Midwife Margaret Baru, 46, left, checks on a newborn baby at Nyumanzi Health Centre II in Adjumani district, Uganda before handing it back to its mother. Photo: Sylvia Nabanoba/Save the Children
Maternal and newborn health in Nyumanzi refugee camp
Every midwife’s nightmare is losing a mother or baby on her watch. They know that these are things that do happen, sometimes because you simply cannot prevent them, but it is still heartbreaking when they do.
This is what 46-year-old Margaret Baru dreaded when one night in June the watchman called out to inform her that a mother in the maternity ward was bleeding uncontrollably.
“She had delivered very well and seemed to be recovering well too. After the delivery, I let her rest before transferring her to the ward. But then the watchman summoned me,” narrates Sr. Baru. “I found her in a pool of blood that kept growing.”
Sr. Baru put the mother on intravenous treatment, but the bleeding did not stop. She had to think and act fast if the mother’s life was to be saved.
“I literally held her uterus for close to two hours in order to make it contract and stop the bleeding. How did I do this? I laid my hands on her stomach and held the uterus. The bleeding eventually stopped,” she says.
Sr. Baru practiced this unconventional method at Nyumanzi Health Centre II in Adjumani District. The health centre is one of those meant to serve refugees who since December 2013 have fled fighting in Southern Sudan and been resettled in several refugee resettlement camps in Adjumani district, Uganda. Nyumanzi is one of the 19 settlements in the district. Currently the health centre serves a population of 25,000 refugees and 5,000 Ugandan nationals who still access services there.
“We are very busy. We have many mothers giving birth here,” Sr. Baru says. “In June (2014) we had 90 deliveries.”
She explains that the high number of births is partly a result of the refugees’ shunning of birth control. According to her, the women say their husbands do not allow them to use modern methods of family planning. They opt for the natural methods, which frequently fail them.
It is these barely spaced pregnancies that result in the very common complications that Sr. Baru has encountered at Nyumanzi since she was posted there in April 2014. She explains that bleeding before and after delivery is a common complication, coupled with mal-presentations such as arm prolapse and delayed labour pains. Frequent pregnancies make the uterus flabby and it fails to contract quickly after childbirth, thus the post-delivery bleeding. A flabby uterus also increases the chances of mal-presentations, Sr. Baru says, because it gives the baby a lot of space to wriggle and move about in different directions.
Keeping alive newborns that suffer complications such as asphyxia is another challenge, since the health centre does not have any oxygen or resuscitation equipment.
“We once had a stillbirth. The mother delayed to come to the health centre yet she was in labour, and the baby got tired. It was alive when it was delivered, but had problems breathing. We could have resuscitated it if we had the facilities, but we did not. So sadly it died,” narrates Sr. Baru.
Encouraging mothers and their partners to attend antenatal care (ANC) sessions is the most important avenue the health centre is using to reduce these challenges. When they come for ANC, the mothers are taught how to prepare for birth.
“Many of them would come to give birth without anything – not even a bedsheet in which to wrap the new baby. Or bedsheets for themselves. Now that they are learning, they come prepared,” says Sr. Baru.
She adds that during ANC the mothers are taught about family planning and the importance of giving birth in the health centre, as opposed to delivering from home. They are tested for HIV, too, and those found to be HIV-positive referred to Dzaipi Health Centre II, where they are enrolled on the Prevention of Mother to Child Transmission of HIV to ensure they do not transmit the virus to their newborns.
On 18 August, there were 500 days left to meet the Millennium Development Goals (MDGs).
That really isn’t very long.
The world is on the brink of a major breakthrough in ensuring mothers, newborns and children in the poorest parts of the world can survive and thrive.
And India is at the forefront of this revolution.
Celebrating success, building momentum
It is heartening to note that India is on track to meet MDG 5 by reducing the maternal mortality rate from 437 per 100,000 in 1990 to 178 per 100,000 by 2012.
That’s a decrease of 70% – particularly impressive given that the global figure for the same period has been 48%.
Bringing down the under-five mortality rate
India has also made dramatic progress in bringing down the under-five mortality rate from 114 per 1,000 live births in 1990 to 52 in 2012. That’s a reduction of 58% – more than half, again ahead of the global rate (44.8%).
But it isn’t enough. We continue to lose 1.4 million children a year before they see their fifth birthday. More than half of those are newborn deaths – a particular challenge for India, which accounts for 26.6% of all newborn deaths globally.
A baby’s first day is his or her most vulnerable. If we want to see real progress on child survival it is vital that we find ways to protect these fragile new lives.
From pledges to action
India has already initiated a nationwide push to reach every mother and newborn with essential healthcare services.
The strategy aims to build on existing partnerships and forge new ones, bringing together the business sector, private individuals, training institutions, civil society and faith-based organisations to deliver unprecedented breakthroughs in newborn and child survival.
A Minister speaks out
India’s Health Minister, Dr Harshvardhan, has spelled out this government’s commitment to accelerating progress on maternal and child survival.
Speaking in Washington DC, he said: “It is now evident that with sustained efforts across the globe with a focus on equality, the goal of ending preventable child and maternal deaths by 2035 seems well within our reach.”
Political will is the most important initial factor in achieving any large-scale change. Dr Harshvardhan’s words made clear that we have that.
Keeping the momentum
We know that curbing child mortality levels in India will make a massive difference to global child mortality figures. The world is looking to India to turn our pledges into reality.
Today we are at a critical point and success seems within our grasp. Even with fewer than 500 days to go, one final push will indeed see India achieve the MDG targets on maternal and child survival.
Will India surprise the world?
Raeda, 33, recovers in a bed at Al Awda Hospital after giving birth to her firstborn, a daughter. Raeda lives in Jabalyia, northern Gaza Strip. Photo: Loulou d'Aki/Save the Children
The conflict in Gaza has caused the upheaval of the health system. For women and newborns it has been much more difficult to secure health services like antenatal and postnatal care, which are critical for survival and a healthy start to life.
The Palestinian Ministry of Health has reported that over 4500 babies have been born during the 29 days of active fighting before the first 72-hour ceasefire was agreed to. Amnesty International has also reported that health workers and hospitals have been deliberately attacked during the fighting.
The needs of pregnant women and newborn babies are critical in the best of circumstances and in emergency and conflict settings there is an even greater need to prioritize and deliver care.
- World Vision: Maternal, Newborn and Child Health and Nutrition in Emergencies
- UNFPA: Providing Emergency Obstetric and Newborn Care
- Conflict and Health: Neonatal survival interventions in humanitarian emergencies: a survey of current practices and programs
- Al Jazeera: New life if born amid destruction
MESH-QI mentor conducting training on neonatal resuscitation at health center level
Partners In Health, in collaboration with the Rwandan Ministry of Health, implemented a program entitled Mentorship and Enhanced Supervision at Health Centers and Quality Improvement (MESH-QI) to address inefficiencies in current health center training and clinical practice of nurses. MESH-QI improves care delivery through:
- Decentralized pre-service training at the district level
- Building capacity of the existing district supervisory structure
- Initiation of a systems focus on clinical mentoring and coaching of health center teams
- Use of data for continuous quality improvement
Figure 1: Pillars of Mentorship, Enhanced Supervision and Quality Improvement Program
Current health center training for nurses consists of centralized pre-service training and limited in-service supervision. The pre-service training includes emergency obstetrics and newborn care (EmONC) and focused antenatal care (FANC), but periodic supervision visits by district hospital supervisors are largely consumed with data collection and reporting, with limited opportunities for on-site clinical mentoring and re-training.
To address this gap in training, MESH-QI mentors make routine intensive visits to health centers, lasting at least two days, in which they provide on-site case management observation; support for higher level problem-solving, diagnostic, and decision-making skills; lead case discussions; and address quality improvement issues (see Figure 1). By routinely capturing valuable data on nurses’ clinical skills, facility conditions, and clinical indicators, clinical supervisors also enhance the feedback loop for quality improvement.
Key lessons learned
Mentorship catalyzes translation of theory to practice
Clinicians expressed this as one of the positive aspects of MESH-QI interventions. Mentors use various adult learning techniques to support nurses to address the “knowledge-practice gap.” This facilitates the implementation of FANC at MESH-QI supported sites.
Mentorship improves clinicians’ confidence, motivation and adherence to MCH protocols
Prior to the implementation of MESH-QI, there were challenges in learning how to effectively integrate and utilize national protocols, guidelines, and tools. One nurse mentee mentioned: “They built my confidence not only in screening and case management, but also in general nursing care I provide every day. I feel proud of the work when I can handle even the complicated cases that I could not manage before… their support.”
Mentoring checklists enable evidence-based feedback and continuous QI
Using mentoring and coaching tools, such as checklists for case management, facility, and systems observations, enables mentors to provide objective and constructive feedback and regular monitoring of ANC delivery.
MESH-QI is an effective strategy to improve the quality of antenatal care
Figure 2: Quality of ANC Assessments at Baseline and Post-mentoring
With mentoring, uniform improvement was observed regardless of baseline EmONC/FANC-training status (Figure 2). This demonstrated that mentorship is a promising intervention to help improve the quality of FANC regardless of baseline training status. Mentoring, therefore, is particularly applicable to resource-limited healthcare settings facing human resources challenges. While EmONC and other didactic trainings are still costly—particularly in developing countries—on-site mentorship is an option to mitigate these challenges.
MESH-QI integrates in-service training and systems improvement into routine care delivery
In-service training bypasses the challenge of extracting nurses from their health centers to attend workshops in main cities, which could be hours away. Mentorship and coaching sessions take place at the health facility level, which avoids worsening staff shortages, an already significant challenge in resource-limited settings.
The MESH-QI approach is also proving successful in several other health domains, including neonatal care and integrated management of childhood illness (IMCI), by strengthening the entire spectrum of care for families. The Ministry of Health of Rwanda has a number of efforts underway to replicate and scale this mentorship approach.
To learn more about mentorship, enhanced supervision and quality improvement in Rwanda, please see the following:
- Description of the mentorship program in rural Rwanda
- Perceptions and acceptability of health care workers
- Mentorship and quality improvement strengthened the quality of pediatric care
- Integrated mentorship and quality improvement to improves antenatal care
Photo: Ayesha Vellani/Save the Children
World Breastfeeding Week 2014 was celebrated in August all over the world from the 1st to 7th. The week provided a platform to orient people on how about 800,000 under five child deaths can be prevented if all 0-23 month old infants are optimally breastfed.
Breastfeeding is beneficial both for mother and her children. Breastfed babies have lesser chances of asthma, childhood obesity, ear infections, eczema (atopic dermatitis), diarrhoea and vomiting, low respiratory infections, necrotizing enterocolitis (a disease that affects the gastrointestinal tract in pre-term infants), sudden infant death syndrome (SIDS) and Type 2 diabetes. While mothers who breastfeed their children have lesser chances of breast cancer; breastfeeding assist mothers in healing following childbirth and getting back to their pre-pregnancy weight quicker.
In more than 175 countries worldwide, breastfeeding advocates celebrated the theme 'Breastfeeding: A winning goal - for life’ highlighting that achieving the Millennium Development Goals (especially MDGs 4 and 5) requires more early, exclusive and continued breastfeeding.
EVERY ONE Pakistan commemorated the week with advocacy activities across the country. In Khyber Pakhtunkhwa province, a press briefing session was jointly organised by EVERY ONE and Child Rights Movement Khyber Pakhtunkhwa chapter at the Peshawar Press Club on August 7th. Then again on August 11th, EVERY ONE in collaboration with Child Rights Movement Khyber Pakhtunkhwa held an advocacy seminar for civil society organizations.
Both the events shared how Pakistan is the South Asian country with the lowest exclusive breastfeeding and highest bottle feeding rates. Over the last seven years, only a 0.6% increase has been seen in infants who are exclusively breastfed. According to the Demographic Health Survey, the overall percentage stood at 37.7 in 2012-13: Whereas, the percentage of bottle feeding rose from 32.1 in 2006-07 to 41% in 2012-13. Experts opined that the increasing trends in bottle feeding across the country were due to a lack of awareness.
In the province of Khyber Pakhtunkhwa, the percentage of exclusive breastfeeding is at 27%; percentage of infants ever breastfed is 96.5%; the timely initiation of breastfeeding is at 26.4%; while the continued breastfeeding rate at 12-25 months is 83.6% and at 20-23 months is 55%.
Civil society organisations at these advocacy events were urged to undertake strong lobbying in the form of social mobilization events, meetings with local body members, provincial legislators and the media to put pressure on the Government of Khyber Pakhtunkhwa to expedite legislation for breastfeeding similar to the other three provinces in Pakistan. The protection of children and their mothers from different diseases will be easily possible following the passage of Khyber Pakhtunkhwa Protection of Breastfeeding and Child Nutrition Bill.
Dr. Qaisar Ali, Deputy Director Reproductive Health/Nutrition stated: Except Khyber Pakhtunkhwa where legislation is still pending, all provinces have adopted/passed provincial laws for the protection and promotion breastfeeding. Due to the absence of provincial legislation in Khyber Pakhtunkhwa, the federal Protection of Breast-Feeding and Child Nutrition Ordinance 2002 is still applicable in the province. However, in the context of 18th Constitutional Amendment, Government of Khyber Pakhtunkhwa should introduce provincial legislation keeping in view the provincial realties. Recently, after two and a half year delay, the Khyber Pakhtunkhwa Protection of Breastfeeding and Child Nutrition Bill has been sent to the provincial cabinet for a final nod; however, political will is needed for approval of the bill.
CRM members also urged the implementation of the breastfeeding and marketing code, improved breastfeeding counselling by healthcare providers, and a revision of the undergraduate curriculum with a greater emphasis on good infant and young child feeding practices. The creation of baby-friendly health facilities, behaviour change strategies to promote breastfeeding, the development of effective messages and counselling of women at all education levels was also urged.
Early marriages, the poor status of women, repeated pregnancies, poor maternal nutrition, food restrictions in pregnancies due to taboos/myths, and poor antenatal care were a few of the reasons cited for the poor breastfeeding practices among women in Pakistan.
CRM members also provided information on the MDGs and how they related to breastfeeding and infant young child feeding (IYCF) to showcase the progress made so far and key gaps in breastfeeding and IYCF; to call attention for stepping up actions to protect, promote and support breastfeeding as key intervention in MDGs and in the post 2015 era; and, to stimulate interest among young people of both genders to see the relevance of breastfeeding in today’s changing world.
A documentary on the breastfeeding practices in Pakistan was also launched at the advocacy seminar. Save the Children has always been at the forefront in advocating children’s rights and by launching this impressive documentary, we once again registered our concerns on deaths among children which can be prevented by breastfeeding practices in children.
It is the basic right of an infant to be breastfeed for at least two years. Exclusive breastfeeding for at least 6 months can strengthen the immunity of a child. It gives our babies the healthiest start that will last a life time. The choice to breastfeed is an investment in our babies’ future!
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