Addressing Critical Knowledge Gaps in Newborn Health


By Manisha Nair on September 9, 2014

This blog was written by Dr. Manisha Nair and Dr. Matthews Mathai and discusses their article, Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview. Photo: Prashanth Vishwanathan/ Save the Children

Making health services available to more mothers and children at just over one dollar per person can avert 51% of maternal deaths and 71% of neonatal deaths by 2025 at an estimated cost of US$5•65 billion (US$1•15 per person) . However, these gains can be only achieved if the care provided is of good quality.

Information from 1,951 studies worldwide suggests that there are several common challenges in improving quality of healthcare for mothers and newborns . These include shortage of resources in health facilities, variations in the use of standard care guidelines, and lack of effective mechanism for review and feedback on the care provided. Furthermore, health providers and policy makers often do not pay attention to the perspectives of women, children and their families.

Engaging pregnant women, caregivers and their families in decision making is not a routine process in healthcare provision in most low and middle income countries (LMICs) where there are perceived power differences. Healthcare providers are often equated to ‘God’ and their decisions are carved in stone. “What can an illiterate mother of a 1-month old girl from a poor village know about healthcare?” There is often little effort to engage in active and regular communication with women and their families. Pregnant women are not always treated with respect and dignity, nor do they always receive the desired comfort and support during care provision. These may not culminate in overt protests against the health system, but definitely affect users’ perception about quality of healthcare and these perceptions in turn, affect utilization of services.

In such circumstances, any amount of money spent on improving coverage of health services will not be enough to save the lives of mothers and children. Failure of several LMICs to achieve the Millennium Development Goals (MDGs) 4 and 5 even after increasing coverage of services are perhaps testimony to the lack of strong focus in addressing the barriers to improving quality of healthcare for mothers and children. We are 500 days away from achieving the MDGs, therefore, this is a critical moment for the global community to pause and reflect on the quality of healthcare, before embarking on new policies and programmes. Improving healthcare services should go hand-in-hand with empowering pregnant women, mothers, and carers for decision-making and taking control of their own and their children’s health. Commitment from all stake-holders (politicians, policy makers, healthcare providers, patients, educators, and community members) to improve quality of healthcare services should be an integral part of the new agenda for post-2015.

Click here to download their article.


1. Bhutta ZA, Das JK, Bahl R, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? The Lancet. 2014.
2. Nair M, Yoshida S, Lambrechts T, et al. Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview. BMJ Open. 2014 May 1, 2014;4(5).

By Alexandra Shaphren on September 8, 2014

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Background: Volunteer community health workers (CHWs) form an important element of many health systems, and in Kenya these volunteers are the foundation for promoting behavior change through health education, earlier case identification, and timely referral to trained health care providers. This study examines the effectiveness of a community health worker project conducted in rural Kenya that sought to promote improved knowledge of maternal newborn health and to increase deliveries under skilled attendance.
Methods: The study utilized a quasi-experimental nonequivalent design that examined relevant demographic items and knowledge about maternal and newborn health combined with a comprehensive retrospective birth history of women's children using oral interviews of women who were exposed to health messages delivered by CHWs and those who were not exposed. The project trained CHWs in three geographically distinct areas.
Results: Mean knowledge scores were higher in those women who reported being exposed to the health messages from CHWs, Eburru 32.3 versus 29.2, Kinale 21.8 vs 20.7, Nyakio 26.6 vs 23.8. The number of women delivering under skilled attendance was higher for those mothers who reported exposure to one or more health messages, compared to those who did not. The percentage of facility deliveries for women exposed to health messages by CHWs versus non-exposed was: Eburru 46% versus 19%; Kinale 94% versus 73%: and Nyakio 80% versus 78%.
Conclusion: The delivery of health messages by CHWs increased knowledge of maternal and newborn care among women in the local community and encouraged deliveries under skilled attendance.
*S. Agarwal, A Labrique. Newborn Health on the Line: The Potential mHealth Applications. American Medical Association (July, 2014).
Among the 75 countries with the highest burden of child deaths, 40% of such deaths occur during the neonatal period. Complications arising from preterm birth are now the leading cause of neonatal mortality worldwide. Despite significant survival gains in children younger than 5 years, reductions in newborn deaths continue to lag behind. The rapid proliferation of wireless communication in developing countries has led to the ubiquitous availability and use of mobile phones, even in remote, rural places where public health systems are struggling to gain ground. Does this new reality offer innovative mechanisms through which appropriate care can be delivered during the critical period around childbirth? Research is ongoing across a diverse mHealth space to define the extent to which extending access to information for mothers, improving the targeted delivery of timely care, and replacing inefficient data collection and response systems with real-time accountability can improve the fate of the 7.6 million children younger than 5 years who die each year.
*C. Barbui, M. Purgato. Decisions on WHO’s essential medicines need more scrutiny.  BMJ (July, 2014).
The World Health Organization produced its first essential medicines list in 1977 in response to a request from member states to help them select and procure medicines for priority healthcare needs.1 2 The list included 208 drugs selected on the basis of their efficacy, safety, availability, ease of use in various settings, comparative cost effectiveness, and public health needs.1 It has been updated every two years since by a WHO expert committee.
The list does not include all effective medicines, the latest medicines, or even all medicines needed in a country; rather, it helps define the minimum needs for a basic health system. Essential medicines include, for example, amoxicillin, diazepam, and haloperidol. WHO suggests that essential medicines should be available within functioning health systems at all times, in adequate amounts, in the appropriate doses, with assured quality, and at a price the individual and the community can afford.2
The effect of the essential medicines list has been remarkable. Conceptually, it has led to global acceptance of essential medicines as a powerful means to promote health equity. Countries are not bound by the list, but it has provided a guide for the development of national, provincial, or state lists and helped promote the development of medicine policies and access initiatives.1 However, our review of medicines for mental disorders in the list raises questions about how decisions are made on what is included.
*S. Dalziel, C. Crowther, J. Harding, et al. Antenatal corticosteroids 40 years on: we can do better. The Lancet (August, 2013).
In 1972, Liggins and Howie 1 reported results of their landmark randomised controlled trial of antenatal corticosteroids for the prevention of respiratory distress syndrome associated with preterm birth. That trial provided clear evidence for the drug's efficacy to reduce respiratory distress syndrome and mortality in the 1218 infants enrolled.
Background: Knowledge of the relation between health-system factors and child mortality could help to inform health policy in low-income and middle-income countries. We aimed to quantify modifiable health-system factors and their relation with provincial-level heterogeneity in under-5, infant, and neonatal mortality over time in Mozambique.
Methods: Using Demographic and Health Survey (2003 and 2011) and Multiple Indicator Cluster Survey (2008) data, we generated provincial-level time-series of child mortality in under-5 (ages 0—4 years), infant (younger than 1 year), and neonatal (younger than 1 month) age groups for 2000—10. We built negative binomial mixed models to examine health-system factors associated with changes in child mortality.
Findings: Under-5 mortality rate was heterogeneous across provinces, with yearly decreases ranging from 11·1% (Nampula) to 1·9% (Maputo Province). Heterogeneity was greater for neonatal mortality rate, with only seven of 11 provinces showing significant yearly decreases, ranging from 13·6% (Nampula) to 4·2% (Zambezia). Health workforce density (adjusted rate ratio 0·94, 95% CI 0·90—0·98) and maternal and child health nurse density (0·96, 0·92—0·99) were both associated with reduced under-5 mortality rate, as were institutional birth coverage (0·94, 0·90—0·98) and government financing per head (0·80, 0·65—0·98). Higher population per health facility was associated with increased under-5 mortality rate (1·14, 1·02—1·28). Neonatal mortality rate was most strongly associated with institutional birth attendance, maternal and child nurse density, and overall health workforce density. Infant mortality rate was most strongly associated with institutional birth attendance and population per health facility.
Interpretation: The large decreases in child mortality seen in Mozambique between 2000 and 2010 could have been partly caused by improvements in the public-sector health workforce, institutional birth coverage, and government health financing. Increased attention should be paid to service availability, because population per health facility is increasing across Mozambique and is associated with increased under-5 mortality. Investments in health information systems and new methods to track potentially increasing subnational health disparities are urgently needed.
Funding:  Doris Duke Charitable Foundation and Mozambican National Institute of Health.
Despite having limited training, these TBAs were able to accurately identify critically ill neonates, initiate treatment in the field, and refer for further care. Given their proximity to the mother/infant pair, and their role in rural communities, training and equipping TBAs in this role could be effective in reducing neonatal mortality.
S. Hodgins. Oxytocin: taking the heat. Global Health Science and Practice (August, 2014).
Oxytocin-in-Uniject satisfied the standards of its temperature-time indicator (TTI) in severe home storage conditions, although that required resupply every 30 days—a logistically onerous programmatic standard. Possible advances include: (1) incorporating TTIs with packaged batches of less expensive and more widely used conventional vials of oxytocin; (2) using TTIs calibrated more closely to the actual temperature sensitivity of oxytocin; and (3) researching whether a lower dose of oxytocin would be equally efficacious in preventing postpartum hemorrhage.
M. Mannah, C. Warren, S. Kuria, et al. Opportunities and challenges in implementing community based skilled birth attendance strategy in Kenya. BMC Pregnancy & Childbirth (August, 2014).
Background: Availability of skilled care at birth remains a major problem in most developing countries. In an effort to increase access to skilled birth attendance, the Kenyan government implemented the community midwifery programme in 2005. The aim of this programme was to increase women’s access to skilled care during pregnancy, childbirth and post-partum within their communities.
Methods: Qualitative research involving in-depth interviews with 20 community midwives and six key informants. The key informants were funder, managers, coordinators and supervisors of the programme. Interviews were conducted between June to July, 2011 in two districts in Western and Central provinces of Kenya.
Results: Findings showed major challenges and opportunities in implementing the community midwifery programme. Challenges of the programme were: socio-economic issues, unavailability of logistics, problems of transportation for referrals and insecurity. Participants also identified the advantages of having midwives in the community which were provision of individualised care; living in the same community with clients which made community midwives easily accessible; and flexible payment options.
Conclusions: Although the community midwifery model is a culturally acceptable method to increase skilled birth attendance in Kenya, the use of skilled birth attendance however remains disproportionately lower among poor mothers. Despite several governmental efforts to increase access and coverage of delivery services to the poor, it is clear that the poor may still not access skilled care even with skilled birth attendants residing in the community due to several socio-economic barriers.
Background: Interventions to reduce maternal mortality have focused on delivery in facilities, yet in many low-resource settings rates of facility-based birth have remained persistently low. In Tanzania, rates of facility delivery have remained static for more than 20 years. With an aim to advance research and inform policy changes, this paper builds on a growing body of work that explores dimensions of and responses to disrespectful maternity care and abuse during childbirth in facilities across Morogoro Region, Tanzania.
Methods: This research drew on in-depth interviews with 112 respondents including women who delivered in the preceding 14 months, their male partners, public opinion leaders and community health workers to understand experiences with and responses to abuse during childbirth. All interviews were recorded, transcribed, translated and coded using Atlas.ti. Analysis drew on the principles of Grounded Theory.
Results: When initially describing birth experiences, women portrayed encounters with providers in a neutral or satisfactory light. Upon probing, women recounted events or circumstances that are described as abusive in maternal health literature: feeling ignored or neglected; monetary demands or discriminatory treatment; verbal abuse; and in rare instances physical abuse. Findings were consistent across respondent groups and districts. As a response to abuse, women described acquiescence or non-confrontational strategies: resigning oneself to abuse, returning home, or bypassing certain facilities or providers. Male respondents described more assertive approaches: requesting better care, paying a bribe, lodging a complaint and in one case assaulting a provider.
Conclusions: Many Tanzanian women included in this study experienced unfavorable conditions when delivering in facilities. Providers, women and their families must be made aware of women’s rights to respectful care. Recommendations for further research include investigations of the prevalence and dimensions of disrespectful care and abuse, on mechanisms for women and their families to effectively report and redress such events and on interventions that could mitigate neglect or isolation among delivering women. Respectful care is a critical component to improve maternal health.
H. Merali, S. Lipsitz, N. Hevelone, et al. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy & Childbirth (August, 2014).
Background: Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries.
Methods: We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews.
Results: Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified.
Conclusions: Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.
Multiple Authors. Essential interventions for maternal, newborn and child health. Reproductive Health (August, 2014).
Worldwide, 250,000–280,000 women die during pregnancy and childbirth every year and an estimated 6.55 million children die under the age of five. The majority of maternal deaths occur during or immediately after childbirth, while 43% of child death occurs during the first 28 days of life. However, the progress in limiting these has been slow and sporadic. In this supplement of five papers, we aim to systematically assess and summarize essential interventions for reproductive, maternal, newborn and child health from relevant systematic reviews. This paper is an introductory paper detailing the background and methodology used for grading interventions. The following three papers summarize the evidence on essential interventions for pre-pregnancy, pregnancy, childbirth, postnatal (mother and neonatal) and child heath while the last paper describes the essential interventions as per the level of health care delivery and their proposed packages of care.
The statistics related to pregnancy and its outcomes are staggering: annually, an estimated 250000-280000 women die during childbirth. Unfortunately, a large number of women receive little or no care during or before pregnancy. At a period of critical vulnerability, interventions can be effectively delivered to improve the health of women and their newborns and also to make their pregnancy safe. This paper reviews the interventions that are most effective during preconception and pregnancy period and synergistically improve maternal and neonatal outcomes. Among pre-pregnancy interventions, family planning and advocating pregnancies at appropriate intervals; prevention and management of sexually transmitted infections including HIV; and peri-conceptual folic-acid supplementation have shown significant impact on reducing maternal and neonatal morbidity and mortality. During pregnancy, interventions including antenatal care visit model; iron and folic acid supplementation; tetanus Immunisation; prevention and management of malaria; prevention and management of HIV and PMTCT; calcium for hypertension; anti-Platelet agents (low dose aspirin) for prevention of Pre-eclampsia; anti-hypertensives for treating severe hypertension; management of pregnancy-induced hypertension/eclampsia; external cephalic version for breech presentation at term (>36 weeks); management of preterm, premature rupture of membranes; management of unintended pregnancy; and home visits for women and children across the continuum of care have shown maximum impact on reducing the burden of maternal and newborn morbidity and mortality. All of the interventions summarized in this paper have the potential to improve maternal mortality rates and also contribute to better health care practices during preconception and periconception period.
Childbirth and the postnatal period, spanning from right after birth to the following several weeks, presents a time in which the number of deaths reported still remain alarmingly high. Worldwide, about 800 women die from pregnancy- or childbirth-related complications daily while almost 75% of neonatal deaths occur within the first seven days of delivery and a vast majority of these occur in the first 24 hours. Unfortunately, this alarming trend of mortality persists, as287,000 women lost their lives to pregnancy and childbirth related causes in 2010. Almost all of these deaths were preventable and occurred in low-resource settings, pointing towards dearth of adequate facilities in these parts of the world. The main objective of this paper is to review the evidence based childbirth and post natal interventions which have a beneficial impact on maternal and newborn outcomes. It is a compilation of existing, new and updated interventions designed to help physicians and policy makers and enable them to reduce the burden of maternal and neonatal morbidities and mortalities. Interventions during the post natal period that were found to be associated with a decrease in maternal and neonatal morbidity and mortality included: advice and support of family planning, support and promotion of early initiation and continued breastfeeding; thermal care or kangaroo mother care for preterm and/or low birth weight babies; hygienic care of umbilical cord and skin following delivery, training health personnel in basic neonatal resuscitation; and postnatal visits. Adequate delivery of these interventions is likely to bring an unprecedented decrease in the number of deaths reported during childbirth.
Z. Lassi, D. Mallick, J. Das, et al. Essential interventions for child health.
Child health is a growing concern at the global level, as infectious diseases and preventable conditions claim hundreds of lives of children under the age of five in low-income countries. Approximately 7.6 million children under five years of age died in 2011, calculating to about 19 000 children each day and almost 800 every hour. About 80 percent of the world’s under-five deaths in 2011 occurred in only 25 countries, and about half in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan and China. The implications and burden of such statistics are huge and will have dire consequences if they are not corrected promptly. This paper reviews essential interventions for improving child health, which if implemented properly and according to guidelines have been found to improve child health outcomes, as well as reduce morbidity and mortality rates. It also includes caregivers and delivery strategies for each intervention. Interventions that have been associated with a decrease in mortality and disease rates include exclusive breastfeeding, complementary feeding strategies, routine immunizations and vaccinations for children, preventative zinc supplementation in children, and vitamin A supplementation in vitamin A deficient populations.
In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.
*A. Nove, L. Hulton, A. Martin-Hilber, et al. Establishing a baseline to measure change in political will and the use of data for decision-making in maternal and newborn health in six African countries. International Journal of Gynecology and Obstetrics (July, 2014).
The Evidence for Action (E4A) program assumes that both resource allocation and quality of care can improve via a strategy that combines evidence and advocacy to stimulate accountability. The present paper explains the methods used to collect baseline monitoring data using two tools developed to inform program design in six focus countries. The first tool is designed to understand the extent to which decision-makers have access to the data they need, when they need it, and in meaningful formats, and then to use the data to prioritize, plan, and allocate resources. The second tool seeks the views of people working in the area of maternal and newborn health (MNH) about political will, including: quality of care, the political and financial priority accorded to MNH, and the extent to which MNH decision-makers are accountable to service users. Findings indicate significant potential to improve access to and use of data for decision-making, particularly at subnational levels. Respondents across all six program countries reported lack of access by ordinary citizens to information on the health and MNH budget, and data on MNH outcomes. In all six countries there was a perceived inequity in the distribution of resources and a perception that politicians do not fully understand the priorities of their constituents.
Background: Small for gestational age (SGA) is not only a major indicator of perinatal mortality and morbidity, but also the morbidity risks in later in life. We aim to estimate the association between the birth of SGA infants and the risk factors and adverse perinatal outcomes among twenty-nine countries in Africa, Latin America, the Middle East and Asia in 359 health facilities in 2010–11.
Methods: We analysed facility-based, cross-sectional data from the WHO Multi-country Survey on Maternal and Newborn Health. We constructed multilevel logistic regression models with random effects for facilities and countries to estimate the risk factors for SGA infants using country-specific birthweight reference standards in preterm and term delivery, and SGA’s association with adverse perinatal outcomes. We compared the risks and adverse perinatal outcomes with appropriate for gestational age (AGA) infants categorized by preterm and term delivery.
Results: A total of 295,829 singleton infants delivered were analysed. The overall prevalence of SGA was highest in Cambodia (18.8%), Nepal (17.9%), the Occupied Palestinian Territory (16.1%), and Japan (16.0%), while the lowest was observed in Afghanistan (4.8%), Uganda (6.6%) and Thailand (9.7%). The risk of preterm SGA infants was significantly higher among nulliparous mothers and mothers with chronic hypertension and preeclampsia/eclampsia (aOR: 2.89; 95% CI: 2.55–3.28) compared with AGA infants. Higher risks of term SGA were observed among sociodemographic factors and women with preeclampsia/eclampsia, anaemia and other medical conditions. Multiparity (> = 3) (AOR: 0.88; 95% CI: 0.83–0.92) was a protective factor for term SGA. The risk of perinatal mortality was significantly higher in preterm SGA deliveries in low to high HDI countries.
Conclusion: Preterm SGA is associated with medical conditions related to preeclampsia, but not with sociodemographic status. Term SGA is associated with sociodemographic status and various medical conditions.
S. Saleem, E. McClure, S. Goudar, et al. A prospective study of maternal, fetal and neonatal deaths in low- and middle-income countries. World Health Organization (August, 2014).
Objective: To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.
Methods: A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum.
Findings: Between 2010 and 2012, 214 070 of 220 235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100 000 live births, ranging from 69 per 100 000 in Argentina to 316 per 100 000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97–11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26–5.67) and 7-day (RR: 3.94; 95% CI: 2.74–5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54–9.77).
Conclusion: Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.
*A. Semwanga Rwashana, S.Nakubulwa, M. Nakakeeto-Kijjambu, et al. Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda. Health Research and Policy Systems (August, 2014).
Background: Of the three million newborns that die each year, Uganda ranks fifth highest in neonatal mortality rates, with 43,000 neonatal deaths each year. Despite child survival and safe motherhood programmes towards reducing child mortality, insufficient attention has been given to this critical first month of life. There is urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems. In this paper, we set out to empirically contribute to understanding the causes of the stagnating neonatal mortality by applying a systems thinking approach to explore the dynamics arising from the neonatal health complexity and non-linearity and its interplay with health systems factors, using Uganda as a case study.
Methods: Literature reviews and interviews were conducted in two divisions of Kampala district with high neonatal mortality rates with mothers at antenatal clinics and at home, village health workers, community leaders, healthcare decision and policy makers, and frontline health workers from both public and private health facilities. Data analysis and brainstorming sessions were used to develop causal loop diagrams (CLDs) depicting the causes of neonatal mortality, which were validated by local and international stakeholders.
Results: We developed two CLDs for demand and supply side issues, depicting the range of factors associated with neonatal mortality such as maternal health, level of awareness of maternal and newborn health, and availability and quality of health services, among others. Further, the reinforcing and balancing feedback loops that resulted from this complexity were also examined. The potential high leverage points include special gender considerations to ensure that girls receive essential education, thereby increasing maternal literacy rates, improved socioeconomic status enabling mothers to keep healthy and utilise health services, improved supervision, and internal audits at the health facilities as well as addressing the gaps in resources (human, logistics, and drugs).
Conclusions: Synthesis of theoretical concepts through CLDs facilitated our understanding and interpretation of the interactions and feedback loops that contributed to the stagnant neonatal mortality rates in Uganda, which is the first step towards discussing and exploring the potential strategies and their likely impact.
*C. Thwaites, N. Beeching, C. Newton. Maternal and neonatal tetanus. The Lancet (August, 2014).
Maternal and neonatal tetanus is still a substantial but preventable cause of mortality in many developing countries. Case fatality from these diseases remains high and treatment is limited by scarcity of resources and effective drug treatments. The Maternal and Neonatal Tetanus Elimination Initiative, launched by WHO and its partners, has made substantial progress in eliminating maternal and neonatal tetanus. Sustained emphasis on improvement of vaccination coverage, birth hygiene, and surveillance, with specific approaches in high-risk areas, has meant that the incidence of the disease continues to fall. Despite this progress, an estimated 58 000 neonates and an unknown number of mothers die every year from tetanus. As of June, 2014, 24 countries are still to eliminate the disease. Maintenance of elimination needs ongoing vaccination programmes and improved public health infrastructure.
Background: Skilled care during and immediately after delivery has been identified as one of the key strategies in reducing maternal mortality. However, recent estimates show that the status of skilled care during delivery remained very low in Ethiopia. Birth preparedness and complication readiness has been implemented as comprehensive strategy to fill this gap. However, its effectiveness in improving skilled care use hasn’t been well studied.
Objective: The objective of this study was to determine the effect of birth preparedness and complication readiness on skilled care use in Southwest Ethiopia.
Methods: A prospective follow-up study was conducted from September 2012-April 2013 in Southwest Ethiopia among randomly selected 3472 mothers. Data were collected by using pre-tested interviewer administered questionnaires and analyzed by using SPSS for windows V.20.0 and STATA 13. Mixed-effects multilevel logistic regression model was used to look at the relation between birth preparedness and complication readiness plan and skilled care use and identify other determinant factors.
Results: The status of skilled care use was 17.5% (95% CI: 16.2%, 18.8%). Factors affecting skilled care use existed both at the community as well as individual levels. Planning to use skilled care during pregnancy was found to increase actual use significantly (OR = 2.24; 95%CI: 1.60, 3.15). Place of residence, access to basic emergency obstetric care, maternal education, husband’s occupation, wealth quintiles, number of pregnancy, inter-birth interval, knowledge of key danger signs during labor and ANC use were identified as factors affecting skilled care use.
Conclusions: The status of skilled care use was found to be low in the study area. Birth preparedness and complication readiness had significant effect on skilled care use. Socio-demographic, economic, access to health facility, maternal obstetric factors and antenatal care were identified as determinant factors for skilled care use. Designing appropriate interventions to improve information, education and communication, antenatal care use, family planning and knowledge of key danger signs are recommended.
Background: Despite the global burden of morbidity and mortality associated with preterm birth, little evidence is available for use of antenatal corticosteroids and tocolytic drugs in preterm births in low-income and middle-income countries. We analysed data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess coverage for these interventions in preterm deliveries.
Methods: WHOMCS is a facility-based, cross-sectional survey database of birth outcomes in 359 facilities in 29 countries, with data collected prospectively from May 1, 2010, to Dec 31, 2011. For this analysis, we included deliveries after 22 weeks' gestation and we excluded births that occurred outside a facility or quicker than 3 h after arrival. We calculated use of antenatal corticosteroids in women who gave birth between 26 and 34 weeks' gestation, when antenatal corticosteroids are known to be most beneficial. We also calculated use in women at 22—25 weeks' and 34—36 weeks' gestation. We assessed tocolytic drug use, with and without antenatal corticosteroids, in spontaneous, uncomplicated preterm deliveries at 26—34 weeks' gestation.
Findings: Of 303 842 recorded deliveries after 22 weeks' gestation, 17 705 (6%) were preterm. 3900 (52%) of 7547 women who gave birth at 26—34 weeks' gestation, 94 (19%) of 497 women who gave birth at 22—25 weeks' gestation, and 2276 (24%) of 9661 women who gave birth at 35—36 weeks' gestation received antenatal corticosteroids. Rates of antenatal corticosteroid use varied between countries (median 54%, range 16—91%; IQR 30—68%). Of 4677 women who were potentially eligible for tocolysis drugs, 1276 (27%) were treated with bed rest or hydration and 2248 (48%) received no treatment. β-agonists alone (n=346, 7%) were the most frequently used tocolytic drug. Only 848 (18%) of potentially eligible women received both a tocolytic drug and antenatal corticosteroids.
Interpretation: Use of interventions was generally poor, despite evidence for their benefit for newborn babies. A substantial proportion of antenatal corticosteroid use occurred at gestational ages at which benefit is controversial, and use of less effective or potentially harmful tocolytic drugs was common. Implementation research and contextualised health policies are needed to improve drug availability and increase compliance with best obstetric practice.
Funding: UNDP—UNFPA—UNICEF—WHO—World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.
*M. Yillaa, S. Namb, A. Adeyemo, et al. Using scorecards to achieve facility improvements for maternal and newborn health. International Journal of Gynecology and Obstetrics (July, 2014).
The Government of Sierra Leone launched the Free Health Care Initiative in 2010, which contributed to increased use of facility based maternity services. However, emergency obstetric and neonatal care (EmONC) facilities were few and were inadequately equipped to meet the increased demand. To ensure provision of EmONC in some priority facilities, the Ministry of Health and Sanitation undertook regular facility assessments. With the use of assessment tools and scorecards it is possible to make improvements to the services provided in the period after assessment. The exercise shows that evidence that is shared with providers in visually engaging formats can help decision-making for facility based improvements.
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By Kathryn Millar on September 5, 2014

This blog was originally published by the Maternal Health Task Force. Written by Kathryn Millar

For the first time, the world has international standards for both fetal growth and newborn size. These standards have been developed by a global team led by scientists from Oxford University.

The international standards—one for the growing fetus and the other for newborns—are published today in two papers in The Lancet. They were developed as part of the landmark INTERGROWTH-21st Project, funded by the Bill & Melinda Gates Foundation, which took over 300 clinicians and researchers from 27 institutions across the world six years to complete. To produce the standards, almost 60,000 pregnant women were recruited in eight well-defined urban areas in Brazil, China, India, Italy, Kenya, Oman, the UK and USA. Of these women, over 4,600 healthy, well-nourished women with problem-free pregnancies were studied.

In a previous paper, these researchers declared that growth was not determined by race or ethnicity, but by the health of the mother. Growth can be standard around the world, and now we have a way to measure it.


Identifying Malnourished Newborns

These standards provide growth curves for fetal growth (measured by ultrasound) and for a newborn’s size at birth—including, weight, length and head circumference—according to gestational age. This is a breakthrough. Currently, over 100 differing growth charts are used around the world to assess fetal growth and newborn size. However, these only describe how newborns grow in a particular population, or region, and pose problems for both identifying and treating malnourished newborns. Now, with these new standards, clinicians around the world will be able to detect underweight and overweight newborns early in life.

Why International Standards are Important

Why is accurately measuring growth so important? As of 2010, 27% of births around the world, or 32.4 million babies a year in low- and middle-income countries, are born already undernourished. Poor growth evident by small for gestational age babies has a significant implication on an infant’s start to life—putting them at increased risk of illness and death compared to babies well-nourished at birth. Small birth size also increases a person’s risk of diabetes, high blood pressure, and cardiovascular disease in adulthood. In addition, caring for undernourished newborns puts incredible strain and economic burdens on health systems and societies.

But with these new standards, at least 13 million additional newborns—now considered ‘normal’ based on local charts—will be identified as being undernourished using their international standards globally each year.

“Being able to identify millions of additional undernourished babies at birth provides an opportunity for them to receive nutritional support and targeted treatment, without which close to 5% are likely to die in their first year or develop severe, long-term health problems,” says lead author Professor José Villar of Oxford University. “The huge improvement in health care we can achieve is unprecedented.”

Being born overweight is also a worsening problem, particularly in developed and emerging countries, as a result of rising maternal obesity rates due to overnutrition. Overweight babies are at increased risk of diabetes and high blood pressure later in life.

Reducing Mortality and Morbidities Worldwide

“These new standards for fetal growth and newborn size… are the best ways to compare populations across the globe. We hope their widespread use will contribute to improved birth outcomes and reduced perinatal mortality and morbidity worldwide. When combined with the existing WHO Child Growth Standards, it will be possible globally to make judgements on growth and size from early pregnancy to 5 years of age,’ said Professor Zulfiqar Bhutta, from The Aga Khan University in Karachi, Pakistan, and the Hospital for Sick Children in Toronto, Chair of the INTERGROWTH-21st Project Steering Committee.

Following the same approach as the WHO’s Multicentre Growth Reference, the new fetal and newborn standards will provide health practitioners worldwide with clinical tools to monitor growth from early pregnancy to school.

Next Steps

Now that we have these standards scale up is key. Professor Stephen Kennedy of Oxford University, one of the senior authors of the study, said, “We have produced the first international standards describing how babies in the womb should grow when they are provided with good health care and nutrition, and are living in a healthy environment. We now need to work with politicians and clinicians at regional, national and international levels to introduce the new tools into practice around the world.”

In order to access the complete package of recent publications and tools, follow the links below:

  1. International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal
  2. International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn
  3. The likeness of fetal growth and newborn size across non-isolated populations in the INTERGROWTH-21st Project: the Fetal Growth Longitudinal Study and Newborn Cross-Sectional Study
  4. International standards for early fetal size and pregnancy dating based on ultrasound measurement of crown-rump length in the first trimester


By Resham Khatri on September 4, 2014

Health workers in Nepal learn how to properly wrap a newborn baby at a Save the Children-suppored community-based newborn care training program. Keeping a baby warm is vital in helping them survive after birth. Photo: Sanjana Shrestha/Save the Children

This blog was originally published in Republica. Written by Resham Bahadur Khatri

Controlling Neonatal Death

Nepal has a Millennium Development Goal (MDG) of reducing child mortality by two third from the level of 1990. In the past 20 years, there was an unequal progress in reduction of mortalities among children with 54 percent reduction in under-five mortality rate (U5MR), 55 percent reduction in post-neonatal mortality rate and only 34 percent reduction in neonatal mortality rate (NMR). Between 2000 and 2010, average of reduction of U5MR was 7.6 percent per year compared to NMR of 2.6 percent per year. From 2006 to 2011, the proportion of neonatal mortality in under five and infant mortality rate (IMR) has increased from 42 percent to 61 percent and 63 percent to 72 percent respectively and NMR is stagnant (33/1000 live birth). (See figure aside.) Nepal has one of the highest neonatal mortality rates in the world.

There is an unequal burden of neonatal mortality in Nepal across different sub groups. High neonatal mortality observed in subgroups like mother of no education, poor wealth quintile, ethnic minority like Muslim, mid- and far-west region. Having the prenatal care has two times less likelihood of neonatal death and skilled attendants at birth makes more than two times less chances of neonatal death. Women with no education had two times more likelihood of neonatal mortality than women with higher education. 

Recent study conducted by Child Health Division (CHD) reports that the first one week is the most crucial time for the neonates. About two in five (37 percent) neonatal death occurs in the first day of birth and more than eight in 10 newborn (85 percent) death occurs in the first week of life. Autopsies on causes of neonatal mortality showed that proximate causes of neonatal mortality are neonatal sepsis, birth asphyxia, low birth weight and prematurity related conditions. There is high proportion of stillbirth rate.

The government is doing its part in arresting the trend of neonatal deaths. CHD and Family health division (FHD) have been taking national leadership implementation of newborn health interventions in Nepal. FHD has maternal health program like safe motherhood, Reproductive Health morbidity, and safe abortion while CHD has immunization, nutrition and childhood illness. CHD looks after community based programs and FHD focuses on facility based interventions. External development partners, INGOs, and other concerned stakeholders have been supporting government endeavors through policy, research and technical assistance in newborn health. 

There is significant increase in the access of health services in rural areas of the country after implementation of new health policy in 1991. During mid-1990s, focused child health programs like community-based integrated management of childhood illness (CB-IMCI), bi-annual supplementation of Vitamin A program, expanded program on immunization were implemented in the country and post-neonatal child mortality months reduced remarkably. 

After 2000, newborn health got the high priority and funding was increased. Still, fragmented newborn health interventions from maternal health pose a major challenge for reducing newborn mortality in Nepal. Inclusions of newborn components in maternal health programs were also initiated but newborn health interventions were sidelined by safe motherhood program and got less attention in the program implementation. Nepal has not formulated interventions management of preterm birth. National guideline for management of small and low birth weight babies, absence of national standard treatment guidelines for severely sick newborn have to be developed. It is condemnable that people have to pay from their pockets for newborn care services in referral hospital.

Socio-cultural practices create difficulty to practices in existing postnatal care protocol. Poor infrastructure, inadequate institutional readiness for neonatal resuscitation services, intensive care for the newborn and limited access in critical newborn care services sites are also challenges for the health system.  Health of newborn baby is a part of mother’s health. So, newborn interventions should link newborn health programs with maternal health program. Improving the quality of antenatal care, intra-partum care, and post-natal care could significantly reduce neonatal mortality which needs to be implemented through safe motherhood program approach. Community based service delivery approach for newborn health may not be appropriate to reduce neonatal mortality as cause of death for newborn like birth asphyxia, prematurity and low birth weight demands time sensitive and facility-based services. Low cost and high impact interventions can save lives. Such interventions need to have high effective coverage. 

To reduce neonatal mortality, the government should focus on investment and interventions targeting special care of newborns in rural health facilities. Focused pregnancy care and safe labor and delivery care could help reduce perinatal mortality. Equity gap should be reduced and quality newborn services should be prioritized for improvement. 

The author is MNH Coordinator of Saving Newborn Lives Program, Save the Children, Nepal 

By Sylvia Nabanoba on September 3, 2014
South Sudan, Sudan, Uganda

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

This blog was originally published by the EVERY ONE Campaign. Written by Sylvia Nabanoba.

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.