Addressing Critical Knowledge Gaps in Newborn Health


By Mwereti Kanjo on April 1, 2014

This blog was originally published by MamaYe. Written by Mwereti Kanjo. 

The ball is now in our hands. Presidential running mates have given us the power to hold them accountable for promises made.

The promises...

Once elected into power, Richard Msowoya of the Malawi Congress Party (MCP) said they will ensure that women have access to right information on the importance of delivering in hospitals, improve the education levels of women and fight for a change in culture plus attitude to help reduce deaths of mothers and babies. This is after noting that the biggest challenge is that information does not trickle down well to rural communities where it is needed the most.

The Democratic Progress Party (DPP) through its running mate, Saulosi Chilima, will improve primary health care, encourage hospital deliveries and construct more health centers in the country to help reduce distance to the facility. This is one of the leading contributing factors of maternal deaths in Malawi.

The United Democratic Front (UDF) too has spoken. Dr Godfrey Chapola, its running mate agrees with MCP that there is need to ensure that women have access to information to save mothers and babies in Malawi.

For the People’s Party, Sosten Gwengwe feels that the decrease of maternal mortality rate to 675 per 100 000 lives births from 984 in 2009 can be attributed to the construction of waiting homes which his government is leading on. This they will continue with to ensure that more mothers and babies are surviving.


The question...

These promises were made in response to MamaYe Malawi National Coordinator Charles Makwenda at a Presidential running mate’s debate that was organized by Zodiak Broadcasting Corporation (ZBS). The debate, first of its kind, provided a platform for Malawians to quiz running mates on pertinent issues before being elected into power.

Makwenda’s question: “Between six to eight women die every day in Malawi due to childbirth related causes, we lose two newborn babies every hour and Malawi ranks the highest in the deaths of preterm babies. We want to know, if elected into power, what will your government do to help save the lives of mothers and babies?”

What they should have said...

While the responses are a little vague it still gives us, Malawian, somewhere to start from should they fail to deliver these commitments.

They have all said, we are the employers and they the employees. Should they fail to deliver we should use the powers given to us by the constitution to hold them accountable.

I must say though, as a citizen and an activist, I would have loved to hear them say that before implementing anything they will look at the existing evidence to see what is really leading to so many deaths of mothers and babies in Malawi.

Yes, they weren’t given enough time to explain themselves but I would have loved it even more, if they explained how they plan to implement these commitments. What different thing would they do?

This is because, so many before them have said the same about saving lives of mothers and babies. Yet, Malawi still ranks amongst the highest in maternal and newborn mortality rates.

I am thinking that maybe, just maybe we should start thinking differently in our approach to making a change. Let us look at the evidence on the ground and start from there.

MamaYe Malawi tried to make this easier for the running mates because they each left with a folder that had all the relevant facts and figures that can help them make better informed decisions.

It is my hope that this is just the beginning of good things to come and that it just wasn’t some political propaganda!!!

By Nadeem Shahid on March 31, 2014

Women queue to have their children weighed by a Lady Health Worker (LHW) in Pakistan. LHW's regularly checks children's weight and keep an accurate record, thereby allowing them to see the general health of the children over a period of time and pick up on any early signs of malnutrition. Photo: CJ Clarke/Save the Children

Save the Children’s report on neonatal deaths in Pakistan suggests that the rate of intra- partum stillbirths (death during childbirth) and first day neonatal mortality in Pakistan is the highest in the world at 40.7 per 1,000 total births countywide.

But being an infant or mother is not so easy in Balochistan. The women and children of Balochistan province are most ill-fated in this regard.

The recent study Pakistan Demographic Health Survey (PDHS 2012-13) shows that the Infant Mortality Rate (IMR) is 97/1000, the Under 5 Mortality Rate (U5MR) is 111 and neonatal Mortality Rate at 63/1000. Maternal Mortality Ratio (MMR) is 785 /100000.

According to the National Nutrition Survey (NNS) 2011), malnutrition among children under five is ranked as Severe stunting (Height For Age HFA) is 32.20 %, Wasting (Weight For Height WFH) is 18.60% and under weight (Weight For Height WFA) is 41.80%. On the other hand, 63.50% of children are food insecure.

The front line health workers who provide basic health care services, education and prevention include Lady Health Workers (LHWs) Vaccinators and Community Health Midwifes (CMWs).

Balochistan has 167 community midwifes rendering services in the field by the provincial Health Department. Tragically, only 29.1% deliveries are conducted by the skilled birth attendants. Currently there are 6720 Lady Health Workers (LHWs) covering only 43% of the province. Similarly, there are 943 vaccinators and measles coverage is only 22.9%. These poor health indicators further affect the condition of women and child health.

There is a glaring need to increase numbers of the LHWs, CMWs and Vaccinators, allocating fiscal and human resources for LHWs, Expended Programme on Immunization (EPI), Maternal, Newborn and Child Health (MNCH) and Nutrition programs to minimize the IMR, MMR, Neonatal Mortality Rate and Under 5 Mortality Rate (U5MR) to track the province toward achieving MDGs 4 and 5.

Only one intervention promotion of early initiation of Breastfeeding could save 22% of neonatal deaths. Taking a step toward promoting breastfeeding and discouraging bottle feeding a formula milk the Balochistan assembly recently passed legislation on “Protection and Promotion of Breastfeeding and Young Child Nutrition Law 2014” Arshad Mahmood - The Express Tribune Blog. To monitor and implement this in its true letter and spirit the government of Balochistan must notify the Infant Feeding Board and devise its Term Of Reference. Train the LHWs, Lady Health Visitors (LHVs) CMWS and Health Care providers in Infant & Young Child Feeding practices that teach and encourage mothers to practice optimal feeding and exclusive breastfeeding.

To minimize infants and mother deaths in the province the Balochistan government must allocate budget for Nutrition, Lady Health Workers (LHWs) and Expended Programme on Immunization (EPI) programme. Also, the number of LHWs should be doubled. There must be two of vaccinators union council level, and number of Community Midwives (CMWs) be increased.

By Ian Hurley on March 28, 2014

Photo: David Wardell/Save the Children

First time Mother Tia, holds her 30-minute-old unnamed son. Over the past 15 years, Indonesia has made significant progress in lowering maternal and newborn mortality. The maternal mortality ratio has been steadily declining, from 390 in 1994 to the current level of 228 deaths per 100,000 live births. Skilled attendance at births is reported at 73%. Newborn deaths have declined at a slower pace but still show a steady downward trend with neonatal mortality rates dropping from 30 per 1000 live birhts in 1994 to 19 per 1000 live births in 2007.

A variety of successful initiatives including the placement of midwives at the village level, training and mentoring mechanism for midwives, and social safety net programs such as Jamesmas have resulted in more access to services and the creation of social norms that support skilled attendance at birth and high use of focused antenatal care.

As promising as these trends and achievements are, Indonesia is not on track to achieve Millenium Development Goal (MDG) 5 by 2015, and is at risk of falling off track for MDG 4.

By Abimbola Williams on March 27, 2014
Nepal, Nigeria
Africa, Asia

Each year in Nigeria, more than 240,000 babies die in their first month of life, accounting for more than a quarter of all under-five deaths. Thirty percent of these deaths occur because of severe infections that are acquired soon after birth and during the first days of life, which is when babies are at most risk of dying.

Fortunately, we know most of these lives could be saved by improving hygiene, reducing exposure to life-threatening bacterial infections particularly in the first week of life, and by making antibiotics available to newborns who become sick. The Government of Nigeria has taken action to ensure no newborn dies from preventable causes.  Once such step is its commitment to introduce chlorhexidine for umbilical cord care on a national scale. This inexpensive and widely available antiseptic has been proven to dramatically reduce newborn mortality when applied to the baby’s umbilical cord soon after birth.

This video highlights the Nigeria delegation's learning visit to Nepal to learn about the country's Chlorhexidine for umbilical cord care program. 

A learning visit to Nepal

Considering that two-thirds of births take place at home in the absence of a qualified health worker, Nigeria is keen to introduce community-based approaches and interventions to prevent newborn infections. This is why last month, a delegation of 11 of Nigeria’s most dedicated stakeholders traveled to Nepal, a country that has made remarkable progress in implementing chlorhexidine at the community level. Not only has Nepal made strides in ensuring the antiseptic is widely available in health facilities, it has also provided access to mothers and newborns in remote areas through community-based distribution through their Female Community Health Volunteer program (FCHVs).

The delegation sought to learn from Nepal’s successes and challenges in implementing chlorhexidine in order to provide further guidance for those involved withthe wide-scale introduction and implementation of chlorhexidine for newborn cord care in Nigeria. The team included members from the Federal Ministry of Health, the National Primary Health Care Development Agency (NPHCDA), the National Agency for Food and Drug Administration and Control (NAFDAC), Jigawa State Ministry of Health, the State Primary Health Care Development Agency (from Jigawa and Katsina states), the Nigerian Society for Neonatal Medicine (NISONM), and Save the Children.

Members of the Nigerian delegation including Dr. Kayode Afolabi, Head of the Child Health Division at the Federal Ministry of Health in Nigeria (far left), observe the application of chlorhexidine for umbilical cord care at the Kohalpur medical hospital in Banke district, Nepal. Photo: Narendra Pradhan for Save the Children

A look at Nepal’s delivery mechanisms for chlorhexidine

After arriving in Nepal, we spent the first few days in the capital city of Kathmandu interacting with Nepali stakeholders, including those from Nepal’s Ministry of Health and Population, Save the Children – Nepal, and JSI. These initial meetings gave us a better understanding of the health care system in Nepal, and they also gave us the opportunity to discuss the facilitators and barriers of different delivery strategies, ranging from antenatal and delivery care, to community health workers. In addition, we were able to share with the Nepali stakeholders information on Nigeria’s health care system, including the IMNCH strategy and the Saving One Million Lives Initiative.

We then departed for Banke District, which is in the southwestern part of the country near the Indian border. Upon arriving, the director of the District Public Health Office of Banke gave us an overview of the health system and the remarkable progress they have made in ensuring chlorhexidine is available to all mothers and newborns across the district. The following day, we visited a privately-funded hospital that uses chlorhexidine for clean cord care. The busy referral hospital is also a medical college, where maternal and newborn care services are offered at no charge to women and their families.

One of the highlights of our time in Banke was meeting a few FCHVs.  Prior to the visit, we knew that Nepal has had internationally recognized success in achieving positive health outcomes using this extensive network of volunteers. It was when we were in rural Banke, however, that we realized how big of a role they play. Not only do they provide chlorhexidine to mothers a month before they give birth during routine antenatal visits, they also visit mothers soon after they give birth to ensure that the mother and the baby are healthy. The commitment and motivation of FCHVs is remarkable, and Nepal’s efforts to sustain this cadre are commendable. While health volunteers in Nigeria have a high attrition rate, Nepali FCHVs are remarkably committed to volunteerism—some of the FCHVs we met have been assisting their communities for more than 15 years! We hope to use what we learned in Nepal to inform Nigeria’s system of community health volunteers and the new village health workers scheme recently inaugurated.

After returning to Kathmandu, we visited Lomus Pharmaceuticals, the company that has developed the product for Nepal and now also supplies to other countries, including Nigeria. Since chlorhexidine is locally manufactured, Nepal is able to provide a continuous supply for only about 0.23 USD per single-use application. By interacting with workers at Lomus, we were able to explore issues around drug policy regulation, manufacturing, supply chain management, and social marketing of health commodities.

A discussion with Nepal's Female Community Health Volunteers Sita Yadav and Sharda Oli (pictured in their blueuniforms) and new mothers Chandra Pun and Irada Shahi, both of whom received chlorhexidine during antenatal check-ups. Kamdi, Banke district, Nepal. Photo: Narendra Pradhan for Save the Children

Next Steps

To date, two states in Nigeria – Sokoto and Bauchi – have already initiated implementation of chlorhexidine, supported by partners including USAID’s TSHIP program, the Bill & Melinda Gates Foundation, and JSI. The learning visit also provided a forum for our stakeholders to compare learning emerging from Sokoto and Bauchi, and inform Nigeria’s plans to roll out chlorhexidine within a broader community health program. Furthermore, the availability of chlorhexidine will greatly facilitate progress towards Nigeria's Saving One Million Lives Agenda, the Every Newborn agenda, and the UN Commission on Lifesaving Commodities, which is co-chaired by the president of Nigeria.

Back at home, the policies are mostly in place; what is needed now is action at state and local level to increase coverage and quality of life-saving interventions, while closing the equity gap for the poorest families. We seek to extend the collaboration we made in Nepal among federal, state, and non-government stakeholders to Nigeria as a whole. Such collaboration will include targeted meetings with high-level federal and state officials to revise and finalize Nigeria’s guidelines for chlorhexidine application, formulizing arrangements for the production and distribution of chlorhexidine, state and national-level advocacy, and other efforts that will result in an effective nation-wide chlorhexidine program.

Mothers in Nepal are benefitting from improved care, as evidenced from my conversation with mothers in the postnatal ward at Kohalpur medical hospital in Banke. Photo: Narendra Pradhan for Save the Children

Related Resources

By Craig Ferla on March 26, 2014

This blog was originally published by MamaYe. Written by Craig Ferla

There is always a sense of awe when you have the opportunity to meet with a national leader. This was not lost on me recently when I was privileged enough to meet Tanzania’s Prime Minister, Hon. Mizengo Pinda.

I was part of a White Ribbon Alliance (WRA) delegation made up of a small group of civil society leaders advocating for our mothers and babies survival in Tanzania.

MamaYe! Director Craig Ferla (top left) with the Hon. Pinda (bottom centre) and the White Ribbon Alliance Board and members. Photo: MamaYe!

Hon. Pinda struck me as sincere, courteous, and receptive – I quickly warmed to his leadership presence. 

He welcomed us and duly listened to our cause. The very brillant Rose Mlay pitched the WRA national campaign ask straight at the Prime Minister. They are calling for Tanzanian Government to honour its commitment to saving thousands of lives of mothers and babies by ensuring that emergency care in pregnancy and childbirth is available to all. Including surgery and blood transfusion. Including the majority of women who live in rural communities. All Tanzanian women should have emergency care when they need it.

At the meeting, two things struck me:

  • How Rose, a much seasoned and loved campaigner for mothers’ survival, is so good at being able to get the time and ear of top leadership and decision-makers
  • I was unsure whether the Prime Minister really realised the tragic scale of the loss of our mothers and babies in Tanzania


Statistics, even when in their thousands, can be lifeless and faceless, cold, development speak, and just too big to really understand in everyday ways: less than half or more than 50,000 or 454 deaths out of one hundred thousand live births, etc. etc.

For a moment imagine the depth of grief in just one household, and by her nearest and dearest, at the death of one mother whilst in the act of giving life.

Remember the words you said to your miracle, your new baby, when cradled in your arms for the first time, or the words you imagine that you would say if you haven’t yet been blessed this peerless moment in life...

These are the cherished people we are talking about, our mothers and babies.

I seized a moment to try and bring this home beyond the comfort zone of aggregate statistics.

I had noticed how during the meeting so far every now and again an assistant to the Prime Minister would hand over to him a little note which he would either take a moment of contemplation over, or on one occasion excused himself for a few minutes. My mind imagined what could be on these pieces of paper and maybe making tomorrow’s headlines – scores killed in a community clash over land - a huge horde of ivory intercepted at the port - disastrous flooding in Morogoro region.

I would have no choice but to resign

I asked the Prime Minister what would happen if one of those notes was informing him of a plane crash that had just happened in Tanzania, maybe one of the private airlines that typically carry between 30 – 100 passengers a flight?

It would be considered a disaster.

And then before he had really had a moment to gather his thoughts and act on the unfolding disaster, another note of another plane crash only a few hours later.

What on earth would be his response and the whole nation’s response - if this happened yet again the day after, and again the day after that - let alone for every waking day for the whole year ahead of us.

Yes, that is the scale of loss of our beloved mothers and babies every day it dawns. That’s what it means to lose around 8,500 mothers and nearly 50,000 babies every year in Tanzania.

He responded that he would have no choice but to resign as Prime Minister.

And yet the majority of these precious lives could be saved. We have the answers. We now need action.

I am excited that in a couple of weeks’ time I will have the privilege of the Prime Minister’s company once again, this time as he graces this year’s White Ribbon Day on 15-March that will be held in Mtowisa ward of Sumbawanga Rural district.

We all have our part to play to be a champion of our mothers and babies, especially our top leadership. I eagerly look forward to Hon. Pinda’s participation, leadership and action on this most precious of causes in Tanzania. More of that in this blog