Addressing Critical Knowledge Gaps in Newborn Health

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By Alicia Yamin on March 11, 2015

This post is one in a series of five that explores the themes generated by a panel of global experts — who discussed the need for, barriers to, and the way forward for maternal and newborn health integration — at Putting Mothers and Babies First: Benefits Across a Lifetime, an event at The Forum at Harvard T.H. Chan School of Public Health on February 26th, 2015.

This blog was originally published by the FXB Center for Health & Human Rights at Harvard University. Written by Alicia Yamin.

“Remedies can’t be tied to a broken system.”

Worldwide, about 290,000 women die each year from preventable causes related to pregnancy and childbirth. From a numerical perspective, this figure appears to denote a situation less urgent than that suggested by the figures for other global health threats, such as malaria (630,000 per year) and HIV (1.5 million). In the developing world, where 90 percent of maternal deaths take place, however, maternal mortality has dramatic implications for child survival and has a profound effect on the wellbeing and sustainability of the larger community. Below, FXB policy director and health rights expert Alicia Ely Yamin outlines why maternal mortality should be treated as an urgent global public health priority.

What is one of the major obstacles for reducing maternal mortality in the post-2015 context?
One challenge moving forward is not just integrating services but also increasing meaningful accountability in the health system. One way to do that is to ensure that there is judicial redress. But that’s not the only thing. We need ways to monitor, review and administer those systems. Doing so requires changing the relationship between providers, policymakers, and patients, all of whom should be active participants in the design, implementation, budgeting, and evaluation of health care services.

Are the impacts of maternal death generally well understood at this stage?
In the developed world, people might not understand how lucky they are. Fifteen to 20 percent of pregnancies have severe obstetric complications, but Westerners don’t die, because they have access to treatment.

In the developing world, maternal death is an egregious injustice. For many women, every time she gets pregnant she thinks: ‘I might die.’” The degree to which a woman is at risk has to do with her status in society, with race, with income inequality. If a woman has the misfortune to live in a remote area, is indigenous, disabled, she is far more likely to die. Health systems reflect and exacerbate the structural and systematic discrimination that already exists in societies.

Is maternal mortality sufficiently addressed by the global public health community?
Public health accounting systems tend to see maternal death as relatively rare. Although a woman dies each hour of the day in Tanzania, for example, globally the total is much fewer than the number of deaths caused by malaria and HIV. So, maternal mortality gets a lower priority. However, when mothers die, the mortality rates of children are enormously elevated. Many die within a year of their mother. Research in this area can help determine what happens to kids after their mothers have passed away.

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Alicia Ely Yamin is lecturer on global health in the Department of Global Health and Population at Harvard TH Chan School of Public Health and policy director at the FXB Center. Yamin regularly advises UN bodies in relation to health and human rights and has provided strategic guidance to NGOs and courts on landmark health, sexual and reproductive rights litigation.

By Joy Riggs-Perla on March 10, 2015

This post is one in a series of five that explores the themes generated by a panel of global experts — who discussed the need for, barriers to, and the way forward for maternal and newborn health integration — at Putting Mothers and Babies First: Benefits Across a Lifetime, an event at The Forum at Harvard T.H. Chan School of Public Health on February 26th, 2015. 

Poor integration of maternal and newborn services during pregnancy, childbirth and in the postpartum period can have adverse consequences for the quality of care that mothers and babies receive. It can also affect the equitable access to this care, especially among poor and marginalized populations. In many countries around the world, significant challenges exist at the national, sub-national and local levels for the increase of maternal and newborn health integration. A variety of health system, financial, human resource as well as societal factors must be recognized and addressed to find the right balance of integrated service delivery.

Some challenges are related to health system issues. For instance, when the responsibility for maternal and newborn health services does not sit within the same organizational unit of government health services, there is increased risk of poor coordination in the resourcing and delivery of services. The lack of medicine and supplies for mothers but not babies or vice versa can adversely affect the delivery of quality and timely care. When discussing human resource issues, challenges include the availability of skilled professionals in many low and middle-income countries. Rural midwives frequently find themselves alone having to care for both women and newborns during the delivery process. Under such difficult conditions, where referral services are not readily available, complications for either the mother or her newborn can result in serious disability or death. Furthermore, the lack of reliable data on maternal and newborn service coverage makes identifying implementation problems difficult and monitoring progress very challenging. Other constraints related to integration include national policies that inadvertently affect the affordability and access to care. For example, waiver of fee payments for needed care of either mother or babies (but not both) can create serious financial burdens for patients. Multiple visits to a clinic can add to that financial burden and discourage service utilization.


Rong Mala and six-day-old, Rakhal, receive a postnatal check up at the government clinic built in Badulpur, Habijganj, Bangladesh. This clinic is already having a positive effect in transforming attitudes towards healthcare as, traditionally, the mother and child should not leave the house until one month after the birth. However, at just six-days-old Rong Mala is treading new ground in bringng Rakhal to the clinic. To mitigate this, her mother-in-law accompanied her to the clinic and she carriers a small bag of earth taken from the house, so that mother and child remain connected to the family home whilst they are away.​ Photo: CJ Clarke/Save the Children

While we work to improve health systems, we should also remember that women and communities have the power to improve health outcomes of their families when armed with appropriate information and provided the needed support. Within our own work at Save the Children’s Saving Newborn Lives program, we are placing increased emphasis on improving care seeking, behavior change and community mobilization to impact improvements along the continuum of care. Life-saving interventions such as immediate and exclusive breastfeeding, skin-to-skin care of the newborn, use of uterotonics help prevent postpartum hemorrhage and proper cleansing of the umbilical stump are all steps that can save lives and can be done at the household level.

The Bill & Melinda Gates Foundation has been supportive of this work and is encouraging us to investigate how we might operationalize integration at the country level. Overall, implementing agencies and funders need to do a better job of communicating the importance of strengthening health systems to create solutions for women and newborns that are sustainable. We also need much more investment in implementation research to explore how integration of services can improve outcomes and equity of care, and to help accelerate the expansion of services to reach all populations.

The path towards meaningful and beneficial integration for the mother-baby dyad is not without its challenges, but many partners, donors, public health managers and service providers are committed to its principles and want to make it happen. Challenges translate into opportunities for increased collaboration, and the maternal newborn communities must show our collective commitment to improving outcomes for both women and newborns by working together to find practical solutions.

I encourage you to read the new Putting Mothers and Newborn First: Integrating Policies, Programs and Services policy briefing and become involved in the upcoming Global Maternal Newborn Health Conference taking place this October in Mexico City. The planning has already begun and we look forward to your insights and contributions so that we can work to create practical ways of improving the quality, equity and integration of services for mothers and newborns everywhere.

By Kathryn Millar on March 9, 2015

This post is one in a series of five that explores the themes generated by a panel of global experts — who discussed the need for, barriers to, and the way forward for maternal and newborn health integration — at Putting Mothers and Babies First: Benefits Across a Lifetime, an event at The Forum at Harvard T.H. Chan School of Public Health on February 26th, 2015.

This blog was originally published by the Maternal Health Task Force. Written by Kathryn Millar

At a standing room only event last week at The Forum at Harvard T.H. Chan School of Public Health, global experts gathered to discuss the need for, barriers to, and the way forward for maternal and newborn integration. But what is integration and why is it so desperately needed?

Every year approximately 300,000 women and 5.5 million newborns, including stillborns, die needlessly. The causes of these deaths are often similar since the mother and her newborn are inextricably linked both socially and biologically.

For the panel, Putting Mothers and Babies First: Benefits Across a Lifetime, Ana Langer, Director of the Maternal Health Task Force; Joy Riggs-Perla, Director of Saving Newborn Lives at Save the Children; Alicia Yamin, Policy Director of the François-Xavier Bagnoud Center for Health and Human Rights and Kirsten Gagnaire, Executive Director of the Mobile Alliance for Maternal Action (MAMA), presented the health, rights, and technological advantages to integrating maternal and newborn health financing, policies, training, and service delivery.

Why is integration important?

A woman’s health before conception, during pregnancy, and after her baby is born has a direct impact on the health of her child and the rest of her family. “Biologically the health, and the nutritional status, and the well-being of the mother in general strongly influence the chances of survival and well-being of the fetus during pregnancy, the newborn later and even older children,” shared Langer. Since a woman is the primary caretaker of her family, if her health suffers, everyone is affected.

Recent research from Dr. Yamin quantifies this impact. In South Africa, Tanzania, Malawi, and Ethiopia, if a mother dies during pregnancy or childbirth, there is a 50-80% chance that her newborn will die before reaching his first birthday. The impact of the death of the mother also reached far into the future. When a mother dies there are higher rates of family dissolution; early drop out of school, especially for girls; and nutritional deficits.

What are the challenges to integrating?

Although it is easy to see how the health of the mother would directly affect the health of her fetus, newborn and children, integrated care is rarely seen. Maternal health, newborn health, and child health are siloed as separate initiatives across the health care spectrum: from the policy, donor, financing and monitoring levels to the academic, health system, program and NGO levels. But these problems are seen beyond the program and country level. These “challenges also happen at the global level, failing to provide an enabling environment for those changes at the country level to happen. So too often, we see that different initiatives are either targeted to mothers or to babies and don't make a good enough effort to bring them closer together,” shared Langer.

Divisions in providing maternal and newborn health include separate pre-service training in maternal and newborn health for health care workers, rare HIV-testing and treatment of an infant if the HIV-positive mom dies in childbirth and separate global initiatives, among many others. These persistent separations have created a dearth of evidence of how best to implement integrated maternal and newborn care.

Key areas that remain segregated are ministries of health and data collection systems. Joy Riggs-Perla shared that “there's often a separation [of maternal and newborn health] organizationally in a Ministry of Health… That can cause problems with program coordination. It can cause problems where one or the other gets more or less emphasis. And so that can actually lead to problems in service delivery.” In addition, Riggs-Perla addressed the crucial need to collect data on both mothers and newborns so that programs and health systems recognize and synchronize their approaches to improve health outcomes along the continuum of care. “I think the bottom line in all of this is that if people think about care from a client-centered perspective, or a client-oriented perspective, you naturally come to the continuum of care. And that helps solve some of these problems. Too many of our health services are organized at the convenience of the providers,” concluded Riggs-Perla.

An additional barrier to integration may be societal discrimination. “Ultimately maternal mortality is the culmination of layers of structural, and discrimination, and exclusion that women face in society. And often women and children face or experience their poverty and marginalization through their context with indifferent and dysfunctional health systems,” shared Yamin.

How to break silos

In order to provide comprehensive care that benefits both the woman and her child, current silos in maternal and newborn health need to dissolve. MAMA is working to bring integrated information to pregnant women and mothers precisely when they need it. Through mobile technology, both text and voice messages are used to provide timed and targeted information during pregnancy through their child’s third birthday. These messages are specific to the local context and language and include a wide range of information from nutrition during pregnancy and breastfeeding to cognitive development and immunizations for their children.

Another programmatic example is from the TSHIP project in Nigeria, where misoprostol and chlorhexidine are now distributed together by community health workers: misoprostol to prevent postpartum hemorrhage in women and chlorhexidine to prevent umbilical cord infection in newborns.

The panel provided many potential solutions to the chasm in maternal and newborn health:

  • Integrated national costed plans of action: “[Integration is] very, very difficult if it doesn't start at the beginning: once budgets are separated, programs are designed, job descriptions are formed” and integration is nearly impossible – Yamin.
  • Integrated pre-service training of health care providers
  • Integrated performance and health outcome indicators
  • Excluding initiatives that are narrow, categorical and vertical - Initiatives that strengthen health systems
  • Programs that allow for flexibility and learning, both in activities and funding - Diverse partnerships: “We are increasingly finding ourselves needing to work in a partnership way: in public-private partnerships, bringing in UN agencies, bringing in the host country governments, bringing in bilateral funders, foundations and [the] corporate sector. It takes a tremendous amount of aligning of agendas and understanding how each of these different sectors and entities works, and what their perspectives are. [But,] ultimately I think we get better results from it.” - Gagnaire

While these strategies are promising, there is still a lack of research on integration and so information exchange is key. In order to address this need, Dr. Langer shared news of the upcoming Global Maternal Newborn Health Conference, which will “provide a space for information exchange, for productive debate and for discussion about maternal and newborn health and how to bring it closer together.”

For more details from this event, continue to follow our blog this week to hear more details from Joy Riggs-Perla, Alicia Yamin, Kristen Gagnaire, and Ana Langer.

To watch the webcast, visit the event page at The Forum at Harvard T.H. Chan School of Public Health.

By Eleni Capsaskis on March 8, 2015

 This blog was originally published by the London  School of Hygiene & Tropical Medicine MARCH  Centre. Written by Eleni Capsaskis and Dr. Joy Lawn.

 The theme for International Women’s Day this  year is Make it Happen. In every country, people  are coming together to advocate for women’s  rights, opportunities and choices. Today’s  generation is made up of the largest ever  number of adolescents – but what future do they  face? What about the health and hopes of the  next generation?

 On March 4th 2015, the annual GLOW  conference was held at the Royal College of  Obstetricians and Gynaecologists (RCOG) in  London, jointly hosted by the MARCH Centre of  the London School of Hygiene & Tropical  Medicine and the Institute for Women’s Health of  University College London. GLOW (Global  Women’s Research Society) was created in  2012 to bring together UK based academics to  better advance research and also leadership  development. The GLOW 2015 theme was  “Reaching Every Women, Every Newborn: the  post-2015 research agenda” and the first  keynotes looked back to learn, and then looked  forward.

 “I am optimistic about the future,” said Richard Horton, editor of The Lancet as he opened the GLOW conference. “We are in a moment where we can end preventable deaths in women, newborns and children in one generation…Yet stillbirths are still nowhere to be seen”. The powerful opening speech from Richard Horton, The Lancet’s Editor set the tone for day.

The MARCH centre’s director, Professor Joy Lawn, underlined the need to use the data to inform the future of the Sustainable Development Goals (SDGs), ensuring that targets are set based on evidence and can actually be measured. Shifting to a life course approach, with girls and women at the centre is key to moving from a fragmented, win-lose agenda for women’s and children’s health. Plans for women need to also count stillbirths and newborns making the case for a high return on investment.

Other keynote speakers included Dr Matthews Mathai from WHO, Professor Bob Pattinson from University of Pretoria, South Africa and Professor Peter Brocklehurst of UCL, who all provided clear messages that more needs to be done to make change happen. Deaths should be audited and acted on. High quality services remain a dream if we do not measure them and make the systems accountable for these metrics. If we are to make research count, we need to get the right research question.

From the plethora of high quality research submitted, almost 40 posters showed the breadth of research around the world and throughout the continuum of care. The four top abstracts covered a randomised control trial in India for misoprositol, a meta-analysis of using symphysiotomy instead of C-section in low-income settings, near-miss neonatal death audit in Benin, Burkina Faso and Morocco, and the two year follow up of Africa’s largest cohort of neonates with hypoxic brain injury.

The day was not only about words of reassurance. Much of the research presented showed clear gaps in which need to be addressed moving forward if we want to achieve our goals. Innovations are needed along with a plan for implementation change as well as intentional ways to enable leadership. The UK Royal Colleges have a key role to play in enabling research for trainees and specifically in promoting flexibility and more placements for global health training and research. The presence of many obstetric, paediatric and some very vocal midwives really enriched the discussions, as well as high-level college representatives.

The GLOW conference speaks to the values of the MARCH centre which focuses not only on the woman, or the child or the adolescent but on how we innovate and improve health at all stages of the lifecycle.

“The main message of the day is about collaboration, multi-disciplinary research in reality,” says Professor Joy Lawn, reflecting on GLOW 2015. “To make it happen we need to invest in leadership at all levels- and especially in the highest burden countries. Together, we can make huge strides for girls, women and their babies, real change for the next generation. Thank you everyone for making GLOW 2015 an inspiring and energising day.”

To watch the talks from GLOW 2015, please click here.

GLOW conference website, for more information on this year’s presentations, abstracts and posters. See the agenda.

By Ian Hurley on March 6, 2015
Haiti

Shomi, a one-month-old baby birl, was brought into the hospital in Dessalines, Haiti with a case of pneumonia. Dessalines is in the Artibonite Department, northeast of Saint-Marc. In 2013, 5 percent of all newborn deaths worldwide were from pneumonia. Severe infections, of which pneumonia is a part of along with sepsis, meningitis, and tetnus, represent 23 percent of all newborn deaths worldwide. Photo: Riccardo Venturi/Save the Children

The 7.0 magnitude earthquake that struck Haiti on January 12, 2010 devastated an already strained health system. The subsequent outbreak of cholera has infected over 720,000 people and killed almost 9,000. National Public Radio reports that despite these challenges to the health system, Haiti has made progress in childhood vaccination rates and improving access to HIV treatments.

Some segments of the population are still though missing life-saving vaccinations, especially those given immediately after birth. 

Among other indicators, the most recent DHS report in 2012 also shows that family planning has helped to reduce the number of births in reproductive age from 4 to 3.5. Also, Haiti's neonatal mortality rate has declined from from 38 to 25 per 1000 live births from 1990-2013. 

While challenges for Haiti's health system remain clear, it is encouraging to see some RMNCH indicators moving in the right direction. 

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