Implementation
Effective interventions exist and are low cost, especially when added to existing programs, but current coverage is low, especially for the poor, who have the highest mortality risk. Approximately 53 percent of women worldwide deliver with a skilled attendant: fewer than 30 percent in the poorest countries and more than 98 percent in the richest countries. In Sub-Saharan Africa, average coverage with skilled care has increased at only 0.2 percent per year in the past decade; without faster progress, coverage of skilled attendance will still be less than 50 percent in 2015. Analysis in 50 low-income countries showed that the richest 20 percent of women were, on average, almost five times as likely to use a skilled attendant as the poorest 20 percent (Knippenberg and others 2005). Hence, coverage is low, progress is slow, and inequity is high.
Each country or decision-making unit starts with a different epidemiology and varying coverage and capacity in its health system. No single recipe for strengthening newborn care in health systems is available. Scaling up MNCH care will involve systematic steps to assess local situations and opportunities, improve care within current constraints, and overcome supply and demand constraints—especially for the poor. No country or program can achieve multiple new interventions at once, and scaling up human resources takes time. Therefore, phasing approaches is essential not only to allow faster approaches to reach the poor soon, but also to allow consistent strengthening of the health system (Knippenberg and others 2005).
Step 1: Assess the Situation and Advocate for Action for Newborn Health
Careful examination of local data is required (Lawn, McCarthy, and Ross 2001). Newborn health should be included in general health sector and public sector planning—for instance, for education and transportation. When governments set mortality reduction targets for children under five, they should consider setting simultaneous targets for reducing NMRs (Martines and others 2005). The level of participation—involving multiple stakeholders, including women and communities—and the political will to implement and finance such plans are also crucial to success. Reaching every pregnant woman and every newborn with effective care involves everyone: the family and community provide home care and advocate for access to preventive and curative care; the health system supplies care during normal pregnancy, childbirth, and postnatal care, along with emergency obstetric and young infant care services if required; and the government and global policy makers provide supportive policy and resources, in particular to ensure that there are enough health care providers, such as midwives. National champions can be effective in promoting progress. Global partnerships may also play a role in facilitating broad national plans and promoting donor convergence in implementation (Tinker and others 2005).
The government of Nepal recently held a series of stakeholder meetings and developed a plan for a national newborn health strategy. Representatives from such diverse backgrounds as neonatology, safe motherhood programs, and community mobilization efforts met over a five-month period to create an operational plan for newborn care through 2017 (Khadka, Moore, and Vikery 2003).
Step 2: Achieve Optimal Newborn Care within the Constraints of the Current Health System
Because situations vary even within countries, data-driven prioritization and good leadership are crucial to using resources well (Lawn, McCarthy, and Ross 2001). Program areas related to newborn health include safe motherhood, child survival, immunization, family planning, and nutrition, along with management of sexually transmitted diseases, prevention of maternal-child transmission of HIV, and prevention of malaria during pregnancy. The reality is that such interventions have not reached most women and children and that existing services fail to coordinate along the continuum of care. This situation results in gaps in service and missed opportunities. In Africa, for example, the regional average for prenatal care coverage is 64 percent, yet coverage of tetanus toxoid immunization is 42 percent (Knippenberg and others 2005). Syphilis treatment is another opportunity that frequently is missed during prenatal care (Gloyd, Chai, and Mercer 2001). Including the newborn in transport and funding programs that currently address only maternal emergencies may be of little marginal cost for significant benefit. In India, where integrated management of infant and childhood illness (IMCI) is being scaled up, the marginal cost of adding selected neonatal conditions to the clinical care component of IMCI is low, estimated at less than US$0.10 per capita (box 27.3).
[Box 27.3]
In many settings in South Asia and Sub-Saharan Africa, even where midwives are in place they do not have the skills required for newborn care. Competency-based training in neonatal resuscitation is a rarity and must be incorporated into preservice as well as in-service training (box 27.1). India's National Neonatology Forum identified birth asphyxia as a leading cause of neonatal deaths and launched the Neonatal Resuscitation Program, developing a course with standard guidelines and certification of competency (Deorari and others 2001). Between 1990 and 1992, more than 12,000 physicians and nurses were trained. The effect of the program was evaluated in 14 teaching hospitals in India. Changes in resuscitation practices were noted, and asphyxia-related mortality fell significantly. The prevalence of survivors with disabilities was not assessed.
An alternative model of skill strengthening has been tested in South Africa, where significant improvements in knowledge and skills have been documented as a result of the Perinatal Education Programme, a distance-run self-taught course (Woods and Theron 1995). More than 30,000 midwives in South Africa have passed the examinations, and the program's manuals are used in many undergraduate medical and nursing schools.
Numerous publications have detailed suboptimal hospital management of women in labor or newborns, variously reported as contributing to 10 to 75 percent of all perinatal deaths (Lawn and Darmstadt forthcoming). Thus, there is scope for improving outcomes and client satisfaction in virtually all settings. For example, in much of Sub-Saharan Africa, a significant proportion of women deliver in facilities that collect data that could be used to identify achievable improvements in care (box 27.4).
[Box 27.4]
Step 3: Phase the Systematic Scaling-Up of Newborn Care
Although some resource-poor countries have succeeded in building functional systems (box 27.5), the process, especially for clinical care, takes time. Professional care during childbirth and childhood illnesses is the ideal, but significant costs are involved in increasing the numbers of professionals and retaining them, especially in rural posts. Even maintaining current staff presents challenges, given low pay and high frustration. To markedly increase coverage requires new commitment now to a massive expansion in the number of midwives and to innovative approaches to retain staff, especially in hard-to-serve areas. Supply constraints must be systematically identified and targeted—notably, human resources, accessibility to facilities, financial barriers, and supply of commodities and drugs (Knippenberg and others 2005). Demand-side strategies are also important, including consideration of subsidies for preventive care or transport for emergency care.
[Box 27.5]
In the meantime, most neonatal deaths continue to occur in underserved and poor communities that will wait the longest for access to skilled care. Each year, 60 million women deliver without skilled care present. There is a moral imperative to reach those women now. Feasible strategies to reduce NMRs exist (for example, efforts to improve family behaviors, tetanus toxoid immunization campaigns, and community-based management of acute respiratory infections) and have been demonstrated in poorly developed health care systems. Interim strategies are available, such as linking a group of traditional birth attendants with skilled attendants (Koblinsky, Campbell, and Heichelheim 1999) or medical assistants to perform cesarean sections. Policy conflicts between skilled and community approaches are not helpful. Both approaches are required. With phased program planning, community services can be used now while professional care is being strengthened. The community services can then promote demand for skilled care (Knippenberg and others 2005).
Step 4: Monitor Coverage and Measure Effect and Cost
In most high-mortality countries, NMRs are measured only intermittently (typically every five years through demographic and health surveys). Tracking of coverage indicators, and especially equity of coverage, is important for managing program decision making. Information is lacking, and the information that is available is often not used to improve care. Governments must be encouraged to report funding, coverage, and outcomes related to national plans for maternal, neonatal, and child survival. Donors should also be accountable for reporting funding flows and ensuring that commitments are kept (Martines and others 2005).
