Dr. Lava Abdul Rahman works with Syrian refugees at the UNFPA maternity clinic in Domiz Camp in northern Iraq. Photo: UNFPA/Millat Horiri
DUHOK, Iraq – "The clinic is always crowded," said Lava Abdul Rahman, a gynaecologist at the UNFPA maternity clinic in Domiz, a refugee camp in northern Iraq.
Each day, between 30 and 35 pregnant women come to the clinic for antenatal care, she noted.
More than three years into the Syrian crisis – a catastrophe that has forced hundreds of thousands to flee to Iraq, including more than 3,800 pregnant women – refugee camps have become simply a fact of life for many.
“I am in the ninth month of pregnancy”
Ruqaya, 36, is nine months pregnant, living in
Domiz camp. Photo: UNFPA/Millat Horiri
In the Domiz Camp, in the Duhok Governorate of Iraq, the sea of temporary shelters is slowly transforming into a city. Concrete houses are replacing tents and prefabricated caravans. Shops have sprouted up everywhere.
Syrians there say they have not, and will not, lose hope that peace can be restored in their home country. But for now, life in the camp has settled into a rhythm. Weddings are held every other day, and scattered cries of newborns can be heard as one walks through the camp.
"Despite the hardships and difficulties in making a living, other aspects of life go on normally," said Ruqaya, 36, as she left the UNFPA maternity clinic.
When she and her four children fled their home in Qamishli, Syria, she could not imagine having another baby. But "life goes on," she said. “I am in the ninth month of pregnancy now."
Ruqaya was not alone. The clinic was crowded with other pregnant women.
Faster, more convenient care
The UNFPA clinic here was established when the Domiz Camp was set up in 2012. Since then, more than 60,000 Syrians have arrived.
But until recently, deliveries had to be conducted in hospitals outside the camp. Getting there was timely and required money for transportation.
The clinic now has had the capacity to safely perform deliveries. Between 4 August and 20 September, some 200 deliveries took place there.
“Most of pregnant women want to deliver here if they do not have any pregnancy complications or need a C-section,” Dr. Rahman said. When complications arise, mothers are referred to hospitals, she added.
"We only conduct normal deliveries here," she said.
Having a maternity clinic in the camp is a relief, said Natja, a 25-year-old refugee.
"My daughter is two-and-a-half years old now,” she told UNFPA. “My husband wanted another baby last year, but I was resistant to the idea due to being in refuge, and I was afraid I would not receive good healthcare.”
But after speaking to other women who had become pregnant while living in the camp, she felt assured she would receive proper care from the maternity clinic.
She is now four months pregnant.
Wael Hatahet, UNFPA’s humanitarian coordinator in Iraq, said UNFPA provides the clinic with medics, equipment and reproductive health kits. The cost of Caesarean sections performed in referral hospitals is also covered by UNFPA, which also supports a number of maternity hospitals in the Governorate.
On 18th July, I was part of a team from Save the Children and Mukono district that visited Mukono HCIV to provide support supervision to health workers whom Save the Children had trained in the Helping Babies Breathe Plus (HBB+) package.
When we arrived at the health centre, we met Norah Nakimuli, a Nursing Officer and registered midwife, moving quickly to the HBB+ corner, a newborn baby in her arms. We followed her to see what was going on, and she explained, “This baby has just been delivered in the theater and I have been resuscitating it.”
Norah puts the baby on oxygen
Norah said that the baby’s mother, 30-year-old Margaret Kizza of Seeta Bukerere, had been admitted at 3:00am that morning with labour-like pains which had begun the previous day. This was her fourth pregnancy. Although Margaret’s condition was generally good and she was in active labour, the fetal heart rate was low. At 5:30am, her membranes ruptured with meconium-stained liquior grade 2 and signs of face-to-pubis presentation. The doctor was informed and he ordered an emergency cesarean section.
After the operation, Norah received the baby, who failed to breathe. She wrapped and rushed it to the resuscitation corner in the theater. She positioned it well, cleared the airway using the penguin sucker and dried and rubbed its back. In spite of all this, the baby was still not breathing.
“While praying in my heart, I got hold of the ambu bag and started ventilation as I had learned in the HBB+ training,” says Norah. “Immediately the baby sneezed. The score was 3/10 at one minute, then advanced to 5/10 at five minutes and finally progressed to 7/10 at 10 minutes.” Norah was one of the participants in the HBB+ training that was conducted by Save the Children.
Norah says that all of this was done while maintaining warmth to the baby. The baby eventually started breathing and she transferred it to the labour ward for continuous monitoring as its mother recovered from general anesthesia.
“I felt very good because I saved the life of a baby who will be useful in this world,” said Norah. Margaret’s relatives were not around because she had come alone to the hospital, but Norah believed that they would be happy when they heard the story of the newborn’s survival.
She explained that Margaret would be kept in the health unit for three days on observation since she had undergone a caesarian birth. The doctor ordered antibiotics and dextrose 50% to be given to the baby and oxygen. Norah also gave the baby Vitamin K and tetracycline eye ointment.
Photo: Susan Warner/Save the Children
This post is part of the Maternal and Newborn Health Integration Blog Series, "Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting.
The World Health Organization (WHO) welcomes the revitalized interest in integration of maternal and newborn health care as integration is the key to success for both improving maternal health and for ending preventable newborn deaths.
This is the very reason why WHO, together with UNICEF, UNFPA and the World Bank, have been promoting, already since 2000, Integrated Management of Pregnancy and Childbirth (IMPAC). This is the package of guidelines and tools, which respond to key areas of maternal and perinatal health programmes. IMPAC sets standards for integrated maternal and neonatal care. However, integration is not an end in itself, but should serve the purpose of improving quality and efficiency of health care services provided.
One important element of integration of health care services is that they should be centred around the mother-baby dyad, their needs and preferences. It is important that health care services are organized in a way that this will happen. For a normal pregnancy, childbirth and postnatal period this care can and should be provided by midwifery personnel with the necessary skills. Sometimes, however, the mother or the baby needs special attention and services that can only be provided by health care workers with specialized skills. But even in those cases, addressing the needs of the mother and the baby in an integrated way, remains key for success.
For example, early and exclusive breastfeeding is important for the survival, growth and development of the baby and should not be disrupted by separating the baby from her mother, if this is feasible – and in most cases this is feasible. So-called vertical health programmes, such as the expended programme of immunization (EPI) or the prevention of mother-to-child-transmission (PMTCT) have been successful in addressing certain public health priorities as they provide the necessary focus to make things happen. Sometimes they are perceived as disruptive, however, there are good examples how these programme interventions can be successfully integrated into maternal and newborn care services. Again, IMPAC provides guidance on how best to achieve this integration.
Finally, it will be important to promote a truly perinatal approach, which goes beyond highly specialized health care settings, but which will be based on the principles that only good pregnancy and childbirth care will lead to better neonatal outcomes. In conclusion, maternal and newborn health care should be as integrated as possible and as “vertical” as necessary to achieve high coverage and quality of health interventions for the mother and her baby. In the coming months WHO, UNICEF, UNFPA and partners will be working on a Every Mother Every Newborn initiative to improve the quality of integrated maternal and newborn care.
This newborn baby boy in Northern Nigeria was put to his mother's breast within 30 minutes of delivery to make sure he received the colostrum, the first milk a mother produces. It provides a newborn with important protection from bateria and infections. Photo: Lucia Zoro/Save the Children
We have known for a long time that breastfeeding can prevent the deaths of many babies.
Exclusive breastfeeding for the first 6 months can reduce child deaths by at least 800,000 each year - almost 15% of the total 6.3 million annual child deaths.
Breastfeeding within the first hour of birth has the potential to reduce newborn deaths by up to 560,000 - 20% of the total 2.8 million annual newborn deaths.
Babies who are not breastfed are particularly vulnerable to the leading killers of small children and are 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhea, compared to babies who are exclusively breastfed.
But despite this evidence rates of early and exclusive breastfeeding are very low (around 40%) and haven’t improved much since the early 1990s, despite more than 15 years of advocacy and investment.
It’s not that women don’t understand the value of breastfeeding. Surveys repeatedly show that new mothers across many countries know that breast is best for babies.
It’s not that we aren’t aware of the reasons that mothers don’t breastfeed. Surveys repeatedly show that new mothers are concerned that they don’t have enough milk or time; that they experience pain, exhaustion and rejection from their babies; that they feel awkward breastfeeding in public; that spouses are often unsupportive and that it’s just too hard to breastfeed and work. And don’t forget that although world health authorities recommend exclusive breast-feeding for 6 months most countries don’t offer maternity leave beyond three, and typically without pay.
It’s not that new mothers are hard to reach. With more women delivering their babies in facilities than ever before it has never been so easy to reach millions of mothers in the critical hours after delivery to help them initiate breastfeeding.
Our collective failure to do so has led to a realization that we need a new approach.
UNICEF’s landmark 2013 report, Breastfeeding on the Worldwide Agenda, outlines a powerful argument for change describing the current environment as “policy rich” but “implementation poor”.
At the same time, the Bill and Melinda Gates Foundation’s flagship breastfeeding investment - Alive & Thrive - is demonstrating that large increases in breastfeeding are possible with multi-sector action to shift attitudes among new mothers, the behavior of employers and the policies of governments. With this approach, the exclusive breastfeeding rate in the Vietnamese project sites has risen from 19 to 63% and across the Bangladesh sites from 49 to 83% in just three years.
And the countries that have achieved the greatest progress in reducing child mortality and achieving Millennium Development Goal 4 have all recorded exclusive rates of breastfeeding well above the global average including Rwanda (85%), Cambodia (74%), Malawi (70%), Bangladesh (64%), Nepal (70%), Eritrea (52%), Ethiopia (50%), Tanzania (50%) and Madagascar (51%).
Inspired by these successes and also by what we have learned in the areas of global health that have made the greatest gains though intense, sustained and collective public and private sector action, especially AIDS, malaria and vaccines, it is time for public-private partnerships to drive innovation, progress and deliver results in breastfeeding.
Partnerships that start with the needs of mothers and work backwards.
Partnerships with the goal of identifying and then removing one by one the major barriers and costs of early and exclusive breastfeeding as experienced by mothers.
Partnerships that are best practice and lift ambitions and inspire action in the countries with very low rates of breastfeeding and high numbers of newborn deaths.
Let’s start with Nigeria.
With the second highest number of child deaths in the world - 800,000 - and one of the lowest rates of early and exclusive breastfeeding - 23% and 15% - what happens in Nigeria will not only matter for a large number of Nigerian children but will also matter for the achievement of global health goals.
With Nigeria’s sharply rising population driven by a very high fertility rate (an average of 6 children per woman), the under 5 population is forecast to grow by 10 million in the next 15 years.
What happens in Nigeria increasingly influences the world.
We have the right ingredients for a strong public-private partnership in Nigeria - a federal government committed to saving one million lives by 2015, trusted local NGO partners like the Wellbeing Foundation, support from the global health community; mobilized networks including the 2,500 strong Global Breastfeeding Initiative; and corporations like McCann Health, Philips, Medela, Ameda and Hygeia fully engaged with an appetite for innovation.
A new public-private partnership can tap into the thriving innovation community that is starting to push the envelope on new breast-feeding supportive technologies. MIT’s Media Lab recently hosted a “Make the Breast Pump NOT Suck” Hackathon which produced the Batman-inspired (yes…) Mighty Mom Utility Belt - a fashionable, discrete, hands-free wearable pump that automatically logs and analyses personal data; Helping Hands - a sturdy, easy to clean, minimal parts, hands free compression bra designed by nursing moms; and PumpIO - an open software and hardware platform to make the breast pumping experience smarter, more data-rich and less isolating.
This is the tip of the iceberg of the innovation needed in the category of “breastfeeding supportive technologies”.
Every year more than 140 million new mothers face the decision whether or not to breastfeed and this population is growing fastest in the countries with the highest child mortality. There are 8 million new mothers every year in Nigeria alone.
As more and more of these mothers will come under increasing pressure to go back to work quickly as women’s labor force participation rates rise, new mothers will need intensive support, and even incentives and rewards to continue breastfeeding. If they don’t, we can expect breast-feeding rates to continue to flatline or more likely, to fall.
But we don’t accept this scenario. We know that most new mothers want to breastfeed. It’s the external environment that needs to change to enable mothers to fulfill their aspirations.
The American Academy of Pediatrics (AAP) has developed several newborn care modules under the Helping Babies Survive (HBS) series to assist healthcare providers everywhere, especially in low-resource settings, to deliver consistent, quality care for newborns. Essential Care for Every Baby (ECEB) is one module within the HBS package (ECEB, Helping Babies Breathe (HBB), and Care of the Small Baby). Learner workbooks and flipcharts are designed with an emphasis on clear and simple illustrations, case scenarios, checklists, and algorithms that direct the provider in caring for the newborn beginning immediately after birth. Consistent, user-friendly materials, is a key strength of ECEB and the HBS series.
ECEB responds to a need for a user-friendly training module to complement the existing WHO-UNICEF essential newborn care curriculum. The components of essential newborn care – ensuring warmth, immediate skin-to-skin care, early breastfeeding, umbilical cord care, eye care, Vitamin K administration, and immunization, are already incorporated into national guidelines, protocols and training materials. These components are routinely addressed in pre-service and in-service trainings for health care workers. ECEB does not necessarily aim to teach a new skill set to newborn care providers; rather, its purpose is to reinforce skills and build confidence. ECEB is not intended to replace existing in-country materials, but rather, complements what is already available. Countries have the option to adopt the ECEB materials or use them to augment their existing essential newborn care materials. ECEB takes what providers are already doing and helps them do it better.
The AAP is working with development partners and programs such as USAID/Maternal and Child Survival Program (MCSP) and Save the Children to introduce ECEB to health providers and policy-makers in countries with a high burden of newborn deaths. In May 2014, USAID’s Maternal and Child Health Integrated Program (MCHIP) and the Laerdal Global Health Foundation, in collaboration with the AAP and other partners, hosted a four-day regional workshop in Addis Ababa, Ethiopia to introduce and provide training for ECEB to participants from the Africa region. Countries already implementing HBB at scale shared their experiences and the potential use for ECEB. A total of 85 people attended the workshop, including ECEB trainers from AAP and represented countries, Ministry of Health representatives, national trainers, representatives of professional medical and midwifery associations, and implementing partners. A total of 55 participants from the following countries were trained as ECEB Master Trainers: Ethiopia, Ghana, Kenya, Liberia, Malawi, Nigeria, South Sudan, Tanzania, Uganda, Zambia, Zimbabwe and USA. After the workshop, participants are working with government and development and implementing partners to strategize how ECEB may become a part of newborn training. A similar ECEB workshop is planned for the Asia region in 2015.
ECEB and the HBS series have the potential to help countries realize their goals within the Every Newborn Action Plan and improve the quality of newborn care and neonatal outcomes.
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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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