Addressing Critical Knowledge Gaps in Newborn Health

Blog

By Ashok Deorari on October 7, 2014
India
Asia


Neonatal nurse Rekha Samant counsels a new mother on Kangaroo Mother Care at the Follow Up Clinic, Kangaroo Mother Care Centre at Seth GS Medical College & KEM Hospital in Mumbai. Photo: Ritam Banerjee/Getty Images for Save the Children

With less than 500 days until the deadline for the Millennium Development Goals, it is an important time to re-evaluate the progress that is being made towards them. The Millennium Development Goal 4 (MDG4) sought a two thirds reduction in deaths of children under five years of age by 2015, which India is likely to miss. To achieve success in reducing infant mortality, it is essential that quality clinical care be provided and that qualified, well-trained healthcare professionals are available. India is faced with inadequate numbers of competent nursing professionals in service, and a lack of opportunities for the next generation of nursing professionals to contribute towards improving newborn health due to unstructured teaching curriculum.

Nurses play a pivotal and varied role in many developing countries’ healthcare facilities, including providing prenatal education, labor and delivery, and ongoing newborn care. Most notably, it is nurses who are providing skilled attendance during birth, performing newborn resuscitation, initial newborn care, stabilization of at-risk and sick newborns, and determine the need for transfer to regional hospitals when necessary. In addition, nurses provide counseling to mothers about the importance of instituting kangaroo mother care and breast feeding as well as the special needs of low birth weight babies. Due to a shortage of physicians, especially in rural areas in developing countries, the nurses’ role is especially critical at district, sub-district areas, and villages. Although these nurses generally have a collaborating physician in a regional centre (often located more than an hour away), they generally practice alone in these local care facilities and Special Care Newborn Units (SCNU’s), conducting newborn deliveries and treating at-risk and sick babies brought from the community. Despite these expectations from nurses, strategies for their educational preparation and resources for ongoing learning is varied and often limited.

In a recent paper by Campbell-Yeo and colleagues, a structured evaluation of the identification of the barriers and facilitators for the education of nurses in the care of at-risk and newborn babies in India was conducted. Campbell-Yeo et al. (2014) held twelve Focus Group discussions (FGDs) involving 101 health care providers from facilities that provide various levels of newborn care across three Indian states. The majority of participants were female (97/101) and most of the female participants were nurses (82/97): 10 were Auxiliary Nurse Midwives (ANM’s), 3 were physicians and 2 self-identified as other (administrator or accredited social health activist).  Through the FGDs, the nurses identified several challenges they faced related to access to resources, limited manpower, and system limitations. In addition to challenges, nurses also identified learning needs related to clinical skills and basic management, including resuscitation, immediate stabilization of sick newborns, ongoing clinical care and correct use and maintenance of equipment. It was suggested that joint inter-professional educational opportunities and efforts to enhance working together would be extremely beneficial.

The nurses also identified potential solutions to the above mentioned challenges, including the need for all new nurses to receive a structured and standardized orientation program to ensure a minimum level of competency; ongoing competency evaluation; the identification of persons (preferably nurses) to coordinate educational opportunities at pre-service, in-service and on an ongoing basis; less movement of nurses with an increase in permanent jobs; and incorporating learning opportunities that are easily accessible and financially feasible. Across all levels of neonatal intensive care units (NICUs), the greatest resources that nurses identified were experienced nurses and doctors who could teach and share their knowledge with others.

Based on dialogue with nurses and stakeholders, the findings of this study provide valuable insight into the current healthcare system in India with specific reference to the nursing care of at-risk newborns. Several goals were developed to improve nursing and health policies, both in India and other countries. The study suggests a five-pronged approach necessary for the successful training of nurses in newborn care to improve child mortality outcomes:

  • The first is to identify and evaluate existing resources that can be utilized.
  • A second is to standardize the orientation curriculum for the care of sick and at-risk newborns to ensure nurses are adequately trained in addressing the critical needs of at-risk newborns.
  • The third is to institute learner-based continuing educational opportunities and ongoing competency-based evaluative programs that are easily accessible as part of work environment.
  • A fourth is to incorporate mechanisms for sustainability in training programs, such as creating a centre of nursing excellence (train-the-trainer) with designated central and local nursing positions responsible for education.
  • And fifth to invest in structured curriculum for pre service education of future nurses.

Investments in nursing is all the more important as staff nurses were identified as one of the important service providers to deliver the recently launched India Newborn Action Plan (INAP). According to INAP, nurses are critical for six strategic intervention packages, namely pre-conception and antenatal care , care during labor & childbirth, immediate newborn care, care of the healthy newborn, care of small & sick newborns and care beyond newborn survival. INAP spells out six key principles to achieve its targets including quality of care around the time of birth, convergence, partnerships and accountability. It will focus on equity  and eliminating any gender-based differences in health care.

Overall, the findings from the study by Campbell-Yeo et al (2014) provide some significant revelations in terms of the barriers that nurses in India face when providing care in rural areas to sick and at-risk newborns. By having the nurses also identify facilitators and potential solutions to the barriers, the paper also offers important information related to the direction that needs to be taken to improve the training and resources available to nurses. Without providing support to nurses in rural areas, the struggle to reach the MDG4 of reducing infant mortality will not be reached in India.

The findings of Indo-Canadian Shastri project supported by a matching grant from the WHO SEARO, New Delhi, were shared at a stakeholders meeting attended by key partners (USAID, NIPPI, East Meet West, UNICEF, Indian Nursing Council, Indian Association of Neonatal Nurses, JHPEIGO and others). We hope that policy makers, nursing leaders, neonatologists, academicians, and interested stakeholders will work together to improve the unmet needs of our nursing colleagues to enhance the quality of care provided to at-risk and sick newborns in India.

By Kevin Cedrone on October 6, 2014
Uganda
Africa


Standard neonatal bag value mask (BVM) resuscitator. Photo: AIR Project

The Saving Lives at Birth Grand Challenge calls on the brightest minds across the globe to identify and scale up transformative prevention and treatment approaches for pregnant women and newborns around the time of birth. This is the third installment of the Healthy Newborn Network's series profiling several innovations from this year's DevelopmentXchange. This blog was written by Kevin Cedone, Dr. Santorino Data, Kristian Olson and Jim Wright.

The Augmented Infant Resuscitator (AIR) is an add-on device for bag-valve-mask (BVM) resuscitators to improve emergency ventilation. It monitors manual ventilation to provide real-time feedback on ventilation technique/quality and common errors such as leakage between the face and mask, airway blockage and incorrect pace or volume.

The AIR device was co-invented by a team of doctors and engineers from the Massachusetts Institute of Technology (MIT), Massachusetts General Hospital (MGH) and Uganda’s Mbarara University of Science and Technology (MUST).

This diverse team did not meet in an academic lab, or work together at an existing medical device company. The team met by chance at a hackathon. Hackathons are short events, typically a day or two, where entrepreneurs, investors, engineers, designers, programmers, tinkerers, students, professionals and mentors gather to work together. They usually have a theme (e.g. global health, mobile payments, water, etc.) and a few keynote speakers to provide framing and context to the event. Typically, the event starts with several rounds of pitches where researchers can pitch new technology or methods, or industry people can pitch opportunities or recruit teammates for existing start-ups. Then the work starts. At the end of the event, the team’s progress is evaluated by a panel of judges, usually after a 3 minute elevator-pitch presentation and/or product demo.

The Consortium for Affordable Medical Technology (CAMTech) sponsored the Hacking Medicine hackathon hosted at Massachusetts General Hospital in October 2012 that brought the team together.

The hackathon attracted clinicians, engineers, designers, other stakeholders and experts. Their goal was to rapidly build prototype business models, apps or devices to improve global health.

One of the invited guests from MUST, a CAMTech affiliate in Uganda, Dr. Santorino Data described the issue of perinatal asphyxia. As a national trainer for Helping Babies Breathe (HBB) program he is responsible for training doctors, nurses and midwives in essential newborn care, including emergency ventilation.


Dr. Santorino Data demonstrating BVM resuscitation technique at a training in Mbarara, Uganda. Photo: AIR Project

Dr. Data noticed that although HBB reduced newborn mortality, trainees who successfully completed training sometimes failed to perform neonatal resuscitation in a timely or effective manner when in clinical situations. In order to diagnose the problem in more detail, Dr.Data originally requested a data-logging attachment for BVMs. This device would permit post-mortem analysis of resuscitation failures, and with a time-date stamp, whom was working so they could learn from this event and participate in refresher training.


Dr. Santorino Data making his pitch at the CAMTech Hackathon. Photo: AIR Project

Dr. Data’s brief elevator-pitch presentation attracted interest from Kristian Olson, an MGH internist and pediatrician and HBB Master Trainer, Kevin Cedrone, then a mechanical engineering graduate studying automotive combustion at MIT, and Craig Mielcarz, an electrical engineer. The team rapidly iterated on design concepts, with the medical team members providing physiological insight into the problem of perinatal asphyxia. During these first sessions, the concept evolved twice from the original data logger for post mortem analysis. The first was to provide live feedback to health workers during actual emergency ventilation in a clinical setting, not reserve it for analysis later. The sensors and technology required to log data are capable of providing real-time feedback. The second evolution was to add focus to resuscitation training, not just clinical practice. The AIR device can provide important feedback when trainees are first learning their resuscitation skills, so they are practicing and improving their hands-on technique from the moment they first use a bag-valve-mask resuscitator.

Using some scavenged medical hoses and surplus automotive sensors discarded form the automotive lab at MIT, Kevin and Craig built a working prototype overnight. The improvised unit proved that low-cost sensors could be integrated with a suitable algorithm to make a sophisticated and high-value judgment about the quality of ventilation. Moreover, as an add-on to, rather than replacement for existing BVMs, this tool could extend the range and impact of existing ventilation equipment without requiring replacement. This is especially critical in low-resource settings where funds for resuscitation equipment may be at a premium.

The team demonstrated the prototype to the judges with a graphical user interface (GUI) tethered to a laptop and won first place, best overall invention at the hackathon.


Simple GUI showing raw pressure and flow data. The background is colour-coded red when there is a significant problem, in this case a leak. Photo: AIR Project

Since then, the team continued to develop the device. The cost is lower by one order of magnitude, the sensitivity is higher and the device is smaller and consumes less power.

The size, shape and user interface are being refined based on user feedback. An updated prototype will be submitted for randomized control trials in the Boston area and Uganda to measure its quantitative accuracy, whether (and how much) the AIR device improves ventilation. These developments, and the results of field trials to assess feasibility and technology acceptance will be the subject of future blog posts.

The Saving Lives at Birth grant has been instrumental in our development. Among other things, the Saving Lives at Birth grant:

  1. It has provided essential resources for engineering, business development, and clinical evaluation. The SL@B grant allowed the team to hire a research assistant to gather and analyze experimental in Uganda.
     
  2. Advocacy by the GCC Program staff has elevated visibility of the AIR device. The SL@B project manager with Grand Challenges Canada has given us several valuable introductions during regular progress meetings.
     
  3. The introductions to key personnel and legitimacy that the SLAB award offers is beginning to open avenues for potential scale. The seed grant came at a critical time when the crude, but working proof-of-concept prototype needed time and money for refinement.
By Maria Oden on October 3, 2014
Malawi
Africa


Rice University's BreathAlert device at the Saving Lives at Birth Developmentxchange in Washington, DC. Photo: Ian Hurley/Save the Children

The Saving Lives at Birth Grand Challenge calls on the brightest minds across the globe to identify and scale up transformative prevention and treatment approaches for pregnant women and newborns around the time of birth. This is the second installment of the Healthy Newborn Network's series profiling several innovations from this year's DevelopmentXchange. 

At the Saving Lives at Birth Development Exchange in July, we saw many cutting-edge technologies designed to improve neonatal care in the developing world and prevent the nearly three million newborn deaths annually.

Many newborns will be saved by these technologies. However, too often new health tools such as these focus on improving only one aspect of care, when what is needed to promote and sustain better health outcomes for newborns in the developing world is an integrated set of essential newborn health technologies that supports clinicians delivering essential newborn care.

More than half of all newborn deaths annually are caused by complications from prematurity and infection. The Saving Lives at Birth nominees and other organizations are innovating new tools to address these major causes of neonatal mortality in low-resource settings. Diagnostics For All, for example, is developing a rapid, disposable, point-of-care nucleic acid amplification test for early diagnosis of HIV in infants, enabling ART to be started immediately. The Brilliance phototherapy light designed by D-Rev performs as well as traditional phototherapy devices but operates for longer using less energy at a fraction of the cost. 

With the support of a Saving Lives at Birth grant, Rice University, in partnership with the University of Malawi, is developing BreathAlert, a $25 battery-powered monitor that detects and corrects apnea in premature infants, using a small vibrating motor.  BreathAlert will be evaluated and optimized for use in low-resource settings. The team will also determine the product requirements and specifications to prepare BreathAlert for commercial manufacturing.

The challenge before the appropriate health technology community now is to incorporate the life-saving tools it is developing into affordable technology packages for central and district hospitals in developing countries. An essential newborn health technology package would include technologies that provide adequate hydration and nutrition, offer breathing support, stabilize temperature, prevent and treat infection, and monitor for and treat jaundice. Designed for impact in the developing world, these technologies must be safe, effective, affordable, robust, easy to operate, functional using a range of power sources, and compliant with international regulatory standards. 

The technologies cannot require numerous consumables or batteries, or regular maintenance. For maximum impact, essential newborn health technology packages should be accompanied by appropriate training and mentorship programs for nurses, including a certification program for nurses who specialize in neonatal care and commit to remaining in the neonatal ward.

Recently, we visited the neonatal ward at Queen Elizabeth Central Hospital in Blantyre, Malawi, where we saw a newborn baby boy being treated simultaneously for hypothermia, jaundice, and respiratory distress syndrome (RDS). The baby was sleeping in a wooden incubator heated with incandescent light bulbs that was constructed by the hospital. He was being treated with a phototherapy light designed by Malawi Polytechnic, and a CPAP device designed by Rice University and Queen Elizabeth Central Hospital. Any one of these technologies alone would not have been enough to guarantee the survival of this tiny patient, but together, they made his outlook much brighter. 


Photo: Rice University

Working together, the appropriate health technology community can make effective, affordable, essential newborn health technology packages available to hospitals throughout the developing world. When all babies have access to a comprehensive set of essential newborn health technologies, we can turn the tide on newborn mortality. 

By Leonardo Chavane on October 2, 2014
Mozambique
Africa

This post is part of the Maternal and Newborn Health Integration Blog Series, which shares themes of and reactions to the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting. Photo Credit: Suzanna Klaucke/Save the Children.

Integration of maternal and newborn health care services is a constant topic in health communities in Mozambique. Since the foundation of the post-colonial health system, the notion that integrated care should be provided to mothers and their newborns has always been present.

One of the reasons why integration has been seen as the best way to deliver services is due to the lack of skilled human resources. The number of interventions included in the maternal and newborn care package has increased over time and poses a number of challenges for the organization and quality assurance of service provision. In many low resource settings, health workers must perform multiple tasks at once – caring for both the newborn and the baby. One of the major challenges has been ensuring quality care and client satisfaction while maintaining high efficiency in the use of available resources.

Two major challenges that Mozambique faces in its effort to integrate Maternal and Newborn health care services:

1. Lack of sufficient human resources with the right mixture of competencies

One of Mozambique’s high priorities is the acceleration of training of health workers. We need to ensure that health centers at the periphery, primary and facility levels are staffed with personnel that have the right mixture of skills to provide high quality of both maternal and newborn health care services. Not only should the number of service providers increase, but quality of care should not be compromised. Training and provision should take into account the very best practices based on evidence, meet the needs of the patient and respect the rights of the patient, families and community.

2. Need for improved health care delivery and organization

Although services offered in health facilities have grown over time, the overall organization of service delivery has only undergone minor changes. The current momentum represents an important opportunity for Mozambique to reflect on new innovative ways of delivering services. While integration of care can bring challenges, several approaches to integrated care have been taken to scale successfully in Mozambique. For example, in recent years, efforts to integrate the provision of disease control and prevention of Malaria, Tuberculosis and HIV by the Ministry of Health (MoH) led to a renovated, simplified and integrated health information system that was able to successfully measure all the interventions. A one stop strategy has its benefits and challenges and there is a need for all stakeholders to reflect on the interventions that make sense to integrate for improved health outcomes.

Maternal and newborn communities can make a difference in health outcomes for moms and babies by continuing to support countries at the level of health policy and service delivery. I remain convinced that integration of Maternal and Newborn care services is essential to scaling up efforts to ending preventable newborn and maternal deaths.

I recently attended a two-day technical meeting on the “Integration of Maternal and Newborn Health: In Pursuit of Quality” organized by the Maternal Health Task Force and Save the Children. The meeting brought together health care providers at the frontline, policy makers, researchers and academics, civil society and donors to discuss the challenges and benefits to integrated care. The conversations not only highlighted the need to understand varying contexts within countries, but brought to bear the importance of including the client’s perspective in ensuring quality care. It was clear to me from the depth of discussion that to move integrated care forward we must continue the conversation with all stakeholders. I plan to engage with national efforts to improve integration in Mozambique, and will share lessons learned from this meeting with local stakeholders, keeping in mind the goal: integrate for better maternal and newborn outcomes!

More resources on Human Resources for Health:

By Donna Brezinski on October 1, 2014

The Saving Lives at Birth Grand Challenge calls on the brightest minds across the globe to identify and scale up transformative prevention and treatment approaches for pregnant women and newborns around the time of birth. Stay tuned to the Healthy Newborn Network blog as we share a number of innovations showcased at this year's DevelopmentXchange.

In developing regions of the world, neonatal jaundice is a persistent nemesis. It stands apart from other threats to newborn health, like pneumonia, that present with clear and immediate symptoms. The very nature of jaundice, its onset and progression, expose the gaps in existing patterns of newborn health care that help to explain the residual high death and disability rates:

It is deceptive. Many of the newborns that ultimately succumb to severe neonatal jaundice are born at full term and appear healthy.

It is common. About 60% of all term newborns have some degree of jaundice. The fact that most will recover without intervention can give a false sense of security.

It is stealthy. Jaundice typically evolves over the first few days of life. It becomes symptomatic around day 3 or 4, a time when most newborns, including those delivered in health care facilities, are at home.

It is under-recognized. Some developing areas do not have sufficient resources, like adequately trained health care workers and screening programs, for identifying at-risk newborns. Warning signs, such as progressive yellowing of the skin or dehydration, may go unrecognized by family members until the infant becomes very ill.

It is time-sensitive: Often the first indicator to a mother that something is wrong is that her baby is lethargic and won’t feed. Once this happens, jaundice has progressed to the point where treatment must occur rapidly. Failure to treat rapidly can result in permanent brain injury or death.

Poor outcomes for jaundiced infants in developing countries are especially tragic because, in the context of medical therapies, the preferred treatment is a very simple one – phototherapy. Shining a bright blue light on the skin continuously for 2 to 3 days cures nearly 100% of infants, provided that the treatment is begun quickly. I have personally encountered very few treatments in my medical career that can boast of such a high success rate. If newborn babies are dying from this condition, we are failing.

Why are we failing? I believe it is because efforts have been focusing on only part of the problem. Wherever there are jaundiced babies in developing countries not receiving phototherapy treatment, the response is to provide donated devices or more affordable ones resembling those used in developed countries. Those devices are only useful in urban hospitals that have the reliable electricity and trained personnel needed to operate them. In many developing countries large segments of the population live in rural or tribal areas, far from urban hospitals. For symptomatic jaundiced newborns in those areas, receiving phototherapy treatment requires travel to the city. For some, the additional treatment delay, not to mention the stress of being transported far distances, can have devastating consequences. Others never make the trip at all.

So in addition to the list inherent characteristics associated with risk of poor outcome for neonatal jaundice, we should add another important consideration:

Access.

For years it has been stated that poor outcomes from a condition as treatable as jaundice should be a “never event.” But, as we have discovered, delivery of an intervention as simple as phototherapy in some parts of lower-income countries is still deceptively complex. Morbidity and mortality from jaundice is disproportionately high in rural and tribal regions. Fully addressing this problem will require better local access to phototherapy, as well as to preventative diagnostic interventions.

At Little Sparrows Technologies, we have designed the Bili-Hut™ phototherapy device to make jaundice treatment globally accessible. Our guiding principle is that the user is central and the design elements must address the challenges the user may face.

Our prototype meets the American Academy of Pediatrics requirements for high intensity phototherapy and can be manufactured at low cost. But most importantly, it considers the more difficult challenges faced by users in remote areas without electricity or trained health workers.

The Bili-Hut™ can operate for an extended time on a 12V battery. It weighs only 3 pounds and can be transported in a standard shipping tube. Its tent-like configuration is not only intuitive to set up and use, it also keeps the light fixed at the appropriate height from the baby so that effective treatment is guaranteed with each use.

Bringing the cure out of urban hospitals and closer to the patient means that treatment can occur earlier, and that mothers and babies need not separated. This is not only a big a win for treating jaundice, but also one for promoting breastfeeding, which has its own, significant health benefits for both the baby and the mother.

We are about to begin field studies in India to further develop the Bili-Hut™. We expect to learn what further changes the Bili-Hut™ will need to undergo to best suit this context. But we will be learning from the best teachers. As long as we look to users to guide us, we know we will get it right.

Little Sparrows Technologies LLC was the recipient of the Peer Choice Award and a Seed Grant nominee in the 2014 Saving Lives at Birth Grand Challenge.

From an applicant pool of nearly 500 proposals, Little Sparrows Technologies LLC received one of 26 seed grants at the 2014 Saving Lives at Birth Grand Challenge. Co-sponsored by USAID, the Bill and Melinda Gates Foundation, Grand Challenges Canada, the Government of Norway, and DFID(UK), these awards provide up to $250,000 to support the development and validation of ideas capable of impacting health outcomes for pregnant women and their babies in low-resource settings. In addition, their proposal for the Bili-Hut™ was the recipient of the Peer Choice Award, voted by 52 fellow finalists as the proposal having the highest potential for impact in maternal-newborn health.

 

Bili-Hut™: Low-cost, portable, battery-operable neonatal phototherapy from Donna Brezinski on Vimeo.