Addressing Critical Knowledge Gaps in Newborn Health

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By Jennifer James on August 7, 2014


Photo: Paolo Patruno

This blog was originally published in Impatient Optimists. Written by Jennifer James.  

Did you know that breastfeeding rates have stalled at around 40 percent worldwide or only one in three infants less than six months of age is exclusively breastfed?

Through August 7, World Breastfeeding Week will be recognized by breastfeeding advocates, parents, experts, and global health organizations with the theme: Breastfeeding:  A Winning Goal – for Life! This year’s theme highlights the critical importance of breastfeeding to achieving the Millennium Development Goals, especially MDG #4 that set a goal of decreasing child mortality by two-thirds by the end of 2015.


Photo: Paolo Patruno

These statistics may be hard to believe especially given how beneficial breastfeeding is to the survival and health of newborns and children, but they are accurate and need to be dramatically improved for the sake of the health of newborns and children the world over.

  1. Breastfeeding Saves More Newborns: Breastfeeding within the first hour after birth will save the lives of over 800,000 newborns according to data from a 2013 Save the Children report: Superfood for Babies: How Overcoming Barriers to Breastfeeding Will Save Children’s Lives.  Hundreds of thousands of newborn deaths could be wholly prevented if breastfeeding is initiated within the crucial first hour after delivery when colostrum is produced by mothers for their newborns’ fragile immune systems.
  2. Breastfeeding Protects Against Disease: Breastfeeding reduces the chances that babies will die of pneumonia or diarrhea, two of the leading causes of deaths in children under the age of five.
  3. Breastfeeding Prevents Malnutrition and Wasting: Did you know that breastfeeding provides essential vitamins and minerals that keep babies and children healthy throughout their lives? It also reduces the chances of a child becoming malnourished or wasted.
  4. Exclusive Breastfeeding Can Prevent Close Pregnancies: When mothers exclusively breastfeed they have a reduced chance of becoming pregnant again within six months of their previous deliveries. While this is not fail-safe the World Health Organization says breastfeeding provides 98 percent birth control protectionduring the first six months of exclusive breastfeeding.
  5. Breastfeeding Makes Women Healthier: The World Health Organization says women who breastfeed have a reduced chance of contracting ovarian and breast cancer. Breastfeeding also helps a woman return back to her pre-pregnancy weight faster and reduces her risk of obesity.

The World Health Assembly set a goal in 2012 to achieve at least a 50% exclusive breastfeeding rate globally by 2025.  In order to achieve that, the rate of exclusive breastfeeding must grow across all regions by at least 2.5 percent each year. The current rate of growth is only 1.8 percent.

One way to achieve this is through a consistent emphasis on the benefits of breastfeeding across the globe. That is why in its 22nd year, World Breastfeeding Week continues to be crucial to the global breastfeeding movement.


Photo: Paolo Patruno

How Can You Get Involved in World Breastfeeding Week?

Events are being held through August 7 in over 170 countries. Find an event near you on the World Breastfeeding Week’s pledges page.

All photos are courtesy of Paolo Patruno. His photos about maternal and newborn health in sub-Saharan Africa can be seen at birthisadream.org.

By Chelsea Cooper on August 6, 2014
Africa, Asia, Middle East


Photo: Jhpiego

This blog was originally published by MCHIP. Written by Chelsea Cooper.  

This is a question that many women find themselves asking after childbirth. In fact, breastfeeding, return to fecundity, and postpartum family planning (PPFP) are all closely intertwined.  Exclusive breastfeeding delays a woman’s postpartum return to fecundity and is a critical aspect of the Lactational Amenhorrea Method of family planning (LAM), which requires that women exclusively breastfeed, have a baby less than six months, and have not had a return of menstruation. 

The theme for this year’s World Breastfeeding Week—“Breastfeeding: A Winning Goal - For Life!”—asserts the importance of increasing and sustaining the protection, promotion and support of breastfeeding.  Promotion of LAM and timely transition to another modern FP method can help to advance these goals during the Millennium Development Goal countdown and beyond.  

Evidence from the Healthy Fertility Study in Bangladesh has shown that LAM has a positive effect on the duration of exclusive breastfeeding: length of exclusive breastfeeding was 25% higher at six months among LAM users compared with non-LAM users.  And evidence from Jordan demonstrates that women who use LAM are twice as likely to use FP at one year postpartum (compared with women who are only breastfeeding). 

Observations have shown that almost all healthy newborns placed skin-to-skin immediately after birth are able to locate the nipple without assistance and spontaneously attach and suck. Moreover, studies have suggested early skin-to-skin contact and early initiation of breastfeeding is likely to enhance chances of continued breastfeeding at 1-3 months of age.  

Breastfeeding is practiced and valued by most mothers in developing countries. And the vast majority of women in the first year postpartum want to delay or avoid another pregnancy altogether. Why, then, do substantial gaps in exclusive breastfeeding and postpartum contraceptive use remain?

USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) and the SPRING Project co-facilitate the Maternal, Infant, and Young Child Nutrition and Family Planning (MIYCN-FP) Working Group, which serves as a forum for sharing learning and resources on this topic.  The Working Group has reviewed existing scientific and programmatic literature and has noted a number of factors which influence the practice of optimal MIYCN and FP behaviors. These include:

  • Perceptions about the role of breastfeeding in preventing return to fecundity:  Findings from Egypt, Yemen and other countries reveal that women may think that they are protected from pregnancy for as long as they breastfeed (even beyond six months), or if they are only partially breastfeeding.  It is important to ensure that women understand that they are only effectively protected from pregnancy by breastfeeding for as long as all three LAM criteria are met, and that they should transition to another modern FP method before the criteria are no longer met in order to ensure continuous protection.
  • Knowledge and perceptions about breastfeeding: Program learning has revealed gaps in knowledge about optimal breastfeeding practices and the benefits of exclusive breastfeeding and continued breastfeeding.  In Kenya, for example, MCHIP found that it was important to specify that exclusive breastfeeding involves feeding the child only breastmilk with no other foods, water or other liquids, even during “hungry times” (when food is less plentiful).  Correct practice of exclusive breastfeeding affects the effectiveness of LAM if mothers are trying to use it as a FP method.
  • Knowledge and perceptions about postpartum return to fecundity: Program learning from numerous countries has revealed that women often wait until their menstruation returns to use a modern FP method, even if they say they are using LAM (Uganda, Guinea and Bangladesh LAM Barrier Analyses). In Bangladesh, through the Healthy Fertility Study, a narrative story (“" href="http://www.mchip.net/node/1967">Asma’s Story”) was incorporated within home visits and community mobilization meetings to reinforce the importance of starting a modern FP method before menses return. 
  • Knowledge/retention of LAM criteria and cues to transition among postpartum women: Most women who report using LAM do not meet the criteria for correct LAM practice (Fabic and Choi, 2013). New opportunities to reinforce the LAM criteria and cues to transition should be further explored, such as through LAM Champions or using an e-Health approach.
  • LAM knowledge, perceptions, and counseling practices among health providers: In some settings, health providers do not routinely counsel on LAM, often due to lack of knowledge or misconceptions about the method’s efficacy.  It is important to ensure that health workers are properly oriented (and supervised) on LAM counseling, and to provide them with job aids to help standardize counseling messages.
  • Monitoring and follow-up of LAM users: LAM use is often not tracked in FP registers, and health workers are not proactive in following up with LAM users to encourage a timely transition to another modern method before the woman is at risk. Tracking LAM within FP registers and conducting proactive follow up may help to improve timeliness of transition to another modern method.

A recent study in Egypt revealed that women who are given emergency contraception along with LAM counseling are significantly more likely to initiate regular contraception within or shortly after the first six months postpartum when compared with those in the LAM-only group (30.5% vs. 7.3%) (Shaaban et al, 2013).  

Remaining barriers to optimal breastfeeding, timely postpartum contraceptive uptake, and optimal practice of LAM and transition need to be addressed to improve PPFP and MIYCN outcomes.  New and innovative strategies for communicating about maternal and infant nutrition, LAM, and postpartum return to fecundity should be considered.  It is time to reflect on previous communication approaches and to “think outside the box”—beyond the traditional LAM messages—to focus on designing dynamic, strategic approaches that address barriers and motivate women and health providers.  

By Rae Galloway on August 4, 2014
Yemen
Middle East

Photo: Dr. Ali Assabri

This blog was originally published by MCHIP. Written by Rae Galloway

If exclusive breastfeeding in the first six months of life prevents malnutrition, a subsequent pregnancy (as long as menses has not returned), and potential death from infections, why aren’t more women worldwide choosing to do so? Babies who are not exclusively breastfed have a one- to two-fold greater risk of dying than breastfed babies (with the risk varying by the type of illness). And the risk of mortality is even greater (a two- to four-fold increase) when children receive food and other liquids in addition to breast milk, or are not breastfed at all (a two- to 14-fold increased risk of dying).  

While rates are higher in some countries than others, the unfortunate truth is that fewer than half of children are exclusively breastfed in most countries. In Yemen—which has one of the lowest rates of exclusive breastfeeding in the world—preliminary results from a recent national survey found that only 10% of infants are exclusively breastfed in their first six months. 

To uncover the factors impeding optimal maternal, infant and young child nutrition and family planning practices, including exclusive breastfeeding, USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) in partnership with the Ministry of Public Health and Population conducted formative research on the subject in two ecological zones of Dhamar Governorate. The study results illuminated a clear need among mothers, fathers and other family members for accurate information on how best to feed young children, as well as what women should eat during pregnancy and lactation. 

For example, within the study sample: 

  • Not one child under six months was being exclusively breastfed.
  • Not one child 6-23 months had been exclusively breastfed.
  • One infant had received only water, which the mother had provided to promote speech development, believing that “water lubricates the jaw to make speech easier.”
  • Most mothers had introduced food or animal milk prior to six months, feeling their breast milk was “not enough.” Mothers often made the decision that their breast milk was insufficient because their baby cried after nursing, or other family members advised them that their baby needed additional food. 
  • All infants received liquids before six months—with animal or powdered milk, water and juice being the most common liquids given.
  • More than half of babies younger than six months received food with crushed, sugary biscuits made into a paste with water or milk being a popular food to give to babies, even as young as one month of age.
  • Some mothers gave food because it filled their baby’s stomach, reportedly making them cry less and easier to manage.

In reality, breastfeeding practices in the sample were not optimal, which contributed to inadequate breast milk supply and hungry, unhappy babies. Sub-optimal practices included infrequent feedings, short duration of feedings, feeding from only one breast, and not feeding babies at night time. These practices led to decreased breast milk supply and the introduction of liquids and food, which further reduced breast milk production. Introduction of liquids and foods increases risk of infection, which in turn increases risk of malnutrition and mortality. Half of the women reported some problem with breastfeeding—such as pain, redness, engorgement and cracked nipples—but women were able to manage these problems themselves or seek treatment for them.

To improve infant and young child feeding, including exclusive breastfeeding, MCHIP is developing a package for health facility and community workers to use when counseling mothers. Because of the importance of family planning to the health, nutritional status, and survival of women and children, this package also will include messages about using the lactational amenorrhea method (LAM) in the first six months and transitioning to modern methods of family planning thereafter.

By Ian Hurley on August 1, 2014
Liberia
Africa

Photo: Jonathan Hyams/Save the Children

Hawa, successfully gave birth to a baby boy, 20 minutes old, at a Save the Children supported clinic in Peterstown, Margibi county, Liberia. Hawa is an inpatient at a new Maternal Waiting Home built by Save the Children at Peterstown clinic. The Maternal Waiting Home provides pregnant women with a place to stay, at the clinic, in their final week before delivery to ensure they get the proper professional care they need. Save the Children works with the county health team in Margibi, Liberia, enabling clinics to provide antenatal and postnatal care services, immunisation programmes and delivery of babies, as well as supporting nutritional feeding programmes with other partners.

Hawa stayed in the Maternal Waiting Home at Peterstown Clinic Margibi County Liberia for two weeks before giving birth. She lives in Ansa Town, about three hours walk from the clinic. This is her third child, she has two boys aged five and three. She delivered them at home in her village, before women were encouraged to come to the clinic. Now women like to come to the clinic, because they can stay at the home and feel safer. Two of Hawa's friends are also staying at the clinic and waiting to give birth. She says "We are taken care of here, we are treated well, we feel at home." 

Today marks the start of the annual World Breastfeeding Week. Coordinated by the World Alliance for Breastfeeding Action, this year's theme calls for the protection, promotion, and support for breastfeeding as we draw close to the 500 day mark for the Millennium Development Goals. Events are planned in over 170 countries.  

To coincide with World Breastfeeding Week, a new breastfeeding brochure, Early Initiation of Breastfeeding, was release to provide an overview of why breastfeeding is important and what some of the challenges to wider implementation are. It was developed by WHO and UNICEF along with 15 other organizations. 

Breastfeeding also features prominently in the recently launched Every Newborn action plan. Under Strategic Objective 2, it calls for rectifying the shortage of breastfeeding counsellors. The plan also places emphasis on the role of the private sector in protecting and supporting exclusive breastfeeding and conforming to the provisions of the International Code of Marketing Breastfeeding Substitutes. Importantly, Every Newborn sets the nutritional goal of 50% exclusive breastfeeding in all countries by 2025. As countries work to sharpen their existing health plans to meet the coverage goals of Every Newborn, lets work to support them and improve their efforts to scale up this critical intervention. 

By Pauline Irungu on July 30, 2014
Kenya
Africa


A newborn baby at the Lugube Primary Health Center in Nigeria. Photo: PATH/Evelyn Hockstein

This blog was originally published by PATH. Written by Pauline Irungu

On June 30, Pauline Irungu, PATH’s senior policy and advocacy officer in Kenya, took part in the launch of the Every Newborn action plan in Johannesburg, South Africa.

Since the launch of the Every Newborn action plan, I feel more optimistic than ever about the future of newborn health, globally and in Kenya. At the Partnership for Maternal, newborn & Child Health Partners' Forum in Johannesburg last month, I joined hundreds of advocates, each deeply invested in the health of the world's women, children and newborns. We gathered to discuss the final months of the Millennium Development Goals (MDGs) and potential new health targets as the world transitions from the MDGs to the Sustainable Development Goals.

A key goal is to reduce the number of preventable newborn deaths. Over the past two decades, improvements in newborn death rates have failed to keep pace with improvements for older children. There is a growing commitment among the global health community to address this failure, and an understanding of what needs to be done to save these young lives. As a major, worldwide, first step, the landmark Every Newborn action planoutlines a strategy to prevent 2.9 million newborn deaths and 2.6 million stillbirths each year.

Where do we go from here?

Attention to newborn health is especially necessary in sub-Saharan African countries, which are making the slowest progress in reducing newborn deaths. I’ve already seen a dramatic increase in commitment to newborn health in Kenya as global initiatives like the MDGs, the Every Newborn action plan, and the UN Commission for Life-Saving Commodities for Women’s and Children’s Health have raised the profile of newborns and highlighted countries’ lagging progress toward health goals.


Photo: PATH/Evelyn Hockstein

On behalf of PATH, I’ve been collaborating with partners and the Kenyan government to push forward two groundbreaking initiatives. The first is the Maternal and Newborn Health Scale-Up Strategy and Implementation Plan, which is set to become Kenya’s first policy to focus on key interventions for the three leading causes of newborn deaths: prematurity, sepsis, and birth asphyxia. The second is the development of maternal, newborn, and child health legislation that provides a legal framework to prioritize reducing the deaths of women, newborns, and children. Among other key provisions, the legislation will institutionalize the tracking of newborn deaths, which will help Kenya identify—and fix—gaps in its health system.

As a member of the Every Newborn Political Advocacy Working Group, which seeks to coordinate advocacy action and push for country-level policies that support the plan, I am excited to see Kenya make such strong commitments to newborn health.


Photo: PATH/Evelyn Hockstein

Action through innovation

Moving forward, we will need to harness the motivation I witnessed in Johannesburg and direct it toward technological, social, and systems innovations that can contribute to the end of preventable deaths. Kenya, for example, needs creative methods to get all mothers to give birth in health care facilities (40 percent still don’t). We also need inventive ways to keep babies warm in places with limited electricity, to transport newborns from remote locations to health care facilities, to develop technologies to help newborns breathe, and to ensure the financial sustainability of maternal, newborn, and child health services.

Watch Pauline Irungu speak about the importance of innovation for newborn health at the Partners' Forum.

PATH is working on health innovations that promise to drive down newborn and maternal deaths. More than half of premature babies struggle to breathe, which is one of the reasons premature birth is the leading cause of newborn death. PATH is advancing an affordable bubble continuous positive airway pressure device that can save lives by gently flowing pressurized air into babies’ lungs. We’re also working on solutions for postpartum hemorrhage and—two of the leading causes of maternal death. Five of these groundbreaking newborn health innovations will be featured at USAID’s Saving Lives at Birth: A Grand Challenge for Development event from July 30 to August 1 in Washington, DC. These tools will save the lives of newborns as well as women, because babies are less likely to survive when their mothers don’t. According to the action plan, investments in quality care at birth could save the lives of millions of babies and women who die needlessly each year.

Though we—the global health community—have much work to do to end preventable newborn deaths, I am energized about global commitments and the motivating force of the Early Newborn action plan. This motivation will be critical to create real and lasting change for the world’s newborns.

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