Addressing Critical Knowledge Gaps in Newborn Health


By Leith Greenslade on September 24, 2013
Africa, Asia

Photo: Merck

This blog was originally published in Degrees Live

TO ACHIEVE MILLENNIUM DEVELOPMENT GOAL 4 (MDG 4), we need to prevent the deaths of an additional 1.5 million newborns by December 31st, 2015. At the current rate of progress we won’t get there. Rates of reduction in newborn deaths need to be four times faster to achieve MDG4. And with newborn deaths at 44% of all under 5 deaths, how to save newborn lives quickly has become the most critical child survival challenge in the 800 days left to the MDG4 deadline.

Given the concentrations of newborn deaths in just a handful of countries – India, Nigeria, Pakistan, China and the Democratic Republic of Congo – and the strong relationship between levels of maternal education and reductions in child mortality – one approach is to design and execute a series of education and behavior change campaigns focused on improving homecare of newborns.

But not just any education and behavior change campaigns – campaigns designed and executed by the top creative teams at the world’s leading advertising agencies. The same people who make sure that Coca-Cola is available no matter where you go in Africa and South Asia. The same people who make sure every teenager in the remotest communities craves a certain sporting shoe. The same people who make sure that every adult in the most desperate slums strives for that particular smart phone.

Just think what these people could do if they applied their considerable talents to changing the behaviors of new mothers most at risk of losing a newborn.

Imagine a series of state of the art campaigns that focused on the three or four behaviors that dramatically reduce the risks to newborns – early and exclusive breastfeeding, how to recognize the dangers signs of a sick newborn and know what to do, how to keep a newborn warm and critically, what not to do – early bathing, exposure to the elements, applying harmful substances etc.

Imagine campaigns that created a powerful emotional connection between new mothers and these new behaviors and actually empowered mothers to both provide and demand better care for their newborns, through the use of incentives like cash payments and other rewards.

Imagine campaigns that reached mothers directly, through all of the communication channels they prefer and have ready access to – village groups, television, radio, mobile phones – at the most critical times including the months prior to birth and the week after birth when newborns are at greatest risk of death.

Where advertising agencies have been engaged in public health challenges the results have been impressive. Cigarette use has dropped, road safety has increased, more condoms have been used, nutrition and levels of physical activity have improved, and contraceptive use, screening for cervical and breast cancers and vaccination rates have all risen. Strong results have also been recorded for campaigns to increase the use of insecticide-treated bed nets in Africa, and breastfeeding rates and the use of oral rehydration salts and zinc across South Asia.

One of the most impressive recent efforts is McCann Health’s “Dumb Ways to Die” campaign for the Melbourne train authority. Rather than a typically earnest public service announcement, McCann opted for a mix of offbeat humor, a catchy tune and a collection of amiable animated characters to launch the message as an online music video under the irreverent title “Dumb Ways to Die”. The video has now amassed close to 57 million views and 3.8 million shares. More importantly, 39% of the target audience has stated that they would be safer around trains because of the campaign, and the Melbourne train authority recorded a 21% reduction in accidents and deaths on its network.

Another encouraging development is the handful of leading corporations joining forces with top advertising agencies to create mass media campaigns for public health and safety in ways that are directly connected to their business operations, brand development and customer loyalty. The creative talent of the world’s leading advertising agencies is clearly demonstrated in the following three campaigns:

1. “It Can Wait”, to stop texting and driving, sponsored by AT&T, Verizon Wireless, T-Mobil and Sprint;
2. “Turning 5” to encourage use of hand washing with soap, sponsored by Unilever; and
3. “
Real Beauty Sketches” to improve women’s body image and confidence, sponsored by Dove.

We need leading corporations to join forces with ad agencies to drive newborn health messages direct to mothers and families in the countries with the greatest newborn challenges. Corporations are already investing huge sums in advertising their own brands in an effort for build market share all over Africa and South Asia. Why not do so in a way that advances newborn health where the connection with company’s core business is clear?

The stakes are high. If we don’t do this, the massive global effort underway to increase the supply of quality, affordable newborn health products may fail. The UN Commission on Life-Saving Commodities for Women and Children has prioritized 13 commodities for accelerated introduction in the counties where maternal and child deaths are concentrated. In the newborn area the target products are chlorhexidine, newborn resuscitation devices, injectable antibiotics and antenatal steroids.

But this effort won’t yield strong results if mothers and health care providers are unaware of these products and don’t understand the connection between their own behaviors and newborn deaths. The approaches that are used by advertising agencies to successfully stimulate demand for product brands like Coca-Cola in developed markets are not so different to those that can be used to transform unhealthy behaviors into healthy ones in rural villages across Africa and South Asia.

Turns out that selling Coca-Cola and saving newborn lives might not be such different challenges, and if we could get the kind of results in newborn health that Coca-Cola has achieved in some of the hardest to reach communities in the world, we would be a long way to closing the MDG4 achievement gap.

The MDG Health Alliance is an initiative of the United Nations Special Envoy for Financing the Health MDGs and works in partnership with governments, non-government organizations, academic institutions and corporations to accelerate global progress towards the health related Millennium Development Goals, especially Goal #4: saving 3.5 million children’s lives by 2015. The Alliance operates in support of Every Woman, Every Child, an unprecedented movement spearheaded by the United Nations Secretary-General to intensify global action to improve the health of women and children.

By Gary Darmstadt on September 24, 2013
Africa, Asia

The third leading cause of death in children around the world before their fifth birthday is serious infections like sepsis and meningitis during the first 28 days of life (the neonatal period). Each year, an estimated 800,000 newborns succumb to such infections. Once a newborn becomes infected, the two key things in preventing progression of the condition to death are early recognition of the clinical signs and prompt administration of effective antibiotic treatment. 

It may sound simple, but in other respects, particularly from a systems point of view, the challenges are overwhelming and further complicated by cultural, social and economic factors.

In developed countries newborns with infections receive the “gold standard” of care, which typically entails meeting or exceeding a World Health Organization (WHO) recommendation of a 10- to 14-day regimen of two antibiotics given by intramuscular injection or intravenously in a hospital setting, as anything less would be considered “unethical”.  Providing the standard of care is possible because the majority of parents have access to affordable, high-quality institutional care.

However, this is not the reality for most newborns in most developing countries. More often than not, women deliver at home without the assistance of a skilled birth attendant. If their newborn develops an infection, they might not recognize the warning signs promptly - if at all - or they may recognize the signs but attribute them to something else such as spiritual forces. If they do recognize the illness as something they can potentially manage, they may face a plethora of logistical, cultural and economic challenges to gain access to a health worker with the skills, equipment and supplies necessary to provide the curative care their newborn needs. 

Furthermore, many parents consider seeking care outside the home as unacceptable during the first few days to weeks of life, and often if they seek care they suffer “opportunity costs”, for example due to lost time at work, and face the challenges of receiving sub-standard treatment due to barriers of cost, hospital under-staffing or lack of supplies and beds, and they run the risk of being treated poorly.

In an unprecedented collaboration, the World Health Organization (WHO), Save the Children/Saving Newborn Lives (SC/SNL), The United States Agency for International Development (USAID), and the Bill & Melinda Gates Foundation (BMGF) came together with local institutions in Nigeria, Kenya, the Democratic Republic of Congo, Bangladesh and Pakistan to collaborate with the common understanding that to significantly reduce neonatal mortality, new innovative solutions for recognizing and treating newborn infections needed to be developed.  In 2007, a technical advisory group of partners recommended the development of large-scale clinical trials to evaluate the possibility of providing simplified antibiotic regimens for newborns with infections outside the hospital setting.

Even though it took almost five years in the making, we are currently wrapping up trials in communities and primary care clinics in Democratic Republic of Congo, Kenya, Nigeria, Bangladesh and Pakistan. The ethical challenges were considerable, as we struggled to reconcile the current “standard” of care with the reality that the standard of care is so high that the majority of babies don’t receive treatment, and most families refuse treatment in their local health system as it currently exists.

"The idea that newborns with serious infections could be treated as outpatients at home or at community clinics with regimens that include oral antibiotics is a bold, paradigm-shifting hypothesis that the study teams are taking the risk to test through a rigorously designed and implemented randomized controlled trial." 

In order to reconcile the ethical concerns, all families in the study were offered the standard of care in a hospital setting, and only if they refused care were they offered the simplified treatments in a health facility closer to home or at home. Simplified treatments consisted of various combinations of antibiotics given by intramuscular injections or orally, The idea that newborns with serious infections could be treated as outpatients at home or at community clinics with regimens that include oral antibiotics is a bold, paradigm-shifting hypothesis that the study teams are taking the risk to test through a rigorously designed and implemented randomized controlled trial.

The results of this study could be ground breaking, empowering parents with the opportunity to choose treatment approaches that are provided closer to home while breaking down many of the cultural, social and economic barriers they face, and giving newborns throughout low and middle income countries the chance they need to survive the newborn period. This could result in saving many of the 800,000 newborns that die each year from infections.

I write this blog as I sit in Nigeria with my colleagues to review the initial results of the study in Africa. The ability of the country teams to conduct this complex trial under extremely challenging circumstances is truly inspirational. The study involved the best possible partnership between local organizations, who truly “owned” the conduct of the study and its outcomes, and the WHO, who provided the oversight and the capacity building these organizations needed to grow and be successful. The study also allowed the Bill and Melinda Gates Foundation to step into its “sweet spot” in funding partnerships to create innovative solutions to pressing problems that require taking risks to solve.

I am very hopeful, and look forward to sharing with you our learnings as the data is published over the coming months and we turn our efforts towards disseminating the results and advocating for policy change to give every newborn the chance to receive life-saving treatment for serious infections.

A special series published in this month’s Pediatric Infectious Disease Journal presents several community-based treatment regimens for severe infections, currently being evaluated through multi-partner research trials in South Asian and African countries. The 9-paper supplement details the SATT and AFRINEST trials, describes the studies' methods, the development and rationale of their approach, the standardization and quality control processes across studies, and the global policy implications.

Click here to view and read the supplement.

By Carole Presern on September 23, 2013

The following piece was originally published in the Huffington Post. 

As we look towards our December 2015 deadline to achieve the U.N. Millennium Development Goals (MDGs), there are reasons to celebrate. The number of children dying each year has fallen by almost 50 percent, from over 12 million deaths in 1990 to 6.6 million in 2012. The number of women who die each year from pregnancy or childbirth-related complications also dropped nearly 50 percent in the same time -- from 543,000 in 1990 to 287,000 in 2010.

Good news, to be sure. But such global numbers disguise the fact that almost seven million women and children die each year -- largely from preventable causes and at shockingly high levels in many parts of the world where poverty, conflict and gender disparities remain firmly entrenched. These factors are particularly acute for the most vulnerable, such as newborns, which now account for nearly half of all child deaths (44 percent). Not such good news, in fact.

A new report from The Partnership for Maternal, Newborn & Child Health (PMNCH) --The PMNCH 2013 Report; Analysing Progress on Commitments to the Global Strategy for Women's and Children's Health -- gives cause for hope. The report shows that more organizations, governments and the private sector are making commitments to improve women's and children's health every year, and that those commitments are being followed up with real action.

The Report-- the third such annual report of its kind -- analyzes commitments to the United Nations Secretary-General Ban Ki-moon's Global Strategy for Women's and Children's Health, launched in 2010. The Strategy aims to save 16 million lives in the world's 49 poorest countries by the MDG deadline of 2015 by guiding all of us -- governments, civil society, the U.N. and the private sector -- about the actions that we need to take to save the most number of lives in the most efficient way possible.

Since its launch in 2010, nearly 300 organizations have made tangible, time-bound commitments to address the goals set out in the Strategy. Each of these commitments are published on the Every Woman Every Child website, and are reported on annually through a public report launched each fall by an independent group of experts reporting directly to the U.N. secretary general -- a truly unique platform for accountability in the health and development world.

The PMNCH Report contributes to the work of the Independent Expert Review Group by surveying each of the nearly 300 commitment-makers about the progress they have made in keeping their Global Strategy promises and by mapping the content of those pledges against the goals of the Global Strategy.

So, three years on, have commitment-makers implemented their commitments, and how do those commitments contribute to reaching the goals of the Global Strategy?

There is some promising news in this year's report:

  • Progress towards implementing commitments to the Global Strategy has accelerated substantially and there are now almost 300 commitments made to the Global Strategy to date, including pledges from 70 governments. That is almost triple the 111 commitments made at the launch in 2010.
  • Growth is largely attributed to several new, focused initiatives, such as the Family Planning Summit in 2012, which helped ensure that 40 percent of all new commitments contain family planning content.
  • Commitments that can be expressed in dollars come to as much as $45 billion. Of that, an estimated $25 billion has been disbursed to date -- more than double the total which had been dispersed only one year ago.
  • The Report was also able to identify new funding not previously committed to women's and children's health -- as much as $22 billion, with an estimated $17 billion targeted to the 49 Global Strategy focus countries.

This is all good news for women and children in these countries and is indeed proof of concrete action being taken as a result of the Global Strategy. One example is the strong response which materialized to the high levels of fertility, unmet need for family planning and need to broaden access to contraception due to the FP2020 Summit and initiative.

Now, here is the not so good news:

  • Some key interventions are receiving less attention than others, but are still critical to improving women's and children's health. We need to call on partners and countries to give greater emphasis to these interventions, including postnatal care for mothers and newborns, antibiotics for pneumonia and adequate sanitation facilities.
  • The Report notes that countries with high numbers of maternal and child deaths have received special attention -- and rightly so. However, it points out that countries with very high child and maternal mortality rates, albeit lower numbers of deaths, are also deserving of special consideration.
  • The Report also details health systems shortfalls. Acknowledging that some progress is being made in the realm of human resources, it warns that is not the case for infrastructure development.

Newborn focus

As part of its thematic analysis, the Report draws special attention to the plight of newborns, which now account for almost half of child deaths. With only 25 percent of all commitments directed to newborns, the Report warns that achieving the Global Strategy goals -- to prevent more than three million newborn deaths and treat an additional 2.2 million neonatal infections by 2015 -- will require a much greater effort. Acknowledging that newborn initiatives, such as A Promise Renewed and Born Too Soon, have led to new commitments, the Report warns that this is simply not enough.

We at The Partnership join in the plea for increased resources generally -- with a focus on newborn health -- and put forward the hope that a newly-crafted Global Newborn Action Plan, embedded in the continuum of care, will bring new commitments and resources on a country, regional and global level.

All stakeholders -- countries and development partners -- have a role to play in addressing the gaps in and challenges for implementation. And all have a responsibility to be accountable for their promises -- and to make good on those promises.

There is still much work to be done to achieve the Millennium Development Goals -- and only 799 days to do it.

Download the PMNCH 2013 Report here.

The PMNCH 2013 Report was launched in New York on September 22, 2013 at the Accountability Breakfast with partners: the World Health Organization, the Countdown to 2015 and the Independent Expert Review Group to the Commission of Information and Accountability for Women's and Children's Health.

By Patricia Coffey on September 20, 2013

The following post was originally published on the Huffington Post. 

Cutting the umbilical cord at birth marks a baby's first step toward independence. But in developing countries, that simple act too often creates an entry point for bacteria, leading to a more generalized infection. And that's a very dangerous thing for a newborn.

Almost half of all newborn deaths in developing countries are related to infection.

Now there's a new tool to protect newborns, an antiseptic solution called chlorhexidine that is applied to the cord right after it is cut. As secretariat of the Chlorhexidine Working Group,PATH has worked with other organizations in the group to adapt this decades-old antiseptic into a new formulation for umbilical cord use (7.1 percent chlorhexidine digluconate).

For less than fifty cents a dose, this product could save an estimated 422,000 babies over the next five years.

Our next step is to scale up this proven innovation globally and support its adoption and rollout in the countries where it is needed most. Chlorhexidine has a long shelf life, does not need to be refrigerated, and is very easy to apply to umbilical cords. Very few interventions show this kind of potential for rapidly reducing newborn mortality at such a low cost.

The most recent data show that despite overall declining rates of mortality in children under 5, the proportion of under-5 deaths that occur within the first month of life continues to rise. Expanding access to life-saving solutions like 7.1 percent chlorhexidine digluconate through targeted donor investments and country leadership can help reverse that trend as we work toward achieving the Millennium Development Goals.

Learn more about PATH's work on chlorhexidine here.

This post is part of a series produced by The Huffington Post and the NGO alliance InterAction around the United Nations General Assembly's 68th session and its general debate on the Millennium Development Goals (MDGs), "Post-2015 Development Agenda: Setting the Stage" (September 24-October 2, 2013). The session will feature world leaders discussing progress made on the MDGs and what should replace them when they expire in 2015. To read all the posts in the series, click here; to follow the conversation on Twitter, find the hashtag #No1Behind. For more information about InterAction, click here.

By Areba Panni on September 20, 2013

Bilkis Begum and her baby girl.
Photo: MamMoni Project

This blog was originally published by MCHIP. Written by Areba Panni.

Joskesori Village, Habiganj District—In late summer, 23-year-old Bilkis Begum delivered a baby girl at Shipasha Union Health and Family Welfare Center (UH&FWC) in rural Bangladesh. This birth, the 500th safe delivery at the rural, hard-to-reach facility, is what makes it remarkable; just two years ago, access to 24-hour safe delivery services by skilled birth attendants was non-existent at Shipasha UH&FWC.   

At that time, Bilkis’s first baby, a boy, was born at home and delivered by an untrained traditional birth attendant. However, as members of the community action group in their village, Bilkis and her husband became more aware of the importance of maternal and newborn health services. As a result, Bilkis visited Shibpasha UH&FWC consistently for her antenatal checkups during her second pregnancy, and made up her mind early to have an institutional delivery.

As it turned out, her baby was the 500th newborn to be delivered safely at the facility in Shibpasha, making way for another milestone achieved by the facility. Bilkis is very happy to have delivered under the care of a skilled birth attendant. 

MaMoni is a USAID associate award to the MCHIP Program, implemented by Save the Children and two local nongovernmental organizations, Shimantik and FIVDB.

In 2011, MaMoni, in partnership with KOICA and Save the Children/Korea, initiated the renovation and staffing of two government owned UH&FWCs (at Shibpasha and Kakailseo) to provide high-quality maternal and newborn health and family planning services, and to ensure round the clock normal delivery services. The facility in Shibpasha opened its doors to the community in October 2011 and two more union health facilities (Murakuri and Kakailseo) followed.

The facilities provide safe delivery services around the clock by skilled paramedics who have prior hands-on training experience at the District Hospital and Maternal and Child Welfare Center. Interestingly, the facilities are centered around a network initiated by the MaMoni project that links volunteers and frontline health workers in the community with the wider health system, thus strengthening community engagement, improving service delivery, and enhancing systems strengthening.

In 2013, two more existing facilities in hard to reach unions (Daulatpur and Khagaura) were streamlined by the project for 24/7 delivery services, and another (at Nabiganj Union) is expected to be launched by the end of the year in Habiganj.