Addressing Critical Knowledge Gaps in Newborn Health

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By Carolyn Miles on December 22, 2014


Midwife Watta Borbor helps T-Girl, 24, breastfeed her  baby at a Save the Children supported clinic in Peterstown, Margibi county, Liberia. T-Girl is an inpatient at a new Maternal Waiting Home built by Save the Children at Peterstown clinic. Pregnant women and mothers in some rural areas in Liberia have to walk up to eight hours to reach the nearest health clinic. The Maternal Waiting Home provides pregnant women with a place to stay, at the clinic, in their final week before delivery to ensure they get the proper professional care they need. Photo: Jonathan Hyams/Save the Children

This article was originally published in The Huffington Post. Written by Carolyn Miles.

On December 25, as millions across the world come together to celebrate the holiday season with family and friends, an estimated 800 mothers and 7,500 newborns will die in labor, childbirth or from complications in the first month, almost all of them with little public notice. And these numbers do not include the more than 7,000 stillbirths that also occur every day.

More than 95 percent of these deaths take place in poor countries where such deaths are so commonplace that in some regions babies often go unnamed until they survive the first month of life.

This staggering death toll of mothers and babies -- at least two-thirds of whom could be saved with adequate care -- represents one of the greatest health challenges of the 21st century.

While recent success in treating pneumonia, diarrhea and malaria, among other diseases, has spurred significant progress in reducing the deaths of children who survive the first month of life, there has been less progress in saving mothers and newborns. Babies dying within the first month of life now account for 44 percent of all deaths of children under age 5. In some countries babies account for nearly 60 percent of child deaths.

We can do better, especially considering the huge inequities involved. In Africa, for example, a newborn's risk of dying is 5 times greater than in Europe, and a woman's risk of dying in pregnancy and childbirth is 30 times higher. Even in countries that have made progress in saving maternal and newborn lives, there are often major disparities in death rates of mothers and newborns among a country's wealthiest and poorest populations.

We know what are causing these deaths. More than 40 percent of maternal deaths, newborn deaths and stillbirths occur around the time of birth. Babies that are born too small or too soon are at the greatest risk. Other babies cannot breathe at birth and die of asphyxiation while others develop deadly infections. Solutions as basic as an inexpensive antiseptic to protect the umbilical cord from infection or a bag and mask resuscitation device to help babies breathe have the potential of saving hundreds of thousands of lives. Old norms and customs around child birth also continue to claim countless lives. In some areas, mothers are allowed to bleed to death based on the misconception that "bad blood" from the mother needs to be purged.

To put a halt to these needless deaths, 194 countries endorsed the Every Newborn Action Plan at the World Health Assembly in 2014. This action plan is part of the UN Secretary General's Every Woman, Every Child initiative and A Promise Renewed -- both of which seek to accelerate progress for ending preventable maternal, newborn and child deaths. A broad range of experts, activists and government officials -- representing the interests of reproductive, maternal, child and adolescent health -- have agreed to work together to save the lives of mothers and their babies, with a special focus on Africa and South Asia, where the majority of these deaths take place.

An important component of the action plan is identifying effective ways to support country efforts to end preventable maternal and newborn deaths. The Ministries of Health in many countries, including India, Ethiopia, Uganda, Ghana and others, already have adopted new policies to make it easier for health workers to save newborn and maternal lives. The next big step -- and this is already happening in many countries -- is to put these new policies into practice and scale up proven interventions in ways that will have impact country-wide.

This is not an easy or simple undertaking. Health systems in many countries are weak, and the demand for services is huge. But with increased attention and focus on mothers and newborns, 2015 could well be a turning point in ensuring that more new parents in the future can celebrate this time of year with joy rather than sadness and loss.

By Ian Hurley on December 19, 2014
Africa

Mothers whose babies were born prematurely and who successfully went through Kangaroo Mother Care are photographed at the Mtwara District Hospital in Mtwara, Tanzania. Over the last year Save the Children has trained 392 health workers in the Lindi region of Tanzania, and provided them with the skills they need to stop preventable deaths associated with child birth and newborn babies. Lindi region is one of the Tanzania's poorest areas - where children and mothers die in higher numbers than anywhere else in the country. Under-five mortality rate in Lindi is as high as 117 per 1,000 live births. Children's health in this region is influenced by complex issues including remoteness, poor infrastructure such as roads and electricity, lack of education, inadequate planning and budgeting for health, lack of equipment and staff training as well as socio-cultural and religious beliefs. Photo: Jordi Matas/Save the Children 

Despite the odds these mothers have helped to save their preterm babies and given them a chance to thrive. In addition to providing optimal thermal heating for a newborn, Kangaroo Mother Care promotes the mother-baby bond, helps to prevent infections and strengthens early initiation of breastfeeding. Read this report on Early Initiation of Breastfeeding by WHO, UNICEF and several other health organizations. 

The Healthy Newborn Network also features comprehensive resources on Kangaroo Mother Care implementation and practice. These are especially useful for country level health professionals, program manangers and other MNCH practitioners who are looking to start or improve the performance of their own programs. 

By Lindsay Grenier on December 18, 2014


A midwife examines a pregnant woman in South Sudan. Photo: Kate Holt/Jhpiego 

This blog was originally published in Impatient Optimists. Written by Lindsay Grenier.

Complications from prematurity are now the number one cause of death in children under five. While great strides have been made in reducing deaths from infectious causes—such as pneumonia, diarrhea and measles—progress has been slow in improving outcomes from preterm birth.

In developed countries, most pregnant women can rattle off their gestational age (GA) to the week, and their health practitioners estimate and record it to the day at every antenatal visit. It’s reflex for health care workers in these settings to find out the GA of a patient presenting in triage or on the labor ward as one of their first courses of action. This is because GA greatly impacts how maternal and newborn care providers team up to manage their patients and what treatment options they will consider.

By contrast, when USAID’s flagship Maternal and Child Health Program (MCHIP) began a research project in Cambodia aimed at increasing the use of dexamethasone[1] in the management of preterm birth, staff discovered that many records didn’t include GA, and those that did estimated it to the month—not the week, let alone the day. We found this trend repeated in country after country when we looked: at worst, no GA; at best an entire month given.

Unlike their counterparts in developed countries, women in these settings rarely know their GA to the week, and their health care providers may or may not estimate and record it at all. This is in part because, until recently, they have had little reason to, as many of the interventions long in use in developed countries have been unavailable to them. Therefore, knowing a woman’s GA would not change their management plan. The baby would come when it would come, and there was little they could do to help prepare it for life prematurely.

However, as greater focus is being placed on addressing mortality in the neonatal period, that story is changing. National health systems and development partners are collaborating to improve quality of care for prematurity by strengthening the use of certain key interventions in the management of preterm birth—including antenatal corticosteroids (ACS) for fetal lung development; continuous positive airway pressure to support inflation of underdeveloped preterm baby lungs; magnesium sulphate for neuroprotection; and antibiotics in the case of preterm, prelabor rupture of membranes to prolong pregnancy.

These lifesaving interventions will enable maternal care providers to reduce the complications of prematurity in newborns in low-resource settings, just as their counterparts do in the developed world. In fact, MCHIP’s follow on project—the USAID-funded Maternal and Child Survival Program—is already leading an effort with the Survive and Thrive Global Development Alliance to create a clinical training package for the management of preterm birth under the Helping Babies Survive series.

Yet a critical element necessary for the correct use of interventions for preterm birth management is accurate GA estimation, as highlighted by findings from the recent [2] The authors found significantly higher mortality among infants given ACS and born with an estimated gestation ≥37 weeks. This study does not negate the previous 21 randomized controlled trials, which found a 30% reduction in neonatal mortality when steroids are given to women at risk of imminent preterm delivery between 24 and 34 weeks gestation; rather it points, in part, to the need for careful and improved gestational dating. When an intervention is beneficial at 34 weeks, and potentially harmful at 36 weeks, estimation of GA as “eight months” simply isn’t accurate enough.

(Please see the statement from the UN Commission of Life Saving Commodities ACS Working Group for more details regarding the ACT trial and the programmatic and research implications.)

When used appropriately, ACS are still one of the most beneficial interventions to improve mortality in premature infants. However, GA dating must be improved to ensure their judicious use. Improving GA dating worldwide requires:

  • A clinical behavior shift among maternal and newborn health care providers to actively seek accurate GAs, and diligent recording of this information at each antenatal care visit (driven by the understanding that accuracy of dating is crucial for good clinical decision making in the effort to help save premature babies);
  • Better dating techniques and/or algorithms to support providers in estimating GA with imperfect information (driven by a combination of clinical and implementation research);
  • Judicious use of ultrasound to assist GA assessment when other techniques are not sufficient (driven by an understanding of the correct combination of clinical assessment and technology); and
  • A cultural behavior shift among pregnant women to seek antenatal care earlier and to take careful note of the date of their last menstrual period (driven by the knowledge and belief that early care in pregnancy and accurate knowledge of their gestational age may help their baby survive).

As we turn the spotlight to prematurity, we must also focus on better dating. This will ensure our interventions reach those who need them most, while upholding the most central tenet in medicine: do no harm.

[1] The most commonly used antenatal corticosteroid

[2] Althabe et al. (Lancet, October 2014)

By Benjamin Foot on December 17, 2014
Nigeria
Africa

Although I am new to the Country Director position for Save the Children I have been very aware of the importance of the National Health Bill and the need to get it signed into law by the President. So when we learned that it had been signed on 9 December 2014 I there was great rejoicing within Save the Children. The new Act will provide new opportunities for the Government to deliver high quality primary health care services to Nigerians. Importantly, it will release funds from the Federal level down to the State level for primary health care.

The passing and signing of the National Health Bill has been a laborious and lengthy process – starting over 10 years ago. The Bill was first passed in May 2011 by the national Assembly and forwarded to the President’s office but it was returned unsigned 30 days later for amendments. It took another 3 years before it was again passed by the national Assembly in October 2014 and sent again to the President for signing.

The Save the Children Nigeria team, together with partner organizations, has been working tirelessly to get the Bill signed, not only under this President but also under the previous President. Many groups, both from within and outside the country have lobbied hard in support of the bill which finally bore fruit on 9th December. This achievement reflects the determination of activists to ensure that quality health care services are provided to Nigerians and in particular to children.

Now we have to make it happen. First, this means making sure money is released down to the States, and then that the States mobilize and use it. We will work closely with State officials to develop plans for the training of their staff and strengthening their health systems.

The recent National Newborn Health Conference, led by Government of Nigeria in October 2014, reflected the importance of the National Health Bill in addressing child mortality. While the Government has made some significant headway towards meeting the Millennium Development Goal 4 for reducing mortality for children under- five years, it has not made a similar progress in reducing te number of children who die in the first month of life. At the Conference the Government made a commitment to newborns and their mothers by launching the Call to Action to Save Newborn Lives. This calls for an end to all preventable maternal and newborn deaths and stillbirths by 2035. But can we, can those mothers and yet to be born children, wait another 20 years for this to happen? I don’t think so. Action is needed now and we all need to make a commitment to reduce these deaths significantly over the next 2 or so years.

To our partners, the signing of the Bill must provide significant encouragement to move forward and to keep pushing for good quality health services. Save the Children has had the privilege to work with a large network of organizations within the Maternal, Newborn and Child Health Coalition in lobbying for the Health Act over the past few years. We are all now delighted that it has finally been signed into law and that we can move forward together to improve the health of Nigeria’s children.

By Neil Spicer on December 15, 2014
Ethiopia, India, Nigeria
Africa, Asia


Photo: Parth Sanyal/Save the Children

This blog was originally published by IDEAS. Written by Dr. Neil Spicer

“Scale up is a craft not a science”

 - Quote from the IDEAS qualitative study of scale-up in Ethiopia, Nigeria and India

Working in the maternal and newborn health field, don’t we all want our work to benefit the health of as many women and babies as possible?

You may have an amazing innovation proven to improve the health of mothers and babies in your pilot implementation project. How do you get a national government to take notice and scale-up your innovation to benefit more women and babies?

Implementation projects need to use multiple methods

Unsurprisingly there is no ‘magic bullet’ approach. Implementation projects need to plan for scale-up from the start, use multiple methods - all requiring time, energy and resources – and work closely with other organisations and government to achieve scale-up.

Donors need to support scale-up

Donors need to support and fund implementers to catalyse scale-up so it is supported from the start of a project and implementaters have the resources to support scale-up work. When donors work on the ground brokering relationships with government and coordinating international organisations, scale-up is more likely.

Politics play a major role

But most importantly, the skill of achieving scale-up is a craft, not a science: support from a powerful government figure can be as important as having a good intervention and strong evidence. Country politics are very important to scale-up and implementers and donors need to work on building effective relationships with government officials.

These findings come from a paper I recently published (read a summary) based on 150 ‘qualitative interviews’ (meaning we asked respondents open ended questions and encouraged them talk in detail of about the issues they felt were important) with government, project implementers, UN agencies, expects from Ethiopia, Nigeria and Uttar Pradesh, India.

Based on this evidence, here are a few checklist tips implementers and donors can use to catalyse the scale-up of their successful innovations. We have also produced research briefs on this topic for Ethiopia, Northeast Nigeria and Uttar Pradesh, India.

Checklist: what implementers can do to catalyse scale-up

1. Design an innovation that is scalable

Designing an innovation to be scalable isn’t easy. It’s difficult to find a balance between innovations that are very effective but need a lot of money and time – and simpler, cheaper ones that governments can afford to scale-up. Ask yourself, is your innovation:

  • Relevant to the needs and priorities of health workers and communities so they will accept it?
  • Demonstrably effective?
  • Simple for community health workers and communities to use?
  • Adaptable to communities that may be different in terms of religion, wealth etc.?

2. Embed scale-up in your implementation project design

Dedicating staff, time and resources to scale-up as a central part of a project plan is important. Do research early in the project to help plan for scale-up. You may want to look at:

  • The political context, e.g. what health issues does the government prioritise?
  • The social context, e.g. what are the needs and priorities of communities and health workers within those communities?
  • Other organisations. Are there other groups you can link with who will support your work?

3. Effectively advocate government for support

  • Present strong quantitative evidence showing your innovation has a positive impact and is cost effective. Without this it’s unlikely a government with limited resources will agree to put resources in for scale-up.
  • Use qualitative data to demonstrate operational lessons learned and how challenges were overcome.
  • Communicate findings effectively so the government can make informed decisions. Ensure dialogue with government starts early and keeps going throughout the project (not just presenting evidence out of the blue) and try to present during the government’s decision making cycles when the evidence is more likely to be used.

4. Work closely with government and other organisations

  • Get government buy-in. Make sure your innovation fits in with existing government policies and programmes and then build relationships with government officials who may be critical to getting overall government support and buy-in.
  • Work with other organisations on projects, share information, and jointly communicate to government. Coordinate closely with other organisations to avoid a situation where there are lots of international organisations and implementers doing similar work in parallel – reinventing the wheel - then competing with each other for government attention.

Checklist: what donors can do to catalyse scale-up

1. Support and fund implementers to catalyse scale-up

Although donors want their innovations scaled up, work to achieve this is usually added on when a project ends. Supporting scale-up work from the start of a project and ensuring implementers have the resources they need to carry out the work will help to catalyse scale-up.

2. Be active on the ground

Broker relationships with government and help coordinate with other international organisations working in that particular country. Not all of innovations can and will be scaled-up but these checklist tips are based on in-depth qualitative evidence which I hope will help implementers and donors to get their successful innovations scaled up to benefit more women and newborns.