UNICEF SOUTH ASIA TARGET
500,000 additional newborn lives saved by 2021
Reduction in newborn mortality to 12 per 1,000 live births by 2030
Needless deaths of women, newborns and children must stop. We must do more and we must do better because every action counts and every life counts.”
Chair, the Partnership for Maternal, Newborn & Child Health
This tragedy strikes about a million newborns and their families every year in South Asia. Moreover, the day a baby is born is the most dangerous day for children in both rich and poor countries alike. The good news is that almost 70 percent of newborn deaths are preventable, and many lives can be saved with relatively simple and inexpensive interventions.
500,000 additional newborn lives saved by 2021
Reduction in newborn mortality to 12 per 1,000 live births by 2030
We know how to prevent newborn deaths. It requires a range of actions with buy-in from families, communities, health care workers and governments (figure 1).
Figure 1: Framework for saving newborn lives in South Asia.
The number of newborn deaths declined from 2 million per year in 1990 to 1 million per year in 2015. However, even now nearly 3,000 newborns die each day in South Asia. Figure below shows the projected mortality among newborns if current trends continue versus if South Asia is able to accelerate progress to meet the 2017 and 2030 targets.
Data Source: UNICEF analysis based on 2015 data from UN interagency group for mortality estimation
As shown in figure below, there are huge disparities in newborn death rates by wealth quintile, mother’s education, and residence in South Asia. A child born into one of the poorest families, to a mother with no education, or in a rural area is much more likely to die in his or her first 28 days.
Data Source: UNICEF analysis based on MICS, DHS and other nationally representative sources
Institutional delivery is an intervention that saves newborn lives, but huge inequities exist within countries. The good news is that disparities between the poorest and the richest have reduced dramatically in India and slightly in Nepal and Pakistan. However, a worrying trend is that disparities have increased in Afghanistan and Bangladesh (figure 4).
1 - LEADERSHIP AND GOVERNANCE
Progress on Newborn Action Plans
By June 2017, all eight South Asia countries had finalised national newborn plans or strengthened relevant components within their national health strategies. In Afghanistan, provincial maternal newborn and child health (MNCH) action plans in 9 out of 10 provinces were developed and approximately 1,500,000 underserved children under 5 and women of reproductive age benefitted from timely implementation of these plans. In India, all 15 UNICEF supported States have endorsed reproductive maternal newborn child and adolescent health (RMNCAH) strategy implementation with a focus on high priority districts. In Pakistan, four provinces (Punjab, Sindh, Balochistan and KP) have finalized Provincial Newborn Care Strategies.
Every Newborn Action Plan (ENAP) Advocacy
During 2016, country engagement and partner harmonization efforts continued around ENAP through advocacy, progress tracking and partner coordination. All eight countries are tracking ENAP progress. UNICEF ROSA recognizes newborn deaths as one of the priority health problems in South Asia. In order to galvanize discussions and generate momentum in efforts to save newborns in the region, ROSA organized a regional health advocacy event in November 2016. During the event ROSA released the South Asia Health Atlas which highlights deprivations and underlying contributing factors of newborn deaths across and within countries in the region. In addition, the Nepal Newborn Action Plan – a stellar example of Nepal’s tremendous progress and efforts to tackle newborn deaths occurring every year – was also launched in collaboration with UNICEF Nepal and the Government of Nepal. The event included a panel discussion and an exhibition hall showing photos and maps illustrating remaining disparities in countries in South Asia. In addition, UNICEF ROSA released a videographic on the problem of newborn mortality in South Asia which, as of early April 2017, had received over 40,000 views on UNICEF ROSA’s Facebook page as well as a social media toolkit and other materials.
Strengthened national coordination system for quality improvement on Maternal and Newborn Health (MNH) services in Bangladesh
UNICEF has been working with Government of Bangladesh for the development of the Programme Implementation Plan (PIP) and Operational Plan of the 4th Health Sector Programme, in which quality improvement (QI) of maternal and newborn health care has been prioritized. The national coordination system for QI is functioning, and the Government has developed national QI scale-up plan through stock-taking and mapping of QI activities. The RMNCAH QI framework is under development. Together, these actions have provided a strong basis for improving quality of care on RMNCAH in Bangladesh.
Strengthened stewardship in India
In India, supportive supervision checklists, which are used for block monitoring as part of the Call to Action (CTA), capture the health facilities in their role as “delivery points.” However, until recently there was no community component of the checklists. The Ministry of Health and Family Welfare (MoHFW), together with UNICEF and other development partners reviewed the existing checklists and introduced a community component in addition to the facility checklist. All CTA district level consultants working in 107 districts supported by UNICEF have received training on the revised supportive supervision checklists which are expected to be in use in the field in 2017. Following a series of training and capacity building sessions for all district level CTA consultants in high priority districts (HPDs) (except for one HPD in Puducherry), all other selected delivery points in UNICEF supported HPDs have received supportive supervision visits by district level CTA consultants. UNICEF and partners supported the MoHFW in developing standardized feedback tools using the data from supportive supervision visits, with regular feedback sharing with all concerned states and HPDs for their action and follow up.
Joint activities with partners
In November 2016, in order to strengthen regional efforts to end preventable maternal and child mortality, a Regional Health 6 (H6) Working Group on RMNCAH was established and the terms of reference were finalised. Since that time, H6 agencies have been working together to provide technical support to countries on implementation of ENAP and QI on maternal and newborn health.
2 - HEALTH FINANCING
Financing-related policies and actions
All eight countries in South Asia have implemented policies of national health insurance scheme/free policy covering maternal and newborn care including sick newborns a policy.
Increasing and tracking budget allocations in India
The Government of India (GoI) keeps increasing budget allocations to high priority districts (HPDs) to improve maternal, newborn and child health. In 2016, GOI increased the existing budget by 30% for these HPDs. At state levels, 56% (60/107) of HPDs reported more than a 20% increase in proposed budgets during 2016, in comparison to 2015. However, there are varying levels of progress in terms of actual allocation/approved budgets. All districts of Andhra Pradesh, Bihar, Chhattisgarh, Telangana, Kerala, West Bengal, Uttar Pradesh, Telangana, Tamil Nadu, Odisha, Rajasthan, Karnataka and Manipur and some districts of Arunachal Pradesh, Maharashtra, and Meghalaya have received a budget increase. UNICEF has supported district and state governments in using district gap analysis findings and monthly supportive supervision visits to influence planning and budgeting in these HPDs.
3 - HEALTH WORKFORCE AND TRAINING
Investment in the health workforce
By 2016, Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka had developed national human resource plans or strategies for skilled birth attendants.
|1. A human resource plan/strategy for skilled attendance at birth is in place||Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, Sri Lanka||Maldives|
|2. A retention policy/strategy for skilled attendance at birth or relevant cadres is in place||Afghanistan, India, Nepal||Bangladesh, Bhutan, Pakistan, Sri Lanka|
|3. Competency-and skill-based service/training/education for maternal and newborn health is in place||Afghanistan, Bhutan, India, Nepal, Pakistan, Sri Lanka|
The South to South Collaborative for Health
UNICEF’s new South 2 South Collaborative for Health brings colleagues together for learning opportunities on key issues in reproductive, maternal, newborn, child and adolescent health. The aim of the S2S initiative is to systemically share practical experiences and ‘know how’ from one country to another, mainly in South Asia.
In 2016, ROSA arranged four South 2 South events including Advanced Paediatric Life Support and a related instructor course, Kangaroo Mother Care (KMC), Costing Newborn Care Plans and Auditing of Maternal and Perinatal Near-death Incidents (“near-misses”). Each event included the development of related products (such as manuals) and follow-up interventions for sustainable implementation. Subsequent to the Advanced Paediatric Life Support and related instructor course, Maldives conducted a national level training on the same to improve the capacity of their health professionals in improving the quality survival of newborns. Following the KMC exchange visit, Pakistan has established KMC in Punjab province.
Knowledge management on maternal and newborn health
Knowledge management is one of ROSA’s key areas. In 2016, ROSA organised webinars on topics such as experience sharing on quality improvement for maternal and newborn health and kangaroo mother care in South Asia, essential newborn care, the Lives Saved Tool, and early childhood development. The webinar on essential newborn care gave countries the opportunity to share their experience on promotion of essential newborn care, kangaroo mother care and infection control. The webinar attracted large numbers of participants from across multiple UNICEF regions and headquarters offices. ROSA also organised several learning sessions through webinars with health facilities working to implement QI projects.
4 - HEALTH INFORMATION SYSTEMS
The global ENAP supports monitoring progress within countries, including to map the coverage of four specific newborn care interventions: use of antenatal corticosteroids, resuscitation, KMC and management of neonatal sepsis. In South Asia, India has integrated all four of these newborn-specific indicators in its national Health Management Information System (HMIS) or district health information system (DHIS). Other high burden countries have included at least one or two newborn indicators in their national HMIS. ROSA and HQ have initiated discussions with a global metrics group to convene a multi-country meeting on inclusion of maternal, newborn and child health specific indicators in HMIS/DHIS.
|Indicator in the National HMIS||Yes||In process||No|
|1. Antenatal corticosteroids||India||Bangladesh, Sri Lanka||Afghanistan, Bhutan, Maldives, Nepal, Pakistan|
|2. Performance of resuscitation||Afghanistan, Bhutan, India||Bangladesh, Sri Lanka||Nepal, Pakistan|
|3. Newborns benefiting from KMC||India||Bangladesh, Sri Lanka||Afghanistan, Bhutan, Nepal, Pakistan|
|4. Management of neonatal sepsis||Afghanistan, India, Nepal||Bangladesh, Sri Lanka||Bhutan, Pakistan|
Tracking every newborn for decision making and QI in Bangladesh
Government of Bangladesh, with support from development agencies including UNICEF, developed a defaulter tracking system using DHIS2, an open source web-based software. The software is used by 14,000 community clinics (CC) and now every pregnant mother and child under 5 (U5) is registered online using a laptop provided to all CCs. The community health service providers (CHCPs) based in the CCs work together with Health Assistants and Family Welfare Assistants to make a unique list of pregnant mothers and U5 children on a weekly basis. They register them online and continuously update information by visiting households. The system creates a list of all defaulters on its dashboard and helps with monitoring. Based on the online list, the CHCP makes a phone call to motivate the mother to come to the facility for scheduled services for herself or her child. Health managers at higher levels of the health system can also monitor online and can provide timely direction to the supervisors to ensure adequate services. The system captures all services (including provider information) into one platform. This tracking system for pregnant women and children has helped with performance monitoring, assessing quality of services, analysis of bottlenecks and taking corrective actions, proper planning and budgeting, and to improve effectiveness and efficiency of service delivery. The data show significant reductions on maternal and child deaths at community level. Bangladesh has also integrated a maternal and perinatal death surveillance and response (MPDSR) system into the DHIS2.
5 - HEALTH SERVICE DELIVERY
Adopt standards of quality of care
South Asia countries have made great progress in establishing appropriate policies and plans to improve the quality of maternal and newborn care at all levels of the health system.
|Status of policies supporting quality of care||Yes||In process||No|
|1. National quality improvement initiative included in policy||Afghanistan, Bangladesh, Bhutan, India, Nepal, Sri Lanka||Pakistan|
|2. National QI programme has a specific focus on MNH||Afghanistan, Bangladesh, India, Nepal||Pakistan||Bhutan, Sri Lanka|
|3. Health workers authorized to administer life-saving MNH interventions||Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, Sri Lanka|
|4. Policy adapted for maternal death notification||Afghanistan, Bangladesh, Bhutan, India, Sri Lanka||Nepal||Pakistan|
|5. Perinatal audit and newborn death notification||Nepal, Sri Lanka||India||Afghanistan, Bangladesh, Bhutan, Pakistan|
Introduction of KMC in Bhutan and Pakistan
Despite the achievement in infant and under-five mortality reduction, in Bhutan, neonatal mortality is still high at 21 per 1,000 live births and contributes to about 70 percent of infant and 56 percent of under-five mortality. In addition, preterm birth accounts for 37% of neonatal mortality. The country’s 2015 National Nutrition Survey revealed that 7.8% of babies are born with low birth weight.
To improve newborn health and address newborn health issues, Bhutan’s Newborn Action Plan (BNAP), was developed in 2015, which identifies care of small and sick newborns through KMC as a key intervention. However, implementation of KMC is still at an early stage in the country. Bhutan is planning to roll it out in the two Regional Hospitals. In addition, ROSA has worked with an international expert to plan a training of trainers (ToT) on KMC, to develop a KMC plan and an M&E plan for KMC implementation. KMC implementation is underway and an evaluation is planned.
Pakistan is ranked the fourth among ten countries with the highest number of preterm births in the world. More than 100,000 babies born premature in the country die because of preterm complications. KMC is one of the most cost-effective interventions to manage preterm babies, but was not available in Pakistan previously. The UNICEF-supported KMC Ward at the Services Institute of Medical Sciences (SIMS) was established in August 2016. Since that time, around 200 babies have benefited from KMC. Doctors and nurses from Punjab and other provinces have been trained by doctors and nurses from SIMS; establishment of KMC in several hospitals is planned.
Establishing a centre of excellence for newborn health and KMC implementation in Afghanistan
Supported by Indira Gandhi Institute of Child Health Hospital, a centre of excellence for newborn care has been established in Afghanistan and quality services were made available for almost 2105 sick newborns in a six month period. In addition, in Malalai hospital, a Kangaroo Mother Care Unit was established and inaugurated by the Minister of Health.
Introduction and implementation of QI for maternal and newborn health in Bangladesh and Pakistan
With support from UNICEF, two provincial workshops for Improving Quality of Hospital Care for Maternal and Newborn Health were conducted in Lahore, Pakistan in December 2016 including training of trainers for hospital staff from Punjab Province and an orientation workshop for national and professional association staff. Healthcare professionals (obstetricians, paediatricians, neonatologists, nurses and midwives) from 5 hospitals, national and provincial government officials, and clinicians from gynaecological and paediatric associations were trained. During the workshop, global and regional experiences on QI initiatives were shared, and actions for hospital QI were planned. Supported by the USAID ASSIST project, ROSA has been providing technical support from the planning stage through to follow up activities. Implementation of the QI project is currently underway.
In Bangladesh, QI in health care facilities in one district has been implemented. QI structures have set up and are functioning. QI projects by applying plan, do, check, action (PDCA) approach are undergoing and preliminary results show improved clinical procedures and reduced neonatal sepsis.
WASH in health care facilities is on the QI agenda in Bangladesh
Improving WASH in health care facilities has become a strong component in implementation of QI in Bangladesh. Bangladesh’s experience with creating an enabling environment for basic water, sanitation and waste management facilities in a primary health care facility and measuring quality of maternal and newborn health care with a focus on creating an enabling environment by adequate WASH services was shared at a UNICEF global learning event organized in March 2017 in Kathmandu.
Improving facility-based maternal and newborn care in India
UNICEF India has prioritised improvement of quality of skilled attendance at birth, care of small and sick newborns with real-time monitoring and community follow up of at-risk newborns. Sustained advocacy and technical support has led to improved quality of skilled birth attendance and has ensured supportive supervision in 107 district hospitals in HPDs. One-fourth (27/107) of district hospitals in HPDs achieved model labour room standards while two-thirds (66/107) achieved partial model labour room standards. All district hospitals received technical support for labour room standardization toward achieving model status. Supportive supervision and technical support for water, sanitation and hygiene (WASH) in health facilities was initiated targeting 1,105 health facilities in 107 HPDs. Baseline data from 1,026 health facilities in these HPDs indicate that 32/1026 (3.1%) were WASH functional while 691/1,026 (67.3%) were partially functional. Technical support was provided on WASH improvement plans at all 1,026 facilities. Special Newborn Care Units (SNCUs) scale-up in HPDs continued and the number of functioning SNCUs increased from 63% to 73% (77/107) since 2015. Between 2015 and 2016, India’s total number of SNCUs also increased from 602 to 682. Accreditation guidelines for SNCUs have been developed and released in India. The accreditation process has started in states like MP and AP with relevant activities budgeted in the State programme implementation plans.
Improving community-based newborn care in Afghanistan
In Afghanistan, the national comprehensive newborn operational plan and toolkit were developed and implemented. Increasing coverage of MNCH services to reach every newborn, child and woman of child-bearing age is one of the main strategies in UNICEF Afghanistan. UNICEF Afghanistan has prioritised community-based integrated outreach MNCH service package by introducing and scaling-up high impact mother/infant/child survival initiatives including Information, Education and Communication (IEC) particularly aimed at under-served districts. Around 755,000 pregnant women and children under 5 in focus provinces are benefitting from life-saving interventions in their villages through 54 mobile teams.
Improving postnatal home visits
Postnatal care is vital for reducing newborn mortality. Remarkable progress has been made in South Asia in implementation policies relating to home-based postnatal care in Bangladesh, Bhutan, India, Pakistan and Sri Lanka.
6 - ESSENTIAL MEDICAL PRODUCTS AND TECHNOLOGIES
Essential medicines for newborns
The extent to which recommended essential medicines and commodities for high-impact interventions are included in National Essential Medicines Lists (NEMLs) varies by country. Within South Asia, Bhutan and Pakistan have included all essential drugs relating to newborn health in its NEML (table 4).
|Essential medicine||Yes||In process||No|
|1. Oxytocin||Bangladesh, Bhutan, India, Nepal, Paksitan, Sri Lanka||Afghanistan|
|2. Misoprostol||Afghanistan, Bangladesh, Bhutan, India, Nepal, Paksitan||Sri Lanka|
|3. Magnesium Sulphate||Afghanistan, Bangladesh, Bhutan, India, Nepal, Paksitan, Sri Lanka|
|4. Injectable antibiotics||Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, Sri Lanka|
|5. Antenatal corticosteroids||Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, Sri Lanka||Maldives|
|6. Chlorhexidine||Afghanistan, Bangladesh, Bhutan, Nepal, Pakistan, Sri Lanka||India|
|7. Neonatal resuscitation devices (Ambu bag and mask)||Afghanistan, Bangladesh, Bhutan, India, Pakistan||Maldives, Nepal, Sri Lanka|
Prioritization of a research agenda
The prioritization of a research agenda for maternal and newborn health has begun in several countries in South Asia. However, planning for a research agenda around the issue of stillbirths still needs to gain greater traction.
ROSA has engaged with countries to prioritize a research agenda. A systematic review on female newborn health seeking in South Asia has been completed. Based on the results of this review, qualitative research to understand factors relating to female newborn health seeking is starting in Bangladesh. It is expected that the results will be used to inform policy and to develop a culturally appropriate communication strategy. Another area of research ROSA is pursuing is to understand the private sector’s role in supporting maternal and newborn health. The results of this study will guide countries to develop policy and strategies on engaging and working with the private sector to achieve universal health coverage for women and children.
7 - COMMUNITY, OWNERSHIP AND PARTNERSHIP
Community maternal and newborn engagement strategies
By the end of 2016, communication strategies were available in all South Asia countries.
Establishment of a community support system in Bangladesh
To create demand for maternal and newborn health services, UNICEF Bangladesh supported the establishment of 2,061 Community Support Systems (ComSS) in 14 districts through existing community groups formed by the Ministry of Health and Family Welfare. More than 7,300 female community health volunteers were trained to conduct birth preparedness sessions, to facilitate referral, and on newborn health and major childhood illnesses.
UNICEF advises that a skilled birth attendant should provide care during delivery, as this is an important way to reduce neonatal mortality. Yet disparities remain:
Huge inequities between countries in South Asia: Almost all births in Sri Lanka (99%) are attended by skilled health staff compared to only 42% in Bangladesh.
Vast disparities between rural and urban areas: In Nepal, only 51% of rural births are attended by a skilled provider compared to 90% in urban areas.
(Afghanistan: 82% urban, 37% rural).
Wealth and education disparities: In Bangladesh, about 3/4 of the wealthiest or best educated women have a medically trained provider at birth – only 18% of poor or uneducated women enjoy this support.
(India: 85% wealthiest versus 24% poorest).
Source: UNICEF global databases 2016 based on DHS, MICS and other nationally representative surveys
MONITORING AND EVALUATION OF ENAP IMPLEMENTATION
In 2016, UNICEF Regional Office for South Asia tracked ENAP implementation and progress in South Asia, particularly to assess achievements towards national milestones. With the full support of government and development partners, all country offices were tracked progress to ensure ENAP. The main areas of progress made in 2016 were the development of national and subnational costed newborn action plans and inclusion of essential medicines for newborns in essential medicines lists, initiation of KMC and quality improvement in some countries. These have lifesaving potential.
Areas requiring further attention include the inclusion of specific newborn health-related indicators in health management information systems, the implementation and scale-up of quality improvement for maternal and newborn health care.
Table 1. Impact of essential medicines for newborn
Essential newborn medicines
% of newborn deaths averted
The key to regional success in reducing newborn mortality lies with three countries: Afghanistan, India and Pakistan. If these three countries can dramatically reduce newborn deaths, it will have a huge effect on the region’s ability to achieve its goals.
The figure below shows the annual rates of reduction in newborn deaths that are required to meet the 2030 targets versus the current trends projected to 2030 for Afghanistan, India and Pakistan.
Pakistan: Observed ARR*: 1.7 / Required ARR: 9.5
Afghanistan: Observed ARR: 2.7 / Required ARR: 8.6
India: Observed ARR: 3.6 / Required ARR: 5.4
Source: UNICEF analysis based on 2017 UN IGME data
ARR*: Annual rate reduction
ACCELERATING PROGRESS TO REDUCE STILLBIRTHS IN THE REGION IS ALSO CRITICAL
Stillbirths in South Asia account for more than one-third of the total number of stillbirths globally. To achieve the target of no more than 12 stillbirths per 1000 live births by 2030, South Asia needs to more than double the current annual rate of reduction from 2.2 percent to 5.2 percent. If high burden countries (in this case, Afghanistan, Bangladesh and Pakistan) can dramatically reduce their rates of stillbirths, it will have a major impact on the region as a whole.
© UNICEF/Pakistan/2017/Adresh Laghari
Baby Afaq, born premature, at one and a half months. His mother, Komal Fahad has brought him in for his regular checkup with the doctors at the UNICEF-supported Kangaroo Mother Care Ward of the Services Institute of Medical Sciences (SIMS), Lahore.
KANGAROO MOTHER CARE HELPING PRETERM BABIES SURVIVE
By Adresh Laghari
UNICEF initiated kangaroo mother care in Pakistan: www.unicef.org/pakistan/reallives_10308.html
LAHORE, Punjab – March 2017: Komal Fahad (24) had become an expert mother when she had her first baby more than two years ago. During her second pregnancy, she was confident there will be no problems. Unfortunately, her second child was born premature. The doctors at the Services Institute of Medical Sciences (SIMS) Lahore, a teaching hospital, told her that her premature son Afaq had a critically low birthweight of only 1.6 kilograms (kg). Komal did not have a clue of what she was supposed to do next.
Dr. Naureen Rasul, an assistant professor at the Gynecology and Obstetrics Unit-II of SIMS, informed Komal that the incubator can be avoided. The baby and the mother could be admitted into the newly established Kangaroo Mother Care (KMC) Ward until Afaq showed signs of consistent weight gain. “ KMC is an alternative approach for premature newborns. Continuous skin-to-skin contact between the mother and the baby is the key element of this treatment along with covering the child in a warm blanket. This encourages the babies to start controlling their own body temperature and warmth and strengthens the emotional bond between mother and child. As some of the babies are too weak to be breastfed, their mothers feed them with expressed breastmilk out of a small measuring cup. Babies are kept in the KMC Ward till they develop a base weight of 2.5kgs and are strong enough to be breastfed.
Bangladesh Demographic and Health Survey, 2011, accessed 9 April 2015.
Every Newborn Action Plan, 2014, accessed 9 April 2015.
Nepal Demographic and Health Survey, 2011, accessed 9 April 2015.
The World Bank, ‘Births Attended by skilled health staff (% of total)’, accessed 9 April 2015.