Addressing Critical Knowledge Gaps in Newborn Health

Blog

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. 

Related Resources

By Carol Bales on March 3, 2015
Ghana
Africa

Photos: Carol Bales/CapacityPlus and IntraHealth

Interviews conducted by Carol Bales and Gracey Vaughn. This feature originally appeared on the CapacityPlus website. CapacityPlus is a global project funded by the US Agency for International Development and led by IntraHealth International.

An accident. A car wreck on the roadside in Kumasi, Ghana. A pregnant woman cut, injured. Ave Maria Quist rushes over to help.

“I applied pressure to the part that was bleeding, and I called for an ambulance,” she says. “Then we took the woman straight to the hospital for further treatment.”

Ave Maria is a midwifery student at nearby Garden City University College. The injured woman was lucky Ave Maria had the skills to help her. Almost 2,000 Ghanaians die every year from injuries caused by road accidents, which are one of the top ten causes of death in the country. But the woman also faced another life-threatening risk: having a baby.

The 2014 State of the World’s Mothers report ranks Ghana as one of the worst places in the world to be a mother (150 out of 174 countries). Women in Ghana face a one-in-68 lifetime risk of dying in childbirth.

Ghana needs more midwives

The country desperately needs more skilled birth attendants to improve maternal health. Only 54% of births are assisted by a trained health worker. Ghana has fewer than half the minimum amount of doctors, nurses, and midwives recommended by the WHO for adequate access to care.

Garden City, a small but rapidly growing private school, recognizes the need to educate more students like Ave Maria. It started a new bachelor of science program in midwifery in 2014, enrolling 65 students in the first year.

If Ave Maria and all her classmates go on to become midwives, together they will provide care for 7,000 more women every week (based on the estimate that a public health midwife in Ghana provides services for 119 clients each week).

And it’s not just safe maternity care they will provide. Midwives play an important role in reducing mother-to-child transmission of HIV and counseling mothers about family planning. Ashanti Region, where Garden City is located, has the second largest HIV epidemic yet reports the lowest coverage (24%) for HIV testing and result reporting. In 2009, only about one-fourth of HIV-positive Ghanaian women and a fifth of their babies received antiretroviral therapy to prevent new infections. Midwives can help change that. They can also address Ghana’s 35% unmet need for family planning. Midwives are trained to describe potential side effects of and dispel myths about contraception and offer a wide range of contraceptives.

Private health professional schools can fill the gap

Private schools like Garden City are expanding rapidly and helping to graduate more health workers. “What the public sector is producing is woefully inadequate,” says Dr. Wilhelmina Donkor, the school’s acting president.

With health training needs only increasing and developing-country budgets not keeping pace, private-sector schools will soon produce more health workers than public-sector institutions.

Garden City’s midwifery program builds on its nursing program, which started in 2007. So far, 340 nurses have graduated and 138 more are expected to graduate this year.

Now Garden City is one of the first schools in the country to offer a bachelor of science degree in midwifery, targeting the population’s health needs and providing a viable career path for midwives—a cadre that previously had few academic and professional opportunities for advancement.

“Midwives were stuck at being registered midwives because they didn’t have any mobility,” says Dr. Donkor. “So over the years when the young ladies started to go to school, they didn’t choose midwifery because they knew they would be stuck there.”

Bottlenecks, best buys, and school management

Health professional schools around the world play an important role in developing a competent workforce that can help achieve national health goals and universal health coverage. But like Garden City, many of these schools have limited resources to scale up their programs.

IntraHealth's CapacityPlus project is partnering with Garden City and 29 other schools in sub-Saharan Africa to apply innovative approaches for graduating more health workers.

Garden City used CapacityPlus’s Bottlenecks and Best Buys Approach. This new tool helps school leaders assess their current production capacity and identify bottlenecks that are keeping them from scaling up the quality and quantity of graduates and define best buys that have the largest potential for overcoming constraints with the least amount of additional cost.

The school also used CapacityPlus’s forthcoming School Management Package, a set of tools for improving the use of existing resources through examining and refining current management practices.

School leaders identified 47 practices that could be improved, prioritized them according to long-term goals, and worked to streamline management processes in the priority areas. After a year, they used the School Management Self-Assessment Tool to reevaluate the management processes.

The School Management Package includes guidance for modifying DHIS 2 (an open source and freely available software) into a “Dean’s Dashboard” that will allow deans and other school officials to produce graphical reports and quickly gauge progress toward goals.

Big changes

Garden City chose a handful of priority goals, and is already making good headway on meeting many of them.

  1. Increase student applicants and enrollment
    The school developed and began executing a marketing strategy (a best buy) to increase the number of applicants. The school nearly doubled the number of students that enrolled in August 2013 from the previous year—a record number of 850 students. “I have people in the field doing outreach, talking to students who will be graduating from the secondary schools,” says Dr. Donkor. “They also visit social groups in the churches, in the mosque. They’re taking it to the grassroots and letting them know what we have here, that we are a viable alternative.”
     
  2. Gain accreditation for new programs
    In addition to obtaining approval to start the bachelor of science in midwifery program, the school gained accreditation for additional bachelor of science programs for lab technicians and medical assistants, other types of health workers that are in short supply. “We are the only private university in Ghana that is even offering a medical laboratory technology program,” says Dr. Donkor. And in December 2014, the school gained accreditation for a master’s in nursing program.
     
  3. Improve the recruitment and retention of high-quality faculty
    The school implemented a competitive, competency-based process for recruiting staff. Dr. Donkor was hired through this process.
     
  4. Monitor progress toward management goals using a visual reporting system
    The school needed to gather data before it could use a system like a Dean’s Dashboard. CapacityPlus collaborated with the school to identify an appropriate faculty and student tracking system, called SARIS, and the school has already started using it. The school also appointed a data quality manager to improve data collection and use.

Ave Maria’s goals

After Ave Maria graduates and passes her licensing exams, the Nursing and Midwifery Council of Ghana and the Ministry of Health will offer her a position in a health facility or hospital. She says she loves helping women get through labor safely and deliver healthy babies, and she’s got big plans for the future.

“My plan is to do my national service and practice as a midwife for a year or two—and then apply for my master’s.” Next she’ll seek funding to open her own maternity clinic to save the lives of more mothers and babies.

By Leith Greenslade on March 2, 2015
India, Nigeria, Pakistan
Africa, Asia

In a powerful statement of support for a new push to prevent preterm birth, more than 50 organizations came together in New York City on February 18th, 2015, to discuss the first public-private partnership to prevent preterm birth, with an initial focus on the three countries where one third of all preterm births and an astounding half of all newborn deaths from preterm complications occur - India, Nigeria and Pakistan.

Co-hosted by the March of Dimes, Every Preemie—SCALE and the MDG Health Alliance, the meeting attracted wide representation from the reproductive, maternal, newborn and child health and development sectors and fields of infectious and chronic diseases, disability and nutrition. The United Nations, non-government sector, private foundations, academic institutions and corporations were all represented at the table.

Participants were welcomed by Dr. Chris Howson from the March of Dimes, a longtime advocate for a greater focus on prevention in maternal and child health, Judith Robb-McCord, who leads the new USAID funded initiative, Every Preemie—SCALE, to expand uptake of interventions that can reduce the burden of preterm birth and low birth weight in 24 USAID priority countries, and Leith Greenslade, a Vice Chair at the MDG Health Alliance, which catalyzes new initiatives with the potential to dramatically accelerate achievement of global health goals.

 Chris Howson outlined how a greater focus on preventing  preterm birth was critical to the achievement of the new  global  goal of “ending preventable newborn deaths” by  2030, and  would also contribute reductions in rates of  maternal death,  stillbirth and other causes of mortality and  disability such as  congenital disorders, as many adverse  maternal and birth  outcomes share risk factors including  early or advanced  maternal age, certain infections, non-  communicable diseases,  and nutritional insults.

Judith Robb-McCord emphasized that as preterm birth is now the #1 cause of death for children under five, new approaches and much greater collaboration within the reproductive, maternal, child and adolescent health community and beyond is needed to achieve results. Drawing parallels to the successful prevention agendas in the areas that have achieved the strongest results under the MDGs (i.e. malaria, diarrhea, pneumonia and HIV/AIDS), Leith Greenslade called for a robust preterm birth prevention agenda prioritizing the populations of women where preterm deaths cluster.

Speaking on behalf of the UN Secretary-General’s Every Woman, Every Child movement, Natalie Africa welcomed a public-private partnership to prevent preterm birth as advancing the aims of the movement as it transitions to the post-2015 environment. Mary Kinney from Save the Children and Lori McDougall from the Partnership for Maternal, Newborn and Child Health, representing the Every Newborn movement, both acknowledged the need for a greater focus on prevention and welcomed the new partnership as part of the global efforts underway to implement the Every Newborn Action Plan.

Presenting the current state of the evidence for prevention, Dr. Jim Litch, from the Global Alliance to Prevent Prematurity and Stillbirth and Every Preemie—SCALE, cited a wide range of factors that increase the risk of preterm birth including sexually transmitted infections, tobacco use, depression, intimate partner violence, anemia, diabetes and hypertension, malnutrition and micronutrient deficiencies, and adolescent pregnancy and short birth intervals. He concluded that targeted investments in these areas would not only reduce preterm birth rates but also reduce stillbirths, newborn deaths and low birth weight babies and have a sizable impact on reducing the many costs associated with the delivery of care for premature babies. Dr. Litch emphasized that preterm birth is a complex challenge that requires increased investment to better understand what works and could be scaled-up in low resource settings to prevent preterm birth, manage preterm labor, care for preterm babies and nurture wellness through early childhood.

The Public-Private Partnership to Prevent Preterm Birth aims to halve the rates of preterm births among specific sub-populations of women and girls in India, Nigeria and Pakistan by targeting the leading risk factors for spontaneous preterm birth identified in the landmark 2012 Born Too Soon report. These factors, include (1) Lifestyle+, (2) Infection, (3) Nutrition and (4) Contraception. See the chart below for a more detailed explanation of each of the “LINC” factors. Acknowledging that we need to know much more about the specific causes of preterm birth among specific populations of women, the Partnership will proceed with the evidence that we have and act as a platform to try new approaches and test innovation all the while contributing to the development of more robust evidence base.

The partnership will undertake three major activities:
(1) Population-specific roadmaps outlining five year strategies to achieve target reductions in preterm birth rates based on local assessments of preterm birth prevalence, mortality and disability, prevalence of LINC factors and coverage of interventions; with performance milestones and target outcome indicators.

(2) Premature Birth Report Cards, modeled on those issued annually in the United States by the March of Dimes, to measure progress in reducing the preterm birth rate and newborn deaths from preterm complications in each target region; rating local performance on the priority LINC factors for wide media and public circulation.

(3) Targeted, high saturation, mass media, interpersonal and mobile communication campaigns to educate women, their families and health professionals about the dangers of preterm birth and how to reduce risk by intervening on the LINC factors and increasing healthy and care-seeking behaviors for specific pre-pregnancy and prenatal services.

Locally-led multi-stakeholder teams with representation from governments, civil society, professional associations and corporations would lead each of the three efforts, and advocate for their endorsement and implementation by governments and other key stakeholders, supported by a Global Steering Committee.

The partnership was welcomed by leading representatives from existing multi-country maternal and newborn initiatives, including the Global Preterm Birth Initiative, Survive & Thrive, Saving Newborn Lives, the Maternal Health Task Force, the Newborn Foundation and Women Deliver, and by a number of professional associations including the International Federation of Gynecology and Obstetrics, the International Confederation of Midwives, the International Pediatric Association, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Importantly, representatives from the nutrition, contraception, chronic disease and disability sectors expressed their support (1000 Days, Family Care International, Guttmacher Institute, World Diabetes Foundation, Handicap International). Leading corporations in attendance, including Johnson & Johnson, Becton Dickinson, GlaxoSmithKline, DSM, Hygeia, Medtronic and Novo Nordisk embraced the opportunity to join forces with a broader group of actors to prevent preterm births.

All participants acknowledged the fast pace of change since the Global Report on Preterm Birth and Stillbirth in 2010, the landmark Born Too Soon Report in 2012 and the Every Newborn Action Plan in 2014, but agreed that the pace of change needed to be even faster with preterm birth rates rising in most countries. All agreed that with a new Sustainable Development Goal of ending preventable deaths just around the corner, efforts to prevent preterm birth and its associated mortality and disability need to accelerate now

A Global Steering Committee is now in formation, chaired by the March of Dimes, to develop the proposal and launch the partnership later this year.

If you would like to be involved in the partnership, please contact Chris Howson at the March of Dimes on CHowson@marchofdimes.org

Presentations from the meeting, the concept note describing the Partnership and the presentations by Jim, Leith and Chris can be found here.

Photo: Maternal and Newborn Heaith in Ethiopia Partnership

By Joy Marini on February 27, 2015
Uganda
Africa

Photo: Mark Tuschman/Johnson & Johnson

This blog was originally published in The Huffington Post Global Motherhood. Written by Joy Marini.

Each International Women's Day, the global community pauses to reflect on women who inspire. Sometimes these women are famous, sometimes they are historical -- but just as often they are seemingly regular women you've never read about in a newspaper or text book.

On a recent field visit with Save the Children in Uganda, I was inspired by Eva and Damalie, two midwives who face incredible challenges, yet still dedicate themselves to helping others. As I reflected on my time spent with these women, it occurred to me that no matter the country or circumstance, women who inspire share five common traits.

1. They have purpose. Even facing incredible challenges, inspiring women forge ahead with the confidence that they are making a difference. On a sunny morning at the Nakaseke District Hospital in Uganda, I met a midwife named Eva. On the day that I arrived, the hospital had not had running water or electricity for two weeks. This is all too common in Uganda, where the infant mortality rate is 44 deaths per 1,000 live births. Even without those basic necessities, Eva arrived every morning full of hope that more women would come to the hospital to deliver their babies.

2. They believe in what they are doing. Women like Eva are not afraid to challenge the status quo, even at personal or professional risk. That morning, as Eva and I stood by a bedside admiring a mom with her new baby Michael, she revealed that the baby had been in trouble during his birth the night before. Following a long and difficult labor, he emerged quietly, not breathing. The physician sadly shook his head, believing the baby was dead. Eva stressed that the baby was alive and began using the skills to revive a baby that she learned in Helping Babies Breathe (HBB) training provided by Save the Children, the American Academy of Pediatrics, USAID and Johnson & Johnson. Earlier that morning, Eva proudly pulled the doctor into the maternity ward to see healthy baby Michael breastfeeding.

3. They have empathy. They feel an obligation to help others. Damalie Mwogererwa is a Ugandan midwife who always wears a wide smile on her face. She reminisced about a decade of working in the delivery room without adequate equipment or knowledge to save the lives of mothers and babies. "We didn't even know that we could do something else," she said, "I felt like I was delivering babies to die."

4. They encourage others. Both Eva and Damalie love sharing knowledge with other midwives. After learning the newborn resuscitation skills in HBB, Damalie enthusiastically began training other midwives. "I want to train other people so that we build the capacity... and we cause change." In addition to training others, Damalie and Eva motivate their colleagues by example. "We had many neonatal deaths" before the HBB training Eva explained. "Since I've resuscitated many and I've seen them surviving, I'm so confident when doing it." That confidence is infectious and motivates her colleagues to believe that change is possible.

5. They think big. Inspiring women aren't discouraged by how things are now. They have a vision for the future. In Damalie's words, "We can change the trend of newborn death in Uganda." With each newborn saved and each midwife trained, Eva and Damalie inspire those around them to work for a brighter future. And I'm no exception. This International Women's Day and every day, I am inspired to improve the lives of mothers and children.

Editor's Note: Johnson & Johnson is a sponsor of The Huffington Post's Global Motherhood section.

By Kathryn Millar on February 26, 2015
Africa

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

 As we reflect on lessons learned from the MDGs and set strategies for  improving global maternal health, it’s time to identify what has worked  and what more is needed to not only avert preventable maternal deaths,  but also provide quality health care for every woman.

 In a paper published today, Tamil Kendall, a post-doctoral fellow of the  Maternal Health Task Force, summarizes priorities for maternal health  research in low- and middle-income countries based on three broad  questions she asked 26 maternal health researchers from five  continents:

Critical maternal health knowledge gaps

“We know what to do. But the interactions between the interventions and the health system have not been studied”

The most prominent knowledge gap that remains is implementation research for health systems strengthening. Not only do we need to identify the most effective ways to deliver, scale up and sustain both basic and comprehensive emergency obstetric care, especially for postpartum hemorrhage and pre-eclampsia, but implementation research is needed to ensure we deliver the right packages of care at the right levels of care.

Other priorities:

  • Improving the quality of maternal healthcare
  • Improving the quality and availability of information about maternal mortality
  • Supporting women’s empowerment Increasing the availability and uptake of contraception
  • Increasing access to safe abortion services
  • New treatments for major causes of maternal deaths

Neglected and crucial issues

“The human resource crisis.”

The most neglected and crucial issue identified is strengthening the health workforce, another health systems issue. This topic is broad and includes assessing ideal models for task-shifting, training, supervising and assessing the competence of private or unregulated providers. In addition, other priorities are both global and region-specific:

  • Preventing and eliminating disrespect and abuse
  • Over-medicalization of birth
  • Demand generation for facility births, especially in Africa
  • Maternal morbidities

Future directions for implementation research

“Over and above medicine, we cannot forget about the socioeconomic situations­—poverty and inequity—that lead to morbidity and mortality.”

While globalization has affected the rising per capita income in many low- and middle-income countries, deep inequities still exist. What’s more is that measuring equity can be elusive. Researchers called for improved measures and better data to allow us to narrow equity gaps. Specifically, adolescents may suffer some of the most inequitable care, which include higher rates of obstetric complications and poorer neonatal health outcomes.

Future directions for implementation research:

  • Increasing burden of non-communicable diseases
  • Urbanization
  • Information and communication technologies to enhance maternal health
  • Translating knowledge about the developmental origins of health and disease into practice
  • Geopolitical factors influencing maternal health

To read more details about the way forward for research and programs in maternal health, access Critical maternal health knowledge gaps in low- and middle-income countries for post-2015: Researchers’ perspectives.