Addressing Critical Knowledge Gaps in Newborn Health


By Petra ten Hoope-Bender on June 18, 2014

This blog was originally published by MamaYe. Written by Petra ten Hoope-Bender.  

What if you had all the evidence, data and considered arguments you needed to make the strongest case to government, donors and decision makers to invest in midwifery services? What would the world be like? How many women and babies would live who would otherwise die without access to these life-saving health professionals?

This ideal world is a long way off, unfortunately. Collecting detailed information across a wide variety of settings, where resources are often scarce, always makes for an incomplete picture.

However, the Lancet Series on Midwifery will go a long way to helping make the case that investment in midwifery is a highly effective way of improving a nation’s health, as well as just the right thing to do from a woman’s perspective.

So, the stage is set, the data collected, the evidence peer reviewed. The audience are waiting in anticipation to hear from the authors of the Lancet Series on Midwifery, all of us lined up to encourage the whole audience to take action. This was our rallying cry – let the Lancet Series set new standards of care and new stimulus for action.

We were a panel of women who have come together to help deliver this vital action, with chair and colleague Jim Campbell in the middle:

From left to right: Professor Caroline Homer, Associate Professor Rafat JanJim Campbell, lead investigator Professor Mary RenfrewProfessor Zoe Matthews, and finally me Petra ten Hoope-Bender, series coordinator

The audience gather swiftly to their seats, delightfully keen to hear from us – what is the evidence base? How can we make all women of the world benefit from midwifery services? Why does quality of care matter?

We take it in turns to outline the papers we have authored:

Paper one: Midwifery and Quality of Care, which lays the evidence base for a new Framework for Quality Maternal and Newborn Care from the perspective of women and newborn, as well as setting out short, medium and long term outcomes for health and well being – all important for defining a quality midwifery service and the specific role of midwives.

Paper two: Impact of Scaling Up Midwifery, which takes the framework to create a package of care, a collective of all interventions, rather than considering them in isolation. It means that we can begin to calculate the cost and benefits of investing in midwifery through the Lives Saved Tool (LiST), so that countries can hold and informed and evidence-based policy dialogue

Paper three: Deploying Midwives in High Burden Maternal Mortality Countries, which used experts from a wide range of disciplines, such as economics, statistics and health systems analysis, to outline lessons learnt from countries that successfully deployed midwives and reduced maternal and newborn mortality. Using country case studies as exemplars, it tells a story of what worked and how it worked.

Paper four: Improving Maternal and Newborn Health through Midwifery, which builds on the previous papers to provide the international policy brief for taking quality maternal and newborn care forward and links it into the global SRMNH agenda and the post 2015 discussions.

Separately, but by no means less important, two more papers will be published as well as numerous commentaries – one on Human Rights and Midwifery and one on the Research Agenda. All vital pieces of the jigsaw and embedding midwifery as central to improving health across the world.

Over to the audience, who are very engaged. Lots of lively questions, challenging and relevant, reminding us that midwives want evidence, but need to be able to see how it translates to the real world. The audience are generous with us when we are not able to tell more until publication on 23 June. They collectively promise to pick up the baton when the Lancet Series comes out.

How great to have so many advocates among the midwifery community ready to take action. We feel the enthusiasm of the audience well up while we speak and we leave the room confident that we have an army of midwives willing to be part of its implementation.

I would like to pay thanks to the big crew of 35 international researchers and many more reviewers and supporters who worked with us on the development and special thanks to Zoe Mullen of the Lancet who was a fantastic advocate for the series and for midwifery.

This is only the beginning. Some of the hard work has been done, but it is now over to all of you to use this to make a difference in your country. Keep following @MidwiferyAction or #LancetMidwifery for more information and play your part.

By Kathryn Millar on June 16, 2014

This blog was originally published by Katie Millar on the Maternal Health Task Force blog.

On May 24th, 2014 a critical commitment was made to newborn health: All 194 member states endorsed the Every Newborn Action Plan (ENAP)at the 67th annual World Health Assembly (WHA). In order to set the stage for making newborn health a global priority, The Lancet released their Every Newborn series on May 20th, 2014 during the WHA convening. This series is critical to next steps for newborn health as it provides data on global estimates and causes of neonatal mortality and morbidities, weaknesses in health systems to address these causes, and priority actions for mitigating death and ensuring health.

One of these priority actions is to have maternal and newborn health converge in research, policy, and programming. Adequate maternal care, health and nutrition from before conception through the first 1,000 days of life are essential to fetal and newborn outcomes. This key integration is evident in the ENAP strategic objectives:

  • Strengthen and invest in care during labour, birth and the first day and week of life
  • Improve the quality of maternal and newborn care
  • Reach every woman and every newborn; reduce inequities
  • Harness the power of parents, families, and communities
  • Count every newborn—measurement, programme-tracking and accountability

In order to translate ENAP’s goals into reality, the Every Newborn series identified proven interventions and tools to recommend for scale-up, including new fetal growth standards developed by International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st).

We learn in the Every Newborn series paper, “Progress priorities potential beyond survival” that small babies have the greatest risks of death in utero, during the newborn period, and into childhood. Addressing adequate growth and weight in both fetuses and newborns is essential for decreasing fetal and newborn deaths. Unfortunately there are no global growth standards and the variety of standards we do have is based on live birth data from 1991 in the United States. In order to address this gap, INTERGROWTH-21st is producing evidence-based growth standards for fetal, preterm and newborn growth, as well as a classification system to phenotype preterm, intrauterine growth restricted, macrosomic and stillborn babies according to level of risk. These tools have strong implications for more effectively managing and preventing preterm and small for gestational age (SGA) births.

Developing these tools is one thing, but often countries face challenges in timely implementation of new tools and interventions. As such, INTERGROWTH-21st is also producing supportive resources to aid in the effective implementation of the new growth standards, like a new international equation for estimating gestational age through ultrasound.

With the research and tools INTERGROWTH-21st is creating, we can join with the ENAP to help make this world a better and healthier place for newborns and their mothers.

By Jorge Hermida on June 12, 2014

Photo: American Academy of Pediatrics 

Last week I had the pleasure of participating in and presenting at the Essential Care for Every Baby (ECEB) workshop, on behalf of URC and the USAID ASSIST Project in Addis Ababa, Ethiopia.

The four-day workshop was organized jointly by USAID, MCHIP, the American Academy of Pediatrics, Save the Children, and the Laerdal Foundation. The objective was to introduce nearly 100 delegates from MOHs and cooperating agencies from 10 African countries to this newly developed training program on essential newborn care based on latest WHO guidelines.

It gave me great pleasure to have the opportunity to present and lead discussions about what a quality improvement approach entails, why it’s critical to newborn health, and how the quality improvement approach can be applied to the ECEB protocol to improve its implementation and quality.

Too often health care organizations assume that just by training personnel on a new care intervention it will be widely implemented and that such implementation will be of high quality. In reality, it is much more likely that training alone will result in poor levels of implementation and that quality could be compromised. Thus the basic point I made was that training is one of the inputs –necessary but not sufficient- to ensure improvement in the way care is provided to the newborn.

In addition, several other inputs will be necessary, and what is even more important, is that the actual process of providing newborn care needs to be constantly examined, and its quality measured and systematically improved. This is what a quality improvement approach to ECEB is, and I believe it will result in much higher chances of implementation and quality, and thus any investment in it is worthwhile. 

In leading a small group working session on the topic of measuring the quality of the process of newborn care, I asked participants to identify a feasible indicator related to inputs, one related to process and one related to results in relation to the ECEB protocol, and concrete major obstacles to the implementation of ECEB related to quality. All groups were able to produce important examples of indicators, such as the existence of working scales or vitamin K –for inputs; and the percentage of babies that were correctly classified as having danger signs and given the right antibiotic –for processes. One group even experienced putting together a “bundle” indicator, grouping several actions that need to be taken when preventing disease in a newborn, such as eye care, cord care and giving vitamin K.

A consensus was reached that it is absolutely necessary that a quality improvement approach be included together with the clinical training for successful implementation. For me this was a sign that integrating improvement methodology into the ECEB clinical training package was a success.  The main take-away from the workshop is that clinical training - including the knowledge and skills of health workers - is necessary but not sufficient, and that a method for continuous monitoring and improvement of newborn care is absolutely needed. This was something that was very clear and well accepted by organizations and participants in attendance at the ECEB workshop.

It seemed that the improvement methods and tools we have developed at URC over the course of the USAID Health Care Improvement Project and now through the USAID ASSIST Project were easily understood and manageable by participants who didn’t have a strong background in quality improvement.  And as a result, I believe that quality improvement should and will be linked to the future rollout of ECEB. I hope that we can continue to collaborate to further with this work, including streamlining our USAID ASSIST quality improvement training module to fully integrate improvement science with the ECEB clinical training in the expected rollout of ECEB in Africa and elsewhere.

By Nazrul Islam on June 11, 2014

Pronita Rani Raha of Bangladesh, right, is presented with the 2014 International Midwife Award by Mary Higgins, Board Member of the International Confederation of Midwives, left, and Prof. Joy Lawn of Save the Children, center, at the ICM 30th Triennial Congress in Prague. Photo: Bex Morton/Save the Children

This blog introduces one of the 2014 International Midwife Award winners Pronita Rani Raha. 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, Michaela Michel-Schuldt. 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.

“During my 25 year career as a nurse in Bangladesh, I have seen the importance of skilled attendance at birth and become passionate about caring for mothers and newborns in my country. I have been fortunate to play a part in many happy birthdays, and have also fought for mothers who’ve struggled during childbirth. Today, now that my country has embraced midwifery as an important cadre for improved survival, I am proud to be among the first who are training other nursing instructors and senior staff nurses around Bangladesh to teach and develop the midwifery education program.”

Pronita Rani Raha embodies the promise of a country that is committed to deliver for its women. She aspires to promote the right to maternal health and establish proper midwifery education programs across Bangladesh. As an instructor at Dhaka Nursing College, she firmly believes that the newly developed cadre of dedicated midwives will be able to meet the needs of women in Bangladesh, especially those who struggle to access quality care.   

Pronita Rani Raha, right, looks at photos with fellow 2014 International Midwife Award winner Agnes Kasaigi of Uganda during the ICM Congress in Prague, June 2nd. Photo: Bex Morton/Save the Children.

“The lack of health education and information are some of the main reasons that hamper the sustainability of health services,” reflects Pronita. “But the commitment made by our Honorable Prime Minister to educate 3,000 midwives and employ them in the health care system in Bangladesh by 2015 is coming into action, and I am honored to be a part of this change for my fellow women and their babies.”

Pronita has a clear understanding of what a professional midwife is able to achieve for the well-being of women and their children. She has been involved in the development of the curriculum, syllabus and lesson plans for the three-year diploma in midwifery program. The first two batches of students into the direct entry program is scheduled to give Bangladesh over 1250 midwives by 2015. In parallel, practicing nurses have enrolled in a 6-month advanced midwifery program, and many of them have been deployed to serve mothers and their newborns around the country.

2014 International Midwife Award winner Pronita Rani Raha speaks
at the Every Newborn midwives session at the ICM Congress in Prague.
Photo: Bex Morton/Save the Children.

Pronita devotes six days a week to teaching future midwives and in her free time she is also an active member of the Bangladesh Midwifery Society, which was established just three years ago. “I try to encourage and inspire them (student midwives) to show professionalism, responsibility, and accountability. Not only for themselves and for their career ladder, but for their patients.”

For her active contribution to the improvement of the health and survival of mothers and babies, she has been awarded the 2014 International Midwife Award at the 30th Triennial Congress of the International Confederation of Midwives (ICM).She is leaving the Congress in Prague with a renewed energized about her work. She is more determined than ever to help advance the midwifery profession and continue training Bangladesh’s future midwives. “I’m inspired, even more so than before. I feel more responsible for the profession.”  


By Sylvia Nabanoba on June 10, 2014

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.

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