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.
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).
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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.
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:
- International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal
- International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn
- 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
- International standards for early fetal size and pregnancy dating based on ultrasound measurement of crown-rump length in the first trimester
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
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
Midwife Margaret Baru, 46, left, checks on a newborn baby at Nyumanzi Health Centre II in Adjumani district, Uganda before handing it back to its mother. Photo: Sylvia Nabanoba/Save the Children
Maternal and newborn health in Nyumanzi refugee camp
Every midwife’s nightmare is losing a mother or baby on her watch. They know that these are things that do happen, sometimes because you simply cannot prevent them, but it is still heartbreaking when they do.
This is what 46-year-old Margaret Baru dreaded when one night in June the watchman called out to inform her that a mother in the maternity ward was bleeding uncontrollably.
“She had delivered very well and seemed to be recovering well too. After the delivery, I let her rest before transferring her to the ward. But then the watchman summoned me,” narrates Sr. Baru. “I found her in a pool of blood that kept growing.”
Sr. Baru put the mother on intravenous treatment, but the bleeding did not stop. She had to think and act fast if the mother’s life was to be saved.
“I literally held her uterus for close to two hours in order to make it contract and stop the bleeding. How did I do this? I laid my hands on her stomach and held the uterus. The bleeding eventually stopped,” she says.
Sr. Baru practiced this unconventional method at Nyumanzi Health Centre II in Adjumani District. The health centre is one of those meant to serve refugees who since December 2013 have fled fighting in Southern Sudan and been resettled in several refugee resettlement camps in Adjumani district, Uganda. Nyumanzi is one of the 19 settlements in the district. Currently the health centre serves a population of 25,000 refugees and 5,000 Ugandan nationals who still access services there.
“We are very busy. We have many mothers giving birth here,” Sr. Baru says. “In June (2014) we had 90 deliveries.”
She explains that the high number of births is partly a result of the refugees’ shunning of birth control. According to her, the women say their husbands do not allow them to use modern methods of family planning. They opt for the natural methods, which frequently fail them.
It is these barely spaced pregnancies that result in the very common complications that Sr. Baru has encountered at Nyumanzi since she was posted there in April 2014. She explains that bleeding before and after delivery is a common complication, coupled with mal-presentations such as arm prolapse and delayed labour pains. Frequent pregnancies make the uterus flabby and it fails to contract quickly after childbirth, thus the post-delivery bleeding. A flabby uterus also increases the chances of mal-presentations, Sr. Baru says, because it gives the baby a lot of space to wriggle and move about in different directions.
Keeping alive newborns that suffer complications such as asphyxia is another challenge, since the health centre does not have any oxygen or resuscitation equipment.
“We once had a stillbirth. The mother delayed to come to the health centre yet she was in labour, and the baby got tired. It was alive when it was delivered, but had problems breathing. We could have resuscitated it if we had the facilities, but we did not. So sadly it died,” narrates Sr. Baru.
Encouraging mothers and their partners to attend antenatal care (ANC) sessions is the most important avenue the health centre is using to reduce these challenges. When they come for ANC, the mothers are taught how to prepare for birth.
“Many of them would come to give birth without anything – not even a bedsheet in which to wrap the new baby. Or bedsheets for themselves. Now that they are learning, they come prepared,” says Sr. Baru.
She adds that during ANC the mothers are taught about family planning and the importance of giving birth in the health centre, as opposed to delivering from home. They are tested for HIV, too, and those found to be HIV-positive referred to Dzaipi Health Centre II, where they are enrolled on the Prevention of Mother to Child Transmission of HIV to ensure they do not transmit the virus to their newborns.
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