study took place.
Findings: mothers had high level of knowledge about the significant benefits of Kangaroo Mother Care but 84% were not aware of the services prior to their hospitalisation. 18.6% (n=19) were not counselled prior to KMC practice. Mothers preferred KMC to incubator care. There were factors affecting compliance and continuation of KMC, which were lack of support, culture, lack of assistance with skin-to-skin contact, multiple roles of the mother and stigma.
Key conclusions: mothers had a positive attitude towards KMC once fully aware of its benefits.
Implications for practice: there is need for awareness campaigns on KMC services, provision of counselling, support and assistance which can help motivate mothers and their families to comply with the guidelines of KMC services.
Millennium Development Goal (MDG) # 4 targets a 2/3 reduction of under 5 years of age deaths by 2015 (United Nations, 2013). However, preventable neonatal deaths which constitute nearly half of this under 5 years of age mortality hinder the achievement of MDG. Strategic implementation of programs and initiatives to improve neonatal outcomes relies on effective utilization of neonatal workforce at the regional, national, and global level. The Council of International Neonatal Nurses (COINN), Inc. identified as the only international neonatal nursing organization recognizes the need for an updated data which is not only updated but neonatal specific, in order to identify the gaps in care providers compared to neonatal outcomes. Neonatal nurse workforce shortages and how it relates to the quality or the availability of care is reported widely, however, in a fragmented manner. This article will describe the significance of the neonatal workforce to the neonatal health and neonatal nursing by reporting the existing evidence related to the neonatal workforce and the current efforts being made globally.
A. Exavery, A. Malick Kanté, M. Njozi, et al.  Access to institutional delivery care and reasons for home delivery in three districts of Tanzania. International Journal for Equity in Health (June, 2014).
Introduction: Globally, health facility delivery is encouraged as a single most important strategy in preventing maternal and neonatal morbidity and mortality. However, access to facility-based delivery care remains low in many less developed countries. This study assesses facilitators and barriers to institutional delivery in three districts of Tanzania.
Methods: Data come from a cross-sectional survey of random households on health behaviours and service utilization patterns among women and children aged less than 5 years. The survey was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania, using a closed-ended questionnaire. This analysis focuses on 915 women of reproductive age who had given birth in the two years prior to the survey. Chi-square test was used to test for associations in the bivariate analysis and multivariate logistic regression was used to examine factors that influence institutional delivery.
Results: Overall, 74.5% of the 915 women delivered at health facilities in the two years prior to the survey. Multivariate analysis showed that the better the quality of antenatal care (ANC) the higher the odds of institutional delivery. Similarly, better socioeconomic status was associated with an increase in the odds of institutional delivery. Women of Sukuma ethnic background were less likely to deliver at health facilities than others. Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery.
Conclusion: Institutional delivery in Rufiji, Kilombero, and Ulanga district of Tanzania is relatively high and significantly dependent on the quality of ANC, better socioeconomic status as well as between-partner communication about family planning. Therefore, improving the quality of ANC, socioeconomic empowerment as well as promoting and supporting inter-spousal discussion on family planning matters is likely to enhance institutional delivery. Programs should also target women from the Sukuma ethnic group towards universal access to institutional delivery care in the study area.
*S. McDonald, P. Middleton, T. Dowswell. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (Review) A Cochrane Review Journal (June, 2014).
Background: Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord more than one minute after the birth or when cord pulsation has ceased. The benefits and potential harms of each policy are debated.
Objectives: To determine the effects of early cord clamping compared with late cord clamping after birth on maternal and neonatal outcomes
Search methods: We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (13 February 2013).
Selection criteria: Randomised controlled trials comparing early and late cord clamping.
Data collection and analysis: Two review authors independently assessed trial eligibility and quality and extracted data.
Main results: We included 15 trials involving a total of 3911 women and infant pairs. We judged the trials to have an overall moderate risk of bias.
Maternal outcomes: No studies in this review reported on maternal death or on severe maternal morbidity. There were no significant differences between early versus late cord clamping groups for the primary outcome of severe postpartum haemorrhage (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.65 to 1.65; five trials with data for 2066 women with a late clamping event rate (LCER) of ~3.5%.
Multiple Authors. A Call to Action to End Newborn Death. Save the Children and World Vision (June, 2014).
At the 67th World Health Assembly on 24 May 2014, governments from around the world made a historic commitment to end preventable newborn deaths. Health ministers of 194 countries endorsed the Every Newborn Action Plan (referred to from here on as Every Newborn) and ratified a resolution calling for its implementation.
This is very welcome progress. Until this point, newborn survival had been badly neglected. We strongly support Every Newborn as a catalyst to promote newborn survival, and to end all preventable deaths among newborn babies.
The Every Newborn Action Plan sets a target to end all preventable newborn deaths by 2035 and achieve universal coverage of key services. Specifically, theworld has committed to a powerful and crucial setof promises:
  • Fewer than ten newborn deaths per 1,000 live births and ten stillbirths per 1,000 total births in and within each country by 2035, resulting in a global average of seven newborn deaths per 1,000 live births and eight stillbirths per 1,000 total births by 2035.
  • 95% of women to give birth with skilled attendance by 2025
  • 75% of babies who do not breathe at birth to be resuscitated; 75% of preterm babies to receive kangaroo mother care; and 75% of newborn babies with bacterial infection receiving antibiotics by 2025
  • 90% of women and newborns to receive good-quality postnatal care within two days of birth by 2025, with tracking of content and outcomes such as 50% exclusive breastfeeding.
These targets are aligned with the child survival target of 20 or fewer under five deaths per 1,000 live births – a global commitment made as part of A Promise Renewed and the UN Secretary-General’s Every Woman Every Child initiative – and the working definition of an end to preventable child deaths.
At the Partners’ Forum of the Partnership for Maternal, Newborn and Child Health, we are calling on governments, development partners, donors, civil society and the private sector to make bold and additional commitments to Every Woman Every Child so that every newborn survives and thrives and every birth is supported with good-quality care.
Multiple Authors. Annual Progress Report to Congress: Global Health Programs FY 2013. U.S. Agency for International Development (June, 2014).
Through its ongoing commitment in advancing science, research, innovation and implementation and its strong partnerships with host country governments, other U.S. agencies and many other organizations and leaders around the world, USAID – as the largest investor in global health – believes these goals are attainable and sustainable. This report describes the Agency’s progress in furthering President Obama’s vision to end extreme poverty through its contributions in global health by ending preventable child and maternal deaths, creating an AIDS-free generation and protecting communities from infectious diseases.
Through our partnerships, we are aggressively scaling up high-impact, low-cost interventions. We are using data to make smart investments and maximizing technology and innovation to solve some of the toughest development challenges. This report presents a summary of USAID's key global health accomplishments in FY 2013. Along with our partners, we believe we have the tools and knowledge to save and improve lives today and are looking optimistically toward the future.
Multiple Authors. Every Newborn Action Plan. World Health Organization (June, 2014).
The Every Newborn action plan is based on the latest epidemiology, evidence and global and country learning, and supports the United Nations Secretary-General’s Every Woman Every Child movement. The preparation was guided by the advice of experts and partners, led by WHO and UNICEF, and by the outcome of several multi-stakeholder consultations and a web-based consultation with more than 300 comments. Discussed at the 67th World Health Assembly, Member States endorsed the document and made firm commitments to put in practice recommended actions. The Director General has been requested to monitor progress towards the achievement of the global goal and targets and report periodically to the Health Assembly until 2030.
3 million babies and women could be saved each year through investing in quality care around the time of birth and special care for sick and small newborns. Cost-effective solutions are now available to protect women and children from the most dangerous day of their lives – the day of birth.
Unfinished agenda: Newborn health and stillbirths are part of the “unfinished agenda” of the Millennium Development Goals for women’s and children’s health. With newborn deaths still accounting for 44% of under-5 deaths globally, newborn mortality and stillbirths require greater visibility in the emerging post-2015 sustainable development agenda if the overall under-5 mortality is to be reduced.
We have solutions to address the main causes of newborn death: More than 80% of all newborn deaths result from three preventable and treatable conditions – complications due to prematurity, intrapartum-related deaths (including birth asphyxia) and neonatal infections. Cost-effective, proven interventions exist to prevent and treat each main cause. Improving quality of care around the time of birth will save the most lives, but this requires educated and equipped health workers, including those with midwifery skills, and availability of essential commodities.
Women’s and children’s health is a smart investment, particularly with specific attention to care at birth: High coverage of care around the time of birth and care of small and sick newborns would save nearly 3 million lives (women, newborns and stillbirths) each year at an additional running cost of only US$ 1.15 per person in 75 high burden countries. This would have a triple impact on investments – saving women and newborns and preventing stillbirths.
Action with a plan: The Every Newborn action plan was developed in response to country demand. It sets out a clear vision of how to improve newborn health and prevent stillbirths by 2035. The plan builds on the United Nations Secretary General’s Global Strategy for Women’s and Children’s Health and the Every Woman Every Child movement by supporting government leadership and providing guidance on how to strengthen newborn health components in existing health sector plans and strategies, especially those that relate to reproductive, maternal and child health. Every Newborn calls upon all stakeholders to take specific actions to improve access to, and quality of, health care for women and newborns within the continuum of care.
Multiple Authors. IntraHealth International 2013 Annual Report. IntraHealth International (June, 2013).
At IntraHealth International, we improve global health by going to the source of all health care: health workers. In 2013, we reached 178,000 health workers through our many programs. And in turn, those workers provided care to 356 million people around the world. We’ve worked in 100 countries for 35 years. And we’ll keep going until we’ve made sure every person in every community—rich or poor, young or old, rural or urban—has access to high-quality health care.
*Multiple Authors. The Lancet: Midwifery Series. The Lancet (June, 2014).
The essential needs of childbearing women in all countries, and of their babies and families, are the focus of this thought-provoking series of international studies on midwifery. Many of those needs are still not being met, decades after they have been recognized. New solutions are required. The Series provides a framework for quality maternal and newborn care (QMNC) that firmly places the needs of women and their newborn infants at its centre. It is based on a definition of midwifery that takes account of skills, attitudes and behaviours rather than specific professional roles. The findings of this Series support a shift from fragmented maternal and newborn care provision that is focused on identification and treatment of pathology to a whole-system approach that provides skilled care for all.
Midwives are central to the challenge of reducing maternal and newborn deaths. But the number of midwives falls far short of the need. Moreover, their services are unequally distributed - among and within countries.
The State of the World’s Midwifery (SoWMy) 2014 presents findings on midwifery from 73 low and middle- income countries. The report, produced by UNFPA, the International Confederation of Midwives (ICM), the World Health Organization (WHO) and several other partners, shows the progress and trends that have taken place since the inaugural 2011 edition, and also identifies the barriers and challenges to future progress. The report focuses on the urgent need to improve the availability, accessibility, acceptability and quality of midwifery services. Despite a steady drop in maternal and newborn deaths since 1990, hundreds of thousands of women and newborns continue to die each year during pregnancy and childbirth: An estimated 289,000 women and about 3 million newborn babies died in 2013 alone. The vast majority lost their lives due to complications and illnesses that could have been prevented with proper antenatal care and the presence of a skilled midwife during delivery.
Multiple Authors. Twinning as a Tool for Strengthening Midwives Associations. International Confederation of Midwives (June, 2014).
Strengthening Midwives Associations’ systems, skills, structures  and strategies, empowers the associations with the capacity to identify challenges, develop context appropriate solutions for problems. Robust systems enable Midwives Associations to initiate interventions targeted at resolving identified problems; and to identify suitable partners to work with in order to address challenges.
It is imperative for midwives in each country to take their position as critical care providers especially for women, newborns, children and families. Evidence abounds that midwives save lives when they are well educated, regulated and supported through a strong association. ICM through its strengthening Midwives Associations programme facilitates midwives to optimise their value, take their position in care provision and contribute to policy making and effective implementation. However, in countries with a high rate of maternal and infant morbidity and mortality, midwifery and midwives are often of a very low status matching the status of women. With this backdrop, ICM developed the Twinning approach as one of the strategies for strengthening Midwives Associations. By strengthening Midwives Associations, countries are able to benefit fully from their midwifery workforce. Strong Midwives Associations unify midwives; give them a sense of belonging and identity and maximise their contribution to the provision of maternal newborn and child health care within the context of their Ministry of Health’s strategic plans. Due to the various developments taking place in the field of maternal, newborn and child health, midwives need to have a strategy which enables them to learn from others and to share their knowledge. Strong Midwives Associations give midwives a voice within their countries. They are able to take on the roles of advocacy, lobbying for better working conditions for themselves and for the families they serve. They are able to promote the profession of midwifery within their communities, to improve the image of midwives and increase the number of families accessing their services.ICM is using Twinning as one of the strategies to facilitate the development of collaborative relationships which are aimed at mutual learning, support and development among Midwives Associations. ICM’s first experience with initiating and supporting twinning relationships between Midwives Associations was with the Sierra Leone Midwives Association (SLMA) and the Royal Dutch Organisation of Midwives (KNOV). Since then ICM has engaged in initiation of new twinning relationships between Midwives Associations informed by the lessons learnt from the SLMA/KNOV experience. This manual is intended to assist Midwives Associations, and other organisations that plan to engage in a Twinning relationship. The content is based on ICM’s experience with initiating Twinning relationships for ten countries over a period of five years.
S. Premji. Mobile Health in Maternal and Newborn Care: Fuzzy Logic. International Journal of Environmental Research and Public Health (June, 2014).
Whether mHealth improves maternal and newborn health outcomes remains uncertain as the response is perhaps not true or false but lies somewhere in between when considering unintended harmful consequences. Fuzzy logic, a mathematical approach to computing, extends the traditional binary "true or false" (one or zero) to exemplify this notion of partial truths that lies between completely true and false. The commentary explores health, socio-ecological and environmental consequences-positive, neutral or negative. Of particular significance is the negative influence of mHealth on maternal care-behaviors, which can increase stress reactivity and vulnerability to stress-induced illness across the lifespan of the child and establish pathways for intergenerational transmission of behaviors. A mHealth "fingerprinting" approach is essential to monitor psychosocial, economic, cultural, environmental and physical impact of mHealth intervention and make evidence-informed decision(s) about use of mHealth in maternal and newborn care.
*E. Russell, C. Swanson, R. Atun, et al. Systems thinking for the post-2015 agenda. The Lancet (June, 2014).
Global priorities have progressed from the Millennium Development Goals (MDG) that will expire in 2015 to global sustainable development. Although there is not yet a consensus on the specific goals for the post-MDG era, the post-2015 investment agenda for health will probably emphasise social determinants of health, sustainable development, non-communicable diseases, health systems strengthening, universal health coverage, the health of women and children, and ageing.
The MDGs were undoubtedly successful in focusing international donor financing and domestic investments to achieve the targets set in these goals. Yet, undue emphasis on financing narrow disease programmes used to achieve disease-specific targets in the MDGs often missed opportunities to effectively strengthen health systems.1 Consequently, several low-income countries with weak health systems have struggled to reach the targets set in health-related MDGs and will not achieve them by 2015.2 An important lesson from the MDGs is that current and emerging global health challenges require action that embraces interdisciplinary and intersectoral approaches to development,3 which acknowledge the path-dependence and context-dependence of implementation. Top-down approaches to global health and development will not address the present and future challenges. As we look forward to the post-MDG era, it is clear that new ways beyond selective approaches are needed to address the complex challenges that lie ahead.
We contend that so-called systems thinking offers the principles and methods necessary to address existing and future health challenges. Systems thinking encompasses a wide range of constructs, including complex adaptive systems, systems dynamics, and cybernetics, to name a few. Its advocates recognise the dynamic and sometimes unpredictable interactions among actors (such as policy makers, providers, organisations, and communities) in complex systems such as health. By contrast with selective approaches, systems thinking is based on understanding relationships, a commitment to multiple perspectives, and an awareness of boundaries.
Background : Bacterial infections are a leading cause of the 2·9 million annual neonatal deaths. Treatment is usually based on clinical diagnosis of possible severe bacterial infection (pSBI). To guide programme planning, we have undertaken the first estimates of neonatal pSBI, by sex and by region, for sub-Saharan Africa, south Asia, and Latin America. We included data for pSBI incidence in neonates of 32 weeks gestation or more (or birthweight ≥1500 g) with livebirth denominator data, undertaking a systematic review and forming an investigator group to obtain unpublished data. We calculated pooled risk estimates for neonatal pSBI and case fatality risk, by sex and by region. We then applied these risk estimates to estimates of livebirths in sub-Saharan Africa, south Asia, and Latin America to estimate cases and associated deaths in 2012.
Findings: We included data from 22 studies, for 259 944 neonates and 20 196 pSBI cases, with most of the data (18 of the 22 studies) coming from the investigator group. We estimated that in 2012 there were 6 middot;8 million cases (uncertainty range 5·4 million–8·2 million) of pSBI in neonates needing treatment: 3·5 million ·8 million–5·2 million) in south Asia, 2·6 million (2·0 million–3·1 million) in sub-Saharan Africa, and 0·75 million (0·6 million–0·9 million) in Latin America. The risk of pSBI was greater in boys (risk ratio 1·12, 95% CI 1·06–1·18) than girls. We estimated that there were 0·67 million (0·45 million–0·91 million) neonatal deaths associated with pSBI in 2012.
Interpretation: The need-to-treat population for pSBI in these three regions is high, with ten cases of pSBI diagnosed for each associated neonatal death. Deaths and disability can be reduced through improved prevention, detection, and case management.
Funding: The Wellcome Trust and the Bill & Melinda Gates Foundation through grants to Child Health Epidemiology.
Background: Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) decreases adverse effects of malaria during pregnancy. Zambia implemented its IPTp-SP programme in 2003. Emergence of SP-resistant Plasmodium falciparum threatens this strategy. The quintuple mutant haplotype (substitutions in N51I, C59R, S108N in dhfr and A437G and K540E in dhps genes), is associated with SP treatment failure in non-pregnant patients with malaria. This study examined efficacy of IPTp-SP and presence of the quintuple mutant among pregnant women in Mansa, Zambia.
Methods: In Mansa, an area with high malaria transmission, HIV-negative pregnant women presenting to two antenatal clinics for the 1st dose of IPTp-SP with asymptomatic parasitaemia were enrolled and microscopy for parasitaemia was done weekly for five weeks. Outcomes were parasitological failure and adequate parasitological response (no parasitaemia during follow-up). Polymerase chain reaction assays were employed to distinguish recrudescence from reinfection, and identify molecular markers of SP resistance. Survival analysis included those who had reinfection and incomplete follow-up (missed at least one follow-up).
Results: Of the 109 women included in the study, 58 (53%) completed all follow-up, 34 (31%) had incomplete follow-up, and 17 (16%) were lost to follow-up after day 0. Of those who had complete follow-up, 15 (26%, 95% confidence interval [CI] [16–38]) had parasitological failure. For the 92 women included in the survival analysis, median age was 20 years (interquartile range [IQR] 18–22), median gestational age was 22 weeks (IQR range 20–24), and 57% were primigravid. There was no difference in time to failure in primigravid versus multigravid women. Of the 84 women with complete haplotype data for the aforementioned loci of the dhfr and dhps genes, 53 (63%, 95% CI [50–70]) had quintuple mutants (two with an additional mutation in A581G of dhps). Among women with complete follow-up and quintuple mutants, 22% had parasitological failure versus 0% without (p = 0.44).
Conclusions: While underpowered, this study found 26% failure rates of SP given the moderate prevalence of the quintuple mutant haplotype. Despite the presence of resistance, SP retained some efficacy in clearing parasites in pregnant women, and may remain a viable option for IPTp in Zambia.
U.S. Agency for International Development. Acting On the Call: Ending preventable child and maternal deaths. USAID (June, 2014).
All women and all children — no matter where they are born — deserve the same chance to survive and thrive. Over the last 30 years, the global community has responded to the urgency of this mission, raising child and maternal survival to the top of the international development agenda. Just as the Green Revolution transformed agricultural production and prevented widespread famine, the child survival revolution is saving millions of lives and unleashing a virtuous cycle of progress and opportunity.
*J. Walsh, L. Doyle, P. Anderson , et al. Moderate and Late Preterm Birth: Effect on Brain Size and Maturation at Term-Equivalent Age. Radiology (June, 2014.
Purpose: To compare the size of multiple brain structures, maturation in terms of both brain myelination and gyral development, and evidence of brain injury between moderate and late preterm (MLPT) and term-born infants at term-equivalent age.
Materials and Methods: The study was approved by the human research ethics committees of the participating hospitals, and informed parental consent was obtained for all infants. One hundred ninety-nine MLPT and 50 term-born infants underwent 3-T magnetic resonance (MR) imaging brain examinations at 38–44 weeks of corrected gestational age. T1- and T2-weighted MR images were compared between groups for size of multiple cerebral structures, degree of myelination in the posterior limb of the internal capsule, gyral maturation, signal intensity abnormalities, and presence of cysts by a single assessor who was blinded to the gestational group and perinatal course of the infants. Group differences were compared by using linear regression for continuous variables and logistic regression for categorical variables, and interrater and intrarater reliability was assessed by using intraclass correlation coefficients.
Results: Compared with those in the term-born control group, measurements of brain biparietal diameter, corpus callosum, basal ganglia and thalami, and cerebellum were smaller in infants in the MLPT group (all P ≤ .01), while extracerebral space was larger (P < .0001). Myelination of the posterior limb of the internal capsule was less developed, and gyral maturation was delayed in the MLPT group (both P < .001). Signal intensity abnormalities and cysts were uncommon in both groups, with 13 (6.5%) MLPT infants and one (2%) term infant having abnormalities. Inter- and intrarater reliability was good for most measures, with intraclass correlation coefficients generally greater than 0.68.
Conclusion: MLPT birth is associated with smaller brain size, less-developed myelination of the posterior limb of the internal capsule, and more immature gyral folding than those associated with full-term birth. These brain changes may form the basis of some of the long-term neurodevelopmental deficits observed in MLPT children.

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