By: Sharmin Akter, Cory Cerritelli, Aisha Hussain, and Joseph Johnson
In the crowded urban slum of Hazaribag, Boubazar Balur Maath (in photo above) is a pregnant woman that looks onward into the sprawl in front of her. A wild dog is walking among the garbage looking for food. We can see the shanty town in the background which sets the scene for many women’s pregnancies and even the health of their newborns. Boubazar Balur Maath is one of the many women assisted by the Johnson & Johnson-funded Improving Newborn Survival Project (INSP).
Bangladesh is one of the world’s most densely populated countries. According to the United Nations (World Population Prospects 2019), the country is growing rapidly and urbanizing fast. Of the approximately 40 million people living in urban areas, over half reside in slum areas, as depicted above. Over time, estimates show that this may grow to 27 million.
Over the last 30 years, Bangladesh has made impressive progress in the health sector, particularly decreasing the newborn mortality rate (NMR) by more than half. Even with this improvement, those born to parents with lower socioeconomic status are more than twice as likely to die than those born to wealthy parents. The leading cause of these deaths is complications from preterm birth.
Pregnant women face dire health consequences. Bangladesh faces higher rates of maternal and neonatal mortality and morbidity than many other countries. Women living in underprivileged urban areas are at risk of receiving inadequate antenatal and perinatal care, and complications for both mother and baby are common. Although primary health care services at the community level in urban areas are provided by different NGOs and the private sector, there is often no care available for premature or small infants or sick newborns. Tertiary hospitals are often available, but inaccessible to urban slum dwellers.
Only a quarter of newborns receive general care within two days of birth and, only 2.4% of newborns receive comprehensive essential newborn care. As a result, the INSP seeks to increase utilization of newborn healthcare services by urban slum dwellers in Dhaka, Bangladesh. The program works in collaboration with service providers at three tertiary hospitals located in close proximity to urban dwellers in Dhaka. In collaboration with the Ministry of Health, Save the Children is working to improve care for premature and small babies by establishing and strengthening Kangaroo Mother Care (KMC) units in the three hospitals. The program is also supporting NGO clinics located in the urban slum, and their community health workers (CHWs), to reach pregnant women, mothers and newborns for initial assessment and referral, as needed.
The program takes a two-pronged approach to increase and improve uptake of care for preterm and small babies. The first is to ensure availability of KMC services through improvement of service readiness, provider capacity and motivation, and quality of care at the hospitals. The second is to increase care-seeking behaviors and improve caregivers’ understanding of the needs of preterm and small newborns in the community.
As part of its quality improvement (QI) process, the INSP conducted an assessment of the current capacities and skills of hospital staff to identify areas to strengthen. Formal training and mentorship were provided to build staff capacity and skills. A skills laboratory – an equipped space for providers to continue practicing their acquired skills in the management of preterm and small babies – was established within each hospital.
QI committees were established at each hospital to ensure KMC services are provided as per standard clinical protocol. Each facility has two committees to address quality improvement, which include a coordination committee and an implementation committee. As part of the QI process, the program has established a monitoring system, where data is used to identify and address quality issues related to the care for preterm and small babies in the hospitals.
The program has supported hospitals to introduce the government-approved KMC registers and entry through the online reporting system known as DHIS-2. The DHIS-2 system has made it easier for staff to track the hospital performance in care for KMC patients – both uptake of the intervention and quality of the service. The next two photos show this process in action.
Postnatal care-seeking behavior for both mother and baby is low in urban slums. Also, the majority of preterm and small infants are not taken to health facilities for care, nor do the few who do receive care return for follow-up after discharge. Postnatal care-seeking behaviors have also been historically low in urban slums. INSP worked with hospital administration as well as the managers of the NGO Surjer Hasi clinic (Smiling Sun) to establish and strengthen referral systems between the hospitals, other NGO clinics and the urban slums. Using client data, nurses make phone calls to remind mothers of their upcoming follow-up appointments and send text reminders to parents for their follow-up visits. In addition, information on discharged newborns is sent to CHWs in the urban slums so that they can visit the babies at home.
Doctors and nurses from NGO clinics are trained on KMC follow-up and referral. They identify and refer low-birth-weight babies for care at tertiary hospitals. They are also trained on comprehensive newborn care, KMC and counseling to ensure caretakers and families understand how to provide essential newborn care and handle basic newborn health problems. Caretakers and mothers then fully understand how to take care of the small baby after discharge.
A community health worker (CHW) from an NGO-clinic conducts a home visit for a pregnant woman. Home visits help with demand generation for maternal and newborn health services. Pregnant women and mothers are encouraged to seek routine care and are referred to a community clinic or hospital if they or their newborn have any danger signs.
In addition, a CHW can use the KMC android app, an app that records and tracks discharged KMC patients’ information including scheduled follow-up visits, to provide follow-up support to KMC babies. They can additionally refer clients for KMC services and update the app to establish future follow up care. Doctors and nurses are also able to provide remote support to mothers as needed via mobile devices. Remote support allows for more detailed conversations between visits and helps increase health-seeking behavior with increased adherence to care. Below, is a set of photos showing the android app and a doctor holding a video call with her patient.
Collage of KMC application usage as part of the post-discharge compliance system with CHW’s role to provide support.
The community is leveraged to support the INSP through community health activities in targeted slums. This is through awareness-raising activities and demonstration through puppet shows. Puppet shows are used to educate the community on maternal and newborn care-seeking issues. It serves to create awareness for new parents or caregivers for the need to seek prompt care for preterm and small babies.
Community health workers conduct more than just home visits. They also conduct learning sessions, as seen in the next two photos, for new mothers and pregnant women to teach more about newborn health and care. These sessions help increase individual knowledge for mothers, ensuring that they learn how to care for newborns and identify common problems that can be solved at home or require care at a health facility. Below are a few pictures showing CHWs leading learning sessions.
In summary, INSP works to support pregnant women, mothers and caregivers living in urban slums to provide adequate care for their preterm and small babies. This requires a functioning system of care along the household-to-hospital continuum. By working with three tertiary hospitals and NGO clinics together with their team of CHWs, INSP has strengthened this continuum of care to ensure preterm and small babies receive timely and quality care to survive and thrive in Dhaka, Bangladesh.
Thank you to the Johnson & Johnson Foundation for their partnership and dedicated support, making the success of the Improving Newborn Survival Program in Bangladesh possible.
Photo credits: Save the Children