Addressing Critical Knowledge Gaps in Newborn Health

Blog

By Sylvia Nabanoba on June 10, 2014
Uganda
Africa

This blog introduces one of the 2014 International Midwife Award winners Sister Agnes Kasaigi. The awards were sponsored by The International Confederation of Midwives and Save the Children. This blog was adapted from Agnes' application submitted by her nominator, Sylvia Nabanoba. The award winners were announced at this year’s International Confederation of Midwives 30th Triennial Congress in Prague, Czech Republic on June 3rd. Click here to learn more.

"One day while I was on the ward, a pregnant woman came to give birth. She had not attended antenatal care at our hospital. She was severely anemic and I wondered whether she had had any antenatal care at all. What kind of health worker would let a pregnant woman deteriorate to that level without doing something about it?” recalls Sister Agnes Kasaigi, head of the Maternity Unit at Buwenge Hospital in Jinja district, Central Uganda.

Agnes goes on to explain that the case was too complicated to be handled by her hospital and immediate referral was sought. “Our ambulance was down, and the woman’s relatives did not have money. We tried our best to ensure that we got her to a referral hospital in time. We approached the local council chief who was willing to give us some money, and hired a car that took her to hospital. Unfortunately, she died before she could give birth to her baby. The baby died too,” continues Sr. Kasaigi.  Because of this tragic incident, Agnes works to ensure pregnant women seek proper antenatal care, and she teaches women the risks that place pregnant mothers’ lives and those of their babies in danger. 

When Agnes Kasaigi recalls the maternity unit at Buwenge Hospital in Uganda’s Jinja District a few years back, she remembers a disturbing pattern: babies would die during labor and within a short time of being born. “We did not know how and were not equipped to save these lives. We used to get many stillbirths because we did not have the knowledge and equipment for resuscitating babies,” she remembers. The start of trainings on newborn resuscitation were a turning point for Sister Kasaigi, head midwife working in the hospital's maternity ward. She says that many at Buwenge hospital just accepted these deaths but she thought that something more could be done. After training, she committed to put in place a resuscitation area, and decided to ask the hospital’s matron-in-charge to invest in a mattress and equipment to help babies breathe at birth.

Sister Kasaigi’s was granted these resources and after taking part in the training of others in her hospital on this life-saving skill, she confidently assures that no stillbirths have occurred under her watch. “Today the way we conduct our work is different – and so is the situation in our hospital. Initially, I would register one or two stillbirths per month under my watch. But now, I can spend months without handling a mother with a stillbirth,” Sr. Kasaigi confidently says.

Last week, Sister Kasaigi became one of the two recipients of the 2014 International Midwife Award at the 30th Triennial International Confederation of Midwives (ICM) Congress last week.

Her award and achievements are especially impressive because Agnes faces daily struggles in her rural hospital in Central Uganda. “We face many challenges every day. A lack of midwives is a big one.” According to the recent report, State of the World’s Midwifery, when trained and supported by a functional health system, midwives could provide 87% of the essential care needed for women and newborns, and could potentially reduce maternal and newborn deaths by two thirds.

Sister Agnes takes part in the training of nurses and midwives, alongside managing the maternity unit, which cares for 60-70 neonatal cases a month. Her contributions at the hospital have not gone unnoticed by her colleagues. Rahil Kirunda, in-charge at Buwenge hospital proudly says: “I have worked with Agnes for 10 years now, and she has showed great love and respect for her role as a midwife to the community. They have embraced her and trusted her with their lives during pregnancies. Our hospital serves an area which is mostly rural poor, and many are affected by HIV and face the stigma for the disease.” Agnes also delivers interventions that prevent the transmission of HIV from mother-to-child, and is respected and trusted among the community and surrounding areas.

“It is a miracle. When an HIV-positive mother comes to me for proper antenatal care, takes her required medication, and delivers a live, healthy baby,” Agnes says. “One of these mothers has in fact delivered not one but three HIV-negative babies, and they are happy and healthy children.”


Agnes Kasaigi receives the 2014 International Midwife Award from Mary Higgins, Board Member of the International Confederation of Midwives, left, and Prof. Joy Lawn on the London School of Hygiene & Tropical Medicine and Senior Advisor for Save the Children, center, at the ICM 30th Triennial Congress in Prague on June 3rd. Photo: Bex Morton/Save the Children

Agnes thinks that people interested in midwifery should be compassionate towards mothers and their babies, approachable, and determined to help babies survive. They should also “be kind and so lovely”, says Agnes who accepted the international recognition at the ICM Congress in Prague.

Related Resources

By Mamuda Aminu on June 9, 2014

 

This blog was originally published In The Lancet Global Health Blog

Maternal and neonatal survival have been in the headlines again this week as the Institute for Health Metrics and Evaluation and WHO released new figures and Save the Children published its annual State of the World's Mothers report. May 5 was International Day of the Midwife: what can skilled birth attendance do for maternal and neonatal health and how can it be scaled up? Recent figures from WHO indicate that the proportion of under-5 deaths that occur in the first month of life increased from 37% in 1990 to 44% in 2012, resulting in 2.9 million neonatal deaths annually. One of the strategies to reduce neonatal mortality is promoting the provision of essential newborn care by skilled birth attendants (SBAs). However, with an estimated 46 million women who are likely to deliver alone or without adequate care, one wonders whether promotion of skilled birth attendance is being prioritised enough to bring about the much desired reduction in global neonatal mortality.

In a systematic review estimating the effect of various childbirth care packages on neonatal mortality due to childbirth-related events in term babies, Lee and colleagues reported that skilled birth care could reduce neonatal mortality by 25%. The review also reported the potential in the provision of comprehensive emergency obstetric care and basic emergency obstetric care to reduce these deaths by 85% and 40%, respectively.

However, many developing countries struggle to provide basic care for women and their babies. In a cross-sectional survey of 378 health facilities in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh, and India, Ameh and colleagues reported that only 23.1% of the health facilities aiming to provide comprehensive emergency obstetric care were able to offer the nine required signal functions and only 2.3% of health facilities expected to provide basic emergency obstetric care provided all seven signal functions. The picture is not different in many other sub-Saharan African and Asian countries. The global shortage of health-care providers certainly does not help the situation.

In addition, there is evidence of a “skills gap” for many SBAs in countries where most of the neonatal mortality occurs. In a study that mapped out cadres of health-care providers considered to be SBAs in nine sub-Saharan African countries, Adegoke and colleagues found that a total of 21 different cadres of health-care provider were reported to be an SBA. Most of these cadres lacked the skills to provide the signal functions of emergency obstetric care and early newborn care. Utz and colleagues also reported similar findings when they did a similar study in four countries in southeast Asia.

Task shifting is one of the strategies recommended by WHO to improve availability of emergency obstetric care and newborn care services. Lower-level and middle-level health-care providers such as community health workers are trained to perform specific tasks that may otherwise be performed by higher-level staff that take longer and cost more to train.

In the continuum of care, because newborn care is closely related to maternal care, training of lower-level health-care providers also provides the additional benefit of addressing challenges related to both demand for and supply of maternal care.

It is on this premise that the Making it Happen programme, which is being delivered by the Centre for Maternal and Newborn Health at the Liverpool School of Tropical Medicine, UK, is helping health-care providers in developing countries to increase their knowledge and develop skills in the provision of basic and comprehensive emergency obstetric care and early newborn care.

A short competency-based "skills and drills" training package for health-care providers in resource-poor countries was developed in 2006 by the centre in collaboration with the Royal College of Obstetricians and Gynaecologists and the Department of Making Pregnancy Safer at WHO. The package focuses on the signal functions of emergency obstetric care and early newborn care. With the support of UK Department for International Development, the programme has been rolled out in 12 sub-Saharan African and Asian countries.

In a before-and-after study involving 222 health-care providers in Somaliland who were trained in the Making it Happen programme, participants were evaluated on change in knowledge, skills, behaviour, and functionality of their facilities during and immediately after training, and at 3 and 6 months post-training. There was improvement in 50% of knowledge and 100% of skills modules assessed. Availability of signal functions for basic and comprehensive emergency obstetric care in participating facilities improved from 43% and 56%, respectively, to 100%.

For the long-term success of interventions, it is crucial that they follow the guiding principles of the forthcoming WHO Every Newborn Action Plan. In line with these principles, the Making it Happen programme ensures ownership of the intervention by training some of the higher-level health-care providers as trainers so that, with the aid of training equipment that is also supplied to the participating countries, they can continue to build skills within their countries even after the programme. Additionally, the monitoring, evaluation, and feedback mechanisms that have been built within the programme enables the Centre for Maternal and Newborn Health and other stakeholders to continuously refine and innovate for even better delivery and impact.

Finally, with current evidence suggesting that training of health-care providers is effective in increasing availability and quality of maternal and newborn care services, this strategy should be placed higher on the newborn health stakeholders’ list of priorities, and continued improvement of skilled birth attendance in developing countries should be supported.

By Alexandra Shaphren on June 4, 2014
Research

Read June's Research Roundup by clicking here. 

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*M. Cernada, E. Serna, C. Bauerl, et al. Genome-Wide Expression Profiles in Very Low Birth Weight Infants With Neonatal Sepsis. Pediatrics (May, 2014).
 
Background: Bacterial sepsis is associated with high morbidity and mortality in preterm infants. However, diagnosis of sepsis and identification of the causative agent remains challenging. Our aim was to determine genome-wide expression profiles of very low birth weight (VLBW) infants with and without bacterial sepsis and assess differences.
 
Methods: This was a prospective observational double-cohort study conducted in VLBW (<1500 g) infants with culture-positive bacterial sepsis and non-septic matched controls. Blood samples were collected as soon as clinical signs of sepsis were identified and before antibiotics were initiated. Total RNA was processed for genome-wide expression analysis using Affymetrix gene arrays.
 
Results: During a 19-month period, 17 septic VLBW infants and 19 matched controls were enrolled. First, a three-dimensional unsupervised principal component analysis based on the entire genome (28 000 transcripts) identified 3 clusters of patients based on gene expression patterns: Gram-positive sepsis, Gram-negative sepsis, and noninfected control infants. Furthermore, these groups were confirmed by using analysis of variance, which identified a transcriptional signature of 554 of genes. These genes had a significantly different expression among the groups. Of the 554 identified genes, 66 belonged to the tumor necrosis factor and 56 to cytokine signaling. The most significantly overexpressed pathways in septic neonates related with innate immune and inflammatory responses and were validated by real-time reverse transcription polymerase chain reaction.
 
Conclusions: Our preliminary results suggest that genome-wide expression profiles discriminate septic from nonseptic VLBW infants early in the neonatal period. Further studies are needed to confirm these findings.
  
 
Background: India launched JSY cash transfer programme to increase access to emergency obstetric and neonatal care (EmONC) by incentivising in-facility births. This increased in-facility births from 30%in 2005 to 73% in 2012 however, decline in maternal mortality follows a secular trend. Dysfunctional referral services can contribute to poor programme impact on outcomes. We hence describe inter- facility referrals and study quality of referral services in JSY.
 
Methods and Results: Women accessing intra natal care (n = 1182) at facilities (reporting .10 deliveries/month, n = 96) were interviewed in a 5 day cross sectional survey in 3 districts of Madhya Pradesh province. A nested matched case control study (n = 68 pairs) was performed to study association between maternal referral and adverse birth outcomes. There were 111 (9.4%) in referrals and 69 (5.8%) out referrals. Secondary level facilities sent most referrals and 40% were for conditions
expected to be treated at this level. There were 36 adverse birth outcomes (intra partum and in-facility deaths). After matching for type of complication and place of delivery, conditional logistic regression model showed maternal referral at term delivery was associated with higher odds of adverse birth outcomes (OR- 2.6, 95% CI: 1.0–6.6 p = 0.04). Maternal death record review (April 10–March 12) was conducted at the CEmOC facility in one district. Spatial analysis of transfer time from sending to the receiving CEmOC facility among in-facility maternal deaths was conducted in ArcGIS10 applying two hours (equated to 100 Km) as desired transfer time. There were 124 maternal deaths, 55 of which were among mothers referred in. Buffer analysis revealed 98% mothers were referred from ,2 hours. Median time between arrival and death was 6.75 hours.
 
Conclusions: High odds of adverse birth outcomes associated with maternal referral and high maternal deaths despite spatial access to referral care indicate poor quality of referral services.
 
 
Reducing maternal mortality and providing universal access to reproductive health in resource poor settings has been severely constrained by a shortage of health workers required to deliver interventions. The aim of this article is to determine evidence to optimize health worker roles through task shifting/sharing to address Millennium Development Goal 5 and reduce maternal mortality and provide universal access to reproductive health. A narrative synthesis of peer-reviewed literature from 2000 to 2011 was undertaken with retrieved documents assessed using an inclusion/exclusion criterion and quality appraisal guided by critical assessment tools. Concepts were analysed thematically. The analysis identified a focus on clinical tasks (the delivery of obstetric surgery, anaesthesia and abortion) that were shifted to and/or shared with doctors, non-physician clinicians, nurses and midwives. Findings indicate that shifting and sharing these tasks may increase access to and availability of maternal and reproductive health (MRH) services without compromising performance or patient outcomes and may be cost effective. However, a number of issues and barriers were identified with health workers calling for improved in-service training, supervision, career progression and incentive packages to better support their practice. Collaborative approaches involving community members and health workers at all levels have the potential to deliver MRH interventions effectively if accompanied by ongoing investment in the health care system.
 
 
Background: Despite a substantial decrease in child mortality in Ethiopia over the past decade, neonatal mortality remains unchanged (37/1000 live-births). This paper describes a qualitative study on beliefs and practices on immediate newborn and postnatal care in four rural communities of Ethiopia conducted to inform development of a package of community-based interventions targeting newborns.
 
Methods: The study team conducted eight key informant interviews (KII) with grandmothers, 27 in-depth interviews (IDI) with mothers; seven IDI with traditional birth attendants (TBA) and 15IDI with fathers, from four purposively selected communities located in Sidama Zone of Southern Nationalities, Nations, and Peoples (SNNP) Region and in East Shewa and West Arsi Zones of Oromia Region.
 
Results: In the study communities deliveries occurred at home. After cutting the umbilical cord, the baby is put to the side of the mother, not uncommonly with no cloth covering. This is largely due to attendants focusing on delivery of the placenta which is reinforced by the belief that the placenta is the ‘house’ or ‘blanket’ of the baby and that any “harm” caused to the placenta will transfer to the newborn. Applying butter or ointment to the cord “to speed drying” is common practice. Initiation of breastfeeding is often delayed and women commonly report discarding colostrum before initiating breastfeeding. Sub-optimal breastfeeding practices continue, due to perceived inadequate maternal nutrition and breast milk often leading to the provision of herbal drinks. Poor thermal care is also demonstrated through lack of continued skin-to-skin contact, exposure of newborns to smoke, frequent bathing—often with cold water baths for low-birth weight or small babies; and, poor hygienic practices are reported, particularly hand washing prior to contact with the newborn.
 
Conclusion: Cultural beliefs and newborn care practices do not conform to recommended standards. Local perspectives related to newborn care practices should inform behaviour change messages. Such messages should target mothers, grandmothers, TBAs, other female family members and fathers.
 
 
Background: The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100 000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.
 
Methods: We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990—2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.
 
Findings: 292 982 (95% UI 261 017—327 792) maternal deaths occurred in 2013, compared with 376 034 (343 483—407 574) in 1990. The global annual rate of change in the MMR was −0·3% (—1·1 to 0·6) from 1990 to 2003, and −2·7% (—3·9 to −1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290—2866) maternal deaths were related to HIV in 2013, 0·4% (0·2—0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1—1262·8) in South Sudan to 2·4 (1·6—3·6) in Iceland.
 
Interpretation: Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.
 
Funding: Bill & Melinda Gates Foundation.
 
D. Morof, K. Kerber, B. Tomczyk, et al.Neonatal survival in complex humanitarian emergencies: setting an evidence-based research agenda. Conflict and Health (May, 2014).
 
Background: Over 40% of all deaths among children under 5 are neonatal deaths (0-28 days), and this proportion is increasing. In 2012, 2.9 million newborns died, with 99% occurring in low- and middle-income countries. Many of the countries with the highest neonatal mortality rates globally are currently or have recently been affected by complex humanitarian emergencies. Despite the global burden of neonatal morbidity and mortality and risks inherent in complex emergency situations, research investments are not commensurate to burden and little is known about the epidemiology or best practices for neonatal survival in these settings.
 
Methods: We used the Child Health and Nutrition Research Initiative (CHNRI) methodology to prioritize research questions on neonatal health in complex humanitarian emergencies. Experts evaluated 35 questions using four criteria (answerability, feasibility, relevance, equity) with three subcomponents per criterion. Using SAS 9.2, a research prioritization score (RPS) and average expert agreement score (AEA) were calculated for each question.
 
Results: Twenty-eight experts evaluated all 35 questions. RPS ranged from 0.846 to 0.679 and the AEA ranged from 0.667 to 0.411. The top ten research priorities covered a range of issues but generally fell into two categories- epidemiologic and programmatic components of neonatal health. The highest ranked question in this survey was "What strategies are effective in increasing demand for, and use of skilled attendance?"
 
Conclusions: In this study, a diverse group of experts used the CHRNI methodology to systematically identify and determine research priorities for neonatal health and survival in complex humanitarian emergencies. The priorities included the need to better understand the magnitude of the disease burden and interventions to improve neonatal health in complex humanitarian emergencies. The findings from this study will provide guidance to researchers and program implementers in neonatal and complex humanitarian fields to engage on the research priorities needed to save lives most at risk.
 
 
Objective: Conduct a global situational analysis to identify the current facilitators and barriers to improving quality of care (QoC) for pregnant women, newborns and children.
 
Study design: Metareview of published and unpublished systematic reviews and meta-analyses conducted between January 2000 and March 2013 in any language. Assessment of Multiple Systematic Reviews (AMSTAR) is used to assess the methodological quality of systematic reviews.
 
Settings: Health systems of all countries. Study outcome: QoC measured using surrogate indicators––effective, efficient, accessible, acceptable/patient centred, equitable and safe. Analysis Conducted in two phases (1) qualitative synthesis of extracted data to identify and group the facilitators and barriers to improving QoC, for each of the three population groups, into the six domains of WHO's framework and explore new domains and (2) an analysis grid to map the common facilitators and barriers.
 
Results: We included 98 systematic reviews with 110 interventions to improve QoC from countries globally. The facilitators and barriers identified fitted the six domains of WHO's framework––information, patient–population engagement, leadership, regulations and standards, organisational capacity and models of care. Two new domains, ‘communication’ and ‘satisfaction’, were generated. Facilitators included active and regular interpersonal communication between users and providers; respect, confidentiality, comfort and support during care provision; engaging users in decision-making; continuity of care and effective audit and feedback mechanisms. Key barriers identified were language barriers in information and communication; power difference between users and providers; health systems not accounting for user satisfaction; variable standards of implementation of standard guidelines; shortage of resources in health facilities and lack of studies assessing the role of leadership in improving QoC. These were common across the three population groups.
 
Conclusions: The barriers to good-quality healthcare are common for pregnant women, newborns and children; thus, interventions targeted to address them will have uniform beneficial effects. Adopting the identified facilitators would help countries strengthen their health systems and ensure high-quality care for all.
 
J. Sandberg, K. Odberg Pettersson, G. AspInadequate, et al. Knowledge of Neonatal Danger Signs among Recently Delivered Women in Southwestern Rural Uganda: A Community Survey. PLOS One (May, 2014).
 
Background: Early detection of neonatal illness is an important step towards improving newborn survival. Every year an estimated 3.07 million children die during their first month of life and about one-third of these deaths occur during the first 24 hours. Ninety-eight percent of all neonatal deaths occur in low- and middle-income countries like Uganda. Inadequate progress has been made globally to reduce the amount of neonatal deaths that would be required to meet Millennium Development Goal 4. Poor knowledge of newborn danger signs delays care seeking. The aim of this study was to explore the knowledge of key newborn danger signs among mothers in southwestern Uganda.
 
Methods: Results from a community survey of 765 recently delivered women were analyzed using univariate and multivariate logistic regressions. Six key danger signs were identified, and spontaneous responses were categorized, tabulated, and analyzed.
 
Results: Knowledge of at least one key danger sign was significantly associated with being birth prepared (adjusted OR 1.7, 95% CI 1.2-2.3). Birth preparedness consisted of saving money, identifying transportation, identifying a skilled birth attendant and buying a delivery kit or materials. Overall, respondents had a poor knowledge of key newborn danger signs: 58.2% could identify one and 14.8% could identify two. We found no association between women attending the recommended number of antenatal care visits and their knowledge of danger signs (adjusted OR 1.0, 95% CI 0.8-1.4), or between women using a skilled birth attendant at delivery and their knowledge of danger signs (adjusted OR 1.2, 95% CI 0.9-1.7).
 
 
Background: Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success.
 
Methods: We generated updated estimates of child mortality in early neonatal (age 0—6 days), late neonatal (7—28 days), postneonatal (29—364 days), childhood (1—4 years), and under-5 (0—4 years) age groups for 188 countries from 1970 to 2013, with more than 29 000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030.
 
Findings: We estimated that 6·3 million (95% UI 6·0—6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1—18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6—177·4) in Guinea-Bissau to 2·3 (1·8—2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from −6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000—13 than during 1990—2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only −1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone.
 
Interpretation: Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030.
 
Funding: Bill & Melinda Gates Foundation, US Agency for International Development.
 
WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Trends in Maternal Mortality: 1990 to 2013. World Health Organization (May, 2014).
 
Millennium Development Goal (MDG) 5 Target 5A calls for the reduction of maternal mortality ratio by three quarters between 1990 and 2015. It has been a challenge to assess the extent of progress due to the lack of reliable and accurate maternal mortality data – particularly in developing-country settings where maternal mortality is high. As part of going efforts, the WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division updated estimates of maternal mortality for the years 1990, 1995, 2000, 2005 and 2013.
 
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By Alice Kadango on June 4, 2014
Malawi
Africa

This blog is part of a series introducing the 2014 International Midwife Award sponsored by The International Confederation of Midwives and Save the Children. These blogs were adapted from the applications of finalists. The award winners were announced at this year’s International Confederation of Midwives 30th Triennial Congress in Prague, Czech Republic on June 3rd. Click here to learn more about the winners.

Finalist, Professor Address Malata, is a Nurse, Midwife and Professor from Malawi. As the Principal of the University of Malawi, Kamuzu College of Nursing (KCN), Address has been essential to the advancement of the nursing and midwifery workforce in Malawi. Her leadership has led to establishing six new masters programs, and launching a PhD program at the University.

In addition to her leadership in education, Address has made substantive contributions to the improvement of health care of women, children, and persons with HIV and AIDS through research, publications, and presentations. She has initiated training in essential newborn care, resuscitation, and kangaroo mother care. She has been first author or co-author on numerous publications focused on maternal and child health care, and care related to HIV and AIDS. As a consultant to numerous organizations including the Malawian Ministry of Health, the United Nations Family Planning Agency, the World Health Organization, and the United States Agency for International Development, the Commonwealth Secretariat, and other non-governmental organizations, Address has furthered midwifery education, reproductive health policy, human rights, child survival, and program evaluation.

Prof. Malata is a dynamic, motivated and passionate leader in nursing and midwifery, and has improved midwifery and neonatal care for the people of Malawi. Through her leadership, Malawi has highly qualified Midwives providing hands-on newborn care at the bedside, work essential to reducing the country’s infant mortality rate.

Congratulations to Address Malata on her nomination to this year’s 2014 International Midwife Award.

Read about other International Midwife Award finalists by clicking below:

This blog was written by Address' nominator, Alice Kadango. Alice is a Registered Nurse Midwife working as a Lecturer in Maternal and Child Health at The University of Malawi, Kamuzu College of Nursing in Malawi (AMAMI). Currently she is the Publicity Secretary of The Association of Malawian Midwives that nominated Professor Adress Malata as a contender for to receive an award for improving Maternal and Child Health delivery services in Malawi.

By Gwewasang Che Martin on June 3, 2014
Cameroon
Africa

This blog is part of a series introducing the 2014 International Midwife Award sponsored by The International Confederation of Midwives and Save the Children. These blogs were adapted from the applications of finalists. The award winners will be announced at this year’s International Confederation of Midwives 30th Triennial Congress in Prague, Czech Republic on June 3rd.

Finalist, Njumbe Benedict Ngyia, is a man who has dedicated his life to the care of women and children. He has been a nurse-midwife since 1994 when he started taking an active role as primary midwife to provide prenatal, postnatal and birth care for local tribal populations in Cameroon. Njumbe founded Nightingale, a community-based birth clinic. He currently provides midwifery and nursing care to high-risk antepartum, intrapartum, and postpartum women from ethnically diverse populations in the Sub-Sahara Africa.

"We must remove barriers to midwifery education in order to improve outcomes for mothers and babies." - Njumbe Benedict Ngyia.

Njumbe is also the Clinical Director of the first private “Clinical Training Center for Family Planning (CTCFP)” project authorized by the ministry of public health. The CTCFP is created to prepare graduate and undergraduate nurses and midwives to manage a woman’s normal obstetrical and gynecological needs during the childbearing years, manage the care of the normal newborns, and provide primary care to women. Njumbe has dedicated his whole life to saving the lives of women in Cameroon, a country with a high burden of maternal and neonatal deaths.

Njumbe is a positive role model-dynamic, motivated, passionate, and an agent for change. He encourages staff growth, mentorship, learning, and development. His leadership qualities and impact for newborn care has increased access to affordable disease prevention, counseling, family planning, gynecological and prenatal care for women and care after birth.

Congratulations to Njumbe Benedict Ngyia on his nomination to this year’s 2014 International Midwife Award.

Read other stories of finalists:

This blog was written by Njumbe's nominator, Dr. Gwewasang Che Martin. Dr. Martin is an independent practicing clinician. For more than 20 years he has been working in public health sector on community based family planning/immunization integration, long acting family planning, and adolescent issues. He has also played a major role in bringing innovative approaches to increase access to modern contraceptive methods, especially LA/PMs, in the non-profit health sector in Cameroon.