It all comes down to a golden minute.
In those first 60 seconds after a baby enters the world, the tenor of her life rests in the hands of her deliverers. The care she receives will determine her ability to breathe and whether oxygen gets to her brain; it will determine whether she lives, dies, or has a disability. It is a moment when the term “deliverables” takes on a greater meaning.
For essential caregivers—whether they’re physicians, midwives, or skilled birth attendants—training can mean the difference between life and death. Did they have lessons on neonatal resuscitation, temperature support, stimulation to breathe, or assisted ventilation? What happens to a struggling newborn if her caregivers are not trained in these essential skills? In that first minute, a health worker’s education can shape not only the life of the child, but that of her family and community as well.
According to UNICEF, newborn deaths represent approximately 60% of infant deaths worldwide. Moreover, close to 40% of the estimated 9.7 million deaths of children under five in 2012 were of newborns. The neonatal mortality rate in Uganda, for example, is 28 per 1,000 live births—seven times that of the United States.
Such statistics underline the imperative to equip health professionals with neonatal resuscitation techniques, since these skills can radically improve the chance of newborn survival.
I founded Seed Global Health to help create a sustainable solution to the severe shortage of skilled health care providers worldwide. We work in partnership with both the public and private sectors to enhance the training of local health professionals in the countries where we work.
One of our current projects to prevent newborn asphyxiation in Uganda is a partnership with Mbarara School of Nursing, Healthy Babies Uganda, and Massachusetts General Hospital Center for Global Health. We send U.S. nurse educators to the Mbarara School of Nursing, where they partner with faculty for the year and offer hands-on training on newborn care and resuscitation, both in the classroom and at the bedside.
The idea is simple: if our nurse educators teach 200 nursing students, then those 200 will not only be more skilled in their clinical practice, but they can each also become local educators to teach the next generation of Ugandan nurses.
The ripple effect from each educator can be enormous—and the consequences of improved health care delivery can be the difference between life and death today and in the future of a country tomorrow.
People are at the heart of a health system. Without skilled nurses, our chances of improving neonatal mortality statistics in Uganda—or elsewhere—are limited. Investing in training 200 nurse educators today can lead to better health care delivery, result in a lower rate of neonatal mortality, and strengthen Uganda’s health system. Building a larger cadre of well-educated nurses is essential to the future of neonatal health in Uganda and around the world.
Learn more about and get involved with Seed Global Health’s partner initiative to train 200 nurses at Mbarara School of Nursing. If you have any questions—or are interested in Seed Global Health’s other health care professional education projects, such as the Global Health Service Partnership, a joint program with the Peace Corps—please email email@example.com.
Photo: Jonathan Hyams/Save the Children
An expectant mother stops in a doorway while at the Maternal Waiting Home in Paterstown clinic in Margibi county, Liberia.
Despite the rapid urbanization that is occuring across low- and middle-income countries, many rural women give birth at home. Maternal waiting homes give mothers with a supervised and safe place to wait before giving birth at a hospital or health center. The World Health Organization has in several reports recognized the important role that maternal waiting homes can plan in assuring that women do not give birth alone, and do so with a skilled birth attendant. The caveat being that the cost of building and maintaining them needs to be further evaluated along with an accurate assessment of how many women are utilizing them.
In Liberia, where this photograph was taken, some women have to walk up to eight hours to reach the nearest health clinic. The government's county health team is working with several partner organizations to provide antenatal and postnatal care services in addition to supporting nutritional feeding programs.
When Megan suddenly goes into labor at just 25 weeks gestation, she rushes to the hospital and gives birth to Sophia 15 weeks early. Sophia is transferred into the hospital’s Neonatal Intensive Care Unit and put in an incubator, which allows her time to grow and develop enough to be able to function on her own. She has to undergo several surgeries over the following months, but the doctors say her outlook is good.
However, when Mary goes into labor, also at 25 weeks, she has no way of getting to the hospital. Her family doesn’t have a car and the nearest health clinic is miles away. In a remote village, she gives birth on the dirt floor of her hut to a daughter, Rose, who weighs less than a pound. With immature lungs, Rose struggles to breathe in a world she was not prepared for, and does not survive the night.
Depending on where in the world a preterm birth occurs, it can be anything from a speed bump to a death sentence. The allegorical stories of Sophia and Rose provide a glimpse into similar situations that occur millions of times every year.
A frontline healthworker cares for a baby in Bangladesh. Photo: © Paul Joseph Brown/GAPPS
Babies born prematurely in high-income countries have access to the best technology and highly skilled doctors, giving them a good chance of survival. In middle-income countries, survival rates for preterm babies are somewhat lower. However, those who do survive face much higher rates of enduring health problems, from asthma to cerebral palsy to developmental delays. The situation is worst in low-income countries, where mothers may not have any access to health facilities or trained health workers. The risk of a neonatal death due to complications of preterm birth is at least 12 times higher for an African baby than for a European baby1. This is where frontline health workers can step in to fill the gap and oftentimes be the difference between life and death.
It is heartbreaking to know that there are low-cost interventions to manage preterm birth and care for preterm infants, but without enough frontline health workers and without implementation of known interventions, more than a million preterm babies die every year.
In a global call to action, scientific experts from the Bill & Melinda Gates Foundation, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, GAPPS, and the March of Dimes Foundation published in Lancet Global Health A solution pathway for preterm birth: accelerating a priority research agenda.
The solution pathway includes critical steps in development and delivery science that can help scale up interventions to improve the survival of preterm infants in low- and middle-income settings. Key to implementation are the frontline health workers that deliver care, including the solutions outlined below, in the most remote and inaccessible parts of the world:
Practical solutions need to be developed and moved to scale to improve care. An expanded implementation science agenda will accelerate application of effective strategies at the community and facility level, including antenatal corticosteroids, newborn resuscitation, kangaroo mother care, nutrition, intrapartum monitoring, newborn skin emollients, chlorhexidine cord care, preconception care, and strengthened commodities and essential drug programmes. Adaptations of interventions for newborn care are needed..
- Lackritz et al, Lancet Global Health, Vol. 1, No. 6, Dec. 2013
The schematic below summarizes key elements of the solution pathway for preterm birth research, across the range of discovery, development, and delivery science. The agenda is global in its approach; strategies more relevant to high-income countries are in pink, and low-income and middle-income countries (LMIC) are in grey. The full graphic is available in the Lancet article here.
The solution pathway outlines a shared research agenda to address the global burden of preterm birth, which has become the leading cause of newborn death. By harnessing the political will and expanding investment in healthcare delivery by frontline health workers, we can dramatically improve the outcomes for millions of babies like Rose who are born prematurely around the world.
Born Too Soon: The Global Action Report on Preterm Birth (2012).
Photo: Sala Lewis/Verve Photography
Guest post by Alison Chatfield, Project Manager at the Women & Health Initiative, on behalf of the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st).
If the idea of implementing and managing global research effectively, and uniformly, across eight global study sites sounds challenging, that’s because it is.
Confronted with the lack of evidence-based, universally-applicable growth charts for monitoring fetal, preterm and newborn growth, a network of researchers formed the International Fetal and Newborn Growth Consortium for the 21st Century to fill these gaps. Implemented in the US, the UK, Brazil, China, Oman, Kenya, Italy, and India, the project is by far the largest collaborative venture in the field of perinatal health research.
The results of the studies will now inform robust resources for monitoring growth and development in the first 1,000 days of life.
Uniform implementation of methodology in each of the eight study sites was critical to success. Controlling variability both within and between study sites ensured that the population-based data from all sites could be combined into a single data set that would inform new international growth standards. To achieve uniformity in such a large, multicenter project, all study sites followed the same standardized anthropometry procedures to measure newborns.
While each study site was unique, three generalizable “lessons learned” emerged from implementing and managing this global research project:
- Assemble the right team. Principal Investigators in each study site were responsible for recruiting a team of anthropometrists. The number of people within each team depended on various institutional characteristics, e.g. size of institution; availability full- or part-time staff. However, team members across all study sites were selected based on some universal criteria: motivation, education, skills, organizational capacity and language ability. Team members not only had to be skilled anthropometrists, they were also required to have the interpersonal skills needed to explain the protocols to parents and effectively measure newborns. Each study site had access to leadership throughout the project’s duration; lead anthropometrists were selected based on experience, leadership abilities, and availability, and a core expert group of anthropometrists from the Coordinating Unit were also key to ensuring standardization amongst the study sites. Dedicated data managers at each site were accountable for regularly uploading measurements to the central database.
- Train dynamically. Before data collection began, rigorous training and standardization sessions were conducted at each study site. These trainings were organized by the local lead anthropometrist and were supervised by an expert. The goals of these sessions were to ensure that measurers develop, refine, and maintain their techniques so that the measurements they yield would be repeatable and reproducible values. Training materials, including a protocol manual creating by the Coordinating Unit and an open-access training video, were used as resources in each site. These trainings covered the over-arching goals of taking measurements, as well as details that might affect the day-to-day measurement process, e.g. the measurer’s nerves, infant struggle, and air and light conditions. Frequent standardization sessions, i.e. every three months, functioned as audits to ensure anthropometry teams were following recommended techniques by monitoring the precision and accuracy of their measurements on real newborns. Hands-on corrections were made and explained, if required.
- Provide the right tools to achieve high standards. “Gold standards” of measuring newborns were established from the project’s outset. During standardization sessions, measuring and re-measuring would be performed by an anthropometrist and an expert to ensure consistency and model the expected behavior. Study sites were provided the same equipment and instructions on how to use it. The training materials developed by the Coordinating Unit leveraged open-access resources, such as an anthropometry training video and evidence-based measurement practices, when available. An online data management system provided central coordination of the data and provided built-in range and consistency checks.
The measurements gathered through the INTERGROWTH-21st Project form a unique and important data set that will advance our understandings of human growth and development. It is also interesting to note that the research team observes that implementing standardized anthropometric methodology in these study sites appears to have improved the overall quality of infant measurements in the participating health institutions.
For more information about the anthropometric protocols and how the research team standardized their quality, and the overall methodology of the INTERGROWTH-21st Project, please refer to the INTERGROWTH-21st Project’s supplement in the British Journal of Gynaecology and Obstetrics.
Photo: Prashanth Vishwanathan/Save the Children
After spending the day caring for mothers and newborn babies, community health worker Durgesh leaves Jahangir Puri in Delhi, India.
Durgesh leaves her home at 10 am daily, to meet new and expectant mothers to discuss prenatal, childbirth and postnatal care. As part of her work, she counsels mothers on proper nutrition during pregnancy to ensure that both mother and baby are as healthy as possible. Importantly, she guides mothers to MHU and nearby hospitals for further treatment and delivery. Her work day officially ends at 2 p.m but her call to duty extends to any emergency that arises day or night.
In June 2012 the Government of India along with the Governments of United States and Ethiopia led the Child Survival Call to Action summit, where it committed to ending preventable child deaths by 2035. In response in February 2013 it launched the multi-year RMNCH+A (Reproductive, Maternal, Newborn, Child Health and Adolescents strategy). Given that 50% of India's under-five child mortality rates are due to neonatal mortality, India should now see that its efforts to address newborn health are integrated into the overall RMNCH+A plan, and that the newborn action plan is successfully implemented.
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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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