The Health and Development Foundation launched a new nationwide mHealth program in Russia, IVF/ART School, for clients undergoing assisted reproductive technology treatment January 21 in Moscow at the Federal Kulakov Center for Obstetrics, Gynecology, and Perinatology.
This initiative is aimed at informing and supporting women and their families undergoing infertility treatment through an innovative combination of traditional and mHealth approaches. IVF/ART School will reach its core audience through a multi-tiered approach including offline seminars with reproductive health specialists at clinics; social networks, a program site, and regular webinars online; and text messages to participants' mobile phones. This comprehensive approach will enable us to maintain a strong connection with our target audience, each component informing and reinforcing program messages, and provide them with multiple chances for interaction with peers and experts.
HDF developed the program through collaboration with the Kulakov Center, the Russian Ministry of Health, and the Russian Association of Human Reproduction, a professional organization of reproductive technology specialists. The program received financial support from MSD Pharmaceuticals.
IVF/ART School is the second national reproductive health program implemented by HDF to use mobile technology and eHealth resources; in February 2012, the foundation launched Text4baby Russia.
Text4baby Russia, adapted from the successful U.S. program text4baby, provides new and expectant mothers with information on caring for their own health and the health of their children through free text messages to their mobile phones. Women can also take part in free interactive webinars with experts to get more in-depth information on program topics like nutrition, breastfeeding, smoking cessation, legal rights, developmental milestones, and more.
These free programs are designed to work well together, as women who have undergone successful IVF/ART treatments can then become subscribers to Text4baby Russia, and continue to receive useful, expert support and information throughout their pregnancy and the first year of their babies’ lives.
Photo: Jeff Holt/Save the Children
Rohima Begum, 35 (centre) with health clinic and water ambulance paramedics Shapna Islam, 24 (front) and Shaheba Aktar, 40 (behind) next to the water ambulance in Kakailseo Union, Ajmiriganj Upazila, Bangladesh. Rohima came to the clinic with complications of preclampsia and was transported from the clinic to a hospital in Ajmiriganj town and then on to a hospital in Baniachong, where she gave birth to twin girls, Shrishti and Mukta.
*Journal subscription required for full access
Each year, more than 1 in 10 of the world’s babies are born preterm, resulting in 15 million babies born too soon. World Prematurity Day, November 17, is a global effort to raise awareness about prematurity. This past year, there has been increased awareness of the problem, through new data and evidence, global partnership and country champions. Actions to improve care would save hundreds of thousands of babies born too soon from death and disability. Accelerated prevention requires urgent research breakthroughs.
*Thairu, L., Wirth, M. and Lunze, K. Innovative newborn health technology for resource-limited environments. Tropical Medicine & International Health, 18: 117–128. doi: 10.1111/tmi.12021 (January, 2013)
Objectives: To review medical devices addressing newborn health in resource-poor settings, and to identify existing and potential barriers to their actual and efficient use in these settings.Methods: We searched Pubmed as our principal electronic reference library and dedicated databases such as Maternova and the Maternal and Neonatal Directed Assessment of Technology. We also researched standard public search engines. Studies and grey literature reports describing devices for use in a low- or middle-income country context were eligible for inclusion.Results: Few devices are currently described in the peer-reviewed medical or public health literature. The majority of newborn-specific devices were found in the grey literature. Most sources described infant warmers, neonatal resuscitators, and phototherapy devices. Other devices address the diagnosis of infectious diseases, monitoring of oxygen saturation, assisted ventilation, prevention of mother-to-child transmission of HIV, assisted childbirth, weight or temperature assessment, and others.Conclusion: Many medical devices designed for newborns in the developing world are under development or in the early stages of production, but the vast majority of them are not available when and where they are needed. Making them available to mothers, newborns, and birth attendants in resource-limited countries at the time and place of birth will require innovative and creative production, distribution, and implementation approaches.
Gabrysch S, Civitelli G, Edmond KM, et al. New Signal Functions to Measure the Ability of Health Facilities to Provide Routine and Emergency Newborn Care. PLoS Med 9(11): e1001340. doi:10.1371/journal.pmed.1001340 (November, 2012)
Emergency obstetric care (EmOC) signal functions, reflecting health facilities' capacity to respond to important obstetric complications, are widely used to construct indicators of service provision. However, no signal functions are agreed for emergency newborn care (EmNC), except newborn resuscitation, or for routine non-emergency care for mothers and newborns. Current large-scale facility survey efforts mainly collect data on the established EmOC functions, and two EmNC functions (newborn resuscitation and prevention of mother to child transmission of HIV). Routine maternal or newborn care data are not regularly included. We propose maternal and newborn signal functions, focussing on delivery and postnatal care, that could be used to characterize both routine and emergency care in health facilities.
Background: Globally, approximately 3 million babies die annually within their first month. Access to adequate care at birth is needed to reduce newborn as well as maternal deaths. We explore the influence of distance to delivery care and of level of care on early neonatal mortality in rural Zambia and Malawi, the influence of distance (and level of care) on facility delivery, and the influence of facility delivery on early neonatal mortality. Methods and Findings: National Health Facility Censuses were used to classify the level of obstetric care for 1131 Zambian and 446 Malawian delivery facilities. Straight-line distances to facilities were calculated for 3771 newborns in the 2007 Zambia DHS and 8842 newborns in the 2004 Malawi DHS. There was no association between distance to care and early neonatal mortality in Malawi (OR 0.97, 95%CI 0.58–1.60), while in Zambia, further distance (per 10 km) was associated with lower mortality (OR 0.55, 95%CI 0.35–0.87). The level of care provided in the closest facility showed no association with early neonatal mortality in either Malawi (OR 1.02, 95%CI 0.90–1.16) or Zambia (OR 1.02, 95%CI 0.82–1.26). In both countries, distance to care was strongly associated with facility use for delivery (Malawi: OR 0.35 per 10km, 95%CI 0.26–0.46). All results are adjusted for available confounders. Early neonatal mortality did not differ by frequency of facility delivery in the community. Conclusions: While better geographic access and higher level of care were associated with more frequent facility delivery, there was no association with lower early neonatal mortality. This could be due to low quality of care for newborns at health facilities, but differential underreporting of early neonatal deaths in the DHS is an alternative explanation. Improved data sources are needed to monitor progress in the provision of obstetric and newborn care and its impact on mortality.
*Sudhof, L., Amoroso C, et al. "Local use of geographic information systems to improve data utilisation and health services: mapping caesarean section coverage in rural Rwanda." Tropical Medicine & International Health 18(1): 18-26. (December, 2012)
Objectives: To show the utility of combining routinely collected data with geographic location using a Geographic Information System (GIS) in order to facilitate a data-driven approach to identifying potential gaps in access to emergency obstetric care within a rural Rwandan health district. Methods: Total expected births in 2009 at sub-district levels were estimated using community health worker collected population data. Clinical data were extracted from birth registries at eight health centres (HCs) and the district hospital (DH). C-section rates as a proportion of total expected births were mapped by cell. Peri-partum foetal mortality rates per facility-based births, as well as the rate of uterine rupture as an indication for C-section, were compared between areas of low and high C-section rates. Results: The lowest C-section rates were found in the more remote part of the hospital catchment area. The sector with significantly lower C-section rates had significantly higher facility-based peri-partum foetal mortality and incidence of uterine rupture than the sector with the highest C-section rates (P < 0.034). Conclusions: This simple approach for geographic monitoring and evaluation leveraging existing health service and GIS data facilitated evidence-based decision making and represents a feasible approach to further strengthen local data-driven decisions for resource allocation and quality improvement.
Objective: To assess the utilization of antenatal care (ANC) services among currently married women in Rajasthan. Methods: The data have been extracted from District Level Household and Facility Survey (DLHS-3) which was conducted during 2007-2008, all over India. A total of 12 458 currently married women in the age group of 15-49 were taken as the sample for the study. Cross tabulation and binary logistic regression method were applied to determine the factors influencing ANC. Results: Out of 12 458 respondents, 43.4 percent women not received even a single ANC during their pregnancy period. 45.1 percent of the women not received tetanus toxoid injection and 13.0 percent of the women not received Iron folic acid tablets during their pregnancy period. Only 6.6 percent of women fulfilled the minimum recommendation with regard ANC services. Conclusions: The study points to the avenues through which policy makers can formulate and implement policies on a realistic basis by identifying critical variables and target groups for effective utilisation of ANC.
Background: Unsafe abortion imposes heavy burdens on both individuals and society, particularly in low-income countries, many of which have restrictive abortion laws. Providing family planning counseling and services to women following an abortion has emerged as a key strategy to address this issue. Study Design: This systematic review gathered, appraised and synthesized recent research evidence on the effects of postabortion family planning counseling and services on women in low-income countries. Results: Of the 2965 potentially relevant records that were identified and screened, 15 studies satisfied the inclusion criteria. None provided evidence on the effectiveness of postabortion family planning counseling and services on maternal morbidity and mortality. One controlled study found that, compared to the group of nonbeneficiaries, women who received postabortion family planning counseling and services had significantly fewer unplanned pregnancies and fewer repeat abortions during the 12-month follow-up period. All 15 studies examined contraception-related outcomes. In the seven studies which used a comparative design, there was greater acceptance and/or use of modern contraceptives in women who had received postabortion family planning counseling and services relative to the no-program group. Conclusions: The current evidence on the use of postabortion family planning counseling and services in low-income countries to address the problem of unsafe abortion is inconclusive. Nevertheless, the increase in acceptance and/or use of contraceptives is encouraging and has the potential to be further explored. Adequate funding to support robust research in this area of reproductive health is urgently needed.
Objective: maternal mortality represents the single greatest health disparity between high and low income countries. This inequity is especially felt in low income countries in sub Saharan Africa and Southeast Asia where 99% of the global burden of maternal death is borne. A goal of MDG 5 is to reduce maternal mortality and have a skilled attendant at every birth by 2015. A critical skill is ongoing intrapartum monitoring of labour progress and maternal/fetal well-being. The WHO partograph was designed to assess these parameters. Design and setting: a retrospective review of charts (n=1,845) retrieved consecutively over a 2 month period in a tertiary teaching hospital in Ghana was conducted to assess the adequacy of partograph use by skilled birth attendants and the timeliness of action taken if the action line was crossed. WHO guidelines were implemented to assess the adequacy of partograph use and how this affected maternal neonatal outcomes. Further, the timeliness and type of action taken if action line was crossed was assessed. Findings: partographs were adequately completed in accordance with WHO guidelines only 25.6% (472) of the time and some data appeared to be entered retrospectively. Partograph use was associated with less maternal blood loss and neonatal injuries. When the action line was crossed (464), timely action was taken only 48.7% of the time and was associated with less assisted delivery and a fewer low Apgar scores and NICU admissions. Conclusion: when adequately used and timely interventions taken, the partograph was an effective tool. Feasibility of partograph use requires more scrutiny; particularly identification of minimum frequency for safe monitoring and key variables as well as a better understanding of why skilled attendants have not consistently ‘bought in’ to partograph use. Frontline workers need access to ongoing and current education and strategically placed algorhythims.
*Kizler, R, Hollins Martin, C. J. "Could introducing vacuum delivery into the education curriculum of community midwives in Yemen improve maternal and neonatal mortality and morbidity outcomes?" Nurse Education in Practice. (November, 2012)
At present in Yemen the neonatal mortality rate stands at 12%. A contributing factor is that when abnormalities arise during labour in rural areas, there is an absence of trained medical staff to manage complications. Consequently, childbearing women are expected to travel long distances to hospitals to receive Essential Obstetric Care (EOC). This paper presents a debate over whether vacuum delivery should be introduced into the education curriculum of community midwifery courses in Yemen. It is proposed that this fundamental change to both the educational system and the community midwives role could facilitate a reduction in maternal and neonatal mortality and morbidity figures in Yemen.
*Kapungu, C. T., J. Mensah-Homiah, et al. "A community-based continuum of care model for the prevention of postpartum hemorrhage in rural Ghana." International Journal of Gynecology & Obstetrics. (November, 2012)
Objective: To report on Phase 1 of an operations research study designed to reduce postpartum hemorrhage (PPH)-related morbidity and mortality in rural Ghana. Methods: Phase 1 of the study—which included a needs assessment, community sensitization, implementation of blood collection drapes, training of service providers, and baseline data collection—comprised preliminary work to prepare for misoprostol distribution in Phase 2. Seventy-four primary healthcare providers were trained on safe-motherhood practices, use of blood collection drapes, and data collection. Baseline data were collected from 275 women regarding home deliveries, who attended the deliveries, incidence of PPH, and use of blood collection drapes. Results: Blood collection drapes were used at 67.6% of deliveries, increasing to 88.5% over the final 6 months of Phase 1. Community health extension workers (CHEWs) were present at 57.1% of all deliveries but attendance increased to 86.9% during the last 6 months of Phase 1. Overall, 96.0% of deliveries resulted in healthy outcomes for the mother; 4.0% of births had complications. Conclusion: The preliminary work conducted in Phase 1 of the study was crucial in guiding misoprostol distribution in Phase 2. However, challenges existed, including inadequate community sensitization, low home-birth attendance by CHEWs, and data collection problems.
Objective: to assess the level, type and content of pre-service education curricula of health workers providing maternity services against the ICM global standards for Midwifery Education and Essential competencies for midwifery practice. We reviewed the quality and relevance of pre-service education curricula of four cadres of health-care providers of maternity care in Northern Nigeria. Design and setting: we adapted and used the ICM global standards for Midwifery Education and Essential competencies for midwifery practice to design a framework of criteria against which we assessed curricula for pre-service training. We reviewed the pre-service curricula for Nurses, Midwives, Community Health Extension Workers (CHEW) and Junior Community Health Extension Workers (JCHEW) in three states. Criteria against which the curricula were evaluated include: minimum entry requirement, the length of the programme, theory: practice ratio, curriculum model, minimum number of births conducted during training, clinical experience, competencies, maximum number of students allowable and proportion of Maternal, Newborn and Child Health components (MNCH) as part of the total curriculum. Findings: four pre-service education programmes were reviewed; the 3 year basic midwifery, 3 year basic nursing, 3 year Community Health Extension Worker (CHEW) and 2 year Junior Community Health Extension Worker (JCHEW) programme. Findings showed that, none of these four training curricula met all the standards. The basic midwifery curriculum most closely met the standards and competencies set out. The nursing curriculum showed a strong focus on foundations of nursing practice, theories of nursing, public health and maternal newborn and child health. This includes well-defined modules on family health which are undertaken from the first year to the third year of the programme. The CHEW and JCHEW curricula are currently inadequate with regard to training health-care workers to be skilled birth attendants. Key conclusions: although the midwifery curriculum most closely reflects the ICM global standards for Midwifery Education and Essential competencies for midwifery practice, a revision of the competencies and content is required especially as it relates to the first year of training. There is an urgent need to modify the JCHEW and CHEW curricula by increasing the content and clinical hands-on experience of MNCH components of the curricula. Without effecting these changes, it is doubtful that graduates of the CHEW and JCHEW programmes have the requisite competencies needed to function adequately as skilled birth attendants in Health Centres, PHCs and MCHs, without direct supervision of a midwife or medical doctor with midwifery skills.
Background: The maternal mortality ratio in Sub-Saharan Africa remains high, despite progress in reducing maternal mortality in other parts of the world. Objective: To explore the perceptions of women and communities to identify barriers to the uptake of obstetric services. Search strategy: A systematic review of qualitative studies exploring perceptions of pregnancy and obstetric services, with thematic synthesis of the included studies. Selection criteria: Qualitative studies reporting findings from focus group discussions and in-depth interviews between 1996 and 2009 were included. Data collection and analysis: Thematic synthesis involved collating and reviewing quotations taken directly from included studies. Themes were generated and clustered for analysis. Main results: Twenty-seven studies were included and 6 major themes identified: perceptions of healthcare workers; perceptions of the hospital environment; cultural perceptions of women; cultural perceptions of pregnancy; perceptions of traditional birth attendants and traditional healers; and role of the community in pregnancy and birth. Conclusion: Community attitudes regarding cultural beliefs and interactions with healthcare providers were identified as barriers to the utilization of healthcare services during pregnancy in Sub-Saharan Africa. These prevent engagement with prenatal care and timely use of medical services. Addressing the barriers will be seminal to the success of any healthcare intervention.
*Al Serouri, A. W., A. Al Rukeimi, et al. "Findings from a needs assessment of public sector emergency obstetric and neonatal care in four governorates in Yemen: a human resources crisis." Reproductive Health Matters 20(40): 122-128. (2012)
Recent reviews suggest that it is unlikely Yemen will reach Millennium Development Goal 5 on maternal health by 2015. We conducted a needs assessment in 2010 to identify the human resources constraints in delivery of emergency obstetric and neonatal care (EmONC), in one urban and three under-served rural governorates. The assessment tools were adapted from the UN Guidelines for Monitoring Availability and Use of EmONC. Findings showed that while the urban governorate (total population 666,210 with 26,648 expectant mothers yearly) had 54 obstetricians, 10 anaesthetists and 72 paediatricians, the three rural governorates (total population 1,885,371 with 75,414 expectant mothers yearly) together had only three obstetricians, three anaesthetists, and eight paediatricians. Furthermore, in the rural governorates, with an 0.5% caesarean section rate, which is far below the 5% minimum for this UN indicator, no district hospital had an operating surgeon or an anaesthetist. There was also a marked scarcity of female general physicians and a large disparity in the proportion of births with a skilled attendant between the rural (12%) and urban (34%) governorates. Findings emphasize the need for increasing the coverage of EmONC nationally, but especially in rural areas, through more equitable staff distribution and promotion of task shifting. Developing a national human resources plan and ensuring an enabling policy are prerequisites.
*Raza, A.S., Avan, B.I. “Disposable clean delivery kits and prevention of neonatal tetanus in the presence of skilled birth attendants.” International Journal of Gynecology & Obstetrics 10.1016/j.ijgo.2012.07.030. (2012).
Objective: To determine whether the use of disposable clean delivery kits (CDKs) is effective in reducing neonatal tetanus (NNT) infection, regardless of the skills of birth attendants in resource-poor settings. Methods: A secondary analysis was conducted on data from a matched case–control study in Karachi, Pakistan, involving 140 NNT cases and 280 controls between 1998 and 2001. Conditional logistic regression was performed to assess the independent effect on NNT of CDKs and skilled birth attendants (SBAs). Results: After adjustment for socioeconomic factors, both CDKs (adjusted matched odds ratio [mOR] 2.0; 95% confidence interval [CI], 1.3–3.1) and SBAs (adjusted mOR 1.7; 95% CI, 1.1–2.7) were independently associated with NNT. The association with CDKs remained significant when additionally adjusted for SBAs (mOR 2.0; 95% CI, 1.0–3.9; P = 0.05). The population attributable risk for lack of CDK use was 24% in the study setting. Conclusion: In the context of resource-poor settings in low-income countries with poor coverage of tetanus toxoid immunization, the use of CDKs seems to be an effective strategy for reducing NNT infection, irrespective of the skill levels of birth attendants. Approximately one-quarter of NNT cases could be prevented in low-income populations with the use of CDKs.
Medema-Wijnveen JS, Onono M, Bukusi EA, et al. How Perceptions of HIV-Related Stigma Affect Decision-Making Regarding Childbirth in Rural Kenya. PLoS ONE 7(12): e51492. doi:10.1371/journal.pone.0051492 (December, 2012)
Introduction HIV prevalence among pregnant women in Kenya is high. Furthermore, there is a high risk of maternal mortality, as many women do not give birth with a skilled healthcare provider. Previous research suggests that fears of HIV testing and unwanted disclosure of HIV status may be important barriers to utilizing maternity services. We explored relationships between women’s perceptions of HIV-related stigma and their attitudes and intentions regarding facility-based childbirth. Methods 1,777 pregnant women were interviewed at their first antenatal care visit. We included socio-demographic characteristics, stigma scales, HIV knowledge measures, and an 11-item scale measuring health facility birth attitudes (HFBA). HFBA includes items on cost, transport, comfort, interpersonal relations, and services during delivery at a health facility versus at home. A higher mean HFBA score indicates a more positive attitude towards facility-based childbirth. The mean HFBA score was dichotomized at the median and analyses were conducted with this dichotomized HFBA score using mixed effects logic models. Results Women who anticipated HIV-related stigma from their male partner had lower adjusted odds of having positive attitudes about giving birth at the health facility (adjusted OR = .63, 95% CI 0.50–0.78) and less positive attitudes about health facility birth were strongly related to women’s intention to give birth outside a health facility (adjusted OR = 5.56, 95% CI 2.69–11.51). Conclusions In this sample of pregnant women in rural Kenya, those who anticipated HIV-related stigma were less likely to have positive attitudes towards facility-based childbirth. Furthermore, negative attitudes about facility-based childbirth were associated with the intention to deliver outside a health facility. Thus, HIV-related stigma reduction efforts might result in more positive attitudes towards facility-based childbirth, and thereby lead to an increased level of skilled birth attendance, and reductions in maternal and infant mortality.
* Coffey P S, Sharma J, Gargi K C, et al.“Feasibility and acceptability of gentamicin in the Uniject prefilled injection system for community-based treatment of possible neonatal sepsis: the experience of female community health volunteers in Nepal” Journal of Perinatology 32, 959-965 doi:10.1038/jp.2012.20. (December, 2012)
Objective: Explore feasibility and acceptability of gentamicin in the Uniject prefilled injection system, in combination with oral cotrimoxazole-p and an appropriate newborn weighing scale, for treatment of possible neonatal sepsis when administered in the community by female community health volunteers.Study Design: In a community-based program in Nepal, 45 volunteers recorded 422 live births. Among these, 82 infants were identified as having possible severe bacterial infection. In all, 67 of these infants were treated with gentamicin in Uniject and 15 were referred to the health facility. Mixed methods were used to collect data about Uniject performance, acceptability and safety.Result: Volunteers successfully treated 67 infants with gentamicin in Uniject. Gentamicin in Uniject performed well and was acceptable.Conclusion: Gentamicin in Uniject, in combination with cotrimoxazole-p and an appropriate newborn weighing scale, is a feasible and acceptable option for treatment of possible neonatal sepsis in the community by female community health volunteers.
Uganda's Ministry of Health, together with partners, has introduced integrated community case management (iCCM) for children under 5 years. We assessed how the iCCM program addresses newborn care in three midwestern districts through document reviews, structured interviews, and focus group discussions with village health team (VHT) members trained in iCCM, caregivers, and other stakeholders. Almost all VHT members reported that they refer sick newborns to facilities and could identify at least three newborn danger signs. However, they did not identify the most important clinical indicators of severe illness. The extent of compliance with newborn referral and quality of care for newborns at facilities is not clear. Overall iCCM is perceived as beneficial, but caregivers, VHTs, and health workers want to do more for sick babies at facilities and in communities. Additional research is needed to assess the ability of VHTs to identify newborn danger signs, referral compliance, and quality of newborn treatment at facilities. Disclaimer: The opinions expressed are the opinions of the authors and do not necessarily reflect the views of The Bill & Melinda Gates Foundation
Waiswa P, Peterson SS, Namazzi G; et al. The Uganda Newborn Study (UNEST): an effectiveness study on improving newborn health and survival in rural Uganda through a community-based intervention linked to health facilities - study protocol for a cluster randomized controlled trial. NCBI and Makerere University School of Public Health (November, 2012)
BACKGROUND: Reducing neonatal-related deaths is one of the major bottlenecks to achieving Millennium Development Goal 4. Studies in Asia and South America have shown that neonatal mortality can be reduced through community-based interventions, but these have not been adapted to scalable intervention packages for sub-Saharan Africa where the culture, health system and policy environment is different. In Uganda, health outcomes are poor for both mothers and newborn babies. Policy opportunities for neonatal health include the new national Health Sector Strategic Plan, which now prioritizes newborn health including use of a community model through Village Health Teams (VHT). The aim of the present study is to adapt, develop and cost an integrated maternal-newborn care package that links community and facility care, and to evaluate its effect on maternal and neonatal practices in order to inform policy and scale-up in Uganda. METHODS: Through formative research around evidence-based practices, and dialogue with policy and technical advisers, we constructed a home-based neonatal care package implemented by the responsible VHT member, effectively a Community Health Worker (CHW). This CHW was trained to identify pregnant women and make five home visits - two before and three just after birth - so that linkages will be made to facility care and targeted messages for home-care and care-seeking delivered. The project is improving care in health units to provide standardized care for the mother and the newborn in both intervention and comparison areas.The study is taking place in a new Demographic Surveillance Site in two rural districts, Iganga and Mayuge, in Uganda. It is a two-arm cluster randomized controlled design with 31 intervention and 32 control areas (villages). The comparison parishes receive the standard care already being provided by the district, but to the intervention villages are added a system for CHWs to visit the mother five times in her home during pregnancy and the neonatal period. Both areas benefit from a standardized strengthening of facility care for mothers and neonates. DISCUSSION: UNEST is designed to directly feed into the operationalization of maternal and newborn care in the national VHT strategy, thereby helping to inform scale-up in rural Uganda. The study is registered as a randomized controlled trial, number ISRCTN50321130.
Tetui M, Ekirapa EK, Bua J; et al. Quality of Antenatal care services in eastern Uganda: implications for interventions. Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.(October, 2012)
INTRODUCTION: More efforts need to be directed to improving the quality of maternal health in developing countries if we are to keep on track with meeting the fifth millennium development goal. The World Health Organization says developing countries account for over 90% of maternal deaths of which three fifths occur in Sub-Saharan African countries like Uganda. Abortion, obstetric complications such as hemorrhage, dystocia, eclampsia, and sepsis are major causes of maternal deaths here. Good quality Antenatal Care (ANC) provides opportunity to detect and respond to risky maternal conditions. This study assessed quality of ANC services in eastern Uganda with a goal of benchmarking implications for interventions. METHODS: Data was collected from 15 health facilities in Eastern Uganda to establish capacity of delivering ANC services. Observation checklists were used to assess structural components and completeness of the ANC consultation process among 291 women attending it. Lastly, structured exit-interviews were conducted to assess satisfaction of patients. Data analysis was done in STATA Version 10. RESULTS: There was an overall staffing gap of over 40%, while infection control facilities, drugs and supplies were inadequate. However, there was good existence of physical infrastructure and diagnostic equipment for ANC services. It was observed that counseling for risk factors and birth preparedness was poorly done; in addition essential tests were not done for the majority of clients. CONCLUSION: To improve the quality of ANC, interventions need to improve staffing, infection control facilities and drug-supplies. In addition to better counseling for risk factor-recognition and birth preparedness.
Tomlinson M, Doherty T, Jackson D, Lawn JE; et al. An effectiveness study of an integrated, community-based package for maternal, newborn, child and HIV care in South Africa: study protocol for a randomized controlled trial. Department of Psychology, Stellenbosch University, Stellenbosch, Matieland, South Africa. (November, 2012)
Progress towards MDG4 in South Africa will depend largely on scaling up effective prevention against mother to child transmission (PMTCT) of HIV and also addressing neonatal mortality. This imperative drives increasing focus on the neonatal period and particularly on the development and testing of appropriate models of sustainable, community-based care in South Africa in order to reach the poor. A number of key implementation gaps affecting progress have been identified. Implementation gaps for HIV prevention in neonates; implementation gaps for neonatal care especially home postnatal care; and implementation gaps for maternal mental health support. We have developed and are evaluating and costing an integrated and scaleable home visit package delivered by community health workers targeting pregnant and postnatal women and their newborns to provide essential maternal/newborn care as well as interventions for Prevention of Mother to Child Transmission (PMTCT) of HIV. METHODS: The trial is a cluster randomized controlled trial that is being implemented in Umlazi which is a peri-urban settlement with a total population of 1 million close to Durban in KwaZulu Natal, South Africa. The trial consists of 30 randomized clusters (15 in each arm). A baseline survey established the homogeneity of clusters and neither stratification nor matching was performed. Sample size was based on increasing HIV-free survival from 74% to 84%, and calculated to be 120 pregnant women per cluster. Primary outcomes are higher levels of HIV free survival and levels of exclusive and appropriate infant feeding at 12 weeks postnatally. The intervention is home based with community health workers delivering two antenatal visits, a postnatal visit within 48 hours of birth, and a further four visits during the first two months of the infants life. We are undertaking programmatic and cost effectiveness analysis to cost the intervention. DISCUSSION: The question is not merely to develop an efficacious package but also to identify and test delivery strategies that enable scaling up, which requires effectiveness studies in a health systems context, adapting and testing Asian community-based studies in various African contexts.
*Ijumba P, Doherty T, Jackson Dl et al. Social circumstances that drive early introduction of formula milk: an exploratory qualitative study in a peri-urban South African community. Health Systems Research Unit, Medical Research Council, Durban, South Africa; International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala, Sweden. (December, 2012)
Breastfeeding is widely endorsed as the optimal strategy for feeding newborns and young infants, as well as improving child survival and achieving Millennium Development Goal 4. Exclusive breastfeeding (EBF) for the first 6 months of life is rarely practised in South Africa. Following the 2010 World Health Organization (WHO) infant feeding recommendations (EBF for HIV-positive mothers with maternal or infant antiretroviral treatment), South Africa adopted breastfeeding promotion as a National Infant Feeding Strategy and removed free formula milk from the Prevention of Mother-to-Child Transmission of HIV programme. This study aimed to explore the perceptions of mothers and household members at community level regarding the value they placed on formula feeding and circumstances that drive the practice in a peri-urban community. We conducted in-depth interviews with HIV-positive and HIV-negative mothers in a community-randomised trial (Good Start III). Focus group discussions were held with grandmothers, fathers and teenage mothers. Data were analysed using thematic analysis. The following themes were identified; inadequate involvement of teenage mothers; grandmothers who become replacement mothers; fear of failing to practise EBF for 6 months; partners as formula providers and costly formula milk leading to risky feeding practices. The new South African Infant Feeding Strategy needs to address the gaps in key health messages and develop community-orientated programmes with a focus on teenage mothers. These should encourage the involvement of grandmothers and fathers in decision-making about infant feeding so that they can support EBF for optimal child survival.
Photo: Techiman Hospital in Ghana
Signal functions are a representative shortlist of key interventions and activities that address major causes of morbidity or mortality and that are indicative of a certain type and level of care. For instance, signal functions indicative of "basic emergency obstetric care (EmOC)" could be provided by midwives at the level of a health centre, while "comprehensive EmOC" signal functions indicate a higher level of care, usually at a hospital.
Signal functions for EmOC already exist and are widely used, however no signal functions for emergency newborn care (EmNC) have been defined (except resuscitation). Neither are there agreed signal functions for routine care at health facilities for either mother or newborn (i.e.care for all women and babies, as opposed to emergency care for complications).
Current large-scale facility survey efforts mainly collect data on the established EmOC functions, and two EmNC functions (newborn resuscitation and prevention of mother-to-child transmission of HIV). Routine maternal or newborn care data are not regularly included.
This article contributes a proposed set of 23 maternal and newborn signal functions, focussing on delivery and postnatal care, that could be used to characterize both routine and emergency care in health facilities in low-income settings. The selection was based on literature review and expert opinion. Many thanks to all of you who answered our online survey posted here in March!
Collecting the relevant data and promoting its use in a variety of ways should contribute to monitoring and improving the quality of maternal and newborn care, helping to meet MDGs 4 and 5. In a few years time, when sufficient experience has been gained in different settings, it may be appropriate to revisit both EmOC and EmNC and routine functions and provide more authoritative guidance and benchmarks.
- New Signal Functions to Measure the Ability of Health Facilities to Provide Routine and Emergency Newborn Care
- NEW: Healthy Newborn Network Neborn Indicators page
After I finished my Pediatrics Residency at University of Colorado, I decided to take time off before doing a Neonatal-Perinatal Fellowship to challenge myself by working in a low-resource setting. I found myself in rural Ecuador: I flew from Denver to Quito, boarded a small domestic flight from Quito to Loja, where I was met by a driver who expertly avoided every pot hole on the four hour journey on unpaved roads to La Clinica Nuestra Senora de Guadalupe. Despite my love for ventilators, procedures, and complicated physiology that made me want to be a neonatologist, my time working in rural Ecuador made me recognize that being a neonatologist also means being concerned about newborns that do not have access to these same technologies. In fact, I learned that the majority of newborns that die around the world do so in low-resource settings, where often they die at home without coming to the attention of a medical provider.
In Ecuador, despite the care of pregnant women and children < 5 years being free in the hospitals, I was still asked to attend the delivery of a patient in her home, even after seeing her antenatally and giving her the warning signs for which she should go to the hospital. Instead, her family purposefully waited until the last bus for the local hospital, located 1.5 hours away, had gone, and then came to fetch me when Rosa’s contractions were about 3 minutes apart. I walked ten minutes from the clinic to her home, where she lay writhing on the bed, on a piece of plastic, her two other children asleep nearby. There was no electricity, and her husband was waiting outside the house for me. I recognized in that instant that if there were complications with her delivery, I was almost 2 hours away from being near more advanced medical care for Rosa or her baby. It was a frightening amount of responsibility.
Luckily, this story has a happy ending—Rosa delivered a healthy baby girl two hours later, and when I visited the baby the next day, she was breastfeeding and doing well. When Rosa named her five months later, she did me the honor of giving the baby my name, and I have seen my little namesake on three subsequent visits to Ecuador since I ended my time there. But, the memory of that delivery and the possibilities of all that could have gone wrong that night have stayed with me and made me want to do more than just travel to different locales and treat patients. I wanted to do something sustainable in global health, to leave a lasting impression.
When I returned to University of Colorado for my fellowship, I knew that global health would play a strong role in my future career. Given that one of my mentors was Susan Niermeyer, the Editor in Chief of the Helping Babies Breathe® (HBB) curriculum, I had a natural entry point to get involved. Helping Babies Breathe is a neonatal resuscitation program which is pictorial, skills-based and designed for use in resource limited settings. HBB utilizes a low-cost simulator (NeoNatalie®) , paired learning and an emphasis on continued practice for sustainability. A public-private partnership of professional organizations, the Global Developmental Alliance (GDA), facilitated planning in 51 countries with over 94,000 skilled birth attendants trained to date. The emphasis is on initiating the simple steps of resuscitation (drying, stimulation, suctioning, and bag-mask ventilation) to get all babies to breathe within the Golden Minute®. Understanding newborn physiology in the delivery room is an important part of neonatology, and being able to treat babies with the simplest measures, even while being evidenced-based, has made me a better neonatologist when I am teaching residents about resuscitation, or practicing resuscitation myself, even with the additional gadgets and supports that we have in our delivery rooms in the United States. Being involved with HBB has allowed me to take a valuable skill around the world that will hopefully be sustained in the individuals that I teach, and improve neonatal care and outcomes around the world.
For young trainees and faculty that want to get involved in global health, Helping Babies Breathe is an excellent vehicle to do something sustainable and fun. More than that, given the sobering statistics worldwide about early newborn mortality, and particularly birth asphyxia related mortality, countries/ministries of health are urgently asking for help to support programs for neonatal resuscitation around the world. It’s an ideal opportunity to partner in an official capacity with local and even national leaders to improve newborn care.
I would encourage any young clinician who wants to get involved to use the resources on the HBB website (www.helpingbabiesbreathe.org to understand the training methodology, to contact experienced HBB Master Trainers for countries of interest to you to determine individual countries’ needs, and lastly to become trained as a Master Trainer yourself. Look at the Implementation Guide (on the HBB website) to think through ways to align your teaching with national and local needs and make it sustainable. In the future, there will also be resources that may guide you in formulating research projects that can produce important information that we still do not know about resuscitation in low-resource settings. Every time that I have taught HBB, I get chills at seeing the students come to understand the purpose of simulation and how to successfully make NeoNatalie® breathe by the Golden Minute. It is truly rewarding to hope that they will take these skills and teach someone else or help a baby breathe in a moment of need.
Featured HNN Blogs
About the Blog
The Healthy Newborn Network Blog provides timely information and insights from the global newborn health field and seeks to promote dialogue on important newborn health issues. The blog is a platform for the HNN Editors and guest contributors to post commentaries on current happenings in the newborn health field. The content of each post and comments expressed on the HNN blog are those of the individual contributors and do not necessarily represent the views and opinion of the HNN or its Partner Organizations. >>Read a note on leaving comments
Recent Member Responses
I totally agree with the above article. As we all known the IMR data, apart from above suggested strategy i.e. strengthening of Village Health and...
Thank you for your comments; I agree with you that we are not reaching women as much as we should be to improve knowledge and behaviors for safer...
No doubt technological gains in maternal, newborn care, have improved newborn survival in last decade . Many simple interventions like kangaroo...
Your information is very useful to us. Our product is as used to protect children with lot of care By-...
The stdndard practice for cord care has been not to apply anything on the cord.after cleaning baby and bath cord is left to dry, this has been...