Chapter 5: Previous page | 1,2,3,4,5

No Longer Falling Between the Cracks

Table of Contents Newborns: no longer going unnoticed The Greatest Risks to Life are in its Beginning Progress and some Reversals No Longer Falling Between the Cracks Planning for Universal Access

It is often argued that a radical reduction of the number of newborn deaths is possible only where very high expenditure on health allows for large investments in sophisticated technology. But in actual fact, nurses and doctors can easily acquire the necessary skills without needing to become specialists. Countries such as Colombia and Sri Lanka, with fewer than 15 neonatal deaths per 1000 live births, have demonstrated that expensive technology is not a prerequisite for success. So have Nicaragua and Viet Nam, which lowered their neonatal mortality rates to 17 and 15 per 1000 births, respectively, while their spending on health in the 1990s was only US$ 45 and US$ 20 per capita, respectively. In northern European countries, well-coordinated antenatal, intrapartum and postnatal care for mothers and newborns coincided with reduced rates of mortality before the introduction of neonatal intensive care in the early 1980s ( ⁸ ). Intensive care facilities, specialists and expensive equipment are useful to reduce neonatal mortality even further only after very low levels have already been achieved. Rather than deploying high-tech instrumentation, the challenge is to find a better way of setting up the health care system with continuity between care during pregnancy, skilled care at birth, and the care given when the mother is at home with her newborn.

Care during pregnancy

Many things can, and must, be done during pregnancy. One of the most cost- effective and simple antenatal interventions is immunization against tetanus. In areas where malaria is endemic, intermittent presumptive treatment of malaria can reduce incidence of low birth weight, stillbirths, and neonatal and maternal mortality. Rubella vaccination reduces stillbirths and avoids congenital rubella syndrome. Diagnosis and treatment of reproductive tract infections reduce the risk of premature labour, as well as the direct perinatal deaths caused by syphilis. The antenatal period also presents an important opportunity for identifying threats to the unborn baby’s health, as well as for counselling on nutrition, birth preparedness, parenting skills, and family planning options after the birth. Understanding the need for information and services for women who desire birth spacing methods has the potential to reduce neonatal mortality, as closely spaced births have been shown to be detrimental to the survival of the subsequent child ( ²⁹ ).

These interventions are at the core of an effective antenatal health care package. Ideally, the package of interventions should be provided by the same health worker – the midwife – who will attend the mother during childbirth; this is the best way to ensure seamless care through pregnancy and childbirth. Technically, however, antenatal care can be delegated to other health workers who would not necessarily qualify as having the required skills for attending childbirth. As multipurpose health workers are not in such short supply as midwives, they can help to increase coverage. In such cases, it is imperative, however, to establish links with those who will be in charge of mother and baby at birth: the mother needs to prepare for the birth, and the health services have to be ready to respond.

Professional care at birth

Skilled professional care at birth is as critical for the newborn baby as it is for the mother. For example, effective midwifery ensures non-traumatic birth and reduces mortality and morbidity from birth asphyxia, while at the same time strict asepsis at delivery and cord care reduce the risk of infection. Skilled care makes it possible to resuscitate babies who cannot breathe at birth and to deal with or refer unpredictable complications as they happen to mother or baby. When the birth is appropriately managed by a skilled health worker, it is safer for both mother and newborn. What, then, are the problems?

First, less than two thirds of women in less developed countries and only one third in the least developed countries have their babies delivered by a skilled attendant. Despite recent improvements in some countries, the development of effective maternal health services in many parts of the world has often been hampered by limited resources, lack of political will, and poorly defined strategies ( ³⁰ ): services have not kept up with the need for care at birth and not even with the expansion of antenatal care. Even when services do exist, quality is often poor, or social and financial barriers prevent women from making use of them. Some countries have shown high-level commitment to improving maternal health services and impressive progress in the uptake of professional care at birth (e.g. Bolivia, Egypt, Indonesia, Morocco and Togo). The general picture in Africa, however, where newborn mortality is high, is less positive. The improvement of coverage to underserved communities is likely to prove a major challenge to many resource-poor countries for years to come.

The second problem is that the training of professional health workers who attend childbirth and the focus of their work have often been directed almost exclusively towards the safety of the mother at the moment of childbirth itself, to the neglect of the newborn and the critical week after the birth ( ³¹ ). Newborn care is part of the curriculum and responsibility of midwives, nurse-midwives and the doctors who function as their equivalents, but in practice many of these professionals do not get the training or experience to ensure that they are competent to carry out all of the key procedures for newborns. In Benin, Ecuador, Jamaica and Rwanda, for example, only 57% of all doctors, midwives, nurses and medical interns who routinely assist at births were able to resuscitate a newborn adequately when their skills were tested ( ³² ). Although the technology that is needed is actually quite simple and inexpensive, health workers can be unsure of how to deal with the sudden complications that may become life-threatening in a couple of hours, and essential drugs and equipment are usually even less readily available than they are for the care a mother may need in case of complications.

Even within a hospital, the back-up services for maternal and neonatal care that should be triggered when a complication arises are often not organized quickly enough; hospitals may not be set up to care for newborns in terms of staff training and equipment. Giving birth in a health facility (not necessarily a hospital) with professional staff is safer by far than doing so at home. But the same environment that makes for a safer birth also may put newborns at increased risk of iatrogenic infections, overmedicalization and inappropriate hospital practices. In all too many hospitals, mother and baby may be separated, which makes it difficult for mothers to bond with and provide warmth to their newborns. Babies born in hospitals in some settings are actually less likely to be breastfed than those born elsewhere ( ³³ ).

Maximizing synergies between maternal and neonatal health will require birthing facilities to give special attention to appropriate training of staff and the organization of care that takes account of the needs of the newborn. Facilities will also need to improve infection control, keep medical interventions to a minimum, and actively promote breastfeeding. Where quality is satisfactory, such places are much safer for mother and child than a home birth without professional assistance.

Universal access to professional, skilled care at birth for all mothers has, in combination with antenatal care, an enormous potential for reducing the burden of stillbirths and early neonatal deaths that form the majority of fetal and neonatal mortality. In most countries, the mortality of babies whose mothers benefit from antenatal care and skilled care at childbirth tends to be less than half that of babies whose mothers do not benefit from such care (see Figure 5.5). The consistency of these differences across a wide range of countries suggests that it is access to a continuum of skilled care that makes the difference.

Caring for the baby at home

Professional care at birth has less effect, however, on later neonatal deaths, which occur when the mother and newborn are at home, without professional support. Care within the household is very important for the newborn’s health. If the mother has good parenting skills (which can be enhanced during the antenatal care consultations) and if she can breastfeed and keep the baby warm, it will be mostly fine: being a newborn is not a disease. In societies where women have extensive social networks, mobility, and the autonomy to control resources as well as access to good health care and information, mothers are in a better position to care for their babies. To move in that direction it helps to mobilize communities, for example through women’s groups ( ³⁴ ). In Bolivia, encouraging women to participate in groups involved in promoting the health of the newborn contributed to a reduction in perinatal mortality from 117 to 44 per 1000 live births ( ³⁵ ). In Nepal, the development of a network of women’s groups led to a 30% reduction in neonatal mortality rates, mainly through better uptake of services ( ³⁶ ).

An important aspect of caring for newborns is to seek help when problems occur. Even newborns who are not especially at risk may become ill in the days after birth: it is then important to seek professional care immediately. All high-risk babies, such as those with low birth weight, require professional care, and advice must be available to their mothers. The early weeks of life are particularly problematic because there is often no clear delineation of professional responsibilities to provide assistance to newborns in need of extra care.

Ensuring continuity of care

The handover of responsibilities of the newborn to child health services – typically from the midwife to the health centre – is a critical stage in the continuum of care. Newborn care often falls between the cracks. Maternal health services consider that their responsibility ends after childbirth or when the mother is discharged from hospital with her baby. Child health programmes, on the other hand, have been primarily aimed at preventing mortality in older children, focusing on vaccine-preventable diseases, diarrhoea and acute respiratory tract infections and less on the problems of newborns. The health workers in these programmes often tend to wait until the mother presents her child at the health centre for vaccination. Even when newborns are taken to facilities, health staff often lack confidence or have been inadequately trained to treat very young babies. Where mother and baby are confined to the home after birth, which is the case in many parts of the world, care is inaccessible unless the health worker is willing to make a home visit. In many settings there are no mechanisms for establishing communication and handover between maternal and child programmes.

There is a pressing need to develop and evaluate effective strategies for establishing a continuum of care that bridges the critical first weeks of life. In many countries – particularly in the industrialized world – there is a long tradition of home visits by health staff to check up on mother and newborn in the immediate postpartum period. In some countries this is part of the work of the midwife; in others, paediatric nurses or health visitors have the responsibility. The relative advantages of each solution are unclear, and probably depend on the local and historical contexts; all pose problems of coordination to prevent care of the newborn from slipping between fragmented services. The current shortages of professional skilled attendants mean that much of the postnatal follow-up of mothers and babies, and particularly the postnatal follow-up at home, will most often be shifted from birthing centres to health centre staff – nurses, general practitioners or paediatricians. This creates a need for attention to skills, job descriptions and mechanisms to ensure continuity of care.

Many countries today face a dilemma: either invest in the continuum of care and in access to skilled care at birth or, given the present unavailability of skilled professionals, go part of the way by investing in lay workers who could provide some of the care newborns need that mothers cannot provide themselves. Activities through which lay workers help to improve living conditions, enable women and their families to provide good care in the home, and promote uptake of services have been clearly shown to supplement professional care effectively ( ³⁶ ). Evidence for the usefulness of non-professional community workers providing treatment for newborns under routine circumstances is scantier and is subject to debate. Strategically, the question is whether this brings an added value and whether the opportunity cost is not too high, compared to focusing on expanding professional care and improving care within the home.

In countries and areas where professional skilled attendance at birth is high and increasing, developing a strategy that promotes lay community health workers would have little popular or political support compared to one that aims for universal access. It makes more sense, in such countries, to concentrate on speeding up coverage further, improving quality of professional newborn care by maternal and child health services, and establishing continuity with care at home.

The dilemma is real, however, in areas where present levels of professional skilled attendance coverage are very low. Betting on non-professional care has the appeal of doing something immediately. Ultimately, though, the objective is to roll out networks of effective professional services, to catch up with countries that started to do so in earlier decades. The existence of such professional services is in itself a precondition for lay workers to be effective. Care should be taken to avoid the mistake made in the 1980s, when a strategy of scaling up professional birthing services was replaced rather than complemented by working with traditional birth attendants (see Box 4.4). Likewise, local community health workers can complement professional services in caring for newborns, but they are not an alternative to building up professional services: the opportunity cost would be too high.

The weakest link in the care chain today is skilled attendance at birth. The main thrust of strategies aimed at improving the health of newborns should be to improve access to and uptake of professional care at birth by all pregnant women. It will be necessary to refocus care at birth to make sure that the interests of the newborn are given due attention. This needs to be done at first level and for the back-up services: timely referral here is just as important as it is in dealing with unpredictable maternal emergencies.

Overcoming the present fragmentation of care for newborns is no easy task. What is done before and at childbirth should be linked with what will happen afterwards in the home and within the services that assume responsibility for providing health care for the newborn and, later, the child. The first challenge, though, is to roll out skilled maternal and newborn care fast enough to put an end to the exclusion of nearly half of the world’s newborns from the life-saving care to which they are entitled.

Footnotes

⁸ Lawn J, Zupan J, Knippenberg R. Newborn survival. In: Jamison D, Measham AR, Alleyne G, Breman J, Claeson M, Evans DB et al, eds. Disease control priorities in developing countries, 2nd ed. Bethesda, MD, National Institutes of Health, 2005.

²⁹ Mahy M. Childhood mortality in the developing world: a review of evidence from the Demographic and Health Surveys. Calverton, MD, Macro International Inc., 2003 (DHS Comparative Reports, No.4).

³⁰ Inter-Agency Group on Safe Motherhood. The safe motherhood action agenda: priorities for the next decade. Report of the Safe Motherhood Technical Consultation, 18–23 October 1997, Colombo, Sri Lanka (http://www.safemotherhood.org/resources/pdf/e_action_agenda.PDF, accessed 16 February 2005).

³¹ MacDonagh S. Creating synergies in maternal and neonatal health services. London, Department for International Development, 2003 (unpublished Options working paper undertaken on behalf of DFID).

³² Harvey SA, Ayabaca P, Bucagu M, Djibrina S, Edson WN, Gbangbade S et al. Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement. International Journal of Gynecology and Obstetrics, 2004, 87:203–210.

³³ Bautista LE. Duration of maternal breast-feeding in the Dominican Republic. Revista Panamericana de Salud Pública/Pan American Journal of Public Health, 1997, 1:104–111.

³⁴ Working with individuals, families and communities to improve maternal and newborn health. Geneva, World Health Organization, 2003 (WHO/FCH/RHR/03.11).

³⁵ O’Rourke K, Howard-Grabman L, Seoane G. Impact of community organization of women on perinatal outcomes in rural Bolivia. Revista Panamericana de Salud Pública/Pan American Journal of Public Health, 1998, 3:9–14.

³⁶ Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM et al. and MIRA. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster randomised controlled trial. Lancet, 2004, 364:970–979.

Chapter 5: 1,2,3,4,5 | Next page