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on April 25, 2013
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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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Jahanara Begum talks to Shiuli after delivery.
(Photo courtesy of Md. Tarikul Islam, HBB-BSMMU.)
This blog was originally published by MCHIP. Written by Patricia Kapolyo and Tarikul Islam.
As their baby boy finally started to cry, the smiles of 25-year-old Shiuli Khatun and her husband revealed their relief after a tense and dangerous delivery. Earlier that day, an untrained traditional birth attendant had been unable to deliver Shiuli’s baby at home despite hours of trying. The mother was brought to the Maternal and Child Welfare Centre (MCWC) at Sherpur Sadar Upazila, where Jahanara Begum, a family welfare assistant, helped to successfully deliver the newborn.
However, concern for the baby did not end with his delivery. It immediately became clear that he was suffering from breathing difficulty (birth asphyxia). There was a lot of fluid in his mouth and, even after drying him and cleaning out his mouth with a penguin sucker, he still did not cry.
Jahanara moved quickly to the next procedure she had learned as part of her Helping Babies Breathe (HBB) training for skilled birth attendants. She cut the umbilical cord and artificially ventilated the struggling baby with a bag and mask. After one minute of initiating this ventilation, to everyone’s relief, the baby cried out. In all, it took only three minutes for Jahanara to get the baby breathing.
Shiuli’s second son was born at full term, weighing 2.37 kg (more than 5 pounds), thanks to the emergency interventions taken by Jahanara. HBB trainings aim to strengthen the capacities of skilled birth attendants to provide newborn essential care—including management of birth asphyxia through newborn resuscitation. Developed by the American Academy of Pediatrics, the HBB initiative was designed to equip birth attendants in developing countries with the skills they need to successfully resuscitate babies who do not breathe on their own. At the center of HBB is the concept of "The Golden Minute"SM: within one minute of birth, a baby should be breathing well or should be ventilated with a bag and mask.
The Scaling-up of HBB Initiative to Strengthen Newborn Resuscitation in Bangladesh project is being implemented by the Ministry of Health and Family Welfare in collaboration with USAID, MCHIP, Save the Children, Bangabandhu Sheikh Mujib Medical University, UNICEF, ICDDR,B, and the Laerdal Foundation.
Md. Tarikul Islam, HBB Project, BSMMU
Success in reducing vaccine-preventable mortality has been dramatic, but it cannot be taken for granted. While national vaccination coverage in some countries now exceeds 80 percent, overall national coverage is not the only important metric. Before being exposed to disease, women and newborns must be reached in every region and sub-population of every country with the right vaccines and high-quality services in a safe, timely, effective, and affordable manner, so that they return to complete all their doses.
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R. Davidge. Neonatal Experiential Learning Site and outreach program in KwaZulu-Natal. Journal of Neonatal Nursing. (April, 2013).
The perinatal and neonatal mortality rates in South Africa are inappropriately high. In order to support an improvement in the standard of neonatal care in the hospitals in Area 2 KZN a Neonatal Experiential Learning Site (NELS) was created. Run by a full time coordinator, it consists of a centralized two week learning block and an outreach support and teaching programme. Thus far there has been improved staff morale, increasing awareness by hospitals of the need to improve neonatal care, improved communication and collaboration between doctors and nurses and improved quality of care. Unfortunately numbers accessing NELS training are inconsistent often including junior staff unable to implement change without senior support. Rapid turnover of staff limits sustainability of change. Ongoing poor staff patient ratios decrease the effectiveness of outreach visits and the ability of staff to implement quality improvement. Ongoing support is imperative to ensure sustainable change. It is crucial for a senior nurse/doctor permanently employed in neonatal care to drive the quality improvement process in each hospital. Support from management is vital. Close liaison with Provincial departments will ensure standardization. Accreditation of neonatal units will encourage compliance with the norms and standards set.
B. Kirkwood, A. Manu, et al. Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial. The Lancet. (April, 2013).
Background: In 2009, on the basis of promising evidence from trials in South Asia, WHO and UNICEF issued a joint statement about home visits as a strategy to improve newborn survival. In the Newhints trial, we aimed to test this home-visits strategy in sub-Saharan Africa by assessing the effect on all-cause neonatal mortality rate (NMR) and essential newborn-care practices.Methods: The Newhints cluster randomised trial was undertaken in 98 zones in seven districts in the Brong Ahafo Region, Ghana. 49 zones were randomly assigned to the Newhints intervention and 49 to the control intervention by use of restricted randomisation with stratification to ensure comparability between interventions. Community-based surveillance volunteers (CBSVs) in Newhints zones were trained to identify pregnant women in their community and to make two home visits during pregnancy and three in the first week of life to promote essential newborn-care practices, weigh and assess babies for danger signs, and refer as necessary. Primary outcomes were NMR and coverage of key essential newborn-care practices. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00623337.Findings: 16 168 (99%) of 16 329 deliveries between November, 2008, and December, 2009, were livebirths; the status at 1 month was known for 15 619 (97%) livebirths. 482 neonatal deaths were recorded. Coverage data were available from 6029 women in Newhints zones; of these 4358 (72%) reported having CBSV visits during pregnancy and 3815 (63%) reported having postnatal visits. This coverage increased substantially from June, 2009, after the introduction of new implementation strategies and reached almost 90% for pregnancy visits by the end of the trial and 75% for postnatal visits. The Newhints intervention significantly increased coverage of key essential newborn-care behaviours, except for four or more antenatal-care visits (5975 [76%] of 7859 vs 5988 [74%] of 8121, respectively; relative risk 1·02, 95% CI 0·96–1·09; p=0·52) and baby delivered in a facility (5373 [68%] vs 5539 [68%], respectively; 0·97, 0·81–1·14; p=0·69). The largest increase was for care-seeking, with 102 (77%) of 132 sick babies in Newhints zones taken to a hospital or clinic compared with 77 (55%) of 139 in control zones (1·43, 1·17–1·76; p=0·001). Increases were also noted in bednet use during pregnancy (5398 [69%] of 7859 vs 5135 [63%] of 8121, respectively; 1·12, 1·03–1·21; p=0·005), money saved for delivery or emergency (5730 [86%] of 6681 vs 5525 [80%] of 6941, respectively; 1·09, 1·05–1·12; p<0·0001), transport arranged in advance for facility (2496 [37%] vs 2061 [30%], respectively; 1·30, 1·12–1·49; p=0·0004), birth assistant for home delivery washed hands with soap (1853 [93%] of 1992 vs 1817 [87%] of 2091, respectively; 1·05, 1·02–1·09; p=0·001), initiation of breastfeeding in less than 1 h of birth (3743 [49%] of 7673 vs 3280 [41%] of 7921, respectively; 1·22, 1·07–1·40; p=0·004), skin to skin contact (3355 [44%] vs 1931 [24%], respectively; 2·30, 1·85–2·87; p=0·0002), first bath delayed for longer than 6 h (3131 [41%] vs 2269 [29%], respectively; 1·65, 1·27–2·13; p<0·0001), exclusive breastfeeding for 26–32 days (1217 [86%] of 1414 vs 1091 [80%] of 1371; 1·10, 1·04–1·16; p=0·001), and baby sleeping under bednet for 8–56 days (4548 [79%] of 5756 vs 4291 [73%] of 5846; 1·09, 1·03–1·15; p=0·002). There were 230 neonatal deaths in the Newhints zones compared with 252 in the control zones. The overall NMRs per 1000 livebirths were 29·8 and 31·9, respectively (0·92, 0·75–1·12; p=0·405). Interpretation: The reduction in NMR with Newhints is consistent with the reductions achieved in three trials undertaken in programme settings in south Asia. Because there is no suggestion of any heterogeneity (p=0·850) between these trials and Newhints, the meta-analysis summary estimate of a reduction of 12% (95% CI 5–18) provides the best evidence for the likely effect of the home-visits strategy delivered within programmes in sub-Saharan Africa and in south Asia. Improvements in the quality of delivery and neonatal care in health facilities and development of innovative, effective strategies to increase coverage of home visits on the day of birth could lead to the achievement of more substantial reductions.
N. Jana, S. Dasgupta et al. Experience of a low-dose magnesium sulfate regimen for the management of eclampsia over a decade. International Journal of Gynecology & Obstetrics. (April, 2013).
Objective: To assess the safety and efficacy of a low-dose magnesium sulfate regimen for the management of eclampsia in Indian women. Methods: A loading dose consisting of 3 g of magnesium sulfate intravenously plus 5 g intramuscularly (2.5 g in each buttock) was followed by 2.5 g intramuscularly every 4 hours, for 24 hours beyond the last seizure. In a first phase, which spanned 2001 and 2002, the regimen was evaluated prospectively with 554 women with eclampsia, and the results were compared with results from the Collaborative Eclampsia Trial. Regarding the second phase, which spanned the 9 following years, mortality was analyzed retrospectively for 2929 women treated by the same regimen at the same hospital. Results: The mean ± SD maternal weight and height were 41.7 ± 5.3 kg and 151 ± 7 cm, respectively. The low-dose regimen was associated with a lower seizure recurrence (6.1% vs 9.7%; P = 0.02) and a slightly lower maternal mortality (2.7% vs 3.2%; P = 0.6) compared with the Collaborative Eclampsia Trial. The overall case fatality rate for the second phase was 3.3%. Conclusion: The low-dose regimen was safe and effective for the management of eclampsia in a region where most women are of light weight.
*L. Kuhn, H. Kim, J. Walter, et.al. HIV-1 Concentrations in Human Breast Milk Before and After Weaning. Science Transitional Medicine. (April, 2013).
Concentrations of HIV-1 RNA and DNA in mucosal compartments influence the risk of sexual transmission and mother-to-child transmission of HIV-1. Breast milk production is physiologically regulated such that supply is a function of infant demand, but whether demand also influences HIV-1 dynamics in breast milk is unknown. We tested whether minor and major changes in feeding frequency influence breast milk viral concentrations in 958 HIV-1–infected women and their infants followed, for 24 months during a trial in Lusaka, Zambia. Women were randomized to wean abruptly at 4 months or to continue breast-feeding for a duration of their own choosing. Two weeks after breast-feeding cessation (4.5 months), HIV-1 concentrations in breast milk were substantially higher (median RNA, 2708 copies/ml; DNA, 14 copies/ml) than if breast-feeding continued (median RNA, <50 copies/ml; DNA, <1 copy/ml; P < 0.0001). Among those continuing breast-feeding, HIV-1 concentrations in milk were higher if breast-feeding was nonexclusive (median RNA, 293 copies/ml; DNA, 2 copies/ml; P = 0.0006). Elevated milk viral concentrations after stopping breast-feeding explained higher than expected rates of late postnatal HIV transmission in those who weaned early. Changes in the frequency of breast-feeding peri-weaning and with nonexclusive breast-feeding influenced milk viral concentrations. This may explain the reduced risk of HIV-1 transmission associated with exclusive breast-feeding and why early weaning does not achieve the magnitude of HIV prevention predicted by models. Our results support continuation of maternal antiretroviral drug interventions over the full duration of time when any breast milk exposures may occur after planned weaning.
*E. McClure, R. Goldenberg, A. Dent, et.al. A systematic review of the impact of malaria prevention in pregnancy on low birth weight and maternal anemia. International Journal of Gynecology & Obstetrics. (April, 2013).
Background: Malaria in pregnancy is a significant contributor to adverse pregnancy outcome, especially in Sub-Saharan Africa. Prevention with sulfadoxine/pyrimethamine (SP) during pregnancy has been recommended in malaria-endemic areas but concerns remain about its benefit. Objectives: To evaluate the association between recommended preventative SP programs in pregnancy and low birth weight (LBW) and maternal anemia through available clinical trial, observational, and programmatic evaluation studies. Search strategy: Systematic review of published studies on malaria in pregnancy and pregnancy outcomes. Selection criteria: Clinical studies from Sub-Saharan Africa from the past 10years were included. Data collection and analysis: English articles published since 2002 and listed in PubMed were identified using defined keywords, and their source documents were reviewed. Thirty-three studies involving malaria in pregnancy that recorded treatment rates and birth outcomes were included. Main results: SP use among primigravidae was consistently associated with decreased LBW and anemia rates in clinical trials. Effects were less consistent in observational studies. Conclusions: Although randomized trials have demonstrated the efficacy of SP, studies evaluating scale-up programs found less consistent reductions in LBW and maternal anemia. Additional strategies to improve SP coverage may reduce the LBW and maternal anemia associated with malaria in pregnancy.
S. Trevisanut, G. Arnolda, et al. Reducing neonatal infections in south and south central Vietnam: the views of healthcare providers. BMC Pediatrics 13(1): 51. (April, 2013).
Background: Infection causes neonatal mortality in both high and low income countries. While simple interventions to prevent neonatal infection are available, they are often poorly understood and implemented by clinicians. A basic understanding of healthcare providers' perceptions of infection control provides a platform for improving current practices. Our aim was to explore the views of healthcare providers in provincial hospitals in south and south central Vietnam to inform the design of programmes to improve neonatal infection prevention and control. Methods: All fifty-four participants who attended a workshop on infection prevention and control were asked to complete an anonymous, written questionnaire identifying their priorities for improving neonatal infection prevention and control in provincial hospitals in south and south central Vietnam. Results: Hand washing, exclusive breastfeeding and safe disposal of medical waste were nominated by most participants as priorities for preventing neonatal infections. Education through instructional posters and written guidelines, family contact, kangaroo-mother-care, limitation of invasive procedures and screening for maternal GBS infection were advocated by a smaller proportion of participants. Conclusions: The opinions of neonatal healthcare providers at the workshop accurately reflect some of the current international recommendations for infection prevention. However, other important recommendations were not commonly identified by participants and need to be reinforced. Our results will be used to design interventions to improve infection prevention in Vietnam, and may be relevant to other low-resource countries.
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In the rural west-central district of Nakaseke, Uganda, Senior midwife Teopista enthusiastically comments on her favorite component of the ACT for Birth Uganda Project. ACT for Birth is an integrated innovation and is being implemented by Save the Children’s Saving Newborn Lives Program and partners in Uganda, with funding from the Saving Lives at Birth Grand Challenge. The project comprises a package of interventions aimed at improving the quality of care for mothers and babies in Uganda. We must take action - ACT - where the greatest opportunities for saving lives are, at the most critical time of a life - during and just after birth.
The program consists of 3 different components;
A = Audit: Uganda’s national paper-based mortality audit forms have been adapted to a mobile phone platform, to capture and input information on maternal and neonatal deaths and stillbirths in real time into a central database. This data is analysed and used to inform decision-making for improved quality of care in the health facility of origin and beyond, and captures information on the causes of deaths and missed opportunities for care.
C = Connect Communities: Communities are directly connected to district hospital- or facility-based health workers through Village Health Teams (VHTs) with mobile phones and toll free calls. VHTs assist with referrals of mothers and newborns with danger signs (e.g. requesting emergency transport), report births and deaths at community level to the hospital, and conduct pre- and postnatal visits to promote best maternal and newborn care practices, including care seeking, facility based deliveries and the identification of danger signs.
T = technology and training: An innovative wind-up fetal heart rate monitor, powered by human energy (designed by PET and winner of the global INDEX design award) is paired with training on intrapartum care, empowering health workers to provide better care.
Why change was needed to improve quality of care…
The project is being implemented in Nakaseke Hospital, a typical rural district hospital in Uganda, with 3,000 births per year and very challenging conditions for health workers, mothers and their newborns. There are 3 beds in the labor ward, which is already so small that it leaves very limited working space for the midwives. These beds are often in use, and direct sunshine, at times rain, and all the other possible incidents outside the hospital make themselves known through the broken windows. As if these are not problems enough for the congested rural hospital, power failures are the order of the day, and many babies are born by the light of a mobile phone.
“Audit helps us correct our mistakes and improve our service- the midwives are much more aware of their responsibilities, because in the audit we talk all the time about avoidable factors. I must make sure that I am not the one that did something that was avoidable”, one midwife says. Another midwife adds: “First audit was just for the midwives but now everybody is getting involved. Even the administrators participate, they actually even initiate the meetings. It feels as if they take us more serious now, they listen to our problems and many things are changing. Sometimes pregnant mothers were sent to the general ward, for example mothers who were not in active labour or mothers with malaria, because we did not have enough space. These mothers were not monitored at the general ward, which sometimes resulted in stillbirths . Now the administrators gave midwives a special 1st stage room and a space were we can take care of pregnant mothers with problems. I hope there will be less stillbirths now because of better monitoring. I feel proud of this, I made the suggestion during the meeting and it feels good when people listen to you. Audit helps us communicate what we feel should change.”
Eva, another senior midwife is very happy about the fact that the communities are better linked with the hospital through VHTs:
”The help of the VHTs is great-the mothers now come earlier, they used to only come when they had problems, but now they come before the problems are there, and we can manage labor and birth better. Some of the VHTs are very committed, they even accompany the mothers to the hospital to make sure that she arrives safely.”
The midwives told us that getting VHTs involved in maternal and neonatal care in the communities linked to the hospital has been great for behaviour change and community mobilisation, and there has been an increase in the demand for services.
”Some people were working as TBAs, they were delivering babies at their homes. Now they refer people to the hospital, and now more mothers deliver at the hospital.”
The last component of the program is implementing training and technology. The midwives were trained in intrapartum care and Doppler fetal heart rate monitors were provided. For many midwives and most mothers, it was the first time that they were exposed to a fetal heart rate monitor.
”We love the Doppler, It shows you the fetal heart rate with much more precision, and we can act when something goes wrong. The mothers like it too. When the mother hears the sound, and you tell her that it is the baby’s heart, she smiles and feels happy.”
The training has also proven to be very helpful.
”I feel more empowered, the monitoring is more uniform, everybody does the same thing. We have improved our skills, you feel good about yourself because you know you can give better care. The best thing is that you have a better relationship with the mother when you monitor her correctly, because every 30 minutes you talk with the mother when you do your observation.”
Like in many developing countries and rural health facilities, the problems faced by mothers and health workers are composite. The ACT project has shown the power of an integrated approach to improving quality of care! Sensitization and motivation at community level linked to the health facility will create a stronger and sustained demand for quality services and care. That way, improved facility care will benefit the mothers and newborns who need it most.
Related
Photo: The Bill & Melinda Gates Foundation. This blog was originally published in Impatient Optimists. Written by Gary Darmstadt, Wendy Prosser, Amie Newman.
Newborn health was the topic of a global conversation last week, as you no doubt know if you’ve been following along on Impatient Optimists. In Johannesburg, South Africa, the very first Global Newborn Health Conference gathered together champions of this issue to discuss how to improve the health and lives of newborns. It’s unsurprising, then, that mothers were (and continue to be) a big part of the conversation. Not only were mothers mentioned frequently, in large part because of the important link between newborn health and that of her mother, but also because mothers were and are instrumental in raising awareness of this important topic.
In the United States, mom bloggers collectively raised their voices on behalf of newborn health. Kristine Brite McCormick, a mother who devastatingly lost her daughter Cora, wrote that she was “giving voice” to the millions of newborns who are dying every year in the poorest countries of the world.
Poignantly, some of these women wrote of their own loss; some shared the pain and frustration they feel for and about women halfway around the world who suffer from the death of a newborn, from preventable causes. This group of dedicated women does a tremendous job of bringing attention, through social media, to the importance of good care during those 28 days after birth in order to have a healthy and productive life for years to come.
Some major themes emerged from their Tweets during the conference:
There is outrage at the burden of newborn mortality and rightly so.
Countries are learning from each other to introduce life-saving interventions.
The newborn community cannot improve the chances of newborn survival alone; we need broad, catalytic partnerships looking at the complex system holistically.
One of the greatest messages we heard through the Mom Bloggers was expressed in this tweet:
This concept extends beyond the participants at the conference and the policy makers in the different countries. This concept encapsulates the Mom Bloggers themselves. Their dedication to saving the lives of newborns, especially in the poorest countries in the world, by raising awareness of the issue through blogging, tweeting, video messages and more is truly amazing.
We were equally as inspired by the videos created. Lisa Van Engen expresses her ideas here:
As we continue to speak up about newborn health, and a Global Newborn Action Plan is developed, we must not only listen to the voices of mothers from around the world but include them.