The Sistine Chapel seems an unlikely place to launch a new breastfeeding revolution, but future historians may tell us that’s where it began. When Pope Francis recently invited mothers to feed their hungry infants during a special baptism, he was also sending a global message in support of public breastfeeding. "If they are hungry, mothers, feed them" said a smiling Francis, “because they are the most important people here." Breastfeeding advocates were thrilled, calling on other personalities to follow his lead.
It doesn’t make headlines, but every year 800,000 children under five die because of poor breastfeeding practices. Scientific evidence about breastfeeding’s extraordinary benefits continues to grow. Initiating breastfeeding within the first hour after birth can reduce newborn mortality by up to 20 percent.
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Those are the crucial numbers: initiate breastfeeding during the first hour after birth; breastfeed exclusively for six months; continue till the child’s second birthday. Breast milk is indeed a ‘superfood’, which also builds the bond between mother and child.
Yet the data is stark: the global rate of exclusively breastfed children under six months has remained below 40 percent since the early 1990’s. Lack of progress in ten highly populated countries, with over half the numbers of non-exclusive breastfed children, has significantly impacted the global picture:
Data sources: State of the World’s Children 2014. Numbers are in thousands.
Why has investment in breastfeeding programs remained so low, despite its powerful contribution to child survival, growth and development? What can be done to rally political will for this priority?
In one word: leadership.
That’s the consensus feedback from a recent study conducted by UNICEF, Breastfeeding on the Worldwide Agenda, which analyzes responses from 44 health and nutrition actors across the globe. Interviewees were passionate about their commitment to advance breastfeeding, and frank about their challenges:
“Relative to its importance, it’s just undervalued.”
“There are virtually no resources for breastfeeding support, despite compelling evidence of its impact.” “Leadership trumps everything for me” said one interviewee, distilling a widely shared view. Respondents called on UNICEF and WHO to guide a renewed advocacy drive for breastfeeding, integrating it within existing campaigns. They also prioritized these actions:
- Define a common agenda. Advocates must develop a unified voice all actors can rally around. This includes a space for dialogue on polarizing issues such as partnering with private companies to reduce malnutrition.
- Recast the advocacy case for a 21st century world. Women are increasingly raising children in urban areas, working outside the home, influenced by advertising and accessing mobile phones. Advocates must make an aspirational case for breastfeeding that appeals to them and their families.
- Build support from policy makers, health care providers, businesses and communities. Countries that promote breastfeeding have higher coverage levels. Women need support to begin breastfeeding their infant at life’s beginning and to continue as their babies grow.
- Take urgent action to protect breastfeeding as breast milk substitutes (BMS) companies gain market share in emerging economies. Nothing worried respondents more than the threat this poses to breastfeeding. Civil society groups report ongoing violations of the International Code of Marketing of Breast-milk Substitutes.
There was much good news in UNICEF’s study as well. We may now be at a crucial turning point for breastfeeding advocacy, many said. They pointed to the surge in interest in nutrition that has never been higher worldwide. Investing in the 1,000 days window of opportunity is a message now resonating with political leaders and donors, who pledged $4.15 billion to combat malnutrition till 2020.
UNICEF’s study provides a roadmap for action. Can breastfeeding advocates and their allies capitalize on this historic opportunity?
These are some of the words UNICEF respondents used to describe the focus and tone for a breastfeeding communication campaign.
What will motivate media, politicians and celebrities to provide leadership as Pope Francis has just done? How to convince families enamored by formula advertising that breastfeeding truly is the best choice for the modern woman and her child?
Watch this space. Impatient Optimists will continue to shine a light on this essential topic. We invite you to comment and share on Twitter, with a message such as this one:
Here’s the inside scoop on the politics of #breastfeeding promotion: http://gates.ly/1oIBUpY
"By 2035, there will be almost no poor countries left in the world"
Bill Gates, Annual Letter 2014, p. 7
From our work on the IDEAS project, evaluating the Gates foundation’s funding strategy for maternal and newborn health and working with partners in Ethiopia, India and Nigeria, we have perspectives on each of the three myths that Bill and Melinda have written about this year:
- poor countries are doomed to stay poor
- foreign aid is a big waste
- saving lives leads to overpopulation.
Working to reduce inequity in healthcare within poor communities
The foundation invests in trying to improve conditions for women and newborns in places with the worst statistics for maternal and newborn health and survival. These are also some of the poorest places in the world and, strikingly, even within the context of poverty, there is considerable inequity in health care. In a recent survey in Gombe state, Nigeria, in the “richest” households we surveyed only 8% had electric or gas cooking fuel. And yet even here, the poorest households were worse off with only 18% women from these households getting the 4 pregnancy care visits they should, compared to 65% women from the “richest” households.
Our research will find out whether health care becomes more equitable as Gates-funded projects implement their work, which sometimes means targeting those with the odds stacked highest against them. For example, India's Community Mobilization project is using community self-help groups in some of the poorest areas of Uttar Pradesh State to educate families about good health practices. We will have evidence to show whether there have been improvements in equity when we conduct our endline surveys over the next two years.
The value of "foreign aid"
As public health professionals living in cash-strapped times, how many times have we heard the argument that “foreign aid” is a big waste? Just last year, the UK national press featured quotes supporting this argument from Godfrey Bloom, an ex- Minister of European Parliament for the UK Independence Party: “How can we possibly be giving £1bn a month, when we’re in this sort of debt, to Bongo Bongo Land is completely beyond me.”
It is credit to the foundation that they have funded the IDEAS project to ask, does the aid money given by the foundation have the intended effect of saving the lives of women and babies? Using rigorous quantitative and qualitative methods we will look at whether and how foundation funding results in health care practices and behaviours that are known to save lives.
In short, the IDEAS project will generate evidence to help ensure the foundation’s future investments are spent on cost-effective ways to save lives.
Saving lives and planning families
The projects we working with in Ethiopia, Uttar Pradesh, India, and North East Nigeria are not introducing revolutionary concepts. Instead, they are bringing basic, fundamental knowledge to front line health workers, families and local communities about:
- how to improve the health and survival of mothers and newborns, for example through low-cost, simple approaches such as. breastfeeding, keep the newborn warm, cutting the cord with a sterilised knife, looking out for danger signs during pregnancy), and
- how women can take control of and plan for a healthy, sustainable future for their families.
As Melinda demonstrated in the annual letter (see the Save The People video below), success in saving lives does not lead to overpopulation, and we see maternal and newborn health improvement initiatives integrated with education about family planning.
Our work will end before Bill’s predictions are due to reach their targets, yet we are encouraged by our experience of the foundation’s efforts to interrogate and strengthen its approach to investment. A collective effort of researchers, donors and policy-makers to work with ‘impatient optimism’ and use a solid evidence base for decision-making can surely only help to move us in the right direction.
New mother Nalongo Tamale cares for her three-day-old twins, Kato
(boy) and Babiroie (girl), l to r, as they all receive care at Nakaseke
Hospital in Nakaseke, Uganda. She received antenatal care at the
hospital prior to her pregnancy and she plans to breastfeed both children.
Photo: Ian P. Hurley/Save the Children
By virtue of raising families, mothers and fathers know intimately and first-hand how fragile the lives of newborns are. In low- and middle-income countries where resources and trained health workers can be scarce, the chances of survival for newborns are drastically lowered. In fact, the mortality ratios in poorer nations stand in stark contrast to those in industrialized countries. More newborn lives, however, can be saved in through proven interventions that work effectively when performed by trained healthworkers.
This year saving the lives of newborns is front and center on the global political and development agenda and parents around the world are poised to lend their collective voice to this effort. The UNICEF-and WHO-led Every Newborn Action Plan draft is currently online to be read, shared, and commented upon by a vast coalition of constituents including parents, families, and communities. The plan seeks to provide a joint action platform in which to reduce preventable newborn mortality by scaling up quality care.
Why are the voices of mothers and fathers important to the Every Newborn Action Plan? Parents and families bring a fresh, new perspective to ensuring newborn lives are saved around the world. Shockingly, 2.9 million newborns lose their lives every year. What is particularly troubling is the vast majority of these deaths are wholly preventable. It is a matter of providing the resources, training, care, health access, and health workers that will change the trajectory of newborn lives for the better, but it takes a plan first to ensure these interventions come through.
As a strategic objective, parents’ voices are being sought through February 28, 2014 for comment on the Every Newborn plan. I believe this inclusion is extremely critical given the lack of access everyday people typically have in shaping the lives and livelihoods of millions the world over. Parents’ voices matter like Jennifer Barbour’s who commented, “I think the continuum of care is key. The number of stillborn deaths was staggering to me. Access to skilled health care workers during pregnancy and even preconception can clearly make a big difference. Education around these options will be important, particularly in the harder to reach communities.”
Another mom, Lisa Van Engen wrote, “Kangaroo care is an aspect many mothers can provide, if given the opportunity. I think empowering women in this part of newborn care will continue to improve maternal and newborn health.”
And a father wrote, “A very impressive effort. As a father of a son with a genetic condition, in the US he was identified and treated soon after birth, and is a strong healthy teen; in a less developed country, he would have simply died. We need to work toward a world in which all kids have the same chance to grow up, regardless of their birthplace.”
Jennifer James is the founder of Mom Bloggers for Social Good.
The following blog post was adapted from The Neonatal Alliance's Newsletter.
In conjunction with PAHO/ WHO and national governments from both Latin America and the Caribbean, the Neonatal Alliance participated in the midterm evaluation of the Regional Strategy and Plan of Action within the Continuum of Maternal, Newborn and Child Care. In these meetings it was determined that the majority of Latin American and Caribbean countries have developed Plan of Actions incorporating evidence based interventions, however there is still progress to be made in the implementation of these interventions to reach the most vulnerable populations.
Likewise, the Alliance supported countries in their initiative to form trainers through the basic newborn resuscitation program Helping Babies Breathe (HBB) and the standardization and information exchange in the program implementation of Kangaroo Mother Care (KMC). A virtual KMC Community of Practice was developed to strengthen this intervention, allowing more than 2000 people from the region to share their experiences and to achieve a consensus on indicators used to measure the impact of programs.
Additionally, the Neonatal Alliance participated in meetings and provided technical assistance for global initiatives supporting neonatal health in the continuum of maternal and child health, including:
- The United Nations Commission on Lifesaving Commodities for Women and Children’s Health under the Every Woman, Every Child Initiative, identified 13 essential commodities/ equipment to recommend to governments to improve their availability to reduce maternal newborn, and child mortality. Four of the commodities/ equipment are related to newborn health care: corticosteroids for preterm labor, resuscitation equipment, injectable antibiotics for neonatal sepsis treatment, and topical chlorhexidine, for the prevention of umbilical cord infection and sepsis.
- A Promise Renewed meeting joined together 26 Ministries of Health from Latin American and the Caribbean and 7 international partners, all of whom signed the Panama Declaration to accelerate the prevention of maternal and newborn deaths until 2035. The statement is a call to action to end the inequities affecting the health of mothers and children, including ethnicity, economic status, and other conditions that limit access to health services.
- In October, the KMC Experts Consultation held in Istanbul, Turkey, where the international community recognized that an estimated 450,000 premature babies could be saved each year if the intervention reached universal coverage. Possible mechanisms for implementation and wider country level dissemination of the KMC practice were discussed, and soon the World Health Organization will issue a related technical document. In November, the Alliance also participated in the First International Scientific Kangaroo Mother Care meeting in Bogota, Colombia. Through workshops on indicators measurement and various panels, the meeting served as a forum for the exchange of information and experiences. As you are aware the Neonatal Alliance actively promotes the practice of KMC.
- The Latin America and the Caribbean Neonatal Alliance supports countries in the region in their initiative to reduce maternal and neonatal mortality through: the exchange of information from regional, national, and local experiences; the dissemination of cost effective evidence- based interventions; technical assistance; and advocacy for the newborn and mother.
- The Alliance has become a forum for coordination, through the development of the Neonatal Alliance toolkit. Covering the regional group’s experiences from the formation stage through sustainability, the toolkit recommends specific actions to create and strengthen similar groups, and features 3 country case studies: The Neonatal Alliance of El Salvador, The Collective for Neonatal Health of Peru and The Safe Birth and Motherhood Committee of Bolivia. The toolkit’s objective was to consolidate lessons learned from these experiences to facilitate the strengthening of other alliances and/ or create a forum for countries in which a national Alliance does not yet exist. This document is now available in websites including K4Health, Maternoinfantil.org, and the Healthy Newborn Network (which hosts the Alliance Website), among others. We are pleased to report that in addition to the existing national neonatal alliances, Haiti has formed its Neonatal Alliance, formally commencing their activities in October. Barbados and Paraguay are also working to formalize national alliances.
- In June, Neonatal Alliance members attended the annual regional meeting of Latin America and the Caribbean to review the Annual Plan of Action, to share country experiences (including progress of the KMC network), to present current events and provide regional updates, as well as to welcome new members, such as World Vision and the Ministry of Health and Social Protection of Colombia.
- In 2014, with the support of the entire membership and with the goal of supporting interventions that reach every newborn at the regional level, the Alliance will continue collaboration efforts with existing national alliances and with groups in the formation stage. Members will also support the formation of alliances in other countries in the region.
- The Alliance will continue its efforts to make scientific evidence based interventions addressing the principle causes of maternal and newborn morbidity and mortality (basic newborn resuscitation, Kangaroo Mother Care and management of neonatal sepsis) more accessible for providers of health services and at the community level. Furthermore, an annual meeting for follow up will be conducted regarding the agreed upon regional indicators and national plans. We look forward to your participation.
- Aligned to the Regional Strategy and Plan of Action for Newborn Health, the Neonatal Alliance has participated and will continue as a member of the technical advisory group by reviewing The Every Newborn Action Plan, which seeks to further reduce neonatal mortality globally. The plan focuses on the link between maternal and neonatal health interventions that can be applied during delivery through the first 24 hours of life to achieve the greatest impact on newborn health. Driven by international cooperation among various governments, the private sector and civil society, this document will be presented in May 2014 at the World Health Assembly in Geneva, and will seek endorsement by Ministers of Health. The draft action plan is now open for public consultation on the WHO. The comment period will be closed February 28th, 2014.
In this sense, the Neonatal Alliance has set the following targets in the year 2014: intensify efforts to reduce newborn deaths, particularly due to infection; develop strategies for monitoring newborn mortality; improve further the uptake and use of antenatal corticosteroids; review the first postnatal consultation norms so the first visit occurs within 48 hours (in health facilities and at the community level) and; continue the expansion of interventions such as HBB and KMC.
A nurse at Malawi's Queen Elizabeth Central Hospital sets up a bubble CPAP machine for a preterm infant. Photo: Jocelyn Brown/Rice University
Several years ago, my colleague Maria Oden and I traveled to sub-Saharan Africa. We wanted to learn more from physicians and nurses there about the challenges they face in delivering healthcare, and determine what we, as bioengineering faculty at Rice University, could do to help. In hospital after hospital, we saw the same picture: world-class pediatricians and nurses treating the sickest babies in the world, without access to basic life-saving technologies we take for granted in the United States. Despite the often heroic efforts of these doctors and nurses, without these technologies, many of their tiny patients died.
We came home with an idea: physicians in the developing world would identify challenges they faced in delivering care, and our undergraduates would work to design and implement technologies to address these challenges. With this in mind, we established Rice 360° Institute for Global Health Technologies. Our undergraduates work in interdisciplinary teams under the mentorship of physicians in the developing world to design simple, robust, low-cost technologies that improve healthcare. Through public-private partnerships, we test and scale up the most promising devices in the places where these devices are needed most.
Bubble CPAP devices. Photo: Rice University
At Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, for example, doctors told us that they needed a device to treat babies with respiratory distress syndrome. In the developed world, bubble Continuous Positive Airway Pressure (bCPAP) devices are used, but, at $6,000, these systems are too expensive for QECH. Working with clinical partners QECH and Baylor College of Medicine, and industry partner 3rd Stone Design, Rice students developed a low-cost, high-performance bubble CPAP system using aquarium pumps. This device provides the same therapeutic pressure as bubble CPAP systems in hospitals in the United States, but it can be made for $400. In a clinical trial at QECH in 2012, our bCPAP device was shown to significantly improve neonatal survival related to respiratory distress.
To scale up promising new technologies like the bCPAP in the developing world, Rice 360° leverages public-private partnerships. In collaboration with the Saving Lives at Birth partners and the Malawi Ministry of Health, for example, we are now implementing the bCPAP device in all public hospitals in Malawi. A new award from GlaxoSmithKline and Save the Children will support the roll-out of the device in Zambia, Tanzania, and South Africa. These partnerships enable lifesaving technologies like the bCPAP to have real and sustained impact in the developing world. We are thrilled now to be able to continue our work to improve newborn care throughout the world as part of the Healthy Newborn Network.
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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
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