Dr. Rifat Atun of the Harvard School of Public Health speaks on one of the opening panels during the Integration of Maternal & Newborn Health Care meeting in Boston. Photo: Ian Hurley/Save the Children
Join us over the next two weeks as the Maternal and Newborn Integration Blog Series unfolds. This blog series will dive into the details of the meeting discussions and action items. In addition, meeting participants and speakers will share their reactions to maternal and newborn integration from a variety of perspectives. You can also view this series on the Maternal Health Task Force's blog.
On September 9th and 10th, the Maternal Health Task Force and Save the Children’s Saving Newborn Lives program convened experts in Boston to discuss maternal and newborn health integration. The meeting, “Integration of Maternal and Newborn Health Care: In Pursuit of Quality,” hosted about 50 global leaders—researchers, program implementers and funders—in maternal and newborn health to accomplish the following three objectives:
- Review the knowledge base on integration of maternal and newborn health care and the promising approaches, models and tools that exist for moving this agenda forward
- Identify the barriers to and opportunities for integrating maternal and newborn care across the continuum
- Develop a list of actions the global maternal and newborn health communities can take to ensure greater programmatic coherence and effectiveness
Biologically, maternal and newborn health are inseparable; yet, programmatic, research, and funding efforts often address the health of mothers and newborns separately. This persistent divide between maternal and newborn health training, programs, service delivery, monitoring, and quality improvement systems limits effectiveness and efficiency to improve outcomes. In order to improve both maternal and newborn health outcomes, ensuring the woman’s health before and during pregnancy is critical.
Reviewing the Knowledge Base
Participants work in small groups during the Integration on Maternal & Newborn Health Care meeting. Photo: Ian Hurley/Save the Children
The meeting focused on a variety of themes as global experts led presentations and gathered for small group work to discuss next steps for integration of maternal and newborn health care. While little research thus far has been specifically devoted to maternal and newborn integration, it was shown that great inequity exists among maternal and newborn health interventions and that while about 90% of women receive at least one antenatal care visit, only slightly more than half deliver with a skilled attendant at birth, and about 40% receive postnatal care. These disparities along the continuum of care helped meeting participants identify service delivery points in need of strengthening and optimization to ensure the health of both the mother and newborn. Given the limited knowledge base, leaders were encouraged to strengthen the evidence by engaging in research to identify both the costs, and potential risks of integration.
Opportunities and Barriers for Integration
Overarching themes that emerged while evaluating integration at the meeting included optimization of service delivery points to prevent “content free contact” and the need for efforts to be context specific. There was broad consensus that programmatic and policy efforts for integration need to recognize and reflect the local environment and the capacity of the health system. The meeting concluded that integration should not be viewed as an intervention in and of itself, but rather as a method of reevaluating and designing health systems to effectively provide better maternal and newborn health care, ensure better outcomes, and incur less cost. In approaching integration in the future, it was made clear that some of the most important factors for integration include assessing and understanding contextual factors, as well as anticipating what the woman, family, and health care workers need and want.
Case studies were presented from Ecuador, Nigeria, and the Saving Mothers Giving Life program. Each presenter evaluated approaches for integrating health systems, programmatic strategies, and service delivery in order to optimize maternal and newborn health outcomes. These case studies provided potential models for maternal and newborn health integration in future programmatic efforts.
Actions for Greater Programmatic Coherence
Lastly, and perhaps most importantly, small groups presented action items and next steps to strengthen the evidence for integration and promote integrated care so that no mother or newborn is neglected in programmatic efforts. These action items were created for three levels: facility and service delivery; national policy and programming; and technical partners and donors.
Proposed action items include improving and redesigning health workforce training; ensuring quality improvement; integrating health information systems; aligning global maternal and newborn health initiatives; integrating advocacy tools for maternal and newborn health care; and unifying measurement frameworks.
Nurses and midwives in Pakistanís Sindh province attend a Jhpiego-supported training on Helping Babies Breathe, a program designed to address birth asphyxia and reduce newborn deaths. Photo: Jhpiego
Pakistani nurse revives infant with Helping Babies Breathe techniques
Khairpur, Pakistan–The 36-year-old woman arrived at the Lady Wellington Hospital in labor, exhausted and anxious that her baby would not survive. Abida, the mother of one previous child, had a history of miscarriages and failed pregnancies.
“It was a prolonged labor at home. … The staff performed a vaginal examination and found that she was 10 centimeters dilated but the baby was in distress,” recalls Tasleem Mirani, the only nurse in the labor ward that morning. “I quickly assessed her condition and … prepared her for delivery.”
As Abida gave a last push, “there it was, a tiny baby girl, quite a bundle of joy, except she was pale and almost lifeless,” says Mirani.
The nurse recognized the problem immediately–birth asphyxia, a leading cause of newborn deaths worldwide. Mirani knew she had 60 seconds to resuscitate the newborn before the condition would cause irreparable harm or death. She was among 121 nurses and midwives from Sindh province who had participated in an innovative newborn resuscitation program supported by the U.S. Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego. Helping Babies Breathe (HBB) is an evidence-based program designed to teach resuscitation techniques to midwives in healthcare facilities that lack sufficient health professionals.
Under HBB, the quality of care administered within the first 60 seconds of a baby’s life– “The Golden Minute”–can determine whether or not the newborn will survive.
Although preventable, birth asphyxia contributes to 920,000 newborn deaths a year, approximately 28 percent of the estimated 3.3 million babies who die within the first month of life, according to the Ending Newborn Deaths: Ensuring Every Baby Survives report published by Save the Children, an MCHIP partner. It can lead to serious neurological conditions ranging from cerebral palsy and mental retardation to epilepsy. In Pakistan, approximately 280,000 newborns die at birth, due in part to limited access to skilled birth attendants.
Once Mirani noticed the ashen color of Abida’s baby girl, she sprang into action. She lifted the baby off Abida’s stomach, where she had been placed as part of skin-to-skin contact and mother-to-child bonding, and rubbed the infant’s back.
She used a sucker bulb to remove any mucus clogging the baby’s airways. When that did not help, Mirani cut the umbilical cord and rushed the baby to the labor room’s HBB table, where an Ambu bag — a manual resuscitator — and pictorial instruction chart were waiting.
As the nurse pumped the Ambu bag, the tiny baby girl’s skin began to turn pink and she cried out with life. An exultant Mirani returned the baby to her mother to keep the infant warm. “I was so proud when I gave the crying baby to her mother for skin-to-skin care,” she recalls.
And Abida was overjoyed, knowing that her small family had a new addition–a healthy girl.
A new mother receives breastfeeding support during a postnatal check up in Gowainghat Upazila, Sylhet, Bangladesh as part of the MaMoni Project. Photo: Save the Children
Saturday, September 13th is World Sepsis Day. Pneumonia, sepsis, meningitis, tetanus and diarrhea account for 794,000 (28 percent of) newborn deaths each year. Globally, sepsis also kills 100,000 new mothers each year.
Depsite these grim statistics there have been several promising research studies like the COMBINE study in Ethiopia and the chlorhexidine for umbilical cord care country program in Nepal that are showing signs of combatting newborn sepsis.
From the training perspective, the Global Health Media Project, a partner organization with HNN, produced a video on how health workers can recognize and treat newborn sepsis. Efforts like this can be a boon to health workers who are not able to get easily receive refresher training on how to indentify, treat and refer cases of sepsis.
This World Sepsis Day raise your voice to let you friends, family and colleagues know about just how widespread the problem of sepsis is.
Photo Credit: London School of Hygiene and Tropical Medicine
BMC Pregnancy & Childbirth recently published a study on Competence of birth attendants at providing emergency obstetric care under India’s JSY conditional cash transfer program. In this blog, author Dr. Sarika Chaturvedi shares insights from the study.
Delighted by the success at increasing proportion of facility births in India, especially with the launch of the popular JSY (Janani Suraksha Yojana) program that pays women to access facility care for child birth, many assumed health indicators were bound to improve speedily. However, there came disappointments when national surveys showed decline in perinatal mortality was not as profound as the rise in access to childbirth care. While facility births increased from 30% in 2005 to 73% in 2012 with over 70 million births under the JSY, maternal mortality decline showed a secular trend. This led us to examine what was the missing link between facility births and improved health outcomes. Knowing facility births can reduce mortality through competent emergency obstetric and neonatal care, we set a study to explore if delivering in the JSY program equated to delivering at competent hands that provide lifesaving care in the event of obstetric complications.
At facilities in Madhya Pradesh province in Central India with high maternal and infant mortality, we presented scientifically developed fictitious cases – called case vignettes, to nurse-midwives. We asked them to write what they thought would be appropriate for the nurse to do in the case presented. The cases we presented were for common life threatening obstetric conditions- haemorrhage and eclampsia. We found that two-thirds of the nurse-midwives scored below 35% of the full score. Further, we found only 14% were competent at making a proper assessment of the case, 58% could make the correct clinical diagnosis, while only 20% were competent at providing the required first line care. Moreover, the nurse-midwives were unable to recognise the emergency in the scenario presented and some responses even included harmful actions.
Given the poor competence at caring for common life threatening complications, it is no wonder maternal and infant mortality in India remains slow to decline despite a dramatically improved coverage of institutional care for delivery. Competence of staff at providing care for obstetric complications can make the difference between life and death for several thousand mothers and babies in India. It is now a matter of ensuring staff are ‘able to do’ what is essential to saving maternal and newborn lives.
Improved pre-service and in-service training of staff and ensuring supportive supervision and work environment are essential for improved health outcomes from facility births in India. When ‘what ‘ is done is right, success is determined by ‘how’ it is done; It’s not just doing it , but doing it right that matters.
- Bringing women to facilities for childbirth is not enough to save lives- findings from a study of referral services in the JSY cash transfer program in India
A newborn receives treatment at a government hospital prenatal center in Kurukshetra, India. ©Bill & Melinda Gates Foundation/Ryan Lobo
Dr. Ina Castro describes the typical scenario women with complications from pre-term labor experience when arriving at government hospitals in the Philippines: “The women coming from the rural health facilities in island municipalities have to travel two to four hours by boat. By the time they get to the referral hospital for treatment, it has been too long. And when they finally do manage to arrive, there may be no doctor available in the emergency room, so the patient is not assessed right away.”
The danger for these women’s babies can be great. If born before 37 weeks gestation, they are at risk for various complications, including immature lungs, severe disability, or even death. In fact, death from complications of pre-term birth is the leading cause of newborn mortality in the Philippines and worldwide, resulting in more than one million deaths per year.
However, many of these deaths can be prevented with an inexpensive medication called dexamethasone—a common antenatal corticosteroids (ACS). When given correctly to women who have a complication that can lead to early delivery, dexamethasone acts on fetal lungs, brain and other organs to briefly speed up development. And although the administration of ACS before birth is one of the most beneficial interventions for improving newborn outcomes among women who give birth prematurely, it has been underutilized in most low- and middle-income countries.
With one of the highest pre-term birth rates in the world (at 14.9% in 2010), the Philippines is no different. With this in mind, USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) partnered with the country’s Ministry of Health—in addition to those in Cambodia and Indonesia—for an innovative pilot study to learn how to increase the number of women who receive this lifesaving medicine. The danger for these women’s babies can be great. If born before 37 weeks gestation, they are at risk for various complications, including immature lungs, severe disability, or even death. In fact, death from complications of pre-term birth is the leading cause of newborn mortality in the Philippines and worldwide, resulting in more than one million deaths per year.
Dr. Castro, the study coordinator for the Philippines sites, is encouraged by the early results from the study. This is particularly true of one of the six pilot hospitals—Dr. Paulino J. Garcia Memorial Research and Medical Center—where almost all women at risk of pre-term birth are now receiving dexamethasone. Moreover, the Philippine Ministry of Health has expressed interest in scaling up this important intervention to other hospitals around the country.
According to Dr. Castro, success increasing the use of dexamethasone at this hospital can be traced in part to a policy initiated by the obstetrics department during the study to allow nurses to administer the medicine to women when they arrive at the hospital’s emergency room. Due to the heavy workload in this busy hospital, the doctor on duty may not be immediately available to evaluate the woman and initiate the treatment, causing an unnecessary delay in care. “So allowing nurses to assess women and initiate care based on standard protocols and doctors’ verbal order will help a lot,” Dr. Castro says.
“What we learn from these studies will have substantial implications for reducing newborn mortality in many of the countries where we work,” says Dr. Jeffrey Smith, Maternal Health Team Leader for MCHIP, and the lead for the study. Dr. Smith will share the results and engage partners in a discussion of next steps at an August 4-5 ACS Working Meeting convened by UN Commission on Lifesaving Commodities (UNCoLSC) with support and participation of the Bill & Melinda Gates Foundation (BMGF), MCHIP and key partners (such as Survive & Thrive and Born Too Soon). The objective of the meeting is to advance an implementation package for even broader scale up of ACS, and represents a culmination of partners’ collaborative and multi-faceted efforts in the areas of advocacy, operations research, and resource development to successfully expand the use of ACS.
At this meeting, MCHIP and the Survive & Thrive Global Development Alliance will present a new, simple training module on the use of ACS developed under the Helping Babies Survive and Helping Mothers Survive series. The training materials will use the same approach as Helping Babies Breathe to improve the capacity of providers and advocate for the management of pre-term births using a perinatal team approach—an approach characterized by communication and collaboration in care decisions among newborn and maternal health providers.
While these training materials will go a long way to promoting greater coverage of ACS, challenges remain and more evidence to guide expansion is needed. Recently, in a commentary published in the The Lancet, advocates raised concerns about the efficacy, safety and appropriate gestational age at which to give ACS to patients in low-income countries. MCHIP joined other public health experts—led by Joy E. Lawn of the London School of Hygiene and Tropical Medicine—to address these concerns and call for continued implementation in a response letter published in The Lancet Global Health.
The authors of the letter argued that there is strong evidence about the benefits of ACS and the limited potential harms. Current evidence shows that a single course of ACS can reduce mortality among babies born prematurely by more than 30%, with a very low risk of adverse effects. The letter also addressed the challenge of gestational age assessment, and suggested that when gestational age of an infant is unknown or unclear, the benefits of treatment likely outweigh the risks in high mortality settings.
Through this and other initiatives under way, MCHIP is working in partnership with the BMGF, Survive & Thrive, UNCoLSC and others to advance the use of ACS as an important clinical and public health intervention to reduce newborn mortality. The hope is that these combined efforts—with their focus on collaborative perinatal approaches to care—will allow for the expanded use of this simple intervention by more providers working in hospitals that care for mothers and newborns, thus increasing access to this lifesaving practice.
Dr. Castro summed it up nicely, “Dexamethasone is very inexpensive and the benefits are substantial, so we need to increase its appropriate use.”
 Other components of this perinatal team approach include: standard treatment protocols that are understood, agreed upon, and followed; a perinatal audit system; and regular meetings of the perinatal team to review progress and share individual patient outcomes.
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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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