2014 must be the year of the newborn. As Smith’s recent article states, despite huge strides in child survival, progress during the neonatal period has been disproportionately slow. Inaction is no longer an option – in many countries, persistently high rates of newborn mortality will hold countries back from attaining their Millennium Development Goal (MDG) 4 targets. Looking forward, beyond 2015, as we raise ambition to end all preventable maternal and child deaths, the newborn burden is ever more pertinent. Achieving such gains will require greater political resolve and investment to increase coverage of interventions for those who need them most, while tackling the social determinants of health that shape health inequities. But as the article critically demonstrates, efforts to scale up and sustain coverage must promote complementary and integrated solutions for the sector through strengthening the health system. As such, our focus on newborns must be a catalyst for progress towards universal health coverage (UHC).
A proxy for health system strength
The time of birth and the weeks that follow are when a child is most vulnerable and in need of responsive, quality care. Patterns in newborn survival are a powerful proxy for the strength of the health system, with wide inequities revealing our failure to build robust health systems that ensure all expectant mothers are in reach of a health worker who is appropriately trained, skilled, equipped, supported, remunerated and motivated to meet her needs and those of her newborn baby. Inadequate, ineffective and inequitable health financing, leave the system weak and underfunded and place the burden of ill-health on those most vulnerable and in need, causing an estimated 100 million people to face impoverishment each year.
As countries endeavour to improve newborn survival they will need to address the systemic bottlenecks that impede access to quality care. Progress for mothers and newborns will require comprehensive primary health care systems with referrals that provide integrated care across the two continuums (house to hospital, and reproductive through childbirth to childhood). This will bring value for money with benefits felt during the first month of life and beyond.
A catalyst for UHC
UHC is a concept that links the objectives of scaling up coverage of quality needed interventions and preventing financial hardship whilst doing so. It critically involves the removal of user fees for essential services and increased cross-subsidisation through mandatory and progressive prepayment. It also helps us to move away from thinking and acting in silos within the sector – a danger the article clearly highlights. Comprehensive primary care – that is sufficiently and equitably resourced, and free at the point of use – may be a first step towards UHC.
If our objective is to improve equity in health outcomes of the newborn and its mother, improved nutrition and a focus on the most vulnerable are no doubt imperative. But the current modus operandi in health fosters competition and silos, as expressed by Smith, when discussing the case of newborn survival in Bolivia: “Morales’ presidency came with an agenda promoting the social welfare of the very populations most affected by newborn health problems (poor, rural, indigenous). How could political priority for newborn survival decline in this context?” We must learn to leverage such opportunities to realise our ambition for the newborn baby and his or her family. The basis of UHC in the human right to health has great appeal and we must find ways to seize the potential of sub-sectoral priorities to galvanise progress towards UHC. The Every Newborn Action Plan, which will go through the World Health Assembly in May next year, presents an opportunity to shift gear and accelerate progress towards MDG 4 and beyond.
Time to strengthen accountability
We need increased political will backed with sufficient resources to achieve this. As the article documents, political champions and priorities present both a contribution and challenge to our plight. As fast as they raise the profile of an agenda, attention can turn. This volatility underscores the importance of strengthening accountability. Here the role of communities and civil society organisations is crucial. We’ve seen the potential of health budget advocacy to empower civil society to hold governments accountable for promises, policies and plans. The article cites the pivotal role of evidence to force attention to an otherwise silent scandal – whether it’s survey data or a budget analysis.
When a mother or her baby dies in the act of giving life, the world must hear. Ending this injustice requires political will, strong systems and accountability.
Photo: Evan Shuurman/Save the Children
Just over two years ago the world was celebrating the birth of a Philippine baby girl, Danica, the world’s 7 billionth person. Today we find hope in the stories of Yolando, Jolie and of Bea Joy. We mourn with those families whose babies have not survived, and those who have brought new life into the world amidst much loss.
In the Eastern Visayas region of the Philippines around 60% of women give birth without a skilled attendant present. However, many women in the devastated Tacloban, the region’s most urbanized city, would have been planning for a facility birth when the storm hit. Instead, new mothers like Jolie’s gave birth in an abandoned concrete building with only a midwife present. An estimated 200,000 pregnant women have been affected and are at risk.
Mothers and babies already in the hospital at the time of the disaster have had to move vulnerable babies to makeshift wards with little equipment, unhygienic conditions, and overburdened healthcare workers. Maternal stress is a known contributor to preterm labour and it is plausible that the storm contributed to an uptick in preterm births during a week when communities across the globe observed World Prematurity Day. The humanitarian community and the Philippines national health system is struggling to cater for the needs of premature babies in the typhoon-impacted areas. With incubators unavailable and water supplies compromised, support for mother-led interventions like Kangaroo Mother Care and early and exclusive breastfeeding are more needed than ever.
As Save the Children Philippines Deputy Country Director Ned Olney told CNN, pregnant women and newborns are most at risk. “Anywhere in the world the first day of life is the most dangerous day of your life,” he says, “and in a situation where there is little medical care, no clean water, and no electricity, no antibiotics, and very few doctors and nurses, it’s really a crisis statement that a newborn could survive there.“
While the setting is undeniably more challenging, the interventions for the major causes of newborn mortality—prematurity, intrapartum-related deaths, and infection—don’t change in humanitarian crises. The need for efficient, rapid implementation coupled with information and innovation just becomes even more pressing. In stressed health care systems, low-tech interventions like Kangaroo Mother Care are essential.
Recognising the vulnerability of every newborn, and noting the lack of specific guidance for newborns in humanitarian crises, an inter-agency collaboration including representatives UNFPA, UNICEF, WHO, the U.S. Centers for Disease Control and Prevention (CDC), Columbia University, Save the Children, the Women’s Refugee Commission and World Vision have come together to address this important gap. The forthcoming field guide and tools are intended to be used in concert with the 2010 Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (IAFM) and The Sphere Handbook as well as other tools designed to strengthen maternal, newborn and child health services in emergencies.
This work galvanizes efforts to ensure that life-saving care is available even in the most difficult of circumstances. Many of these deaths could be prevented if women can access care for themselves and their babies and if health workers are enabled to deliver these services, particularly at the time of birth and during the first week of life. The current disaster in the Philippines reminds us the critical role of disaster preparedness for both communities and health facilities and the need to safeguard care for newborns and their families.
- Related Blog: Typhoon Haiyan: He is a Miracle Baby
In Istanbul, Turkey, a city where East meets West, and emblematic of our challenge to meld state-of-the-art science with age-old parental instincts to provide newborn children with food, warmth and love, a group came together in October, 2013, to “bend the curve” on newborn survival through acceleration of adoption of Kangaroo Mother Care (KMC). Perhaps the blending of cultures all around us in that ancient city provided a clue to what must take place in the realm of KMC acceleration.
Over the last 35 years, evidence has amassed that KMC promotes maternal-infant bonding and physiological stability in the newborn, facilitates breastfeeding, provides warmth, reduces the risk of serious infections and mortality of premature infants by about 50 percent. If universal KMC coverage is achieved, it is estimated that it could save 450,000 preterm newborns each year. Yet current global coverage of KMC is less than one percent.
This is a travesty. It led the Maternal, Newborn and Child Health team at the Gates Foundation, together with Save the Children's Saving Newborn Lives initiative, to convene more than 20 organizations representing governments, multinational organizations, non-governmental organizations, donors, civil society and academic institutions to address the fundamental question of what barriers we need to overcome, and what it will take collectively to drive the acceleration of coverage with this critical practice.
"If universal Kangaroo Mother Care coverage is achieved, it is estimated that it could save 450,000 preterm newborns each year."
At the meeting, we all agreed that any efforts to promote a practice that is both feasible for mothers and effective for newborns must put the mother and her baby at the center. We must better understand local social and cultural contexts, so that we can better work with mothers, families, communities, traditional leaders, health practitioners and governments to create an environment that links care in the hospital with behaviors in the community; and empowers and supports the practice of KMC as a norm.
We all agreed that going forward and reaching scale was critically dependent on our ability to effectively integrate KMC into reproductive, maternal, newborn and child health and nutrition programs with a collaborative and coordinated global effort that includes governments, civil society, nonprofit organizations, communities, families and most importantly mothers. Paramount to our success will be our ability to unify around clear goals, targets, and indicators. KMC is not a “poor person’s alternative” to good medical care, but represents a powerful evidence-based, standard-of-care for premature babies.
We came together at this crossroad and emerged with broad consensus on action, captured in a Consensus Statement that is newly published in The Lancet as a first concrete step to act on our resolve to be held accountable for taking these principles forward rapidly to improve care for mothers and their newborns across the globe through acceleration of uptake of KMC. A multi-stakeholder group is now actively shaping these principles into a global strategy to bend the curve on KMC adoption as part of the Every Newborn Action Plan that will be launched in May 2014 in conjunction with the World Health Assembly.
As plans roll out and policy and program shifts are negotiated, and questions of “how” emerge, it will be critical to move beyond the walls and halls of our institutions and keep mothers and newborns, and the context in which they eat, sleep, and live at the center of all we do. For Kangaroo Mother Care, it was most fitting that in Istanbul, Turkey, the city which bridges East and West, we similarly embarked on a journey to bridge evidence to action.
This blog was originally published in Care2. Written by Phil Carroll.
Today marks the 3rd annual World Prematurity Day. Since its founding, much awareness has been raised about the risks associated with being born preterm, but the fact remains that prematurity is still the leading cause of newborn deaths worldwide.
And it’s getting worse.
Preterm birth rates around the globe are increasing and are now responsible for 35 percent of the world’s neonatal deaths; the condition is the second-leading cause of death among children under five, after pneumonia.
One of the striking things about prematurity is that it’s not just an “over there” problem. In fact, here in the U.S. the problem remains more common than in most other industrialized nations.
I experienced this first-hand just last week. I was in Kenya for a work meeting, and during a routine check-in call with my family, I was told that my pregnant cousin, whose due date was around Christmas, had just delivered a baby boy – a full six weeks early.
Having worked in the public health field for most of my career, I immediately knew how dangerous the situation was and felt helpless that I was literally halfway around the world and couldn’t be with my family.
I also knew that, according to research released today in Nature, her baby, because he was male, was more at risk of death and disability than had my cousin given birth to a girl.
According to Save the Children’s Joy Lawn, M.D., PhD, the team leader of the new research, “these disabilities range from learning problems and blindness to deafness and motor problems, including cerebral palsy.”
Luckily, because my cousin acted swiftly and had access to a top-notch hospital, both she and her new baby are doing just fine today.
Women like her in the developing world are not as lucky, but they still have access to low-cost, high-impact interventions that can save their babies’ lives. Kangaroo Mother Care, for example, a simple process of keeping babies skin to skin with their mothers, has been estimated to save up to half a million newborns each year if it was promoted everywhere.
Please take the time to signal your support by joining the World Prematurity Day Facebook page and tell our world leaders that while too many babies are still being born too soon, they are not born to die.
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)
Every year, 15 million babies are born too soon – that’s 1 in every 10 births. Preterm birth is the leading cause of newborn deaths globally, affecting every country; it’s the leading cause of newborn deaths in the U.S. and many other high-income countries, but the burden disproportionately affects Africa and South Asia, where 60% of the world’s preterm births occur.
On World Prematurity Day, it is important to highlight areas where important progress has been made for preterm babies and identify some emerging priorities for improving the quality and effectiveness of their care, especially for the parts of the world most affected by preterm death and disability.
An important progress point is an improved definition of prematurity that shifted from a weight-based, to a gestational-age based, focus. Earlier definitions of prematurity used weight (i.e. if a baby weighed under 2500 grams) as the measure of whether a baby was premature or not, which fails to capture developmental progress achieved through gestational age. Now, by defining preterm birth as a birth before 37 weeks, an important distinction is made between small babies and premature babies.
There has also been progress in developing interventions for preterm babies, such as antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth, appropriate use of antibiotics, and Kangaroo Mother Care, to provide low-cost and effective care for babies born prematurely. Sustained conversations around scaling up the implementation reflect a growing consensus that these interventions improve preterm health outcomes in a diversity of settings. Recent commitments from Malawi, Uganda and India to prioritize preterm and essential newborn care are all promising developments.
In addition to innovations in managing preterm birth, increasing attention is being paid to preventing preterm birth through investment in maternal and preconception health, particularly through attention to risk factors such as birth spacing, infections like HIV and syphilis, and maternal weight.
Yet, rates of preterm birth continue to rise.
More progress is needed to effectively manage and prevent preterm births across the globe. Many groups and organizations are engaging with this agenda – amongst them is the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st), an international network of researchers that has studied fetal and newborn growth in eight global study sites. With improved understandings of growth and development central to the mission of the Consortium, this group has gathered evidence that will inform a series of new tools, guidelines and standards that will support clinical decision-making when it matters most to preterm babies.
These tools will include:
- A new, international equation for estimating gestational age through ultrasound
- An evidence-based phenotypic classification system that will include a more nuanced definition of prematurity and better management guidelines for preventing preterm birth
- New fetal and pre-term specific growth charts for more accurate monitoring and improved decision-making
These innovations will contribute to the range of international collective efforts being made to improve the management and prevention of preterm birth around the world. More information about the INTERGROWTH-21st Project can be found in a special BJOG supplement on the study’s methodology. You can also read more about developing these universally-applicable standards and what went into managing such a large-scale research project.
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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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