Addressing Critical Knowledge Gaps in Newborn Health


By Alexandra Shaphren on June 20, 2013

Read May's Research Round-Up

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E. Ali Yesuf, R. Calderon-Margalit. Disparities in the use of antenatal care service in Ethiopia over a period of fifteen years. BMC Pregnancy and Childbirth (June, 2013).

Background: Little is known about factors contributing to inequities in antenatal care use in Ethiopia. We aimed to assess inequities in the use of antenatal care on the basis of area of residence, administrative region, economic status and education.

Methods: This study was based on data from repeated cross-sectional surveys carried out by Measure Demographic and Health Survey and Central Statistical Authority of Ethiopia. The surveys were conducted in February-June 2000, April-August 2005, and December 2010-June 2011. The surveys employed a cluster sampling design to select a nationally representative sample of 15–49 year-old women. The main outcome variable was at least one antenatal care visit for the last live birth in the 5 years preceding the surveys. Statistical analysis was completed by applying the sampling weights in order to consider the complex sampling design.

Results: A total of 7978, 7307 and 7908 weighted number of women participated in the three surveys, respectively. The rate of antenatal care coverage in Ethiopia has increased from 26.8% in 2000 to 42.7% in 2011. The odds of antenatal care use were 2.4 (95% CI: 1.7-3.2, p < 0.0001), 1.6 (95% CI: 1.2-2.2, p = 0.003) and 1.8 (95% CI: 1.3-2.6, p = 0.001) times higher among women from urban areas than those from rural areas at the three time points, respectively. The odds ratio of antenatal care use among women with secondary or higher education compared with women of no education increased from 2.6 (95% CI: 2.0-3.4, p < 0.0001) in 2000 to 5.1(95% CI: 2.8-9.4, p < 0.0001) in 2011. Moreover, the odds of use among women from the richest households at the three time points were 2.7(95% CI: 2.1, -3.6, p < 0.0001), 4.4(95% CI: 3.3, -6.0, p < 0.0001), and 3.9(95% CI: 2.8, -5.5, p < 0.0001) times higher compared with their counterparts from the poorest households. Furthermore, we have observed a wide regional variation in the use of ANC in Ethiopia.

Conclusions: The wide inequities between urban and rural areas, across economic and educational strata in the use of antenatal care highlight the need to put more resources to poor households, rural areas, and disadvantage regions. We suggest further study to understand additional factors for the deep unmet need in rural areas and some regions of Ethiopia.

*A. Binagwaho, F. Ngabo, C. Mugeni et al. Discrepant estimates of key indicators for Millennium Development Goals 4 and 5: the public sector's experience in Rwanda. The Lancet (June, 2013).

Background: Debates about differing methodologies and results for estimating key global health indicators have major implications for policy makers in developing countries as the 2015 deadline for the Millennium Development Goals (MDGs) approaches. We aim to encourage discussions about accountability to countries on the part of stakeholders involved in estimation by relating Rwanda's experiences working to assess its progress towards MDGs 4 and 5.

Methods: We reviewed publicly available reports and databases maintained by multinational global health agencies to analyse discrepancies related to MDGs 4 and 5 for Rwanda.

Findings: WHO's September 2012 and the United Nations Population Fund's (UNFPA's) November 2012 estimates of Rwanda's child mortality rate differed by 107% (54·1 and 112·0 deaths per 1000 livebirths, respectively), leading to very different conclusions about progress towards MDG 4. Because maternal mortality ratio estimates are based on fewer data sources, recent point estimates did not differ widely between sources; however, retrospective estimates did, making confident assessment of progress towards MDG 5 difficult. WHO, UNICEF, and the GAVI Alliance estimates falsely indicated that vaccine completion rates fell from above 95% to below 85% in just 2 years—a discrepancy with demographic and health surveys and programme data rectified through a technical workshop. Many discrepancies seem to be related to outdated projections of Rwanda's annual birth cohort that account for a 450% rise in contraception uptake and a 25% drop in total fertility rate since 2005. Failing to incorporate such key demographic changes in population estimates can yield declining coverage estimates even if the true proportion of children receiving an intervention remains constant or increases.

Interpretation: The incorporation of country-derived data into international models should be accompanied by country consultations. Countries should be engaged as partners in identifying the most robust and timely primary data sources. Support for the development of vital registration systems in countries like Rwanda must be a pillar of the post-2015 development agenda.

Funding: None.

*R.E. Black, C.G. Victora, S.P. Walker, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet (June, 2013).

Maternal and child malnutrition in low-income and middle-income countries encompasses both undernutrition and a growing problem with overweight and obesity. Low body-mass index, indicative of maternal undernutrition, has declined somewhat in the past two decades but continues to be prevalent in Asia and Africa. Prevalence of maternal overweight has had a steady increase since 1980 and exceeds that of underweight in all regions. Prevalence of stunting of linear growth of children younger than 5 years has decreased during the past two decades, but is higher in south Asia and sub-Saharan Africa than elsewhere and globally affected at least 165 million children in 2011; wasting affected at least 52 million children. Deficiencies of vitamin A and zinc result in deaths; deficiencies of iodine and iron, together with stunting, can contribute to children not reaching their developmental potential. Maternal undernutrition contributes to fetal growth restriction, which increases the risk of neonatal deaths and, for survivors, of stunting by 2 years of age. Suboptimum breastfeeding results in an increased risk for mortality in the first 2 years of life. We estimate that undernutrition in the aggregate—including fetal growth restriction, stunting, wasting, and deficiencies of vitamin A and zinc along with suboptimum breastfeeding—is a cause of 3·1 million child deaths annually or 45% of all child deaths in 2011. Maternal overweight and obesity result in increased maternal morbidity and infant mortality. Childhood overweight is becoming an increasingly important contributor to adult obesity, diabetes, and non-communicable diseases. The high present and future disease burden caused by malnutrition in women of reproductive age, pregnancy, and children in the first 2 years of life should lead to interventions focused on these groups.

This is the first in a Series of four papers about maternal and child nutrition.

*A. Dumont, et al. Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial. The Lancet (May 2013).

Background: Maternal mortality is higher in west Africa than in most industrialised countries, so the development and validation of effective interventions is essential. We did a trial to assess the effect of a multifaceted intervention to promote maternity death reviews and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali.

Methods: We did a pragmatic cluster-randomised controlled trial, with hospitals as the units of randomisation and patients as the unit of analysis. 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled, stratified by country and hospital type, and randomly assigned to either the intervention group (n=23) or the control group with no external intervention (n=23). All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included. The intervention, implemented over a period of 2 years at the hospital level, consisted of an initial interactive workshop and quarterly educational clinically-oriented and evidence-based outreach visits focused on maternal death reviews and best practices implementation. The primary outcome was reduction of risk of hospital-based mortality. Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals. This study is registered with, number ISRCTN46950658.

Findings: 191 167 patients who delivered in the participating hospitals were analysed (95 931 in the intervention groups and 95 236 in the control groups). Overall, mortality reduction in intervention hospitals was significantly higher than in control hospitals (odds ratio [OR] 0•85, 95% CI 0•73–0•98, p=0•0299), but this effect was limited to capital and district hospitals, which mainly acted as first-level referral hospitals in this trial. There was no effect in second-level referral (regional) hospitals outside the capitals (OR 1•02, 95% CI 0•79–1•31, p=0•89). No hospitals were lost to follow-up. Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals. Interpretation: Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions. Maternal death reviews, combined with best practices implementation, are effective in reducing hospital-based mortality in first-level referral hospitals. Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals.

H.E. Knight, A. Self, S.H. Kennedy. Why are Women Dying When They Reach Hospital on Time? A Systematic Review of the 'Third Delay'. PLOS Medicine (May, 2013).

Background: The ‘three delays model’ attempts to explain delays in women accessing emergency obstetric care as the result of: 1) decision-making, 2) accessing services and 3) receipt of appropriate care once a health facility is reached. The third delay, although under-researched, is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries. The aim of this systematic review was to identify and categorise specific facility-level barriers to the provision of evidence-based maternal health care in developing countries.

Methods and Findings: Five electronic databases were systematically searched using a 4-way strategy that combined search terms related to: 1) maternal health care; 2) maternity units; 3) barriers, and 4) developing countries. Forty-three original research articles were eligible to be included in the review. Thirty-two barriers to the receipt of timely and appropriate obstetric care at the facility level were identified and categorised into six emerging themes (Drugs and equipment; Policy and guidelines; Human resources; Facility infrastructure; Patient-related and Referral-related). Two investigators independently recorded the frequency with which barriers relating to the third delay were reported in the literature. The most commonly cited barriers were inadequate training/skills mix (86%); drug procurement/logistics problems (65%); staff shortages (60%); lack of equipment (51%) and low staff motivation (44%).

Conclusions: This review highlights how a focus on patient-side delays in the decision to seek care can conceal the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. We stress the importance of addressing supply-side barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved.

Y. Mekonnen, B. Tensou, D. Telake, et al. Neonatal mortality in Ethiopia: trends and determinants. BioMed Central (May, 2013).

Background: The Ethiopian neonatal mortality rate constitutes 42% of under-5 deaths. We aimed to examine the trends and determinants of Ethiopian neonatal mortality.

Methods: We analyzed the birth history information of live births from the 2000, 2005 and 2011 Ethiopia Demographic and Health Surveys (DHS). We used simple linear regression analyses to examine trends in neonatal mortality rates and a multivariate Cox proportional hazards regression model using a hierarchical approach to examine the associated factors.

Results: The neonatal mortality rate declined by 1.9% per annum from 1995 to 2010, logarithmically. The early neonatal mortality rate declined by 0.9% per annum and was where 74% of the neonatal deaths occurred. Using multivariate analyses, increased neonatal mortality risk was associated with male sex (hazard ratio (HR) = 1.38; 95% confidence interval (CI), 1.23 − 1.55); neonates born to mothers aged < 18 years (HR = 1.41; 95% CI, 1.15 − 1.72); and those born within 2 years of the preceding birth (HR = 2.19; 95% CI, 1.89 − 2.51). Winter birth increased the risk of dying compared with spring births (HR = 1.28; 95% CI, 1.08 − 1.51). Giving two Tetanus Toxoid Injections (TTI) to the mothers before childbirth decreased neonatal mortality risk (HR = 0.44; 95% CI, 0.36 − 0.54). Neonates born to women with secondary or higher schooling vs. no education had a lower risk of dying (HR = 0.68; 95% CI, 0.49 − 0.95). Compared with neonates in Addis Ababa, neonates in Amhara (HR: 1.88; 95% CI: 1.26 − 2.83), Benishangul Gumuz (HR: 1.75; 95% CI: 1.15 − 2.67) and Tigray (HR: 1.54; 95% CI: 1.01 − 2.34) regions carried a significantly higher risk of death.

Conclusions: Neonatal mortality must decline more rapidly to achieve the Millennium Development Goal (MDG) 4 target for under-5 mortality in Ethiopia. Strategies to address neonatal survival require a multifaceted approach that encompasses health-related and other measures. Addressing short birth interval and preventing early pregnancy must be considered as interventions. Programs must improve the coverage of TTI and prevention of hypothermia for winter births should be given greater emphasis. Strategies to improve neonatal survival must address inequalities in neonatal mortality by women's education and region.

P.K. Mony, J. Krishnamurthy, A. Thomas, et al. Availability and Distribution of Emergency Obstetric Care Services in Karnataka State, South India: Access and Equity Considerations. PLOS Medicine (May, 2013).

Background: As part of efforts to reduce maternal deaths in Karnataka state, India, there has been a concerted effort to increase institutional deliveries. However, little is known about the quality of care in these healthcare facilities. We investigated the availability and distribution of emergency obstetric care (EmOC) services in eight northern districts of Karnataka state in south India.

Methods & Findings: We undertook a cross-sectional study of 444 government and 422 private health facilities, functional 24-hours-a-day 7-days-a-week. EmOC availability and distribution were evaluated for 8 districts and 42 taluks (sub-districts) during the year 2010, based on a combination of self-reporting, record review and direct observation. Overall, the availability of EmOC services at the sub-state level [EmOC = 5.9/500,000; comprehensive EmOC (CEmOC) = 4.5/500,000 and basic EmOC (BEmOC) = 1.4/500,000] was seen to meet the benchmark. These services however were largely located in the private sector (90% of CEmOC and 70% of BemOC facilities). Thirty six percent of private facilities and six percent of government facilities were EmOC centres. Although half of eight districts had a sufficient number of EmOC facilities and all eight districts had a sufficient number of CEmOC facilities, only two-fifths of the 42 taluks had a sufficient number of EmOC facilities. With the private facilities being largely located in select towns only, the ‘non-headquarter’ taluks and ‘backward’ taluks suffered from a marked lack of coverage of these services. Spatial mapping further helped identify the clustering of a large number of contiguous taluks without adequate government EmOC facilities in northeastern Karnataka.

Conclusions: In conclusion, disaggregating information on emergency obstetric care service availability at district and subdistrict levels is critical for health policy and planning in the Indian setting. Reducing maternal deaths will require greater attention by the government in addressing inequities in the distribution of emergency obstetric care services.

C. Ndour, S. Dossou Gbété, N. Bru, et al. Predicting In-Hospital Maternal Mortality in Senegal and Mali. PLOS Medicine (June, 2013).

Objective: We sought to identify predictors of in-hospital maternal mortality among women attending referral hospitals in Mali and Senegal.

Methods: We conducted a cross-sectional epidemiological survey using data from a cluster randomized controlled trial (QUARITE trial) in 46 referral hospitals in Mali and Senegal, during the pre-intervention period of the trial (from October 1st 2007 to October 1st 2008). We included 89,518 women who delivered in the 46 hospitals during this period. Data were collected on women’s characteristics, obstetric complications, and vital status until the hospital discharge. We developed a tree-like classification rule (classification rule) to identify patient subgroups at high risk of maternal in-hospital mortality.

Results: Our analyses confirm that patients with uterine rupture, hemorrhage or prolonged/obstructed labor, and those who have an emergency ante-partum cesarean delivery have an increased risk of in-hospital mortality, especially if they are referred from another health facility. Twenty relevant patterns, based on fourteen predictors variables, are used to predict in-hospital maternal mortality with 81.41% sensitivity (95% CI = [77.12%–87.70%]) and 81.6% specificity (95% CI = [81.16%–82.02%]).

Conclusion: The proposed class association rule method will help health care professionals in referral hospitals in Mali and Senegal to identify mothers at high risk of in-hospital death, and can provide scientific evidence on which to base their decisions to manage patients delivering in their health facilities.

S. Singh, Jacqueline, E. Darroch, Lori S. Ashford. Adding It Up: The Need for and Cost of Maternal and Newborn Care—Estimates for 2012. Guttmacher Institute (May, 2013).

  • In 2012, there were an estimated 122 million births in the developing world. All of these women and newborns needed antenatal, delivery and postnatal care.

  • Only 55% of developing-country women who gave birth in 2012 made four or more antenatal visits. Many who received antenatal care did not receive screenings and other necessary services they needed to ensure a healthy pregnancy.

  • Sixty-four percent of women who gave birth delivered in a health facility. This proportion varied from 51% in the poorest countries to 94% in higher-income developing countries.

  • Between 2008 and 2012, the proportion of women receiving adequate antenatal care increased by a modest one percentage point per year. The proportion delivering in health facilities increased faster, by 2.3 percentage points per year, markedly reducing the numbers of women and newborns with unmet need for facility-based delivery care.

  •  An estimated 55 million women giving birth in 2012 had an unmet need for adequate antenatal care (four or more visits), and 44 million women had an unmet need for delivery care in a health facility. Two regions, Sub-Saharan Africa and South Asia, accounted for about 80% of the total unmet need for each of these types of care.

  • Although only a minority of women and newborns experienced medical complications at the time of delivery in 2012, most of them did not receive the recommended care.

  • Unmet need for maternal and neonatal care reflects a number of barriers that need to be overcome, such as weak health infrastructure, lack of trained professionals, distance to care, and issues related to knowledge and attitudes about the need for care.

  • The total cost of providing the recommended levels of maternal and neonatal care to all women giving birth and their newborns is an estimated $24.1 billion annually, of which $8.5 billion is for direct costs and $15.6 billion is for program and systems costs. This is more than double the cost of current care in 2012, estimated at $11 billion.

  • These additional investments would provide immediate returns in terms of saving lives and reducing disabilities among women and newborns, and would bring long-term benefits as human and physical capacity in the health sector is improved.

*H. Toure, M. Audibert, P. Doughty, et al. Public sector services for the prevention of mother-to-child transmission of HIV infection: a micro-costing survey in Namibia and Rwanda. World Health ORganization (June, 2013).

Objective: To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries.

Methods: In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$).

Findings: The estimated costs to the providers of PMTCT, for each mother–infant pair, were US$ 202.75–1029.55 in Namibia and US$ 94.14–342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$ 3.15 million in Namibia and US$ 7.04 million in Rwanda (or < US$ 0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries.

*M. van Dijka, M. Julia Ruizb, D. Letona, et al. Ensuring intercultural maternal health care for Mayan women in Guatemala: a qualitative assessment. Culture Health and Sexuality (June, 2013).

Indigenous (Mayan) women in Guatemala experience a disproportionate burden of maternal mortality and morbidity, as well as institutional failures to respect their rights. The Guatemalan Ministry of Health has started to offer intercultural services that respect Mayan obstetric practices and integrate them with biomedical care. We purposefully selected 19 secondary-level public health facilities of 9 departments that provided maternal healthcare to indigenous women. We carried out semi-structured interviews with biomedical providers (44), Mayan midwives or comadronas (45), and service users (18), exploring the main characteristics of intercultural care. We found that most facilities initiated the implementation of culturally appropriate services, such as accompaniment by a comadrona or family member, use the traditional teas or choosing the birthing position, but they still lacked standardisation. Comadronas generally felt excluded from the health system, although most biomedical providers reported that they were making important strides to be respectful and inclusive. Most users wanted the option of culturally appropriate services but typically did not receive them. In the health facilities, biomedicine is still the dominant discourse. Efforts at offering intercultural care still need strengthening and further monitoring. Involvement and participation of comadronas and indigenous women is key to moving forward to true intercultural services.

*L. Vesel, A. H.A. ten Asbroek, A. Manu, et al. Promoting skin-to-skin care for low birthweight babies: findings from the Ghana Newhints cluster-randomised trial. Tropical Medicine & International Health (June, 2013).

Objective: To evaluate whether the Newhints home visits intervention increased the adoption of skin-to-skin care (SSC), in particular, among low birthweight (LBW) (<2.5 kg) babies.

Methods: A cluster-randomised trial, with 49 Newhints zones and 49 control zones, was conducted in seven districts in the Brong Ahafo Region, Ghana. It included all live births between November 2008 and December 2009. In Newhints zones, existing community-based surveillance volunteers were trained to conduct home visits during which they weighed babies and counselled mothers of LBW babies on SSC. Performance of any SSC and SSC for more than 2 h was evaluated.

Results: Of 15,615 live births, 68.5% had recorded birthweights; 10.1% were LBW. Any SSC was 19.4% higher among babies in Newhints vs. control zones (risk ratio, RR: 1.81; 95% confidence interval, CI: 1.40-2.35). Performance of SSC for more than 2 h was, however, low, at only 7.5%, although more than double compared with control zones (RR: 2.72; 95% CI: 1.80-4.10). LBW babies visited and weighed by a volunteer were more likely to receive SSC (PA ny  = 0.005; P >  2 h  = 0.021), greater for LBW babies, particularly for more than 2 h of SSC (Pinteraction  = 0.050).

Conclusion: Newhints successfully promoted the uptake of SSC in rural Ghana. Although findings are encouraging, promotion in rural community settings in sub-Saharan Africa is challenging. Lessons learned can help shape SSC promotion in efforts to increase adoption and save newborn lives.

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By Nosa Orobaton on June 18, 2013

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.

By Ian Hurley on June 13, 2013

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. 

By Mary Kinney on June 7, 2013

This blog was originally published by the EVERY ONE Campaign and is co-authored by JoAnn Paradis and Mary Kinney, Save the Children.

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 to learn more and help bring forth change for newborns around the world.


By Ian Hurley on June 6, 2013

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.