Addressing Critical Knowledge Gaps in Newborn Health

Blog

By William Keenan on May 1, 2015
Bangladesh
Asia


A newborn baby is weighed on a weighing scale in a health facility located in a remote village in Bangladesh. Photo: Colin Crowley/Save the Children

This blog was originally published in Medium. Written by Dr. William Keenan.

After a long trip from St. Louis to Dhaka, Bangladesh, I finally made it to the Asia launch of Survive & Thrive’s Helping Babies Survive workshop! The workshop combines training in the Essential Care for Every Baby and Essential Care for Small Babies curricula and strategic planning for health systems improvement in the attendees’ home countries.

The goal of our week in Dhaka is to help strengthen health care professionals’ clinical skills and to build their advocacy skills so the participants and their colleagues can take a leading role in improving their nation’s health systems. I’m here to share my expertise as a physician and to build relationships with health professionals from across Asia.

None of my fellow American Academy of Pediatrics volunteers would be here without the Survive & Thrive Global Development Alliance partners, especially USAID’s Maternal and Child Survival Program who organized all the goings-on in Dhaka.

April 8

The opening ceremony featured a who’s who of the maternal, child, and newborn health leaders — including representatives from WHO, USAID and UNICEF. It was inspiring to see them support our launch and it was inspiring to see 80 different leaders representing seven countries involved in the Helping Babies Survive launch.

Here are some highlights:

First to speak was Dr. Bernadette Daelmans. Dr. Daelmans serves as Coordinator for Policy, Planning and Programmes, at the WHO’s Department of Maternal, Newborn, Child and Adolescent Health.

  • Dr. Daelmans called for the elimination of all preventable maternal and newborn deaths.
  • Investing in skilled newborn resuscitation, improved post-partum care, universal breastfeeding and infant infection reduction will help get us there.
  • You can find Dr. Daelmans’ full presentation here.

Dr. Nabila Zaka of UNICEF spoke about the Every Newborn Action Plan.

  • Already, 23 of the 25 countries with the highest rate of neonatal mortality have developed an ENAP plan.
  • You can find Dr. Zaka’s full presentation here.

Senior Maternal and Newborn Health Advisor for USAID Dr. Lily Kak reported on the success of the Helping Babies Breathe (HBB) program. HBB teaches health providers techniques for newborn resuscitation. The HBB curriculum set the stage for the Essential Care for Every Baby and Essential Care for Small Babies curricula.

  • 300,000 health providers in 77 countries have received Helping Babies Breathe training.

April 9

Dr. Altaf Hussain of the Ministry of Health, Bangladesh kicked off the first day of Essential Care For Every Baby (ECEB) training by describing the dramatic partnerships and investments that Bangladesh is making in newborn health. The government, universities, NGOs and professionals have teamed up in a commitment to fully implement Every Newborn Action Plan over the next two years.

ECEB training commenced with “leaders as learners” from nine Asian countries and 12 facilitators from four different countries (India, Bangladesh, Canada and the US). The polite, perhaps slightly skeptical, quiet at the beginning quickly transformed into bustling interactions as the participants joyfully mastered new skills and perceptions. The trainings will continue for another day and a half to include training in the Essential Care for Small Babies (ECSB). Attention will then be turned towards quality improvement, problem solving, and implementation over the last three days of this unprecedented meeting of Asian leadership in newborn health.​

April 10

The 78 learners and 13 faculty spent the morning completing the final portions of the Essential Care for Every Baby curriculum. Dr Nalini Singhal, course master, reminded the group of the many synergies and continuity among the Helping Babies Breathe, Essential Care for Every Baby and Essential Care for Small Babies courses. Conversations at many of the groups around the room were focused on training to performance, training the trainer constructs and transforming training to improved outcomes.

The afternoon sessions were devoted to the Essential Care for Small Babies curriculum. A tired but happy crew completed their day with discussion and practice of the problem solving approaches outlined in the “yellow” zone of the ECSB Action Plan. As the group broke for the day, the issues of implementation and quality maintenance and improvement were on the minds of many.

Dr. William Keenan is a professor in the department of Neonatal-Perinatal Medicine at the Saint Louis University School of Medicine. He is considered a pioneer in the field of neonatal resuscitation and serves as co-chair of the Helping Babies Survive Planning Group. He also serves as executive director of the International Pediatric Association. Dr. Keenan has traveled to 14 countries to train health professionals in neonatal resuscitation and other life-saving interventions.

Survive & Thrive is an alliance of government, professional health association, private sector, and non-profit partners working alongside country governments and health professionals to improve health outcomes for mothers, newborns, and children through clinical training, policy advocacy, and systems strengthening.

By Kate Kerber on April 30, 2015
Nepal
Asia


Residents salvage their belongings from their destroyed homes in Kamalbinayak, Bhaktapur, Nepal. Photo: Jonathan Hyams/Save the Children

Since the earthquake in Nepal on April 25th, over 5000 have lost their lives. Nearly two million children have been affected by the worst earthquake the nation has seen in 80 years, and its aftermath in the Kathmandu Valley and elsewhere in central Nepal. Based on the country’s population trends, in the six days since the earthquake, close to 10,000 women have given birth in uncertain circumstances, potentially distanced from loved ones and critical support networks. National trends before the earthquake would have seen 45% of these women delivering at home, with just over half of pregnant women trying to make their way to a health facility.

Pregnant women and babies receiving care in clinics and hospitals at the time of the earthquake are contending with limited beds, overcrowding and overworked staff while health workers care for survivors. It appears that numerous health facilities are without electricity; many have been damaged. Women delivering at home may be in unsafe, unhygienic conditions with little opportunity to reach extra care if complications occur. Support for mother-led interventions like skin-to-skin care for babies born too small and too soon, safe hygiene practices, and early and exclusive breastfeeding are needed now more than ever.

Nepal is making progress towards reaching every woman and baby with essential care for survival and health. Strong partnerships between government and development partners have ensured effectively-coordinated efforts in maternal and newborn health. Openness to innovations, especially those that improve availability and quality of essential services and engage communities, such as establishing local birthing centres, strengthening women’s groups, promotion and use of chlorhexidine for umbilical cord care, and providing treatment for newborn sepsis at the lowest level facilities, means the country is poised for rapid reductions in newborn mortality to match those recently seen in maternal and child deaths. A major humanitarian emergency like this earthquake will set back these efforts. Primary healthcare services don’t require the same level of infrastructure likely to be damaged in the earthquake but they do rely on people, many of whom who will be trying to locate family members and ensure their own safety.


Displaced people reside in tents provided by the army at a festival and parade ground in the center of Kathmandu on April 27, 2015. Photo: Save the Children

These early days are critical to find survivors and ensure protection for those most at risk, including pregnant women and their newborns. In the coming weeks and months they will need additional support to rebuild clinics, hospitals, roads, and other infrastructure. Amongst the many that have suffered as a direct result of the earthquake, it is important to remember that the repercussions will continue to affect thousands more. In order to help reconstruct a nation after this emergency, we must remember to care for pregnant mothers and their newborns.

The global community needs to support Nepal

If you would like to get involved in relief efforts, we encourage you to support organizations already actively working to help affected areas.

For suggestions, please visit this web site to learn more about what they do and how you can help.

By Ludmilla Reina on April 29, 2015
Ethiopia
Africa


Photo: Sandoz

Sandoz, the generic division of global pharmaceutical company Novartis, is a worldwide leader in generics. Sandoz has a strong presence in Africa and established its Ethiopian operation in 2013 led by Ludmilla Reina. Ludmilla is based in Addis Ababa, where she is Country Head, and she also manages Sandoz operations in Eritrea, South Sudan, Somalia and the Republic of Djibouti.

Childbirth usually takes place at home in Ethiopia, the second largest country in Africa, where 80% of the population lives in rural areas. If there are any complications, little help is available and as a result approximately 250 mothers and newborns die in Ethiopia every day1, 2. There is often no electricity or running water and – if there is a health center in the area – the health workers there typically have limited obstetric training and lack the physical resources required to provide proper care for women and children in need.

Despite these statistics, as I write this blog I feel hopeful – the New Life & New Hope program has been launched!

The program, developed by Sandoz in close collaboration with the Ethiopian Ministry of Health and the Ethiopian Midwives Association (EMA), aims to improve health support for mothers and to reduce child mortality. Although we may not be able to deliver a complete solution for the country’s various unmet health services needs, I am convinced that we are now contributing in a practical, effective way and providing at least part of the solution.

I started dreaming about implementing a program like this soon after I opened our Sandoz office in Addis Ababa in 2013. As I traveled the country many times with various non-governmental organizations, visiting both urban and rural areas, I quickly realized that there was a lack of the basic skills required to deliver babies safely. Knowing that many women and infants died or suffered debilitating complications as a result of circumstances that were completely preventable made me determined to create real, lasting change for Ethiopian women. That was how the New Life & New Hope program was born.

Through this program, which is fully aligned with our global aspiration to contribute in real, meaningful ways to the communities where we operate, Sandoz is sponsoring critical obstetric training for midwives. This program will help the Ethiopian Ministry of Health to achieve its own stated goals as well. By the end of 2015, we hope that approximately 200 midwives in and around Addis Ababa will have taken part in the program, with measurable positive impact on the care of approximately 80,000 pregnant women in the area. The EMA is currently identifying which of its members will participate in the training and who will be able to assist our team with implementation. We are already planning to expand the training into other, more rural areas of the country by later this year.

New Life & New Hope is not only my personal quest to help women and children in Ethiopia; it is also in line with Sandoz’s commitment to the United Nations Millennium Development Goals and to the Every Newborn Action Plan. Two of the eight goals refer to significantly reducing child mortality and improving maternal health by the end of 2015. Sandoz continues to work towards these goals by increasing global patient access to affordable, high-quality, medicines as well as to healthcare services and medical education.

This program gives us the opportunity to address one of the most serious healthcare challenges currently facing Ethiopia and training 200 midwives by the end of this year will be a great achievement. With an estimated Ethiopian population of 97 million, the task feels daunting at times – but we refuse to be overwhelmed.

The way I see it, our job is to improve and save lives. Every time we save one woman or one child, we are taking another step towards making the world a better place. We are bringing new life and new hope.

1. http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/

2. http://www.unicef.org/publications/index_75736.html

By Lydia Wisner on April 28, 2015
Asia

Participants simulate breastfeeding using educational mannequins. All photos courtesy of Ripon Rahman/MCSP

This blog was originally published by MCSP. Written by Lydia Wisner and Esha Dholia.

The first 28 days of life are some of the most important. Nearly three million babies die each year during this newborn phase— almost half within the first 24 hours of life. In all, newborns account for 41% of all child deaths under the age of five.

Fortunately, the three main causes of neonatal death—preterm birth, birth complications, and neonatal infections—are preventable. And the international community is making combating newborn mortality a priority.

Last year, the World Health Organization and UNICEF launched the Every Newborn Action Plan (ENAP) to guide organizations in their work to reduce preventable newborn mortality and stillbirths. This roadmap links the work of key stakeholders and policy makers to encourage change on the national level, and provides specific objectives for organizations to consider while developing strategies and policies.

To support the aims of ENAP, the U.S. Agency for International Development’s (USAID) flagship Maternal and Child Survival Program and its partners—the Bangladesh Ministry of Health and Family Welfare, UNICEF, the American Academy of Pediatrics (AAP), Survive & Thrive Global Development Alliance, Laerdal Global Health Foundation, and USAID’s Applying Science to Strengthen and Improve Systems Project — in collaboration with the World Health Organization, hosted a “Helping Babies Survive” regional workshop in Dhaka, Bangladesh, this month. Helping Babies Survive (HBS) is a series of competency-based newborn care training modules developed by international neonatologists.

The five-day workshop took place, in part, to introduce Asian ENAP countries to the newest HBS training modules—Essential Care for Small Babies (ECSB)—as well as the previously introduced Essential Care for Every Baby (ECEB). These tools include visual guidebooks, flipcharts and posters containing clear, specific instructions for health care providers to follow after the birth of a baby. Attendees, led by global facilitators from AAP and regional facilitators from India, Bangladesh and Uganda, trained on both modules.
2 workshop participants using the MamaBreast. Photo: Rijon Rahaman/MCSP

Equipment donated by Laerdal Global Health also included the company’s MamaBreast, which simulates breastfeeding and breast milk expression, and the educational mannequins NeoNatalie and PreemieNatalie. These inflatable simulators, which mimic the weight and feel of newborn babies, are used for role playing of several scenarios related to essential newborn care following birth, as well as basic neonatal resuscitation.

Eleven country delegations—from Afghanistan, Bangladesh, Cambodia, China, India, Indonesia, Myanmar, Nepal, Pakistan, Philippines and Vietnam—discussed the health system issues that are stalling their efforts to improve newborn training methods and reduce newborn mortality rates. And to keep up the momentum for change once returning home, each team developed preliminary action plans to address challenges and common bottlenecks.

Allyson Bear of USAID/Bangladesh summed up the ambitions of the workshop well: “The people in this room are responsible for the promise that no newborn baby dies, and no woman dies trying to become a mother. It is ambitious, but we are determined.”

For more photos of the workshop, click here.

Middle Photo: Sabita Tuladhar of USAID/Nepal participates in the Essential Care for Every Baby training. Photo: Ripon Rahman/MCSP

By Matthew Chico on April 24, 2015
Africa

Photo: Martine Perret/UN

This blog was originally published by the MARCH Centre at the London School of Hygiene & Tropical Medicine. Written by Matthew Chico.

In sub-Saharan Africa, 10,000 women and 200,000 children under the age of one die each year as a consequence of malaria infection during pregnancy [1, 2]. On this year’s World Malaria Day, the global public health community is coming together to highlight the important and lifesaving role of intermittent preventive treatment in pregnancy (IPTp). IPTp using sulfadoxine-pyrimethamine (SP) is a highly cost-effective intervention with the potential to reduce maternal morbidity and neonatal mortality [3]. Meta-analyses of women in their first and second pregnancies have shown that IPTp reduces the incidence of low birth weight (LBW) by 27%, severe maternal anaemia by 40% [4], and neonatal mortality by 38% [5]. For this reason, the World Health Organisation (WHO) recommends IPTp as a key strategy in its three pronged approach for protecting the close to 50 million pregnancies which occur every year in areas of stable malaria transmission. In addition, WHO recommends the use of insecticide treated bed-nets, and effective case management [5, 6].

Despite being a straightforward intervention that can be delivered to pregnant women under direct observation during routine antenatal care (ANC) visits, IPTp has the lowest coverage among all interventions delivered to pregnant women through the ANC platform, including the provision of long-lasting insecticide-treated nets [7]. The discrepancy between high ANC attendance (75% of women in sub-Saharan Africa attend at least twice) and low IPTp coverage points to substantial missed opportunities at ANC facilities [8, 9]. In 2013, the average coverage of at least two doses of IPTp among pregnant women in sub-Saharan African countries was 24%, well below national and international targets, and only marginally higher than a decade ago when coverage was 14% [9]. Only six countries in sub-Saharan Africa have reached the 60% coverage target for 2005 set by the Roll Back Malaria Partnership (RBM) and not one country has reached the 2010 RBM target of 80% coverage [10, 11]. The WHO estimates that 15 million of the 35 million pregnant women in sub-Saharan Africa malaria endemic countries did not receive a single dose of IPTp in 2013 [12].

What can be done to close this gap?

The recent RBM report on the contribution of malaria control to maternal and newborn health highlighted key programme areas for improvement that will support the scale-up of MiP interventions [13]. The report states that many barriers to IPTp uptake are common across countries and can be overcome with relative ease and speed [13]. These obstacles include a lack of integration and coordination between national reproductive health and malaria control programmes. Healthy coordination across health services is central to preventing MiP given that interventions are delivered through ANC clinics with management from staff in reproductive health and technical oversight from counterparts in malaria control. Other obstacles include: inconsistent, unclear and poorly disseminated information on IPTp policy; confusion among healthcare providers as to when and how to administer IPTp; SP stock-outs at ANC clinics [14], and general barriers to accessing ANC services that have been well-documented [15]. Additional obstacles relate to broader health systems issues and necessitate strengthening the health system overall and ANC services specifically.

What can you do?

As a member of the international public health community, it is important to know what can be done in order to improve access to IPTp. The Global Call to Action provides information on how stakeholders can support global and national strategies to save mothers’ and newborns’ lives from the scourge of malaria.

The Global Call to Action calls upon donors to increase their financial support to health system strengthening generally, and the ANC platform more specifically, support operational research on the quality of delivery of IPTp, promote the inclusion of IPTp and other MiP control strategies in grant proposals, and facilitate private sector engagement for improved outcomes.

The research community can improve the dissemination and translation of research and lessons learned within malaria endemic countries and internationally, validate practical tools for scaling up IPTp, evaluate and promote successful health education campaigns and strategies, conduct research on alternative delivery strategies for IPTp but also on innovative alternatives and work closely with local governments and the WHO to establish monitoring and evaluation plans and support in country ownerships of research.

Civil society also has an important role to play in the reduction of MiP, communicating the importance of IPTp to individuals at risk of malaria and, importantly, can hold governments accountable for the quality delivery of IPTp to pregnant women.

For a full list of recommendations of actions to stakeholders, please visit the RBM website.

“It has been 15 years since the Abuja Declaration called for the scale up of preventive treatment for malaria in pregnancy – and the need is every bit as real today. The time has come!” says Matthew Chico, Lecturer in the Department of Disease Control at the London School of Hygiene & Tropical Medicine. “We have the tools that can save the lives of so many women and newborns; we need to focus our attention and resources to improve access, quality and uptake. If support is broad and spans local to global levels, we can achieve historic impact that touches so many lives.”

Click here to listen to an interview with Matthew Chico talking about MiP on Africa Digest.

To find out more about how LSHTM is working on malaria in pregnancy, please visit the London School’s websites for the Maternal, Adolescent, Reproductive, and Child Health Centre (MARCH) and the Malaria Centre.