The American Academy of Pediatrics (AAP) has developed several newborn care modules under the Helping Babies Survive (HBS) series to assist healthcare providers everywhere, especially in low-resource settings, to deliver consistent, quality care for newborns. Essential Care for Every Baby (ECEB) is one module within the HBS package (ECEB, Helping Babies Breathe (HBB), and Care of the Small Baby). Learner workbooks and flipcharts are designed with an emphasis on clear and simple illustrations, case scenarios, checklists, and algorithms that direct the provider in caring for the newborn beginning immediately after birth. Consistent, user-friendly materials, is a key strength of ECEB and the HBS series.
ECEB responds to a need for a user-friendly training module to complement the existing WHO-UNICEF essential newborn care curriculum. The components of essential newborn care – ensuring warmth, immediate skin-to-skin care, early breastfeeding, umbilical cord care, eye care, Vitamin K administration, and immunization, are already incorporated into national guidelines, protocols and training materials. These components are routinely addressed in pre-service and in-service trainings for health care workers. ECEB does not necessarily aim to teach a new skill set to newborn care providers; rather, its purpose is to reinforce skills and build confidence. ECEB is not intended to replace existing in-country materials, but rather, complements what is already available. Countries have the option to adopt the ECEB materials or use them to augment their existing essential newborn care materials. ECEB takes what providers are already doing and helps them do it better.
The AAP is working with development partners and programs such as USAID/Maternal and Child Survival Program (MCSP) and Save the Children to introduce ECEB to health providers and policy-makers in countries with a high burden of newborn deaths. In May 2014, USAID’s Maternal and Child Health Integrated Program (MCHIP) and the Laerdal Global Health Foundation, in collaboration with the AAP and other partners, hosted a four-day regional workshop in Addis Ababa, Ethiopia to introduce and provide training for ECEB to participants from the Africa region. Countries already implementing HBB at scale shared their experiences and the potential use for ECEB. A total of 85 people attended the workshop, including ECEB trainers from AAP and represented countries, Ministry of Health representatives, national trainers, representatives of professional medical and midwifery associations, and implementing partners. A total of 55 participants from the following countries were trained as ECEB Master Trainers: Ethiopia, Ghana, Kenya, Liberia, Malawi, Nigeria, South Sudan, Tanzania, Uganda, Zambia, Zimbabwe and USA. After the workshop, participants are working with government and development and implementing partners to strategize how ECEB may become a part of newborn training. A similar ECEB workshop is planned for the Asia region in 2015.
ECEB and the HBS series have the potential to help countries realize their goals within the Every Newborn Action Plan and improve the quality of newborn care and neonatal outcomes.
The Lancet Global Health recently published the article Effects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique. In this blog, author Bradley Wagenaar shares insights from the study. Photo Credit: Suzanna Klaucke/Save the Children.
In Mozambique, when a child dies, chances are their death is not recorded in any official capacity. In part, this is because less than half of all children under-5 ever get birth certificates. Officially, they do not exist. If they die, in the eyes of the government, they never died because they never existed in the first place. Even if they were lucky enough to be registered, it is even less likely we will know why they died since less than seven percent of all deaths nationally are reported with their cause-of-death. What little information we do have about the causes and rates of child death come from large, infrequent, and expensive surveys, such as the Mozambican demographic and health survey where researchers physically go door-to-door and ask parents if they know of any children who died, and why.
In a recent article, a group of researchers from the Ministry of Health in Mozambique, the Mozambican National Institutes of Health, and Health Alliance International (HAI is a non-profit organization affiliated with the University of Washington, Seattle and focuses on improving public-sector health systems) used these large-scale population surveys to try to disentangle whether and which health system factors affect rates of child death in Mozambique. Since 90% of the population in Mozambique uses public-sector clinics run by the Ministry of Health that are available to everyone, usually free of charge, we focused on a few factors related to how critical health services are delivered in these facilities.
What we found was that Mozambique has made great strides in decreasing child death over the past decade – a 56% reduction from 2000 to 2010. We also found that three public-health-system factors seem to be most related to gains made in decreasing child death: (1) more women giving birth at public health facilities; (2) more qualified health workers at those facilities; and (3) ensuring there are enough public health facilities as population continues to grow.
What concerned us, however, was that these observed large decreases in the number of child deaths were not distributed equally across Mozambique. While mortality rates aggregated to the country level appear to have made these great reductions, at the provincial level (11 provinces in Mozambique, so ~2 million people per province) or district level (128 districts in Mozambique, so ~200,000 people per district), disparities in child death may actually be increasing.
There is an old adage, which appears to be borne out in some studies, that as the availability or quality of healthcare is improved, disparities in population health may increase in the short-term. This is because the people most likely to take advantage of new health care innovations are those who are more educated and already in better health. When these people access new services, their further separate themselves from the most disadvantaged; often reaching those who most need help is the hardest.
While some provinces in Mozambique showed decreases of up to 80% in neonatal mortality rate over the past decade, some provinces showed decreases as low as 5%. Even more concerning is that current designs of large-scale intermittent community surveys only allow analyses of child deaths to the provincial level in many countries. The differences in rates of death are not trivial. Comparing Provinces in Mozambique, some children are more than three times as likely to die in the first 30 days of life. Disparities in death rates across districts are likely significantly higher.
Alongside proven interventions such as investments in public-sector human resources for health, advocating for safe birth practices in health facilities, and health infrastructure improvements, urgent investments are needed in vital registration systems (births/deaths) and other ways to track district-level (or lower) health disparities. In an age of mobile technology and instant communication, the era of using community surveys to evaluate child deaths at the provincial level or higher should be over. The lack of data on health disparities or real-time statistics on child deaths impedes the development, targeting, and testing of novel innovations to save the lives of children and improve maternal and child health more generally.
We should all advocate for a world where, at the minimum, all children who tragically die before their fifth birthday have their birth, death, and cause-of-death recorded so that we can work to prevent these deaths for other unborn children.
This month's Research Roundup contains five journal supplements. Click here to navigate directly to the supplements.
*Journal subscription required for full access.
- Preconception and antenatal care;
- Care during labour and child birth;
- Immediate new born care;
- Care of healthy newborn;
- Care of small and sick newborn, and
- Care beyond newborn survival.
- Z. Lassi, R. Salam, J. Das, et al. Essential interventions for maternal, newborn and child health: background and methodology.
- Z. Lassi, T. Mansoor, R. Salam, et al. Essential pre-pregnancy and pregnancy interventions for improved maternal, newborn and child health.
- R. Salam, T. Mansoor, D. Mallick, et al. Essential childbirth and postnatal interventions for improved maternal and neonatal health.
- Z. Lassi, D. Mallick, J. Das, et al. Essential interventions for child health.
- Z.S Lassi, R.l Kumar, T. Mansoor, et al. Essential interventions: implementation strategies and proposed packages of care.
- S. Dean, Z. Lassi, A.Imam, et al. Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health.
- S. Dean, Z. Lassi, A. Imam, et al. Preconception care: promoting reproductive planning.
- S. Dean, Z. Lassi, A.Imam, et al. Preconception care: nutritional risks and interventions.
- Z. Lassi, A. Imam, S. Dean, et al. Preconception care: preventing and treating infections.
- Z. Lassi, A. Imam, S. Dean, et al. Preconception care: screening and management of chronic disease and promoting psychological health.
- Z. Lassi, A. Imam, S. Dean, et al. Preconception care: caffeine, smoking, alcohol, drugs and other environmental chemical/radiation exposure.
- Z. Lassi, S. Dean, D. Mallick, et al. Preconception care: delivery strategies and packages for care.
- E. Mason, V. Chandra-Mouli, V. Baltag, et al. Preconception care: advancing from ‘important to do and can be done’ to ‘is being done and is making a difference'.
- S. Ratzan. Preface
- E. Foxa, R. Obregón. Population-Level Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries
- S. Waisbord. Where Do We Go Next? Behavioral and Social Change for Child Survival
- R. Balstera, S. Levy E. Stammer. Evidence Acquisition and Evaluation for Evidence Summit on Population-Level Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries
- J. Eldera, W. Pequegnat, S. Ahmed, et al. Caregiver Behavior Change for Child Survival and Development in Low- and Middle-Income Countries: An Examination of the Evidence
- S. Farnswortha, K. Böseb, O. Fajobib, et al. Community Engagement to Enhance Child Survival and Early Development in Low- and Middle-Income Countries: An Evidence Review
- L. Véleza, M. Sanitatob, D. Barry,et al. The Role of Health Systems and Policy in Producing Behavior and Social Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: An Examination of the Evidence
- J. Kraft, K. Wilkins, G.Morales, et al. An Evidence Review of Gender-Integrated Interventions in Reproductive and Maternal-Child Health
- U. Nayara, A. Stangl, B. De Zalduondo, et al. Reducing Stigma and Discrimination to Improve Child Health and Survival in Low- and Middle-Income Countries: Promising Approaches and Implications for Future Research
- E. Higgsa, A. Goldberg, A. Labrique, et al. Understanding the Role of mHealth and Other Media Interventions for Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: An Evidence Review
- D. Nauglea, R. Hornika, et al. Systematic Review of the Effectiveness of Mass Media Interventions for Child Survival in Low- and Middle-Income Countries
- N. van den Broek, G. Lewis and M. Mathai. Guest Editors' Choice
- J. Heiby, D. Armbruster, T. Jacobs, et al. Better care for every patient, every time: improving quality in low health systems
- F. McConville and D. Lavender. Quality of care and midwifery services to meet the needs of women and newborns
- A. Bacci. Quality of maternal and neonatal care in Central Asia and Europe—lessons learnt
- A. Mahmud, E. Morris, S. Johnson, et al. Developing core patient-reported outcomes in maternity: PRO-Maternity
- L. Hinton, L. Locock, M. Knight. Experiences of the quality of care of women with near-miss maternal morbidities in the UK
- E. Buchmann. Towards greater effectiveness of perinatal death audit in low- and middle-income countries
- V. Flenady, F. Boyle, L. Koopmans, et al. Meeting the needs of parents after a stillbirth or neonatal death
- M. Aminu, R. Unkels, M. Mdegela, et al. Causes of and factors associated with stillbirth in low- and middle-income countries: a systematic literature review
- H. Obara and H. Sobel. Quality maternal and newborn care to ensure a healthy start for every newborn in the World Health Organization Western Pacific Region
- N. Rhoda, D. Greenfield, M. Muller, et al. Experiences with perinatal death reviews in South Africa—the Perinatal Problem Identification Programme: scaling up from programme to province to country
- P. Stratulat, A. Curteanu, T. Caraus, et al. The experience of the implementation of perinatal audit in Moldova
- A. Austin, A. Langer, R. Salam et al. Approaches to improve the quality of maternal and newborn health care: an overview of the evidence.
- Z. Lassi, J. Das, R. Salam et al. Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings.
- R. Salam, Z. Lassi, J. Das et al. Evidence from district level inputs to improve quality of care for maternal and newborn health: interventions and findings.
- J. Das, R. Kumar, R. Salam et al. Evidence from facility level inputs to improve quality of care for maternal and newborn health: interventions and findings.
- Z. Bhutta, R. Salam, Z. Lassi et al. Approaches to improve Quality of Care (QoC) for women and newborns: conclusions, evidence gaps and research priorities.
*Journal subscription required for full access.
This year’s UN General Assembly was full of high-profile moments that reinforced the need for investment and action to improve reproductive, maternal, newborn and child health (RMNCH): the launch of a Global Financing Facility to Advance Women’s and Children’s Health; the release of reports tracking stakeholders’ fulfillment of commitments to Every Woman Every Child; new data on maternal, newborn and child survival from Countdown to 2015; and a plethora of side events focusing on strategies and country progress toward MDGs 4 and 5. For Family Care International, which advocates for improved reproductive, maternal, and newborn health, this unprecedented level of attention to women's and children's health is a welcome sign that our advocacy is having an impact, and that global commitment to ending all preventable maternal and child deaths is stronger than ever.
RMNCH was a key theme in many other important discussions during the week, demonstrating the centrality of the health of mothers and newborns to a range of development challenges.
- Events began with a Climate Summit that brought together leaders from more than 120 countries. The Partnership for Maternal, Newborn & Child Health noted during the Summit that “women and children are the most vulnerable to the effects of a changing climate, and those who are more likely to suffer and die from problems such as diarrhoea, undernutrition, malaria, and from the harmful effects of extreme weather events such as floods or drought.”
- There was a special session to review progress towards achieving the International Conference on Population and Development Programme of Action. The ICPD agenda highlights the importance of ensuring universal access to sexual and reproductive health and rights and the importance of quality and accessible maternal health care, recognizing that healthy girls and women can choose to become healthy moms of healthy babies.
- The UN Security Council held an emergency meeting where President Obama called for swift action on the Ebola epidemic that is destroying lives and decimating African health systems. This crisis highlights already-fragile health systems that lack sufficient health workers, supplies, and essential medicines; the same failures that contribute to maternal and newborn mortality. A recent news story details how pregnant women who are not infected with Ebola risk dying in West Africa due to lack of access to maternal health services, and the same risk exists for newborns and young children. The loss of skilled healthworkers, particularly midwives, could have enormous long term impacts on the ability of women, newborns and children to access life-saving care.
- Finally, the UNGA week included high-level meetings on humanitarian crises in Syria, South Sudan and many other countries. According to the State of the World’s Mothers 2014 report, more than half of all maternal and child deaths occur in crisis-affected places. Discussions of humanitarian response in crisis settings included recognition of the disproportionate impact on women and children of violence, including gender-based violence, displacement, lack of access to food and lack of access to crucial maternal health services and early interventions for newborns. These crises and fragile health systems make achieving the Every Newborn Action Plan recommendations on ensuring quality care for mothers and newborns during labor, childbirth and the first week of life more difficult, but also more critical.
While this long list of world crisis may seem overwhelming, there is some good news on maternal, newborn and child survival. As the UN Secretary-General reminded us, the world is reducing deaths of children under the age of five faster than at any time in the past two decades and significant declines in maternal mortality have occurred in the past 10 years. As the world works together to shape the post-2015 development goals, these experiences during UNGA show that the new agenda must prioritize continuing to address maternal, newborn and child mortality which is linked to many of the world's pressing development challenges, including poverty. As a recent editorial in The Lancet says, “As governments slowly come to an agreement about development priorities post-2015, it is clear that maternal and newborn health will be essential foundations of any vision for sustainable development between 2015 and 2030.”
Over the last decade the Grand Challenges family of programs has fostered innovation and partnership to address some of the world’s most difficult global health and development challenges for the poor and marginalized. This week, as part of an exciting evolution at the Bill & Melinda Gates Foundation, we are launching a new Grand Challenge to more effectively reach and empower the most vulnerable women and girls.
This will be our first Grand Challenge on gender equality and women’s and girls’ empowerment, and it signals a more concerted push to put women and girls at the center of our work.
As Melinda Gates advanced in a recent publication in Science Magazine at the Gates Foundation we are committing to being more intentional about addressing gender inequalities and enhancing women’s and girls’ empowerment. Being unintentional about gender issues – essentially ignoring gender inequalities – causes many development projects to fall short of their objective, and in the worst instances exacerbates gender inequalities and does harm. And when development organizations do not focus on women’s empowerment, they neglect the fact that women empowered with agency and voice – the ability to make decisions about their own life and act on them to achieve a desired outcome, free of violence, retribution, or fear – have the potential to transform their societies. As Melinda expressed in her commentary, we recognize that many other organizations have been working ardently to address gender inequalities for a long time. We committed to joining partners more actively in addressing and confronting inequalities for women and girls as a fundamental right, as well as a key driver of improved health and social and economic progress.
Smart development intentionally addresses and integrates a gender equality perspective alongside sector interventions and measures the impact of health and development programs. Measures, however, not only include sector outcomes – such as contraceptive prevalence rates, agricultural productivity or access to digital financial services – but also gender outcomes – such as equitable decision-making power, shared control over assets and income, personal safety, mobility, and equitable interpersonal relations (Figure 1).
Putting Women and Girls at the Center of Development seeks to accelerate understanding of how to effectively address gender inequalities and empower women and girls, and how to better measure women’s and girls’ empowerment. Although program approaches to improve gender equality and women’s empowerment do exist, we need to better understand how to do this most efficiently and under what conditions the various approaches will be most effective. That is why we have focused the Grand Challenge on developing and testing solutions and generating evidence for approaches – particularly on how to promote equitable decision-making – that are sustainable and cost-effective, with potential for scale. We understand that to achieve gender equality between the sexes we need to engage and transform the attitudes and beliefs of men and boys and encourage and support solutions targeting and engaging them as partners and agents of change.
Among the different approaches to promoting gender equality and women's empowerment, in this first round call for proposals, we have the greatest interest in moving beyond the evidence associating equitable decision-making with improved health and development outcomes to better understanding how to go about achieving equitable decision-making at individual, household and societal levels. However, we also welcome good ideas on other effective approaches that lead to increased women’s and girls’ agency and voice (e.g., control over assets/resources, personal safety, mobility, equitable interpersonal relationships).
We are encouraging multisectoral (e.g. nutrition, agriculture, sanitation, etc. working together) projects that intentionally and effectively address gender inequalities and empower women and girls while improving outcomes in more than one sector. Putting Women and Girls at the Center of Development is a collaborative initiative involving technical and financial contributions from 11 teams at the Bill and Melinda Gates Foundation, representing one of our most collaborative investments ever launched across Agriculture; Water, Sanitation and Hygiene; Financial Services for the Poor; HIV; Strategy, Measurement and Evaluation; Integrated Delivery; Nutrition; Family Planning; Maternal, Newborn and Child Health; Emergency Relief; and the India Country Office. This is part of a broader effort in which we are trying to come together as a Foundation and with our partners and global innovators to put women and girls at the center of our work.
The challenge will fund larger and longer awards ($2.5M over 4 years) as well as smaller exploratory grants ($500K over 2 years). Awards will require low and middle income country leadership, and women-led applications will be particularly encouraged. Based on the results of the 2014 challenge call, we have the potential to issue subsequent rounds as the evidence dictates and we are encouraging funding partners to join us in further supporting and shaping this challenge.
It is our hope that “Putting Women and Girls at the Center of Development” will create opportunities to develop and test bold ideas leading to concrete and effective solutions benefiting women and girls as well as men and boys, and empowering women and girls as agents of change in their families, communities and societies. We also envision the development of new partnerships spanning the fields of gender, global health and development, leading to the creation of a community of practice where partners and grantees collaborate to exchange experiences, overcome challenges and build on each other’s successes. We know this will be a long and difficult path, but this represents the first step we are taking to address what we believe is a monumental grand challenge that must be tackled in order to fulfill our mission of helping all people lead healthy and productive lives.
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
this article is very interesting and nice, I'd loved reading this article of yours.
I learned some thing from this article.
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...