Addressing Critical Knowledge Gaps in Newborn Health

Blog

By Alexandra Shaphren on September 18, 2013
Research

 *Journal subscription required for full access

*Multiple Authors. Supplement, Innovative Treatment Regimens for Severe Infections in Young Infants. Pediatrics Infectious Disease Journal (September, 2013).

This special issue describes in detail several community-based regimens being evaluated through randomized controlled trials in South Asian and African countries. The supplement details the studies' methods, the development and rationale of their approach, the standardization and quality control processes across studies, and the global policy implications.

The supplement includes 9 papers:

1. New Research on Community Management of Severe Neonatal Infections: An Overview. Stoll, Barbara J.; Bhan, Maharaj K.

2. An Innovative Multipartner Research Program to Address Detection, Assessment and Treatment of Neonatal Infections in Low-resource Settings. Qazi, Shamim Ahmad; Wall, Steve; Brandes, Neal; et al.

Background: In pursuit of innovative approaches for the management of severe infections in young infants, which is a major cause of mortality, a multipartner research program was conceptualized to provide right care in the right place. The primary objective was to generate evidence and identify a simple, safe and effective treatment regimen for young infants with severe infections that can be provided closer to home by trained health workers where referral is not possible.

Research: Published and nonpublished data on community-based approaches for the management of neonatal sepsis were critically reviewed by an independent expert panel convened in 2007 by the World Health Organization in collaboration with the United States Agency for International Development and Save the Children/Saving Newborn Lives. These stakeholders agreed to 1) undertake research to improve the specificity of a diagnostic algorithm and revise World Health Organization/United Nations International Children’s Emergency Fund Integrated Management of Childhood Illness guidelines to identify sick young infants for referral, 2) develop research studies with common research designs (1 site in each Bangladesh and Pakistan and a multicentre site in Democratic Republic of Congo, Kenya and Nigeria) and oversight mechanisms to evaluate antibiotic regimens (when referral is not accepted by the family) that are safe and efficacious, appropriate to the severity of infection, and deployable on a large scale and 3) utilize existing program delivery structures incorporating community health workers, skilled health workers to deliver simple antibiotic treatment when referral is not possible.

Conclusions: This research program facilitated innovative research in different geographical, cultural and administrative milieus to generate recommendations for policy.

3. Scientific Rationale for Study Design of Community-based Simplified Antibiotic Therapy Trials in Newborns and Young Infants With Clinically Diagnosed Severe Infections or Fast Breathing in South Asia and sub-Saharan Africa. Zaidi, Anita K. M.; Baqui, Abdullah H.; Qazi, Shamim Ahmad; et al.

Background: Newborns and young infants suffer high rates of infections in South Asia and sub-Saharan Africa. Timely access to appropriate antibiotic therapy is essential for reducing mortality. In an effort to develop community case management guidelines for young infants, 0–59 days old, with clinically diagnosed severe infections, or with fast breathing, 4 trials of simplified antibiotic therapy delivered in primary care clinics (Pakistan, Democratic Republic of Congo, Kenya and Nigeria) or at home (Bangladesh and Nigeria) are being conducted.

Methods: This article describes the scientific rationale for these trials, which share major elements of trial design. All the trials are in settings of high neonatal mortality, where hospitalization is not feasible or frequently refused. All use procaine penicillin and gentamicin intramuscular injections for 7 days as reference therapy and compare this to various experimental arms utilizing comparatively simpler combination regimens with fewer injections and oral amoxicillin.

Conclusion: The results of these trials will inform World Health Organization policy regarding community case management of young infants with clinical severe infections or with fast breathing.

4. Safety and Efficacy of Simplified Antibiotic Regimens for Outpatient Treatment of Serious Infection in Neonates and Young Infants 0-59 Days of Age in Bangladesh: Design of a Randomized Controlled Trial. Baqui, Abdullah H.; Saha, Samir Kumar; Ahmed, A. S. M. Nawshad Uddin; et al.

Background: Because access to care is limited in settings with high mortality, exclusive reliance on the current recommendation of 7–10 days of parenteral antibiotic treatment is a barrier to provision of adequate treatment of newborn infections.

Methods: We are conducting a trial to determine if simplified antibiotic regimens with fewer injections are as efficacious as the standard course of parenteral antibiotics for empiric treatment of young infants with clinical signs suggestive of severe infection in 4 urban hospitals and in a rural surveillance site in Bangladesh. The reference regimen of intramuscular procaine-benzyl penicillin and gentamicin given once daily for 7 days is being compared with (1) intramuscular gentamicin once daily and oral amoxicillin twice daily for 7 days and (2) intramuscular penicillin and gentamicin once daily for 2 days followed by oral amoxicillin twice daily for additional 5 days. All regimens are provided in the infant’s home. The primary outcome is treatment failure (death or lack of clinical improvement) within 7 days of enrolment. The sample size is 750 evaluable infants enrolled per treatment group, and results will be reported at the end of 2013.

Discussion: The trial builds upon previous studies of community case management of clinical severe infections in young infants conducted by our research team in Bangladesh. The approach although effective was not widely accepted in part because of feasibility concerns about the large number of injections. The proposed research that includes fewer doses of parenteral antibiotics if shown efficacious will address this concern.

5. Simplified Antibiotic Regimens for the Management of Clinically Diagnosed Severe Infections in Newborns and Young Infants in First-level Facilities in Karachi, Pakistan: Study Design for an Outpatient Randomized Controlled Equivalence Trial. Zaidi, Anita K. M.; Tikmani, Shiyam Sundar; Sultana, Shazia; et al.

Background: Infection in young infants is a major cause of morbidity and mortality in low-middle income countries, with high neonatal mortality rates. Timely case management is lifesaving, but the current standard of hospitalization for parenteral antibiotic therapy is not always feasible. Alternative, simpler antibiotic regimens that could be used in outpatient settings have the potential to save thousands of lives.

Methods: This trial aims to determine whether 2 simplified antibiotic regimens are equivalent to the reference therapy with 7 days of once-daily (OD) intramuscular (IM) procaine penicillin and gentamicin for outpatient management of young infants with clinically presumed systemic bacterial infection treated in primary health-care clinics in 5 communities in Karachi, Pakistan. The reference regimen is close to the current recommendation of the hospital-based intravenous ampicillin and gentamicin therapy for neonatal sepsis. The 2 comparison arms are (1) IM gentamicin OD and oral amoxicillin twice daily for 7 days; and (2) IM penicillin and gentamicin OD for 2 days, followed by oral amoxicillin twice daily for 5 days; 2250 “evaluable” infants will be enrolled. The primary outcome of this trial is treatment failure (death, deterioration or lack of improvement) within 7 days of enrollment. Results are expected by early 2014.

Discussion: This trial will determine whether simplified antibiotic regimens with fewer injections in combination with high-dose amoxicillin are equivalent to 7 days of IM procaine penicillin and gentamicin in young infants with clinical severe infection.Results will have program and policy implications in countries with limited access to hospital care and high burden of neonatal deaths.

6. Simplified Regimens for Management of Neonates and Young Infants With Severe Infection When Hospital Admission Is Not Possible: Study Protocol for a Randomized, Open-label Equivalence Trial. AFRINEST (AFRIcan NEonatal Sepsis Trial) Group.

Background: In resource-limited settings, most young infants with signs of severe infection do not receive the recommended inpatient treatment with intravenous broad spectrum antibiotics for 10 days or more because such treatment is not accessible, acceptable or affordable to families. This trial was initiated in the Democratic Republic of Congo, Kenya and Nigeria to assess the safety and efficacy of simplified treatment regimens for the young infants with signs of severe infection who cannot receive hospital care.

Methods: This is a randomized, open-label equivalence trial in which 3600 young infants with signs of clinical severe infection will be enrolled. The primary outcome is treatment failure in 7 days after enrollment, which includes death or worsening of the clinical condition on any day, or no improvement in the clinical condition by day 4 of treatment. Secondary outcomes include compliance with study therapy, adverse effects due to the study drugs and relapse or death during the week after completion of treatment.

Discussion: The results of this study, along with ongoing studies in Pakistan and Bangladesh, will inform the development of global policy for treatment of severe neonatal infections in resource-limited settings.

7. Treatment of Fast Breathing in Neonates and Young Infants With Oral Amoxicillin Compared With Penicillin-Gentamicin Combination: Study Protocol for a Randomized, Open-label Equivalence Trial. AFRINEST (AFRIcan NEonatal Sepsis Trial) Group.

Background: The World Health Organization recommends hospitalization and injectable antibiotic treatment for young infants (0–59 days old), who present with signs of possible serious bacterial infection. Fast breathing alone is not associated with a high mortality risk for young infants and has been treated with oral antibiotics in some settings. This trial was designed to examine the safety and efficacy of oral amoxicillin for young infants with fast breathing compared with that of an injectable penicillin–gentamicin combination. The study is currently being conducted in the Democratic Republic of Congo, Kenya and Nigeria.

Methods/Design: This is a randomized, open-label equivalence trial. All births in the community are visited at home by trained community health workers to identify sick infants who are then referred to a trial study nurse for assessment. The primary outcome is treatment failure by day 8 after enrollment, defined as clinical deterioration, development of a serious adverse event including death, persistence of fast breathing by day 4 or recurrence up to day 8. Secondary outcomes include adherence to study therapy, relapse, death between days 9 and 15 and adverse effects associated with the study drugs. Study outcomes are assessed on days 4, 8, 11 and 15 after randomization by an independent outcome assessor who is blinded to the treatment being given.

Discussion: The results of this study will help inform the development of policies for the treatment of fast breathing among neonates and young infants in resource-limited settings.

8. Ensuring Quality in AFRINEST and SATT: Clinical Standardization and Monitoring. Wall, Stephen N.; Mazzeo, Corinne I.; Adejuyigbe, Ebunoluwa A.; et al.

Background: Three randomized open-label clinical trials [Simplified Antibiotic Therapy Trial (SATT) Bangladesh, SATT Pakistan and African Neonatal Sepsis Trial (AFRINEST)] were developed to test the equivalence of simplified antibiotic regimens compared with the standard regimen of 7 days of parenteral antibiotics. These trials were originally conceived and designed separately; subsequently, significant efforts were made to develop and implement a common protocol and approach. Previous articles in this supplement briefly describe the specific quality control methods used in the individual trials; this article presents additional information about the systematic approaches used to minimize threats to validity and ensure quality across the trials.

Methods: A critical component of quality control for AFRINEST and SATT was striving to eliminate variation in clinical assessments and decisions regarding eligibility, enrollment and treatment outcomes. Ensuring appropriate and consistent clinical judgment was accomplished through standardized approaches applied across the trials, including training, assessment of clinical skills and refresher training. Standardized monitoring procedures were also applied across the trials, including routine (day-to-day) internal monitoring of performance and adherence to protocols, systematic external monitoring by funding agencies and external monitoring by experienced, independent trial monitors. A group of independent experts (Technical Steering Committee/Technical Advisory Group) provided regular monitoring and technical oversight for the trials.

Conclusions: Harmonization of AFRINEST and SATT have helped to ensure consistency and quality of implementation, both internally and across the trials as a whole, thereby minimizing potential threats to the validity of the trials’ results.

9. Ongoing Trials of Simplified Antibiotic Regimens for the Treatment of Serious Infections in Young Infants in South Asia and Sub-Saharan Africa: Implications for Policy. Esamai, Fabian; Tshefu, Antoinette Kitoto; Ayede, Adejumoke I.; et al.

Background: The current World Health Organization (WHO) recommendation for treatment of severe infection in young infants is hospitalization and parenteral antibiotic therapy. Hospital care is generally not available outside large cities in low- and middle-income countries and even when available is not acceptable or affordable for many families. Previous research in Bangladesh and India demonstrated that treatment outside hospitals may be possible.

Research: A set of research studies with common protocols testing simplified antibiotic regimens that can be provided at the lowest-level health-care facility or at home are nearing completion. The studies are large individually randomized controlled trials that are set up in the context of a program, which provides home visits by community health workers to detect serious illness in young infants with assessment and treatment at an outpatient health facility near home. This article summarizes the policy implications of the research studies.

Policy Implications: The studies are expected to result in information that would inform WHO guidelines on simple, safe and effective regimens for the treatment of clinical severe infection and pneumonia in newborns and young infants in settings where referral is not possible. The studies will also inform the inputs and process required to establish outpatient treatment of newborn and young infant infections at health facilities near the home. We expect that the information from research and the resulting WHO guidelines will form the basis of policy dialogue by a large number of stakeholders at the country level to implement outpatient treatment of neonatal infections and thereby reduce neonatal and infant mortality resulting from infection.

UNICEF. Committing to Child Survival: A Promise Renewed (September, 2013).

We are pleased to share with you UNICEF’s Committing to Child Survival: A Promise Renewed – Progress Report 2013 which is being launched in conjunction with the Levels and Trends in Child Mortality report from the UN Inter-agency Group for Child Mortality Estimation (links to both and communication materials below). Attached are also the APR press release and the social media strategy.

The APR report assesses the global progress made to date in fulfilling the world’s commitment to save children from dying of preventable causes. The report’s data and analysis sound a clarion call for urgent action. If current trends continue, the world as a whole will not meet its commitment to reduce the under-five mortality rate by two thirds until 2028 – 13 years after the MDG deadline.

The stakes are high: based on current projections, an additional 35 million children will die between 2015 and 2028 – children who could have lived, had we met MDG 4 on time and sustained the progress. These figures are all the more unconscionable because the world has affordable, evidence-based interventions that can prevent so many of these deaths.

The report also inspires hope. The global under-five mortality rate has roughly halved, from 90 deaths per 1,000 live births in 1990 to 48 per 1,000 in 2012. The estimated annual number of under-five deaths has fallen from 12.6 million to 6.6 million over the same period.

Put another way, 17,000 fewer children died each day in 2012 than did in 1990 — thanks to more effective and affordable treatments, innovative ways of delivering critical interventions to the poor and excluded, and sustained political commitment. These and other vital child survival interventions have helped to save an estimated 90 million lives in the past 22 years.

Moreover, the world is currently reducing under-five mortality faster than at any other time during the past two decades. The global annual rate of reduction has steadily accelerated, more than tripling since the early 1990s.

The overall message of A Promise Renewed is clear and compelling: dramatic reductions in child deaths are possible. With political will and the coordinated engagement of the public, private and civil society sectors, the world can fulfill the promise to give every last child the opportunity to survive and thrive.

 

Purpose of review: Considerable debate has emerged on whether Option B+ (B+), initiation of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, is the best approach to achieving elimination of mother-to-child-transmission. However, direct evidence and experience with B+ is limited. We review the current evidence informing the proposed benefits and potential risks of the B+ approach, distinguishing individual health concerns for mother and child from program delivery and public health issues.

Recent findings: For mothers and infants, B+ may offer significant benefits for transmission prevention and maternal health. However, several studies raise concerns about the safety of ART exposure to fetuses and infants, as well as adherence challenges for pregnant and breastfeeding mothers. For program delivery and public health, B+ presents distinct advantages in terms of transmission prevention to uninfected partners and increased simplicity potentially improving program feasibility, access, uptake, and retention in care. Despite being more costly in the short-term, B+ will likely be cost effective over time.

Summary: This review provides a detailed analysis of risks and benefits of B+. As national programs adopt this approach, it will be critical to carefully assess both short-term and long-term maternal and infant outcomes.

 

Background: There is an increased risk of serious neonatal infection arising through exposure of the umbilical cord to invasive pathogen in home and facility births where hygienic practices are difficult to achieve. The World Health Organization currently recommends ‘dry cord care’ because of insufficient data in favor of or against topical application of an antiseptic. The primary objective of this meta analysis is to evaluate the effects of application of chlorhexidine (CHX) to the umbilical cord to children born in low income countries on cord infection (omphalitis) and neonatal mortality. Standardized guidelines of Child Health Epidemiology Reference Group (CHERG) were followed to generate estimates of effectiveness of topical chlorhexidine application to umbilical cord for prevention
of sepsis specific mortality, for inclusion in the Lives Saved Tool (LiST).

Methods: Systematic review and meta-analysis. Data sources included Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, CINHAL and WHO international clinical trials registry. Only randomized trials were included. Studies of children in hospital settings were excluded. The comparison group received no application to the umbilical cord (dry cord care), no intervention, or a non-CHX intervention. Primary outcomes were omphalitis and all-cause neonatal mortality.

Results: There were three cluster-randomised community trials (total participants 54,624) conducted in Nepal, Bangladesh and Pakistan that assessed impact of CHX application to the newborn umbilical cord for prevention of cord infection and mortality. Application of any CHX to the umbilical cord of the newborn led to a 23% reduction in all-cause neonatal mortality in the intervention group compared to control [RR 0.77, 95 % CI 0.63, 0.94; random effects model, I2=50 %]. The reduction in omphalitis ranged from 27 % to 56 % compared to control group epending on severity of infection. Based on CHERG rules, effect size for all-cause mortality was used for inclusion to LiST model as a proxy for sepsis specific mortality.

M. Mahande, A. Dalteveit, B. Mmbaga, et al. Recurrence of perinatal death in Northern Tanzania: a registry based cohort study. BioMed Central (September, 2013).

Background: Perinatal mortality is known to be high in Sub-Saharan Africa. Some women may carry a particularly high risk which would be reflected in a high recurrence risk. We aim to estimate the recurrence risk of perinatal death using data from a hospital in Northern Tanzania.

Methods: We constructed a cohort study using data from the hospital based KCMC Medical Birth Registry. Women who delivered a singleton for the first time at the hospital between 2000 and 2008 were followed in the registry for subsequent deliveries up to 2010 and 3,909 women were identified with at least one more delivery within the follow-up period. Recurrence risk of perinatal death was estimated in multivariate models analysis while adjusting for confounders and accounting for correlation between births from the same mother.

Results: The recurrence risk of perinatal death for women who had lost a previous baby was 9.1%. This amounted to a relative risk of 3.2 (95% CI: 2.2 - 4.7) compared to the much lower risk of 2.8% for women who had had a surviving baby. Recurrence contributed 21.2% (31/146) of perinatal deaths in subsequent pregnancies. Preeclampsia, placental abruption, placenta previa, induced labor, preterm delivery and low birth weight in a previous delivery with a surviving baby were also associated with increased perinatal mortality in the next pregnancy.

Conclusions: Some women in Tanzanian who suffer a perinatal loss in one pregnancy are at a particularly high risk of also losing the baby of a subsequent pregnancy. Strategies of perinatal death prevention that target pregnant women who are particularly vulnerable or already have experienced a perinatal loss should be considered in future research.

M. Miquelutti, J. Cecatti, M. Makuch. Antenatal education and the birthing experience of Brazilian women: a qualitative study. BioMed Central (September, 2013).

Background: Information is still scarce on the birthing experience of women who participate in antenatal systematic education programs. The objective of the study was to report the experience of labor as described by nulliparous women who participated and who did not in a systematic Birth Preparation Program (BPP).

Method: A qualitative study was conducted with eleven women who participated in a BPP and ten women attending routine prenatal care selected through purposeful sampling. The BPP consisted of systematized antenatal group meetings structured to provide physical exercise and information on pain prevention during pregnancy, the role of the pelvic floor muscles, the physiology of labor, and pain relief techniques. A single, semi-structured interview was conducted with each participant. All interviews were recorded, transcribed verbatim and thematic analyses performed. The relevant themes were organized in the following categories of analysis: control of labor, positions adopted during labor, and satisfaction with labor.

Results: Women who participated in the systematic educational activities of the BPP reported they maintained self-control during labor and used breathing exercises, exercises on the ball, massage, baths and vertical positions to control pain. Also they reported satisfaction with their birthing experience. Women who did not participate in systematic educational activities referred to difficulties in maintaining control during labor and almost half of them reported lack of control. Also they were more likely to report dissatisfaction with labor.

Conclusions: Women who participated in the BPP reported self-control during labor and used non-pharmacological techniques to control pain and facilitate labor and expressed satisfaction with the birthing experience.

*C. Moyer, et al. The relationship between facility delivery and infant immunization in Ethiopia. International Journal of Gynecology & Obstetrics (August, 2013).

Objective: To determine whether facility delivery influences compliance with recommended infant immunizations, particularly those that occur weeks or months after delivery.

Methods: In a retrospective analysis, multivariate logistic regression was used to assess data from the 2011 Ethiopia Demographic and Health Survey (EDHS) to determine the strongest correlates of facility delivery. These correlates were then used, along with facility delivery itself, to determine the relationship between facility delivery and infant immunization.

Results: In total, 3334 women delivered a newborn 12–24 months before the 2011 EDHS: 90.2% (3007) delivered at home, and 9.8% (327) delivered in a facility. Education, wealth status, urban residence, and number of children under 5 years living in the household were the factors most strongly associated with facility delivery. When facility delivery and its strongest correlates were entered into multivariate logistic regression models with infant immunizations as the outcome, facility delivery was significantly associated with increased likelihood of DPT-HepB-Hib, polio, and measles vaccination, and increased likelihood of being fully immunized (all P < 0.01). Facility delivery was the strongest single factor associated with infants being immunized, doubling the odds of full immunization.
Conclusion: The impact of facility delivery on health outcomes transcends the immediate delivery and postpartum period.

G. Namazzi, K. Suzanne, P. Waiswa, Bua, et al. Stakeholder analysis for a maternal and newborn health project in Eastern Uganda. BioMed Central (September, 2013).

Background: Based on the realization that Uganda is not on track to achieving Millennium Development Goals 4 and 5, Makerere University School of Public Health in collaboration with other partners proposed to conduct two community based maternal/newborn care interventions aimed at increasing access to health facility care through transport vouchers and use of community health workers to promote ideal family care practices. Prior to the implementation, a stakeholder analysis was undertaken to assess and map stakeholders’ interests, influence/power and position in relation to the interventions; their views regarding the success and sustainability; and how this research can influence policy formulation in the country.

Methods: A stakeholder analysis was carried out in March 2011 at national level and in four districts of Eastern Uganda where the proposed interventions would be conducted. At the national level, four key informant interviews were conducted with the ministry of health representative, Member of Parliament, and development partners. District health team members were interviewed and also engaged in a workshop; and at community level, twelve focus group discussions were conducted among women, men and motorcycle transporters.

Results: This analysis revealed that district and community level stakeholders were high level supporters of the proposed interventions but not drivers. At community level the mothers, their spouses and transporters were of low influence due to the limited funds they possessed. National level and district stakeholders believed that the intervention is costly and cannot be affordably scaled up. They advised the study team to mobilize and sensitize the communities to contribute financially from the start in order to enhance sustainability beyond the study period. Stakeholders believed that the proposed interventions will influence policy through modeling on how to improve the quality of maternal/newborn health services, male involvement, and improved accessibility of services.

Conclusion: Most of the stakeholders interviewed were supporters of the proposed maternal and newborn care intervention because of the positive benefits of the intervention. The analysis highlighted stakeholder concerns that will be included in the final project design and that could also be useful in countries of similar setting that are planning to set up programmes geared at increasing access to maternal and new born interventions. Key among these concerns was the need to use both human and financial resources that are locally available in the community, to address supply side barriers that influence access to maternal and child healthcare. Research to policy translation, therefore, will require mutual trust, continued dialogue and engagement of the researchers, implementers and policy makers to enable scale up.

P. Singh, R. Rai, C. Kumar. Equity in maternal, newborn, and child health care coverage in India. Global Health Action (September, 2013).

Background: Addressing inequitable coverage of maternal and child health care services among different socio economic strata of population and across states is an important part of India’s contemporary health program. This has wide implications for the achievement of the Millennium Development Goal targets.

Objective: This paper assesses the inequity in coverage of maternal, newborn, and child health (MNCH) care services across household wealth quintiles in India and its states.
Design: Utilizing the District Level Household and Facility Survey conducted during 2007_08, this paper has constructed a Composite Coverage Index (CCI) in MNCH care.

Results: The mean overall coverage of 45% was estimated at the national level, ranging from 31% for the poorest to 60% for the wealthiest quintile. Moreover, a massive state-wise difference across wealth quintiles was observed in the mean overall CCI. Almost half of the Indian states and union territories recorded a ≤50% coverage in MNCH care services, which demands special attention.

Conclusion: India needs focused efforts to address the inequity in coverage of health care services by recognizing or defining underserved people and pursuing well-planned time-oriented health programs committed to ameliorate the present state of MNCH care.

*B. Utz, et al. Definitions and roles of a skilled birth attendant: a mapping exercise from four South-Asian countries. Acta Obstetricia et Gynecologica Scandinavica (September, 2013).

Objective: To identify which cadres of healthcare providers are considered to be skilled birth attendants in South Asia, which of the signal functions of emergency obstetric care each cadre is reported to provide and whether this is included in their training and legislation.

Design: Cross-sectional, descriptive study. Setting: Bangladesh, India, Nepal and Pakistan.

Sample: Thirty-three key informants involved in training, regulation, recruitment and deployment of healthcare providers.

Methods: Between November 2011 and March 2012, structured questionnaires were sent out to key informants by email followed up by face-to-face or telephone interviews. Main outcome measures: Mapping of definitions and roles of healthcare providers in four South Asian countries to assess which cadres are skilled birth attendants.

Results: Cadres of healthcare providers expected to provide skilled birth attendance differ across countries. Although most identified cadres administer parenteral antibiotics, oxytocics and perform newborn resuscitation; administration of anticonvulsants varies by country. Manual removal of the placenta, removal of retained products of conception and assisted vaginal delivery are not provided by all cadres expected to provide skilled birth attendance.

Conclusion: Key signal functions of emergency obstetric care are often provided by medical doctors only. Provision of such potentially life-saving interventions by more healthcare provider cadres expected to function as skilled birth attendants can save lives. Ensuring better training and legislation are in place for this is crucial.

 *Journal subscription required for full access

By Carolyn Miles on September 18, 2013
Pakistan
Asia

Photo: Ayesha Vellani/Save the Children

This blog was originally published in The Huffington Post. Written by Carolyn S. Miles.

Building on the first debate to accelerate progress towards the MDGs, the Skoll World Forum partnered with Johnson & Johnson, the United Nations Foundation, the Bill and Melinda Gates Foundation and the Huffington Post to produce another online debate--this time focused on critical issues that do not have enough of a spotlight in the discussions on how to achieve the MDGs or what should be in the next global development framework. As part of that discussion, we asked some of the world's leading experts what's not being discussed during UN Week this year about the post-2015 development framework, but should be? View the full debate here.

As world leaders gather this week to discuss the achievement of the Millennium Development Goals and the Post-2015 Framework, no subject of conversation will be more important than the need for more frontline health care workers. In the last two decades, the world has made tremendous progress in reducing child and maternal mortality, due in no small part to the contributions of the local health worker delivering lifesaving care. Millions of people in impoverished countries are alive today because a midwife was by their side when they gave birth, or they were vaccinated as infants by a nurse, or because their families learned from a community health worker to adopt healthy behaviors like breastfeeding, hand washing, birth spacing, and sleeping under a mosquito net.

I saw the lifesaving power of local health workers first-hand last month when I visited Save the Children's programs in Pakistan, a country with some of the worst health indicators on the planet. According to our latest State of the World's Mothers report, the lifetime risk of maternal death--the probability that a 15 year old woman will eventually die from a maternal cause--is 1 in 110 in Pakistan. Compare this to the United States, where it's 1 in 2,400 and you see my point. Pakistan's children aren't any better than their moms. For every 1,000 children born, 72 of them will die before they reach the pivotal age of five, more than ten times the rate of their American counterparts.

But as harrowing as these statistics are, you would never know it from visiting the maternal and child health clinic in Haripur district. It is one of the most impressive facilities I have seen anywhere in the world at the primary care, or village, level. The spotlessly clean unit is staffed by two female doctors and several nursing staff as well as a pharmacist--all health care workers. A warehouse stocked with supplies is available on-site and the facility provides services 24/7 as needed. Women come here for prenatal visits, for family planning counseling and products, and to give birth in a simple, clean and safe facility with excellent care. Three women were in labor the day I visited and when I saw the care they received, I knew I would have felt comfortable having one of my own children there.

Unfortunately, not everyone in Pakistan--or the rest of the world for that matter--is as lucky to have a health worker in such close proximity. By some estimates, there is a shortage of at least 1 million frontline health workers in the developing world. And many existing health workers are not trained, equipped and supported to deliver basic lifesaving care close to the community. The consequence of failing to close this gap is grave. Every 3 seconds, a child's death is prevented thanks to care provided by a frontline health worker. When a health worker is not accessible, the situation is, predictably, far less rosy.

The challenge for all of us in the business of saving mothers' and children's lives is to ensure that every person, no matter where they live in the world, is within reach of a health worker. We can--and should--start at the UN General Assembly, and continue the drumbeat at the Third Global Forum on Human Resources for Health in Recife, Brazil in November. But, it will take more than a few high-level meetings to make this a reality. That's why Save the Children, in partnership with the Frontline Health Workers Coalition, created The REAL Awards, a first-of-its-kind, annual global awards platform designed to develop greater respect and appreciation for the lifesaving care that health workers provide in the U.S. and around the world. Anyone can take a few moments to nominate an inspiring health worker and help spread the word about the countless unsung heroes who go above and beyond the call of duty. It will make a REAL difference.

Follow Carolyn S. Miles on Twitter: www.twitter.com/carolynsave

By Joy Marini on September 18, 2013
Kenya, Malawi, Uganda
Africa

This blog was originally published in The Huffington Post. Written by Joy Marini.

What can some people accomplish in one minute? Some can put away their shoes or read 250 words. With the right training, some are able to save a newborn's life.

"Save a life?" you ask.

Indulge this author and hold your breath while you read this article.

(Take a deep breath and start now.)

Every year around the world, almost 700,000 babies born in low- and middle-income countries die from birth asphyxia, or an inability to breathe at birth--something that rarely happens in high-income countries.

Many of these infants could be saved if a health provider skilled at neonatal resuscitation is present during labor and childbirth. And yet, 40 million women globally give birth accompanied by their mothers, sisters, or aunties instead of trained health care providers who could intervene if complications arise. More than 2 million women give birth completely alone.

(Are you still holding your breath? You're doing great. About 25 seconds have passed.)

Giving birth without a skilled birth attendant leaves both mothers and newborns without the specialized medical care that's most critical when their lives are at greatest risk. An estimated 1 in 10 infants will struggle to breathe at birth.

There is one "golden minute" of opportunity for a baby to start breathing well. For an infant who is not breathing at birth, perhaps she feels like gasping for air, or maybe her heart rate is increasing to continue bringing oxygen to the brain and tissues. (If you are still holding your breath, you might be feeling this, too. About 45 seconds have passed since you started reading. Many readers won't be able to hold their breath that long.)

In one "golden minute," a newborn must be assessed. If the baby is not breathing, stimulation and assisted ventilation can save a life. But this is only possible if there is a skilled attendant by the mother's side.

For most readers, it took about one minute to read the words contained within this article--one golden minute since you started holding your breath. (You can exhale now!)

Additional skilled birth attendants could help more babies survive childbirth and take their first breath of life. The techniques are simple--like rubbing a baby's feet, keeping him or her warm, and using a ventilator if needed. Birth attendants could be trained to spot the signs--and intervene--in one short minute.

Helping Babies Breathe (HBB) is a neonatal resuscitation curriculum designed to provide birth attendants with the skills to resuscitate babies--especially those born in settings where resources are scarce. This partnership between Johnson & Johnson,Save the Children, the American Academy of PediatricsAMREF, and USAID in Malawi, Uganda, and Kenya has trained more than 600 health care providers in its first two years.

What can you accomplish in one minute? You could give someone a hug--and, if you are trained in HBB, you could save a baby's life.

You can also help save the lives of women and children around the world just by uploading a photo.

For every photo you upload using the free Donate A Photo app, Johnson & Johnson donates $1 to the organization of your choice. Partners include Save the Children, World Wildlife Fund, CARE, and MAMA.

Choose a photo that is inspired by your hopes and dreams for women and children around the world.

This blog is part of a month-long series in partnership with Johnson & Johnson to highlight the successes and remaining opportunities in the Every Woman Every Childmovement. With the aim of improving the lives of women and child around the world, EWEC was launched by UN Secretary General Ban Ki-moon in 2010 to accelerate progress against the Millennium Development Goals (MDGs). To learn more, click here.

Helping Babies Breathe (HBB) is an evidence-based educational program to teach neonatal resuscitation techniques in resource-limited areas. It is an initiative of the American Academy of Pediatrics (AAP) in collaboration with the World Health Organization (WHO), US Agency for International Development (USAID), Saving Newborn Lives, the National Institute of Child Health and Development, and a number of other global health organizations

By Peg Marshall on September 17, 2013
Colombia


Photo: Tanya Weinberg/Save the Children

This blog was originally published in USAID Impactblog. Written by Peg Marshall and Veronica Valdivieso

This blog is part of a series to coincide with A Promise Renewed in the Americas: ”Reducing Inequalities in Reproductive, Maternal and Child Health Summit“ during September 10-12 in Panama.

Each year, over 121,000 babies in Latin America and the Caribbean (LAC) will die during their first month of life. Nearly a quarter of these neonatal deaths are due to prematurity and low birth weight; and these deaths are more likely to happen if the baby is born to a mother who is poor, uneducated, or lives in a rural area.

To prevent neonatal deaths and advance neonatal health in general, many of the LAC region’s ministries of health, the United States Agency for International Development (USAID), several United Nations (UN) agencies, non-governmental organizations, and professional associations (pediatric, obstetrics-gynecology, midwifery, and nursing), have formed a partnership in 2005 called the LAC Neonatal Alliance.

This regional Alliance provides an ongoing platform for active engagement in neonatal issues at the regional and national levels. It champions key initiatives such as the promotion of the Neonatal Integrated Management for Childhood Illness (IMCI) strategy, development of “Trainer of Trainers” workshops for neonatal resuscitation using the Helping Babies Breathe (HBB) protocol, implementation of Kangaroo Mother Care, and creation of communities of practice for  the exchange of experience and dissemination of evidence-based practices. The Alliance model allows for quick action to address priority issues because of its organizational character: transparent and trusting collaboration, plus tightly defined and monitored goals that are supported by a shared annual work plan and budget. This structure has allowed the Alliance to make a significant impact on neonatal health in the LAC region.

An important example of the Alliance’s work involves the implementation of a low-technology, cost-efficient technique to save premature babies. Kangaroo Mother Care (KMC), which involves constant skin-to-skin contact between the newborn and his or her mother (or father), was developed in 1982 in Colombia in response to a lack of incubators. This simple intervention helps newborns regulate their temperature and other physiological processes – but its benefits have not been well understood until recently.  The intervention has been shown to reduce newborn mortality and morbidity in premature and low birth weight infants by approximately 50 percent more than traditional care. A recent USAID-funded study in Nicaragua found that use of KMC reduced hospital stays for newborns by four days, which results in less potential for hospital-acquired infections and allows the family to resume their normal life, including infant-related responsibilities, sooner, while saving an average of almost $400 per infant.

The Alliance has brought teams from 10 LAC countries to Colombia for training in KMC, and eight of these teams instituted training programs in their home countries to further disseminate KMC. Through this work, the Alliance is potentially reaching over 20,000 mothers and their infants per year.

With neonatal deaths remaining a major challenge in Latin America and the Caribbean, especially among disadvantaged groups, the Alliance will keep this issue in the forefront and continue to push for universal adoption of life-saving interventions in the region.

For detailed information on the LAC Newborn Alliance and Kangaroo Mother Care visit the following websites: Kangaroo Foundation, Maternal and Child Health Integrated Program, and the Newborn Alliance.

By Melinda Gates on September 16, 2013

This post was originally published on Impatient Optimiists

Two of my passions are child health and statistics. So I look forward to mid-September every year, to the day when UNICEF reports how many fewer children died the previous year.

Every single year—for at least the last 50 years—the number has gone down. Every. Single. Year.

I challenge you to name something else that gets better on that kind of schedule. The stock market goes up and down. Sprinters keep getting faster, but they don’t set new records every year. The 100 meter record set in 1968 didn’t get broken until 1983.

Meanwhile, the child mortality record set in 1968 got broken in 1969. And 1970. And 1971. And so on.

Keep in mind that we’re talking about the most important statistic in the world—who is alive.

This year, the number is 6.6 million. That’s 300,000 fewer children dying than last year. To give a longer view, that’s 6 million fewer than 1990.

The report is very important from a policy perspective. It tells us which children are still dying and what they’re dying from. For example, the report shows that adolescent mothers are more likely to give birth to premature babies (and are also at a greater risk of experiencing life-threatening complications). It also indicates we still have work to do delivering two relatively new vaccines for diarrhea and pneumonia, because they’re still the leading causes of death among children. And it proves we have to pay more attention to newborn health, because as we get better at saving older children a greater proportion of mortality happens in the first month of a baby’s life.

The report will lead to important conversations about how to make sure health systems deliver all this lifesaving care in a single, integrated package that reaches all families at all stages of life.

But before we move on to the detailed conversations about how to get the number even lower next year, let’s celebrate the beautiful, simple fact that it’s lower again this year. Let’s celebrate this new world record in the most important category there is.