Addressing Critical Knowledge Gaps in Newborn Health

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By Nnenna Ihebuzor on December 10, 2014
Nigeria
Africa


Photo: Lucia Zoro/Save the Children

This op-ed was originally published in the Vanguard

Faced with the enormous challenge of overcoming Ebola earlier this year, Nigeria now has cause to celebrate. In October, the World Health Organization officially announced Nigeria as free from Ebola. Our nation applied the lessons and resources from our extremely effective polio program to respond to Ebola. And our successful approach to stopping Ebola is now a model for other countries. Nigeria has the chance to lead again to save lives. For every mother-to-be and her newborn child in Africa, this could be a turning point.

Globally, and in Nigeria, we have made significant progress in saving the lives of women and children— more women are surviving childbirth and more children are living beyond age five than ever before. But progress on newborn survival and health has lagged.

Nigeria accounts for nearly one-quarter of Africa’s maternal and newborn deaths. In 2013, 260,000 babies died in our country in their first month of life, and an additional 295,000 were stillborn. Newborns currently account for more than 33 percent of all of our deaths of children under age 5.

We must respond to this crisis. In October, the Ministry of Health, with encouragement and support from our President, First Lady, State Governors and parliamentarians, convened the Nigerian Newborn Health Conference, a high-level advocacy event. At the convening, we addressed the newborn crisis and set in place a plan that will drastically improve newborn survival in Nigeria.

Evidence that was presented from the The Lancet Every Newborn Series showed that by 2025, Nigeria could save the lives of as many as 375,000 mothers and babies each year through proven, cost-effective solutions, quality care delivered at the right time, and focused investments. These interventions can turn the tide for newborns and continue to advance progress for women and children in Nigeria.

Our government responded by making a commitment to newborns and their mothers by signing the Call to Action to Save Newborn Lives, initiating the drafting of the Nigerian Every Newborn Action Plan (NENAP). The NENAP has the potential to be the nation’s most ambitious plan to date to save the lives of mothers and babies who are currently dying at alarming rates. The rest of Africa will be watching. If significant progress in maternal and newborn survival around the time of birth can be achieved in Nigeria, it very likely can be done in their country as well.

Nigeria has proved a leader on health challenges like Ebola, and it is time for Nigeria to lead once more. We have the evidence and we know the strategies needed to create a change that will forever shape the lives of mothers and newborns across our continent. The time to act is now. Let us not miss this moment.

Dr. Nnenna Ihebuzor, is Director, Primary Health Care Systems Development, National Primary Health Care Development Agency.

By Collins Mhango on December 9, 2014
Malawi
Africa


Guest of Honor Dr. Charles Mwansambo, Principal Secretary responsible for health services, speaks at Malawi's World Prematurity Day event in Ntchisi District. Photo: Save the Children Malawi

On Friday, November 28, Malawi joined the rest of the world in commemorating World Prematurity Day. The day commemorated under the theme Effective low cost care can save millions of premature babies, took place in Ntchisi District in central Malawi.

Speaking when he presided over the event, the Principal Secretary responsible for health services Dr. Charles Mwansambo said time had come for government and partners to intensify low cost care to save babies born prematurely across the country. While alluding to the fact that Malawi has done very well in reducing deaths of under- 5 children, Mwansambo was quick to point out that the country still leads in prematurity deaths, hence the need for concerted efforts in dealing with it.

“The government of Malawi is committed to reducing deaths of children born prematurely through the Kangaroo Mother Care method, right now plans are underway to introduce this cost-effective and reliable interventions in all health facilities in the country,” said Mwansambo.

During the event, other speakers encouraged people to take an active role in saving babies born prematurely. Senior Chief Malenga urged his community to ensure mothers attend antenatal clinics and deliver at a health facility, stressing this as the only way complications can be timely detected and dealt with professionally.


Mr. and Mrs. Nkombezi give testimony with their fanmily at the World Prematurity Day event in Malawi. Photo: Save the Children Malawi

Lilly Banda, speaking on behalf of USAID, noted that 75% of children born prematurely can be saved through low cost methods like Kangaroo Mother Care (KMC), encouraging women and caregivers to adopt this practice of placing a preterm baby on continuous skin-to-skin to regulate the baby’s temperature, prevent infections, and facilitate breastfeeding. She said it was encouraging to note that about 144 hospitals countrywide already have KMC units.


Tiyamike Nkombeza, a child who was born prematurity, attended the World Prematurity Day event. Photo: Save the Children Malawi

“Different partners have worked hard to ensure mothers and children are surviving, the time has come for communities to take an active role in the same by embracing the Kangaroo Mother Care method. People should be on the look for one another when a mother delivers a premature baby within the community,” said Banda.

Studies show that each year in Malawi, 18,000 children die before reaching 28 days of life. This translates to 49 newborn babies dying every day. Sadly, these deaths are due to preventable causes that include infections, complications from being born too soon or having low birth weight and difficulty to initiate breathing at birth. At 18%, prematurity remains one of the highest causes of newborn deaths in Malawi. World Prematurity Day was set aside to raise people’s awareness on the importance of sustaining pre-term babies’ survival through provision of concerted and collective support and care.


Health workers give a demonstration on how newborn resusciation and Helping Babies Breathe (HBB). Photo: Save the Children Malawi

Meeting my children for first time through a glass

Every pregnant mother anticipates meeting her beautiful tiny baby after 38 and some 40 weeks. The expectations are so high such that in her ‘me times’ she keeps thinking about what name to give to the baby, and envisions the reaction of her husband or father of the baby upon being told the good news. There is no chance given to “what ifs’, no chance at all.

But truth be told, pregnancy brings with it surprises, both pleasant and unpleasant ones. Nobody plans for the unexpected, it just happens, like it did for Mr. and Mrs. Misi of Ntchisi District. The year was 2011, and this couple was expecting a baby, not triplets as it turned out to be.

“I had been progressing well with my pregnancy until one afternoon when I started feeling so much pain. This was my seventh month and I thought it was just some pain that would eventually go away,” explained Mrs. Misi.

When the pain became unbearable, she decided to go to the hospital where she delivered her first baby with a birth weight of 1.4kgs, the second was born with 1.6 kilos and the last one was born weighing 1.5kgs. All this while, her husband anxiously waited for a call from the hospital, and he received one telling him that there were actually three children who were very small and were to stay in the hospital for some time.

“I was excited, but at the same time scared. I did not know what to do, and when I got to the hospital I was told that I would only see my children through the glass. It was demoralizing” said Misi.

With the help of nurses at the hospital, the family accepted that the boys were human beings that had a right to live just like any other newborn babies. Mrs Misi was taught how to take care of the babies; how to feed them, bathe them, and change their nappies. The Misi family was introduced to the KMC method.


Family of Mr. and Mrs. Misi at Malawi's World Prematurity Day with their triplets. Photo: Save the Children Malawi

The whole family took turns to carry the babies the Kangaroo way when we were discharged. My husband, my mother, and our daughter were all dedicated and they all came in handy when I got busy with other household chores or wanted to get a bath,” explained Mrs. Misi to a very attentive audience at Ntchisi Community ground. We would go for check-ups every two weeks, and my boys were picking up weight and progressing well”, continued Mrs. Misi, before her husband chipped in, “but I did not always find it easy at home. My friends made fun of me, they kept asking my motive behind carrying a baby on my tummy and said I looked funny,” explained Mr. Misi amid laughter from the audience. “This can happen to anyone and I urge my fellow men to take an active role if their wives deliver a baby prematurely”

Despite the barriers, the family continued the KMC method and eventually the children were referred to the Under-5 clinic. Now three years old, they boys are healthy and kept running around as their parents shared their experience. As they played, there was no ‘premature baby’ word inscribed on their foreheads. It was just them - three boys born to Mr. and Mrs. Missi in 2011.

By Tunde Segun on December 5, 2014
Africa


Photo: MamaYe

This blog was originally published by MamaYe. Written by Dr. Babatunde Segun.

We do our job in order to save lives. Originally, most of us became medical doctors or entered into health development in order to do just that. Today, we work as MamaYe directors to save mothers and babies’ lives by raising expectations of survival, working to ensure decision-makers have access to good evidence, and mobilising a grass-roots movement to demand more action on this issue.

We know which interventions are critical for maternal and newborn survival, and we are tracking government commitments towards these in order to deter empty promises. Together, we are a strong African voice speaking up for maternal and newborn survival.

And yet too often, the money that makes it all happen escapes our scrutiny. We know the government has committed to upgrading a certain number of clinics to provide basic emergency obstetric care, but we haven’t checked whether the annual budget has factored this in.

In other countries, persistent advocacy efforts have ensured that rural midwives are entitled to additional compensation, but no one’s verified whether the money was actually disbursed.

There are good reasons for this. Analysis of public financial flows is not our area of expertise, budgets are not accessible or sufficiently disaggregated, expenditure information is released years later.

This needs to change.

Budgets and expenditure are the lifeblood of governments’ actions and are essential for us to understand in order to keep our leaders accountable.

Recently, at the Partners' Forum conference in Johannesburg, our colleague and friend Dr Aminu Magashi Garba launched the first Africa Health Budget Network.


Photo: MamaYe

We believe that this network can catalyse our common voice on health budgets both in our own countries and across the continent. Through this network, maternal and newborn health advocates can partner with experienced budget advocacy groups. Through this network, we can loudly call on African leaders to make budgets transparent.

Through this network, we hope to learn from each other on how to best keep governments accountable for what they promise.

Will you join us?

Signed by:

  • Dr Richard Adanu: Country Director, Ghana
  • Charles Makwenda: Country Director, Malawi
  • Dr Babatunde Segun: Country Director, Nigeria
  • Dr Mohamed Yilla: Country Director, Sierra Leone
  • Craig Ferla: Country Director, Tanzania
By Hema Magge on December 4, 2014
Rwanda
Africa


Photo: Partners in Health. Data Manager Jean Napal Manirahari, in the cream shirt, works with a small group, including a community health supervisor at Gashongora Health Center, at the recent training session.

“When you reduce child mortality, you increase life expectancy. We should therefore collaborate to ensure that no baby dies, because all babies count,” said Dr. Christian Rusangwa, the southern Kayonza district clinical director for Partners In Health’s Rwandan sister organization, Inshuti Mu Buzima (PIH/IMB).

Rusangwa delivered this remark during the initial session of the All Babies Count (ABC) Neonatal Learning Collaborative. In the language of Kinyarwanda, the ABC initiative is known as Impinja Ntizigapfe, which comes from a community folk song about a mother's wish that no baby ever die.

Launched in October 2013, ABC is a collaboration between IMB and the Rwandan Ministry of Health to reduce the country’s neonatal death rate through training and mentorship, systems-strengthening initiatives, and quality improvement strategies. This holistic approach is creating change throughout the health care system, from the community to the hospital level. The program was first implemented in two rural Rwandan districts, with two district hospitals and 23 health centers serving approximately 500,000 people.

Although Rwanda has achieved unprecedented reductions in under 5 mortality and is on track to meet all health-related Millennium Development Goals, the neonatal death remains stubbornly high. In 2013 there were 20 neonatal deaths for every 1,000 live births in Rwanda, according to World Bank data. For comparison, the neonatal death rate in the U.S. is four of every 1,000 live births.

At one of the first two-day ABC learning sessions, Rusangwa urged the approximately 50 nurses, community health workers, data managers, and other health workers to do everything in their power to reduce the death rate as a team. The participants, who included nurses, data officers and community health supervisors, had come from PIH/IMB-supported Rwinkwavu District Hospital, as well as from eight other health centers.

In seminars and training sessions, participants discussed best practices and examined specific ways they can contribute to preventing needless newborn deaths. There was a strong emphasis on strengthening neonatal care processes such as bolstering antenatal care services, improving delivery management and post-natal care for all infants, with an emphasis on improving care for preterm infants and preventing birth asphyxia, two leading causes of neonatal deaths.

“We can change the health of our babies if we keep active, share knowledge and skills, and intensify our efforts to save babies by coming up with creative solutions from the real experts in this area—you as health care providers in the field every day in your communities,” Dr. Hema Magge, director of pediatrics at PIH/IMB, told the group. “We should utilize the chance to learn the best practices from this training and from one another. This will pay off in the long run.”

Virginia Uwingabire, a line manager in the pediatric unit at Rwinkwavu Hospital, said she picked up several new skills through the trainings and was eager, albeit a tad nervous, to apply the newfound tools in a clinical setting.

“We have learned so much that will enable us to save lives, but putting this into practice is the challenge,” Uwingabire said. “There is a need for commitment to put into action what is taught in the trainings. We also need continuous trainings to build our capacity and help us achieve our goal of saving babies.”

Fortunately, the ABC initiative was designed with that sentiment in mind. The skills taught in the classroom will be reinforced at the bedside through ongoing clinical mentorship and quality improvement coaching to help the teams implement their new ideas, measure the impact, and effect change. To further build capacity, future training sessions will focus on sharing lessons learned from each facility’s quality improvement efforts, communicating across levels of the health system to tackle issues such as transport and referrals, and provide clinical updates in topics such as essential newborn care and kangaroo mother care.

After nine months the program has yielded measurable results in the two districts it was first implemented. The percentage of newborns screened for danger signs within 24 hours of birth increased from 48 to 97 percent and immediate skin-to-skin care after delivery jumped from 11 to 81 percent.

Most importantly, district hospital case fatality has decreased significantly from 18% to 6% and district-wide neonatal mortality has dropped from 25.8 to 17.6 per 1000 live births in only nine months. Weaving individual clinical mentorship with systems-level quality-improvement initiatives has shown promising results, and discussions have begun regarding expansion and scale-up after the 18-month intensive phase is complete.

“Through supporting each other and learning from one another, we will surely reduce child mortality and save the lives of babies,” concluded Dr. Fulgence Nkikabahizi, the medical director of Rwinkwavu District Hospital.

Acknowledgements: The All Babies Count Initiative was supported in part by the Doris Duke Charitable Foundation African Health Initiative and the World Bank.

Dr. Hema Magge is director of pediatrics for Partners In Health/Rwanda.

By Hannah Blencowe on December 3, 2014


Photo: Jonathan Hyams/Save the Children

Invitation to Contribute Data to Updated Estmates and to Join an Investigator Group if the Data Can be Included

The Every Newborn Action Plan launched this year, along with a World Health Assembly Resolution, aims to support countries to end preventable maternal and neonatal deaths and stillbirths (http://www.everynewborn.org/ ). As part of this commitment, it is critical to accelerate progress in preventing stillbirths, and improve tracking of national stillbirth rates especially from low and middle income settings, where the highest burden rests, and the least data are currently available. The estimated 2.6 million stillbirths each year are an important part of the unfinished agenda for maternal and newborn health at the end of the Millennium Development Goals. Despite this, stillbirths have remained largely invisible on the global agenda.

The London School of Hygiene and Tropical Medicine, together with the World Health Organization, with support from Saving Newborn Lives/Save the Children, are updating estimates of stillbirth rates at national level for the first time since 20091, with time trends and also timing of stillbirth (intrapartum versus antepartum).

Data:
If you have suitable data, these would be a very valuable input to improve the estimates and gain more attention for this important global health issue. These data should meet the following criteria:

  1. Population based or from facilities with at >90% of local births and no major referral bias,
     
  2. Report stillbirths using the WHO defn (≥1000 gms or ≥28 weeks gestation),
     
  3. And/or report intrapartum stillbirths based on the same definition (we can accept datasets with intrapartum stillbirths alone as long as point 1 above is met).

We very much hope that you would consider this request. We would be happy to provide more details on data suitability and a standard data form. Confidentiality will be ensured and the data will be strictly for these analyses only. For each team contributing stillbirth data, two investigators will be invited to be members of the author group on a peer reviewed paper regarding the estimates.

Data will be needed by 5th January 2015 but please let us know if more time would be critical for you.

For more details please contact Dr Hannah Blencowe at LSHTM hannah.blencowe@lshtm.ac.uk or Professor Joy Lawn joy.lawn@lshtm.ac.uk

1. Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, Creanga AA, Tunçalp O, Balsara ZP, Gupta S, Say L, Lawn JE. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet. 2011 Apr 16;377:1319-30.