Where was the Newborn in The Millennium Development Goals?

By Katie Millar, Technical Writer, MHTF

This post is part of the Maternal and Newborn Integration Blog Series, which shares themes of and reactions to the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting.

Dunstan BishangaAround the world, countries are achieving Millennium Development Goal (MDG) 4 and 5—to reduce child and maternal mortality—yet we see little change in the number of newborns who die every year. This fact is one that Dr. Dunstan Bishanga, Chief of Party for USAID’s Maternal and Child Survival Program in Tanzania, emphasized at the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting last week when he said, “Looking at MDG 4 and 5,… there is no indicator for newborn, it is assumed that by improving, reducing under-five mortality rate and infant mortality rate you will definitely be addressing newborn health, but this may not be true.” This is a reality he has seen firsthand in his country of Tanzania.

In Tanzania, under-five mortality (U5MR) and infant mortality have decreased by 58% and 56%, respectively, from 1990 until 2010. Projections show Tanzania likely meeting MDG 4 by 2015 with a goal U5MR of 64 and an IMR of 38.

Yet, neonatal mortality—death in the first month of life—has only decreased by 32%, from 38 in 1991 to 26 per thousand live births in 2010. This makes neonatal mortality 32% of the U5MR and 51% of the IMR in 2010, compared to 20% and 33%, respectively, in 1990.

This stalled progress is likely due to low visibility and lack of measurement of neonatal health in the MDGs.

We have seen it in countries like Tanzania, and also in countries like Ethiopia, [MDG 4] has been attained with no progress on newborn health… so what does that tell us? It tells us that we don’t have valid indicators to measure newborn health progress. That’s why we are achieving MDG 4 without attaining the reductions in the targets for neonatal mortality.

Next Steps

Newborn health has often been an “orphan” topic, with neither the child health nor the maternal health community measuring and taking accountability for neonatal mortality. As these weaknesses have been realized, newborn health has taken a spotlight this year with The Every Newborn Action Plan endorsed by the World Health Assembly in May. This action plan lists five strategic objectives:

  1. Strengthen and invest in care during labour, birth and the first day and week of life
  2. Improve the quality of maternal and newborn care
  3. Reach every woman and every newborn; reduce inequities
  4. Harness the power of parents, families, and communities
  5. Count every newborn—measurement, programme-tracking and accountability

Inherent, then, in this plan is maternal and newborn health integration. Since the timing and delivery of key newborn health interventions often coincide with both the timing and delivery of maternal health interventions, speaking about maternal and newborn health simultaneously in strategy, implementation, monitoring, and evaluation is logical.

A Paradigm Shift

One way to make the global community accountable for newborn health is to change technical guidance from global entities, which have a tremendous impact on what is implemented at the country and community-level. Bishanga affirmed this impact when he said, “In countries like Tanzania where I come from, often they adapt global technical guidance, and [if] the people that get involved [in global policy] have a paradigm shift, then it is easier to make changes at the implementation level.”

So what might this global paradigm shift look like? Clearly measuring newborn health along with maternal health in the post-2015 development goals. Bishanga shared:

[In] the next phase you know, if it was possible, we need to really see that the newborn, even if it is an integral part of maternal and child health care, it needs to stand out and be measured clearly because that will lead even to the planning and implementation to have concrete and specific interventions that will be affecting the indicator for newborn health and neonatal mortality and enhance having a clear focus and attention to newborn health work.

Global Experts Paving the Way

Identifying a potential need and opportunity for improved maternal and newborn health, the Maternal Health Task Force and Save the Children’s Saving Newborn Lives convened experts at the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting to address this problem and others related to integration.

Dr. Bishanga attended and shared his reaction to the proceedings of the two-day meeting.

This was a great meeting, I like the fact that it has brought together people from different background; we have people from the field where the programming happens, we have people from donor community, we have people from policy level, from some ministries and the United [Nations] agencies. And I think also we have global experts in terms of maternal health and newborn health. Most of the time you find that these people meet in their own spheres; you have maternal health experts meeting on their own making strategies and newborn experts meeting on their own. But this kind of meeting brought them together. And the most impressive thing is that both groups appreciate… the need to have integrated care for the mother and the newborn. And that is where things start because these are the people that get involved in global policies, global technical documents and all that. If we have contemporated, and all of us do agree that we need this thing to happen in this way, then I believe that it will bring change.

Using SMS to Integrate Maternal and Newborn Health

By Niyi Osamiluyi, Founder/CEO, Premier Medical Systems Nigeria, Ltd.

This post is part of the Maternal and Newborn Integration Blog Series, which shares themes of and reactions to the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting.

The main causes of newborn mortality are birth asphyxia, birth trauma, low birth weight, prematurity and infections. These accounts for 80% of deaths in the age group. While prematurity can spontaneously occur without any obvious predisposition or previous warning, a lack of obstetric and newborn care is often implicated in birth asphyxia, birth trauma and low birth weight – more especially in the developing countries.

This lack of care—which may occur at any stage of pregnancy, labor or delivery—may manifest as the absence of vital “skills”‎ on the part of the birth attendant or lack of low cost equipment/material such as a mucous extractor. This is why a significant amount of deaths resulting from such causes are labeled as “preventable.” Furthermore, the lack of skill may be manifested by the failure of the birth attendant to recognize the need for an emergency Caesarean.

It becomes evident ‎that if we can ensure antenatal care and the occurrence of delivery in a hospital—where there is likely to be ‘skill’ and low cost equipment—there may be an opportunity or greater possibility of preventing some of these avoidable deaths.

When we consider the commonest causes of maternal mortality—bleeding, obstructed labor, eclampsia, unsafe abortions and infection—obstetric care plays a major role in preventing deaths due to these causes.

In a developing country like Nigeria—where only 38% of deliveries are attended by a SBA and only 35.8% of deliveries occur in a health facility—interventions that will increase facility delivery and consequently newborn care are likely to reduce newborn death.  While I agree that effort should be directed at improving facilities in the hospital, a greater problem is lack of demand for the utilization of these facilities. You will frequently find pregnant women registering in a hospital but not delivering there.

Why do majority of Nigerian women fail to use the services of a SBA? Why are Nigerian women not delivering in the hospital?

In my experience as a medical doctor practicing in rural Nigeria, I found out that ignorance was a major factor. I found out that ignorance often times played a greater role than poverty. You would find a patient that had visited a traditional birth attendant and probably spent three times what she would ordinarily spend in the hospital.

So how do we remove ignorance and enable a pregnant woman to make the decision to deliver in a hospital and thus increase the possibility of maternal and newborn survival? How do we deliver critical and relevant information that will lead to education? We can achieve this by delivering relevant and culturally appropriate information ‎through an existing channel that pervades across the rural and urban landscape. ‎This channel is the mobile phone. In our yet to be published work in delivering health education to expectant mothers via Short Message Service (SMS) in Nigeria, we found that greater than 95% of them had mobile phones. Those that didn’t have claimed it was missing or damaged.

I need to highlight that our work is not really about SMS or mobile technology; it is about the education of expectant mothers. Mobile just happens to be the route considering our environment.

In summary, education via SMS will lead to increased education, antenatal attendance and increased hospital delivery. When delivery occurs in a hospital, there is a greater chance of both the mother and newborn surviving.

Impressions of the Maternal Health Environment from a Mexican Midwife

At the end of August and at the beginning of this month we featured an interview with Cris Alonso, Director of the Luna Maya birth center in Chiapas, Mexico. Here she shares with us her insights on the broader maternal health environment – from obstetric violence to woman-centered care.

Q: What do you believe accounts for the high Maternal Mortality Rate (MMR) in Mexico?

A: There are many aspects: lack of culturally competent care, inaccessibility in rural areas, lack of midwives within the system, over medicalization of birth, massive institutionalization of birth with decreased capacity to attend to the volume of births. Medical training has been proven to be lacking in evidence-based care, which means that women are exposed to unnecessary surgeries, inductions, and interventions that put their lives at risk. In addition, lack of culturally competent care and mistreatment disconnect women from family planning services or from seeking care when a complication arises. Lastly, lack of integration of midwives and obstetric nurses puts excess pressure on gynecologists and residents to attend to two million births a year.

Q: How do you think the concept of Obstetric Violence affects the conversation about Maternal Mortality?

A: Currently in Mexico, the conversation about maternal mortality centers around obstetric violence. A health system that operates without taking into account scientific evidence and that treats women with abuse will incur an increase in mortality and morbidity. The amount of formal complaints has increased tremendously in the last two years as women are becoming more aware of their rights in childbirth. Additionally, high rates of cesareans and interventions are resulting in high and stagnant rates of mortality and morbidity. Currently, federal and state governments, NGOs, and health researchers are taking steps to try to implement programs and policy that will implement humanized birth programs in obstetric institutions.

Q: What changes are needed in the world of women’s health?

A: The Luna Maya model demonstrates that a competent, professional midwife, who is part of her community and provides continuous care throughout the life cycle, impacts maternal mortality. No woman has ever died, or been close to dying of childbirth at Luna Maya. I believe that a femifocal approach to care—a model that listens to women, respects their capacity to integrate health systems and approaches, and is based on trust and confidentiality—encourages women to feel supported by their health care provider and avoid severe morbidity and mortality.

Disrespect and Abuse During Maternity Care Keep Women from Seeking Facility Births

By Koki Agarwal, Director, MCHIP and forward by Katie Millar, Technical Writer, MHTF 

This post is part of the Maternal and Newborn Integration Blog Series, which shares themes of and reactions to the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting.

Forward: In the following post, Dr. Agarwal speaks of an unfortunately common problem between health workers and mothers: disrespect and abuse. This problem and its solution—respectful maternity care—play a role not only in health outcomes for the mother, but for the baby as well. At the Integration of Maternal and Newborn Health technical meeting, Rima Jolivet and Jeff Smith reviewed research that showed emotional support during labor significantly decreases:

  • The need for pain medication during labor
  • The rate of prolonged labor, labor complications, episiotomies, caesarean sections, low apgar scores, lack of exclusive breastfeeding, and severe postpartum depression
  • The risk of newborn sepsis

In addition, global experts identified key areas to address when implementing integration to improve health outcomes for both the mother and newborn. The themes included strengthening service delivery points, preventing “content-free contact,” and understanding context and health systems in order to implement integration.

Recognizing and addressing disrespect and abuse are essential for evaluating context and strengthening service delivery points to improve maternal health outcomes. Lastly, disrespect and abuse may prevent a woman from seeking skilled care, which means she and her newborn are both exposed to unskilled care, or no care at all.

Increasingly, worldwide, more women are delivering in facilities, where they have safer births with trained providers. And while this is good news, statistics on respectful maternity care (RMC) reveal that the care women receive at the facility is one of the biggest drivers—or obstacles—to the type of treatment they’ll choose.

According to Diana Bowser and Kathleen Hill, “examples of disrespect and abuse (D&A) include subtle humiliation of women, discrimination against certain sub-groups of women, overt humiliation, abandonment of care and physical and verbal abuse during childbirth.” The causes of D&A during maternity care can vary – beginning at the community level with a lack of engagement or financial barriers, and extending to individual providers, who may lack training or have personal biases. But the result is often tragically the same: too many women deliver at home and with untrained providers because they fear the D&A that may accompany a facility birth.

In some cases, policy makers, program managers, and care providers are unaware of the D&A that is experienced in their own settings or the settings for which they are responsible. In other cases, people entrusted with the care of women and their newborns may recognize a need for RMC, but may feel ill-equipped to address it.

In response to these needs, USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) launched a Respectful Maternity Care Toolkit in 2013 to provide the necessary tools to these actors to begin implementing RMC in their area of work or influence. With these combined tools, users can help to change and develop attitudes within themselves and among their colleagues and other stakeholders in the care of women and their newborns – and, ultimately, reduce this underutilization of skilled birth care.

For providers, improving RMC can be as simple as addressing patients by name, using understandable language, and conducting examinations privately. It involves sympathy: looking for signs of anger, stress, fatigue and pain. To a fearful patient, it is critical to explain any actions being taken, and to provide reassurance.

But to truly remove D&A from all care, we must gain acceptance at the highest levels: among policymakers and program managers, clinicians, and other groups and institutions who affect the work done every day by providers on the ground. These stakeholders must hold providers accountable by establishing processes for registering complaints and effectively enforcing policies.

As Bowser and Hill point out, “A central factor at the core of addressing disrespectful care at birth is the unequal relationship between the skilled provider and the woman giving birth.” To even this playing field, medical personnel must be held responsible for D&A and even the most marginalized women—those who are illiterate or of an ethnic minority—must be able to assert their complaints without fear of redress.

As we continue marking the final days to the Millennium Development Goals, we know that MDG 5—improving maternal health—can only be met if more women choose safer, facility-based births. RMC is not a checklist, an intervention, or a dialogue that is spoken: it is an attitude that permeates each word, action, thought, and non-verbal communication involved in the care of women during pregnancy, childbirth, and the postnatal period. Let us ensure women receive this basic human dignity during one of the most vulnerable times in their lives.

Integration of Maternal and Newborn Health Care: A Technical Meeting and Blog Series

By Katie Millar, Technical Writer, MHTF

Rifat AtunOn September 9th and 10th, the Maternal Health Task Force and Save the Children’s Saving Newborn Lives program convened experts in Boston to discuss maternal and newborn health integration. The meeting, “Integration of Maternal and Newborn Health Care: In Pursuit of Quality,” hosted about 50 global leaders—researchers, program implementers and funders—in maternal and newborn health to accomplish the following three objectives:

  1. Review the knowledge base on integration of maternal and newborn health care and the promising approaches, models and tools that exist for moving this agenda forward
  2. Identify the barriers to and opportunities for integrating maternal and newborn care across the continuum
  3. Develop a list of actions the global maternal and newborn health communities can take to ensure greater programmatic coherence and effectiveness

Biologically, maternal and newborn health are inseparable; yet, programmatic, research, and funding efforts often address the health of mothers and newborns separately. This persistent divide between maternal and newborn health training, programs, service delivery, monitoring, and quality improvement systems limits effectiveness and efficiency to improve outcomes. In order to improve both maternal and newborn health outcomes, ensuring the woman’s health before and during pregnancy is critical.

Reviewing the Knowledge Base

Small Group WorkThe meeting focused on a variety of themes as global experts led presentations and gathered for small group work to discuss next steps for integration of maternal and newborn health care. While little research thus far has been specifically devoted to maternal and newborn integration, it was shown that great inequity exists among maternal and newborn health interventions and that while about 90% of women receive at least one antenatal care visit, only slightly more than half deliver with a skilled attendant at birth, and about 40% receive postnatal care. These disparities along the continuum of care helped meeting participants identify service delivery points in need of strengthening and optimization to ensure the health of both the mother and newborn. Given the limited knowledge base, leaders were encouraged to strengthen the evidence by engaging in research to identify both the costs, and potential risks of integration.

Opportunities and Barriers for Integration

Overarching themes that emerged while evaluating integration at the meeting included optimization of service delivery points to prevent “content free contact” and the need for efforts to be context specific. There was broad consensus that programmatic and policy efforts for integration need to recognize and reflect the local environment and the capacity of the health system. The meeting concluded that integration should not be viewed as an intervention in and of itself, but rather as a method of reevaluating and designing health systems to effectively provide better maternal and newborn health care, ensure better outcomes, and incur less cost. In approaching integration in the future, it was made clear that some of the most important factors for integration include assessing and understanding contextual factors, as well as anticipating what the woman, family, and health care workers need and want.

Case studies were presented from Ecuador, Nigeria, and the Saving Mothers Giving Life program. Each presenter evaluated approaches for integrating health systems, programmatic strategies, and service delivery in order to optimize maternal and newborn health outcomes. These case studies provided potential models for maternal and newborn health integration in future programmatic efforts.

Actions for Greater Programmatic Coherence

Lastly, and perhaps most importantly, small groups presented action items and next steps to strengthen the evidence for integration and promote integrated care so that no mother or newborn is neglected in programmatic efforts. These action items were created for three levels: facility and service delivery; national policy and programming; and technical partners and donors.

Proposed action items include improving and redesigning health workforce training; ensuring quality improvement; integrating health information systems; aligning global maternal and newborn health initiatives; integrating advocacy tools for maternal and newborn health care; and unifying measurement frameworks.

Join Us

Join us over the next two weeks as the Maternal and Newborn Integration Blog Series unfolds. This blog series will dive into the details of the meeting discussions and action items. In addition, meeting participants and speakers will share their reactions to maternal and newborn integration from a variety of perspectives.