This blog was originally published in the Weekly Trust. Written by Nosa Orobaton.
It was Sunday, April 22, 2013. The starless, breezeless night sky pregnant with rain clouds was aglow with the moon waxing in Gagi suburb of Sokoto town in northwestern Nigeria. It was in a house 300 meters off the main road that public health history was made in Nigeria; and in sub-Saharan Africa. Silently made, it was, save for the piercing, heartwarming first cry of a newborn baby that ushered his arrival alive, into his world, and into our world as we know it. Much of the country’s aspirations are now riding on the expectation that the history making events will mark the beginning of the end of a world of indefensible and avoidable deaths of neonates in their first month of life; as well as the death of mothers during the seven million annually occurring childbirths in Nigeria. For now, he goes by the name Baby Nasiru.
On this Sunday night, the temperature is slightly less than the 45 degrees Celsius which held sway most of the day. Gagi is in transition. Old mud houses are slowly giving way to those built with cement blocks, a sign of growing prosperity. The scatterings of neem trees around the community appear to affirm the community’s unyielding resilience and resolve to challenge the insatiable embrace of the ever-expanding frontiers of the Sahara Desert. It also hints to a touch of community defiance to outside forces, for better or for worse. Much of the community is quiet by night.
Nasiru is the man of the house, the husband of Suwaiba and father of the newborn. He is an unabashed tinkerer and a self-taught electronics engineer. He makes his living cobbling working TVs out of carcasses of abandoned TV sets that presently form a rising three-foot high pyramid on his lot. His electronics laboratory which doubles as his showroom is located in the front of his cement house, which opens into the street. Armed with secondary education, and his deep faith in the practice of Islam, Nasiru passionately brings the world to the community through the television. Over a decade ago, he even briefly set up his own now defunct, private FM radio station that broadcasted to Gagi community. His showroom is also adjacent to the private rooms and courtyard where Suwaiba, his newest and second wife, is confined to a life of purdah.
Suwaiba reads and writes Arabic, and her education was limited to Koranic school. She does not leave the compound. She does not go to the market. Suwaiba has never attended a clinic for prenatal visits, although she has delivered babies five times since she got married at the age of 16 years. Suwaiba is 25 years old. She has never delivered a child in a health facility. Her one source of information is what Nasiru tells her. Another is word of mouth brought in by other women, whom Nasiru approves of. No one can get to Suwaiba without his consent. Similarly, Suwaiba cannot reach out to people and institutions outside her home without Nasiru’s express consent.
It was on this Sunday night that Suwaiba went into labor. She did not go to the nearby health center that was recently upgraded with support from the state and Federal Governments and their partners. It is unlikely she even asked to go to the health center. Less than 1,000 minutes later, her son will be safely delivered at dawn on Monday, just before the call to Fajr prayers. It will be her fifth delivery, and this one produced her first son.
Baby Nasiru is the first newborn to benefit from the Sokoto State government-sponsored community-based distribution programme to deliver to every child, Chlorhexidine 4% gel to prevent cord infections. Also, a part of this program, Suwaiba received and ingested Misoprostol tablets to prevent bleeding associated with childbirth.
It is also the first time that these medicines are being offered to all political wards in a state, in any state in Nigeria, or elsewhere in Africa. It is also the first time that Chlorhexidine 4% is being used for cord care at population level. Only Nepal has a more developed programme. Government statistics estimate that in Sokoto State alone, with the introduction of Chlorhexidine, would save 2,000 newborns from death in the first month of life each year. When applied across Nigeria, 60,000 deaths could be averted. In the case of Misoprostol, 1,000 women will be saved from dying each year in Sokoto State and 10,000 women nationally.
Elsewhere in Abuja, New York, Seattle, Oslo and Geneva, where this event is being closely watched, one lingering question is how this bridgehead of an intervention can be leveraged at national scale to accelerate Nigeria’s quest for results in the final 1,000 day push to meet the UN Millennium Development Goals of 2015. A number of things must happen if what is happening in Sokoto is to spread to other states in Nigeria. The first is that other state governments must launch and agree to finance similar programmes in their respective jurisdictions, and do so with a sense of urgency. Second, these medicines need to be locally available on a predictable and continuous basis. Misoprostol is already available locally. Chlorhexidine gel is only available in Nepal. Fortunately, Dr. Muhammad Ali Pate, Minister of State for Health in Nigeria publicly issued a call-to-action on March 13, 2013. He beseeched all state governors to emulate Sokoto State government, so that there are enough local buyers of Chlorhexidine 4%. In return, the increased and sustained demand for Chlorhexidine 4% will serve as a strong signal for prospective, local manufacturers.
This is a renewed call to all state governors to commit to the Chlorhexidine 4% intervention for cord care. This is a call to civil society organizations to lobby state governors and states lawmakers to commit to the local production of Chlorhexidine 4% gel for cord care. This is a call to local pharmaceuticals to locally manufacture Chlorhexidine 4% gel for cord care.
So on that night, Suwaiba’s husband contacted Halima, the local traditional birth attendant, and trusted woman in the community, who also doubles as a community-based health volunteer. Halima is one of the over 2000 trained community health volunteers in the state. Ten of them are in Gagi. Sokoto State government and USAID worked in tandem to train these volunteers who are now a vital source of information to women and men in communities across Sokoto state. In the last three months alone, largely as a result of these volunteers’ efforts, the average number of prenatal visits per woman has doubled from one to two. Halima contacted a community designated and trained drug keeper who dispenses these medicines when labor is confirmed to have begun.
Halima took the delivery of the baby, gave Suwaiba the recommended three tablets of Misoprostol to swallow, cut the umbilical cord with a clean razor, tied the cord appropriately, applied Chlorhexidine on the cord stump and delivered the placenta. Halima is a critical part of the health system that makes the household level distribution of knowledge, information and medicines possible. She is also a fountain for the nurturing and growth of local trust, the oxygen of this program.
Nasiru allowed information about these two life-saving medicines to penetrate his household. He agreed for the medicines to be used for his wife. He also has consented for his son to be immunized. He did not have to. Yet, he did. It is the spirit of the tinkerer at work. Consenting parents need the backing and support of state governments to ensure that these low cost, high impact lifesaving medicines are available on a predictable basis. Nigeria has the market and industrial capacity to manufacture Chlorhexidine 4% gel. As an act of good governance, elected officials owe it to new, annual seven million newborns in Nigeria, who are us in our most vulnerable time.
Baby Nasiru was brought out to meet visitors when he turned 5 days old. He was very well and very active. His cord stump was dry and clean. In a few days, he will be seven days old. He will get his own name. Suwaiba did not reveal anything. “I thank the Almighty and the government for making this program available. It must be continued for all other women.” Nasiru agreed. No need to tinker with what they now know works. A new dawn may well have arrived. What remains is to sustain it through the power of governance. It rests with state governors to do the right thing.
Photo:Parth Sanyal/Save the Children
Auxiliary Nurse Midwife (ANM) Manashi Sarkar checks the health status of a pregnant woman at the sub-centre in Dhagaria village of Bankura, West Bangal, India.
The ANM looks after the Reproductive and Child Health, communication and socio-cultural areas including Integrated Management of Neonatal and Childhood Illness; and develops positive attitude towards community in providing health care through community participation.
The ANM holds weekly meetings with Accredited Social Health Activist (ASHA), and provides on-job training by discussing the activities undertaken during the week. Sarkar will also guide ASHA in bringing the beneficiary to the outreach session. ANMs utilize the ASHA's in motivating the pregnant women to receive antenatal check-ups and also work with the ASHA's to help bringing married couples to sub centres to motivate pregnant women to take the course of Iron and Folic Acid (IFA) supplements.
Human resources are indispensible for the improvement of newborn survival around the world. Doctors, nurses, midwives and skilled birth attendants all have a role to play. In India, Auxiliary Nurse Midwives have been working on the frontlines - at the sub-center level - since the mid 1960s. More recently they have been assisting facility births and providing basic immunizations. It will be interesting to see how recent government health policy commitments will expand the scope of their role.
For far too many women worldwide, pregnancy and childbirth is a dance with death. Consider the annual death toll: more than 280,000 mothers and nearly 3 million newborns die each year, and this does include 1.2 million still-births that occur during labor and child birth.
So it should be no surprise that women who can plan and seek care during their pregnancies provide a much better start to their babies and make stronger families.
This past week at the Women Deliver conference, the enthusiasm and energy around ensuring all women are able to demand care and lead healthy lives was truly inspiring. The collective cry to end needless deaths was palpable among the global leaders, partners and the thousands of advocates attending the Women Deliver conference in Kuala Lumpur, Malaysia.
Throughout the week, I heard sessions on what must be done to improve the lives of women and girls across the world, and was encouraged by dialogue around ensuring equity and access to quality care where it is needed most. However sadly, not much was said about ensuring women deliver healthy babies, who survive their first day and month of life.
“Any pregnant woman’s wish is to have a healthy newborn baby” -Her Excellency Dr. Christine Kaseba-Sata, First Lady of Zambia
As we move towards a post-2015 world, newborn survival remains a challenge we must tackle in order to achieve our development goals. We know that childbirth is the riskiest time for women, as it is for the newborns they deliver. The sessions at Women Deliver that touched on newborn survival all underlined the importance of linking maternal and neonatal care to maximize chances of survival. In fact, the majority of the 3 million newborn deaths are preventable with solutions that we already have – solutions that are highly effective and cost-efficient, and can be incorporated into existing packages for maternal and child health. In addition, many of the 1.2 million stillbirths which occur globally during labor and childbirth are preventable with interventions that also save mothers and babies. Yet, the issue of stillbirths remains hidden on the global agenda and families often suffer in silence. Sessions on newborn care and stillbirths highlighted the need to close the deadly gap between what we know and what we do.
An Action Plan to Save Every Newborn
Save the Children and the Partnership for Maternal, Newborn and Child Health (PMNCH) hosted a side event introducingEvery Newborn: An Action Plan to End Preventable Newborn Deaths. The panel, which featured Professor Joy Lawn from the London School of Hygiene & Tropical Medicine and Save the Children, Dr. Carole Presern from PMNCH, Her Excellency Dr. Christine Kaseba-Sata, First Lady of Zambia, along with Ms. Anuradha Gupta from India’s Ministry of Health and Lars Gronseth from Norad and moderated by Ms. Joy Marini from Johnson&Johnson, highlighted the incredible burden and yet concrete opportunities to deliver for newborns and save lives.
Every Newborn aims to be a roadmap for actual change in countries. It takes forward the UN Secretary General’s Global Strategy for Women’s and Children’s Health by focusing specific attention on newborn health and identifying actions for improving their survival, health and development. It is more than just a plan as it will bring together the latest available evidence on effective interventions and delivery mechanisms, enabling high-level policy makers and program managers to sharpen national plans, link to existing strategies and take action to accelerate progress.
It will set out a clear vision supported by targets, strategic objectives, innovative actions and opportunities, sharing evidence on costs and impact of interventions, and setting out roles for all stakeholders and actors. At the core of developing this plan is a systematic consultation process to ensure broader ownership and inputs from all stakeholders including governments, researchers and academics, nongovernment organizations, professional associations, civil society and other UN agencies.
At the side event, Save the Children’s Joy Lawn presented some of the evidence and key themes emerging for the action plan, including data from this year’s State of the World’s Mothers report on the first day of life and stressing the importance of quality care at birth for the survival of women and their babies. As stated by Lars, Every Newborn will build on the recommendations of A Promise Renewed for Child Survival, and contribute towards their target of 20 or less under-five death per 1000 live births in each country. India was showcased by Madame Gupta as an example of a country taking concrete action to address newborn survival through rapid policy change in recent months enabling nurses to administer antibiotics for neonatal sepsis and antenatal corticosteroids to women in preterm labor.
The First Lady of Zambia called on each person who is interested in making a difference for women to collectively support and commit to actualizing the Every Newborn plan. We make the same call to each of you. Please visit www.globalnewbornaction.org to learn more and help bring forth change for newborns around the world.
Photo: Jodi Bieber/Save the Children
Rose Muleka rests alongside her newborn son at Tudikolela Hospital in Mbuji Mayi, Democratic Republic of the Congo (DRC). He was born not breathing, but was successfully resuscitated by the nurses at the hospital. Rose's labor was long and hard leaving her with little energy to push, so the nurses had to help facilitate the birth, but when her son was born, he was no longer breathing. After several desperate attempts at resuscitation by the nurses, her son finally breathed. Rose Muleka said, " was happy when I saw that my child was alive, God helped him survive. I was lucky that my baby survived, as many women are not so lucky here in Congo."
As the 1000 days mark until the 2015 Millennium Development Goals (MDGs) deadline has come and gone, there appears to be a renewed emphasis on where we are and what comes next for newborn health. There have been several events – the Global Newborn Health Conference, Women Deliver, the World Health Assembly – and reports – State of the World’s Mothers: Surviving the First Day, Countdown to 2015: 2013 Accountability Report – that have helped to drive this engagement and will help to carry momentum forward.
The just-released Countdown 2013 Accountability Report addresses newborn health within the spectrum of maternal, newborn and child health. Importantly, it highlights country progress and where attention needs to be paid in the run up to the 2015 MDG deadline.
It finds that newborn deaths as a percentage of under-5 deaths are over 50% in 12 of the 75 countries surveyed. It stresses the need to improve prevention of preterm birth and stillbirths, and scale-up coverage of Kangaroo Mother Care, antenatal corticosteroids, chlorhexidine and other low-cost interventions.
Importantly, there is data on the prevention of mother-to-child transmission (PMTCT) of HIV. Stopping the spread of HIV from mother to child is critically important towards making overall gains for child survival.
The report also gives snapshots of coverage levels for skilled attendant at birth, postnatal care for newborns and mothers, exclusive breastfeeding and demand for family planning, among others. It also provides and accountability framework that examines equity, government policies and health system factors.
Since 2000 the global health community has learned a great deal about newborn health. The MDGs have played an important role in that. There has been a greater understanding of not only why newborn mortality is happening, but also what low-cost interventions can make a difference in improving health outcomes. Hopefully we can leverage these reports and global events to continue engagement about newborn health and help reduce the risk of newborn mortality.
It is not every day that Ministers of Health and other global health leaders from around the world gather in one place. This is the case in Geneva, once-a-year in May, during the World Health Assembly (WHA). High level officials are present to actively contribute, influence and help shape major international health policies and frameworks.
Reproductive, maternal, newborn and child health (RMNCH) featured strongly in all of the discussions at this year’s WHA – including through formal agenda items on the MDGs, life-saving commodities and universal health coverage, as well as several side-events. It was stated numerous times that while some countries are on track to meet MDGs 4 & 5 and child mortality has gone down globally, there has been a much slower decline in neonatal mortality - in some countries even an increase.
Globally, newborn deaths now account for 43 percent of all deaths of children under 5-years old — up from 36 percent in 1990.
The Minister of Health of Bangladesh Dr. Haque was just one of many delegates addressing the issue at this year’s WHA. Minister Haque noted that in Bangladesh, neonatal deaths account for 60% of all under-five deaths. While under-five mortality decreased by 60% over the past decade, neonatal mortality only declined by 38%. He said that his country was investing more to address this, including through tackling infections, birth asphyxia, prematurity and low birth weight.
Advocating for global action on newborns
At Save the Children we focused much of our work during the WHA meetings around newborn health and the findings in the most recent State of the World’s Mothers Report. The Ministers of Health of Nigeria, Ethiopia and Bangladesh, among other key delegates, received copies of the report, which calls attention to the fact that more than a third of all newborn deaths take place on the day a child is born.
While an estimated 98 percent of all newborn deaths take place in low-income countries, the report also singled out the United States for its high rate of first-day deaths among industrialized countries. “The US has the highest rate of newborn mortality amongst industrialized countries. We are ashamed and aim to change it”, said Nils Daulaire, Assistant Secretary for Global Affairs, US Department of Health and Human Services.
The Partnership for Maternal, Newborn and Child Health (PMNCH), the World Health Organization (WHO), Save the Children and others also expressed strong support for a Global Newborn Action Plan, which is currently being developed and is expected to be launched at the World Health Assembly in May 2014.
The Global Newborn Action Plan is a roadmap for change to reduce preventable newborn mortality. It takes forward the Global Strategy for Women’s and Children’s Health by focusing specific attention on newborn health and identifies actions for improving their survival, health and development. The Global Newborn Action Plan brings together the latest available evidence on effective interventions and delivery mechanisms. Foremost, it aims to support government leadership and the actions of policy makers and program managers. The goal is not for countries to develop new plans but to sharpen existing national health sector plans.
The content will be developed in the coming months through an extensive consultation process. A consultation was already held during the Global Newborn Health Conference, the first-ever international summit on newborn health, in Johannesburg, South Africa in April 2013, just weeks before the start of the World Health Assembly. All the activities in support of newborn health at the WHA followed the successful conference in Johannesburg.
Commitments on life-saving commodities for newborns
Delegates attending this year’s WHA also passed a resolution to implement the recommendations of the UN Commission on Life-Saving Commodities for Women and Children. They committed to improve the quality, supply and delivery of – and to facilitate universal access for all members of society to - 13 underused life-saving commodities, including four targeted at newborn health:
- injectable antibiotics - newborn sepsis
- antenatal corticosteroids (ANCs) – preterm respiratory distress syndrome
- chlorhexidine - newborn cord care
- resuscitation devices - newborn asphyxia
Need for continued commitment and action
These discussions took place within a wider framework of overwhelming consensus on the centrality of universal health coverage in improving RMNCH. Furthermore, a resolution was approved to sustain and accelerate efforts towards the achievement of the health-related MDGs and to ensure that health is central to the post-2015 UN development agenda.
The momentum is clearly there and the key now is to ensure that newborn health continues to remain central to the wider discussions around the MDGs and that global leaders take the action needed to put an end to preventable newborn mortality. The World Health Assembly was a significant step towards further commitments and action on newborns.
See the official summary of outputs of this year’s World Health Assembly
Please stay tuned: upcoming topics page on HNN for Life Saving Commodities
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The Healthy Newborn Network Blog provides timely information and insights from the global newborn health field and seeks to promote dialogue on important newborn health issues. The blog is a platform for the HNN Editors and guest contributors to post commentaries on current happenings in the newborn health field. The content of each post and comments expressed on the HNN blog are those of the individual contributors and do not necessarily represent the views and opinion of the HNN or its Partner Organizations. >>Read a note on leaving comments
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