Photo: © Paul Joseph Brown/GAPPS
We depart the crowded, noisy, bustling capital city of Dhaka, first by road and then we board a small outboard motorboat. We move downriver, the noisy motorboat cutting through the warm, boggy air of the Bangladesh delta. We pass the quiet work of fishermen casting nets from canoes, low flat barges of coal and cattle, small villages of corrugated tin, women washing clothes, tall spires of kilns making handmade brick. We arrive at our destination, stepping out of the boat and walking the short path from the river to the hospital. We pass through a dark hallway that opens to a sunny courtyard.
And there we see the icons of public health history. Lining the hallway is a row of vinyl cots in bright blue, red, and yellow, each with a hole in the center and a bucket beneath. The bright primary colors of the cots belie their purpose. Cholera beds. These are the cots that have been used to manage the disease that once left a wake of death from populations struck by severe watery diarrhea and dehydration. We have arrived at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Matlab. Originally born from a barge that traveled the river treating cholera patients, this site became a pillar of public health research, where, in the 1960s, the first cholera vaccine trials were conducted, and soon after, the landmark studies of oral rehydration therapy that revolutionized treatment of one of the leading causes of mortality worldwide.
From these beginnings decades ago, icddr,b has grown into a large research institute, investigating a broad repertoire of public health challenges. The project is based on a community cohort of 225,000 people who are visited regularly at their homes to monitor for morbidity, mortality, and health behaviors, linked to a technically-sophisticated laboratory in Dhaka that conducts studies in microbiology, immunology, pathology, nutrition, environmental health, maternal-child health, and climate change.
And today we have come to help support the work of icddr,b to address the next frontier – the one area of child survival that has seen the most limited gains: the relentless burden of death of newborns. We arrive to help support the development of research studies of pregnant women, to establish ways to monitor women throughout their pregnancies, and start to unravel the complex and elusive systems that regulate pregnancy and cause preterm birth. These efforts are aimed at discovering ways to identify women at risk and find new solutions to prevent preterm birth, the leading cause of newborn deaths worldwide. I have confronted supposedly quixotic issues already many times in my career. I’ve worked on malaria in the days of emerging drug resistance and studies of insecticide-treated bednets, and I’ve worked to get AIDS treatment to Africa in the earliest days of antiretroviral therapy. Remarkably, I’ve seen dramatic accomplishment in these fields. But we don’t have answers on how to prevent preterm birth. I don’t know if this can be accomplished in my lifetime. But here we are. We are all here together – these experienced icddr,b epidemiologists, doctors, nurses, laboratory technicians, and data managers.
We have all come to roll up our sleeves and start. Start somewhere.
Photo: © Paul Joseph Brown / GAPPS
The team of midwives that we are working with is a formidable group. Between them, they have decades of experience with pregnant women. You can feel their presence and collective experience, their clear command of managing complex medical situations in the most difficult conditions. We gather together in a small room for ultrasound training. They are already experienced practitioners in ultrasound. We’re now building rigorous systems to accurately assess gestational age. The information to be collected by the midwives forms the cornerstone for the complex array of biological investigations on preterm birth. The decade of bench research that will follow relies on the precision of the work of these women.
Photo: © Eve Lackritz / GAPPS
We gather around our first pregnant patient. The room is dimmed so we can all see the screen. The light of the ultrasound machine glows in the middle of our clinical huddle, the inner circle of pregnant woman and practitioner. Our role as trainers quickly fades; the midwives emerge as a cohesive group talking and guiding each other. With constant, quiet chatter in Bangla, the group guides each midwife as she moves to capture the perfect image and measurements. We move through the week with more ultrasound training, and standardizing ways to collect specimens and samples from placentas. Each time, the pattern is the same – our brief introductory session quickly moves to these proficient practitioners guiding each other to build this research project.
We’re facing a large and complex study – with a projected sample size of 4,000 pregnant women in Bangladesh alone, collecting specimens four times in pregnancy, attending deliveries at all hospitals in the area. The specimens will be shared with a consortium of the top preterm birth researchers in the world, as part of the Preventing Preterm Birth initiative. If it can be done, this group can do it. And if we do it right, we hope even more investigators will join this endeavor, all with the hope to find new answers to the complex problem of preterm birth.
We finally depart our visit. The next frontier has been set in their sights. We leave this ambitious group undaunted by the mission.
This blog is part of the Maternal and Newborn Health Integration Blog Series, "Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting. This blog was co-authored by Ana Langer of the Maternal Health Task Force and Joy Riggs-Perla of Save the Children's Saving Newborn Lives program.
“Students often ask me, how come a neonatologist is working on maternal health? To me the response is obvious. When I was a clinician, most of my interactions were with the mothers. I learned very soon that for the newborn to be healthy the woman needed to be healthy.”
- Ana Langer, Maternal Health Task Force
When thinking about the term integration for maternal and newborn health care we need to keep our focus with the intended outcome. Our attention should be on providing equitable, high-quality care for both the mother and the newborn.
Elvira and Ana Cristina hold their premature babies at the hospital in Petrolina, Brazil. At the hospital they have been taught about the importance of eclusive breastfeeding and how to practice Kangaroo Mother Care with their newborn babies. Photo: Genna Naccache/Save the Children
“Integration of Maternal & Newborn Health Care”—the recent technical meeting hosted by the Maternal Health Task Force (MHTF) and Save the Children’s Saving Newborn Lives program (SNL)—provided the jumping off point for discussing what integration really means, the current knowledge base, promising approaches, and models and tools that exist to move this agenda forward. We believe that, with the global consensus on the importance of the continuum of care approach, we have a unique opportunity to decrease the gaps in care and find actionable and practical ways to foster integration where appropriate.
There were two days of in-depth discussion by more than 50 participants who came from around the world to dive deep into analyzing the challenges of, and opportunities for, integration. This group represented academics, NGOs, governments, multilateral organizations and more from global and national organizations. Country perspectives from Ecuador, Nigeria, Nepal, Mozambique and many others were discussed by the presenters, panelists and audience and gave us a better sense of the power of context and localized solutions to gaps in care. We strongly believe that to bring about meaningful and equitable integration, it is essential to understand and take into consideration the epidemiological and health systems’ realities and specific social contexts of countries and communities.
Meeting participants discuss the challenges to and opportunities for increased maternal and newborn health integration and service delivery at the local, national and global level. Photo: Ian P. Hurley/Save the Children
Perhaps the most critical component of the meeting was to develop a list of actions that the maternal and newborn health communities can take to ensure greater programmatic coherence and effectiveness. Among critical actions, participants saw team-based quality improvement processes, co-location of services, functional referral systems, and simplified and unified maternal and newborn health (MNH) data collection and use, as important steps that countries could take to more effectively deliver quality and equitable care for women and newborns. The group also called for donors and technical cooperation partners to support MNH integration-oriented implementation research to build convincing evidence for policymakers, and to align their investments and technical support with national strategies, taking a country-centric approach. The final action item list included well over 60 steps. The just released final report delves deeper into what these are.
The SNL program and the MHTF are committed to the pursuit of quality and equity in maternal and newborn care, and seek to increase collaboration in the delivery of integrated approaches of care. The rich and honest discussion that took place among those gathered in Boston is only a beginning. We hope you will join us in this ongoing effort to find ways to most effectively provide services to mothers and their families. In the end we must keep the patients at the center and work to achieving better outcomes for them.
Health advocates and government groups have made a pact to improve newborn and child health care in Zambia. Photo: PATH
This blog was originally published by PATH
Today, newborns in Zambia have a better chance for survival and a healthier future thanks, in part, to recent health policy actions that are actively supported by PATH and local health partners.
For nearly 20 years, Zambia has had one of the highest infant death rates in the world. While the country is on track to reduce deaths of children under the age of five (read more about the Millennium Development Goals), it has failed to make similar progress in reducing newborn deaths.
Government policies have been silent on newborn health, and government decision makers have rarely addressed the issue.
The lack of policies has “had a very negative bearing on getting resources allocated to newborn health activities,” says Vichael Silavwe, Zambia’s chief integrated management of childhood illnesses officer in the Ministry of Community Development, Mother and Child Health. He adds that without policies, government officials and health workers have not had the necessary support to improve infant health.
A new beginning for Zambia’s children But the launch earlier this month of two new government health policies signals a major shift in the country’s priority of newborn health. On October 14, 2014, the Honorable Emerine Kabanshi, Minister of Community Development, Mother and Child Health, unveiled two national child health policies: a set of Essential Newborn Care guidelines and the National Integrated Management of Child Illness strategic plan.
Together, these policies provide gold standard guidance for health workers who care for newborns, and they create a foundation for key decision-makers to allocate additional staff and budgets to newborn health services.
Silavwe says the policies are significant because they promise to improve stakeholder coordination for health programs at both the community and national levels.
“This is a great opportunity,” he adds, “to bridge the gap between national policy and local district action to raise coverage of essential interventions, mobilize resources, and measure progress towards reducing infant and newborn deaths.”
Celebrating years of work This is the successful culmination of years of behind-the-scenes work by newborn health advocates dedicated to making newborn health a political priority.
Three years ago, newborn health advocates in Zambia—including PATH, Save the Children, the Ministry of Health, Zambia Pediatrics Association, the World Health Organization, and UNICEF—created a coalition to secure a newborn health policy framework to increase funding for newborn health, improve health worker training, integrate newborn care with other child health services, and raise political visibility. With these mandates in place, they believed doors would open for new treatments, technologies, and better newborn care by doctors and nurses.
Dr. Nanthalile Mugala, PATH’s country manager for Zambia, says, “This process demonstrates the power of policy advocacy. Through partnerships and close coordination, we support the Zambian government in developing policies that provide for the rapid scale-up of newborn health care in the country.”
Moving forward to save newborn lives Now that newborn health policies have been created and launched in Zambia, what comes next?
Advocates will continue working with government partners to ensure these policies are implemented in communities.
Government officials must ensure political will remains high and budgets are allocated towards lifesaving interventions and programming.
Health workers and medical professionals will have opportunities for better training in new practices.
Most importantly, babies in Zambia will have the chance for a brighter future.
New mother Rong Mala and her six-day-old baby Rakhal receive a postnatal check up at the new government clinic in Badulpur, Habijganj, Bangladesh. Photo: CJ Clarke/Save the Children
This blog is part of the Maternal and Newborn Health Integration Blog Series, "Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting.
The continuum of care has become a rallying call to reduce the maternal deaths, stillbirths, neonatal deaths, and child deaths. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). Within the continuum, all women should have access to care during pregnancy and childbirth, and all babies should be able to grow into children who survive and thrive.
Unfortunately in the modern era of medical science the program efforts addressing the health of mothers and newborns are often planned, managed, and delivered separately though from a biological perspective, maternal and newborn health are intimately linked.
Integration of maternal and newborn health is an important approach to avoid separation- between mothers and her newborn baby; places of service delivery; or at any event of health services. A persistent divide between training, programs, service delivery, monitoring, and quality improvement systems on maternal and newborn health limits effectiveness to improve outcomes. But it is evident that at the public-health level, even with scarce human and financial resources, integrated service packages can maximize the efficiency for health services.
In last two decades Bangladesh has demonstrated extraordinary progress in reducing maternal and child deaths, but unfortunately newborn mortality declined in a much slower pace and reduction of stillbirths was not even on the agenda. Fortunately, the country recently prioritized newborn survival and incorporated some priority interventions to reduce neonatal death. Improved delivery care services became one of the key strategies for improving child survival in addition to overall development of the health service delivery system.
The following newborn-specific interventions are prioritized to achieve the commitment of ending preventable child deaths by 2035.
- Ensure essential newborn care, including neonatal resuscitation and application of Chlorhexidine in the umbilical cord.
- Introduce and promote Kangaroo Mother Care (KMC) for premature and low birth weight infants.
- Ensure proper management of newborn infection with antibiotics at the primary care levels.
- Establish specialized newborn care unit at the sub-district and district level.
At the same time ensuring delivery by skilled birth attendants at the community levels, and establish round the clock emergency obstetric and newborn care at all sub-district, district and higher level health facilities along with establishing effective referral linkage to ensure continuum of care from community clinics to the union, sub-district, district and higher level hospitals are incorporated in the declaration. These give a clear indication of the government vision on integrated approaches to improve maternal and newborn health.
Intra-partum complication, prematurity-related complications and newborn sepsis are the major causes of newborn death is Bangladesh. Without integration of maternal and newborn health we cannot reduce mortality especially due to intra-partum complications and prematurity-related complications and these two together causes 67% of all newborn deaths in the country. Bangladesh recently scaled up Helping Babies Breathe initiative and that is a unique example of integration of maternal and newborn health.
Every year in the first day of life, 28,100 newborns of Bangladesh dies indicating the importance of integration of maternal and newborn services in pursuit of quality of care.
This blog was originally published by the EveryOne campaign
On 23-24 October 2014, Nigeria hosted their first-ever National Newborn Health Conference with the goal to build synergy and commitment towards ending preventable newborn deaths.
The conference aimed to build synergy and commitment towards ending preventable newborn deaths by launching “Nigeria’s call to action to Save Newborn Lives.”
On the first day of the conference, Permanent Secretary for Health Linus Awute welcomed participants and acknowledged that newborn health remains the weak link in the maternal, newborn and child health continuum in Nigeria and has not progressed as significantly as maternal and child health. “This conference will, to a great extent, shift the direction of decision-making and policy enactment to enhance pragmatic attention to newborn survival,” he said. Following his welcome address, Permanent Secretary for Health launched The LancetEvery Newborn Series and the national integrated Community Case Management Guidelines. The day proceeded with parallel technical sessions, as well as an overview of the ‘Helping 100,000 Babies Survive and Thrive’ consultation and the launch of the Nigeria State Profiles.
The second day was a High level advocacy event with attendance from the Minister of State for Health and acting Minister of Health, the Permanent Secretary for Health, a representative of the Sultan of Sokoto, State Governors, high level representatives from development partners and professional associations, amongst other distinguished guests. The Minister of State for Health, on behalf of President Dr. Goodluck Ebele Jonathan, launched a Call to Action for saving newborn lives. This is a commitment by the Federal Government to development the Nigerian Every Newborn Action Plan (NENAP), a domestication of the global Every Newborn Action Plan.
The time to act is now. Nigeria shall stop housing the great burden of newborn deaths in Africa.," said Acting Minister of Health Dr. Khaliru Alhassan.
As part of action already taken to address the high burden of neonatal deaths, the FMOH has adopted the National Strategic Health Development Plan and supports a number of initiatives including the Saving One Million Lives Initiative, the Subsidy Reinvestment & Empowerment Program (SURE-P) to build on the Midwives Service Scheme, Essential Newborn Care in-service training, Helping Babies Breathe, life-saving commodities among others. This conference followed a series of pre-conference events including a Ministerial Press Conference and the announcement of the Ebola free status as well as ‘Helping 100,000 Babies Survive and Thrive’ consultation.
The conference was sponsored by the Federal Government of Nigeria in partnership with Save the Children, UNICEF, WHO, CHAI, USAID-TSHIP, USAID-JHPIEGO, The Wellbeing Foundation, Drug field pharmaceuticals, Daily needs ltd, Emzor pharmaceuticals and Nemel pharmaceuticals.
Watch the conference video to get a more detailed insight, which features Save the Children Country Director, Ben Foot, and the Saving Newborn Lives Program Manager, Abimbola Williams.
To access materials from the conference, please visit the Every Newborn event summary.
For more information on newborn health in Nigeria, please visit Healthy Newborn Network’s country page.
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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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Warm greetings from Oz! Great article Gary - we all need access to information like this.
Kind Regards, Julieanne Hensby
This is a good sign that the health care system is doing good in giving better service to the community especially to maternal and pediatric...
Intecconnection between maternal newborn and child health is an excellent step for saving lives of mothers and neonates. But I wonder its...
Thank you for your account of your birth and highlighting the need for more midwives for safeguarding maternal and neonatal survival...