SAVE NEWBORNSSOUTH ASIA HEADLINE RESULTS - 2016 PROGRESS REPORT

  We know what we have to do to save the lives of women and girls everywhere.

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.”

GRAÇA MACHEL
Chair, the Partnership for Maternal, Newborn & Child Health

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A newborn baby dying within the first month of life is a tragedy.

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.

UNICEF SOUTH ASIA TARGET

Reduce newborn deaths from 32 per 1000 live births in 2013 to 25 per 1000 live births by 2017. This will save an additional 300, 000 lives.

South Asia’s target is in line with the SDG target to end preventable deaths among newborns, with all countries aiming to reduce newborn deaths to at least as low as 12 per 1000 live births by 2030. However, the stark reality is that South Asia is badly off-track to achieve this goal. If current trends continue, South Asia will only reduce newborn deaths to 20 per 1000 live births by 2030.

Accelerated progress is critical which is why UNICEF ROSA has set a target for 2017 to get us back on track. This will require further investments in health, as well as the synergistic efforts of government, civil society and development partners. The potential benefits to newborns are enormous.

GLOBAL TARGET

Reduction in newborn mortality to 12 per 1,000 live births by 2030
 
 

ACHIEVING RESULTS

theory of change

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.

DATA PROFILE

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.

Newborn death projections for South Asia through 2030

(current trends versus acceleration needed to reach regional and global 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.

Regional analysis of newborn death rates by wealth quintile, mother’s education, and residence in Bangladesh, India, Maldives, Nepal and Pakistan, 2006-2013


Data Source: UNICEF analysis based on MICS, DHS and other nationally representative sources

Skilled birth attendance (SBA) is an intervention that saves newborn lives, but huge inequities exist both between and within countries. For example, almost all births in Sri Lanka are attended by skilled health staff but only two-fifths of births in Bangladesh. All countries except Maldives and Sri Lanka have huge disparities in SBA between the rich and poor (figure 4).

Percentage of births attended by skilled health personnel by wealth quintile, South Asia countries, 2006-2014


Data Source: data.unicef.org

ACCELERATING CHANGE IN SOUTH ASIA

1 - LEADERSHIP AND GOVERNANCE

Progress on Newborn Action Plans

In December 2015, UNICEF’s Regional Office for South Asia (ROSA) and the World Health Organization’s Regional Office for South East Asia (SEARO) jointly held a technical advisory group (TAG) meeting in New Delhi, India. At this meeting, six partner agencies (WHO, UNICEF, UNFPA, World Bank, UN Women and UNAIDs) signed a Joint Statement to support countries to end preventable maternal, newborn and child mortality by 2030. TAG members provided their recommendations for action and identified technical assistance required from partners. In addition, government leaders, academics and other stakeholders from across South Asia discussed priority actions to reduce newborn death. Follow-up actions are underway.

Political commitment from Afghanistan
In May 2015, the ‘Kabul Declaration for Maternal and Child Health’ was signed with targets to reduce maternal, newborn and child mortality by 2020. Reproductive, Maternal, Newborn, and Child Health Scorecards were developed and formally released with data on key indicators down to district-level, which are designed to improve public accountability in the health sector. In addition, Afghanistan’s government has made high-level commitments to the Secretary General’s Global Strategy for Maternal, Newborn, Child and Adolescent Health for 2030.

Raising awareness about premature babies in Pakistan
To observe World Prematurity Day in 2015, several events were organised in Pakistan. These included press releases and advocacy events at both federal- and provincial-level to emphasise the importance of, and to share key messages on, prevention and treatment of preterm births.

2 - HEALTH FINANCING

Financing-related policies and trainings in the region

To better inform planning for resource allocation and priority setting decisions on newborn health, a regional training on the One Health Tool was held in April 2015. Government officials and researchers from academic institutions across South Asia joined the training. Technical support to countries for costing of national or provincial ENAPs is ongoing from UNICEF’s Regional Office.

Investing in newborn health in Nepal
In 2015, Nepal endorsed the National Safe Motherhood and Newborn Health Act, which provides legal provisions for the rights of women to maternity leave during pregnancy and the postpartum period, and free health services for mothers and newborns. Using an investment case approach, the district action plans produced through these efforts supported by UNICEF have been instrumental in ensuring adequate resource allocations for MNCH services at district-level.

3 - HEALTH WORKFORCE AND TRAININGG

Ensuring a supply of skilled birth attendants
In 2015, Afghanistan, Bangladesh, India, Nepal and Pakistan developed national human resource plans or strategies for skilled birth attendants.

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.

Facilitated by UNICEF, Health Promotion Officials from the Ministry of Public Health and officials from the Ministry of Rural Rehabilitation and Development in Afghanistan undertook a mission to Nepal to learn appreciative inquiry in 2015. As a result of this visit, preparations were completed to establish ‘Golden Villages’ in which communities commit to achieving 100 percent skilled birth attendance among new deliveries.

In addition, facilitated by UNICEF, an exchange was held in October 2015 in which paediatricians, obstetricians, midwives and nurses from Bangladesh were trained at the All India Institute of Medical Science on Kangaroo Mother Care (KMC). KMC was subsequently established in two facilities in Bangladesh.

In November 2015, facilitated by UNICEF, staff from Sri Lanka’s Ministry of Health, national obstetric association and paediatric association visited one of India’s Special Newborn Care Units (SNCUs) to learn about the newborn online (and real-time) data monitoring system. Since this exchange, an online monitoring system has been planned for Sri Lanka.

4 - HEALTH INFORMATION SYSTEMS

Newborn-specific indicators
The global ENAP supports monitoring progress within countries, including to map the coverage of four specific newborn care interventions: use of antenatal corticosteroids, resuscitation, Kangaroo Mother Care (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). Other high burden countries have included at least one or two newborn indicators in their national HMIS.

Tracking sick newborns in India
In 2015, India’s Special Newborn Care Unit (SNCU) monitoring system, initiated by UNICEF, was scaled up to 17 states covering 440 out of 602 SNCUs. An additional 450,000 newborns were registered in the system, representing an 81 percent increase over the 248,000 registered in 2014. Thirteen states initiated community follow up of newborns discharged from SNCUs, facilitating timely data review, feedback and corrective actions.

5 - HEALTH SERVICE DELIVERY

Initiatives to improve the quality of newborn health care
UNICEF, WHO and the US Agency for International Development (USAID) held a regional workshop in Dhaka, Bangladesh in April 2015 on a series of competency-based newborn care training modules called “Helping Babies Survive.” Participants from Afghanistan, Bangladesh, India, Nepal, and Pakistan joined this training. Afghanistan subsequently conducted a “Training of Trainers” on Helping Babies Survive.

In addition, four South Asian countries (Afghanistan, Bangladesh, India and Nepal) implemented quality improvement guidelines for maternal and newborn health in 2015.

In Bangladesh, a national Quality Improvement Secretariat (QIS) and a Total Quality Management (TQM) Unit were established, along with a ‘National Strategic Plan for Quality of Care’ and a related monitoring framework. With support from UNICEF, Bangladesh adopted Every Mother Every Newborn (EMEN) quality improvement standards and criteria and implemented models of Quality Improvement. The Ministry of Health and Family Welfare developed a plan for scaling up Special Care Newborn Units (SCANU). Bangladesh will also start implementing Kangaroo Mother Care (KMC) in two hospitals and in 30 facilities at primary/ secondary and tertiary levels during 2016-17.

Improving facility-based newborn care in India
Global evidence shows that 39 percent of newborn deaths could be averted with hospital care. With UNICEF support, many states in India adopted innovative approaches to leverage funding so as to ensure human resources and equipment maintenance in SNCUs and to set up model labour rooms (a standard design to enable labour rooms to handle both normal and complicated labour). Functional SNCUs in the 23 states supported by UNICEF under the Call to Action increased from a baseline of 49 percent of the high priority districts in 2012 to 63 percent (i.e. 66 out of 105 high priority districts). In addition, the percentage of delivery points in high priority districts having at least one trained staff in SBA increased from 28 percent to 75 percent during this same time period. Currently, about 40 percent of high priority districts have at least one model labour room.

Saving newborn and maternal lives after the earthquake in Nepal
After the devastating April 2015 earthquake, UNICEF supported the re-establishment of essential life-saving MNCH services in areas of Nepal where health facilities were destroyed or damaged. With UNICEF support, 46,522 mothers and newborns were reached with essential and emergency care in earthquake-affected areas, and 22 transitional shelter homes were established to provide care for pregnant women waiting for labour and new mothers and their newborns.

Scaling up postnatal care in Bhutan
A great effort has been made by Bhutan to improve postnatal care with support from UNICEF. Based on the results of a pilot implementation of postnatal care outreach services, a nationwide scale-up covering all 20 districts was launched in 2015.

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, Pakistan is the only country to date that has included all essential drugs relating to newborn health in its NEML. Further, Punjab and Sindh provinces introduced chlorhexidine for cord care, an intervention proven to reduce newborn deaths by up to 23 percent. Chlorhexidine introduction will be replicated in Khyber Pakhtunkhwa (KP) and Balochistan provinces in 2016. Some progress on essential medicines have also been made in Afghanistan and Bangladesh.

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.

7 - COMMUNITY, OWNERSHIP AND PARTNERSHIP

Communication strategies
Communication strategies are available in Nepal and Pakistan. In 2015, Afghanistan, Bangladesh, and India worked to develop national communication strategies on newborns.

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

                       


               


               

The key to realizing Sustainable Development Goals and achieving 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 regional results.

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.

Projected newborn deaths in Afghanistan, India and Pakistan

Current trends versus accelerated trends needed to meet the SDG target by 2030


Data Source: UNICEF analysis based on 2015 UN IGME data

RESEARCH, KNOWLEDGE, EVALUATION

UNICEF ROSA works to create and disseminate new evidence on what works to reduce newborn deaths, particularly among the most deprived populations in the region. Key knowledge management activities include the dissemination of a regular newsletter that includes the most recent evidence from peer-reviewed journals that is either region or country specific, news that is politically or technically relevant to maternal, newborn, child and adolescent health, a summary of upcoming events that might be of interest to colleagues and partners, as well as newly available resources such as reports, videos, guidance, and training materials. With each issue, we will also showcase an interesting initiative from a country in the region (both successes and challenges).

ROSA is also initiating a series of Discussion Papers to highlight new research, data and knowledge that will support advocacy efforts to accelerate results for children. The aims of the Discussion Paper series are to:

1) improve knowledge, generate discussion and deepen engagement to accelerate results on priority programme areas in South Asia
2) create a high quality mechanism through which new knowledge can be disseminated to relevant professionals and networks
3) build UNICEF’s reputation as a leading voice for knowledge generation on issues affecting children, adolescents and women in South Asia
4) build a community of colleagues, internal and external to UNICEF, focussing on improving results- and equity-based programming and cross-sectoral collaboration.

In addition, ROSA has initiated a South 2 South Collaborative for Health which brings together colleagues for learning opportunities on key issues in newborn health, as well as maternal, 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. Collaborative activities to date have focused on appreciative inquiry and the establishment of “Golden Villages” that commit to achieving 100 percent skilled birth attendance among new deliveries (Afghanistan to Nepal); training paediatricians, obstetricians, midwives and nurses on Kangaroo Mother Care (Bangladesh to India); and the establishment of an online (and real-time) data monitoring systems for newborn health (Sri Lanka to India); among others.


MONITORING AND EVALUATION OF ENAP IMPLEMENTATION

In 2015, 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, UNICEF country offices in Afghanistan, Bangladesh, India and Pakistan are tracking progress to ensure ENAP is implemented. The main areas of progress made in 2015 were the development of national newborn action plans and inclusion of essential medicines for newborns in essential medicines lists. These have lifesaving potential. Table 1 shows three essential medicines and their effect on reducing deaths. Future mortality estimates in South Asia will confirm whether these interventions have led to saving newborns.

Table 1. Impact of essential medicines for newborn

Essential newborn medicines
Injectable antibiotics
Antenatal corticosteroids
Chlorhexidin

% of newborn deaths averted
75
31
23

Areas requiring further attention include the inclusion of specific newborn health-related indicators in health management information systems, the implementation and scale-up of communication strategies, and community engagement.


Download South Asia Health Atlas 2016

REAL LIVES, REAL CHANGE

© UNICEF/BANA2015-00075/Mawa
Jannat, a pre-term baby (33 weeks) delivered normally at a private clinic receives a routine follow-up visit from Dr Tahmina Sultana.

SAVING PRETERM BABIES IN BANGLADESH

Quick referral: a key to child survival
Bithy Aktar, 17, knew something was seriously wrong when her few weeks old baby did not feed properly, had poor movement, and would frequently turn blue. The baby named Jannat was born premature with low birth weight at a private clinic in Uttar Para village in Tangail district, Bangladesh. Bithy immediately called Anwara Begum, a Community Health Volunteer who had provided her counselling during her pregnancy like she did to other women in the locality on various pregnancy-related issues, newborn and child health care, etc. After confirming the danger signs, Anwara quickly referred Jannat to the Tangail General Hospital.

Special care for special needs
“We received Jannat in a critical condition. She is a preterm baby and has been suffering from septicaemia – a kind of bacterial infection in the blood – common among preterm babies causing avoidable deaths,” said Dr. Tahmina Sultana at the Tangail General Hospital.
Roughly 60 percent of the newborn babies admitted at the hospital’s Special Care Newborn Unit (SCANU) are low birth weight or preterm babies. Dr. Sultana added, “But we are well-equipped here. You will be amazed to know that even a 900 gram baby has survived after being admitted here. That’s the lowest I have seen surviving with our effort.” But not all are lucky. One reason low birth weight or premature babies are at greater risk of illness and death is that they lack the ability to control their body temperature. They get cold or hypothermic very quickly. A cold newborn stops feeding and is more susceptible to infection.
In Bangladesh, newborn deaths currently account for approximately 61 percent of all deaths of children under five years of age. “Complications due to prematurity have been identified as one of the three major causes of death after birth asphyxia and infections,” says Dr Lianne Kuppens, Chief of Health at UNICEF Bangladesh, “Birth weight is also a significant determinant of newborn survival.”

Avoiding preventable newborn deaths
The SCANU at Tangail General Hospital is among 28 hospitals in the country supported by UNICEF in collaboration with the Government of Bangladesh and with financial assistance from the Korea International Cooperation Agency, so that high-risk low birth weight or preterm newborns get proper life-saving treatment.
After putting up a brave fight for nine days at the hospital, Jannat was finally sent home bringing back the lost smile on Bithy’s face.
“We can avoid preventable causes of newborn deaths. This requires more focus on the most effective interventions across the continuum of care,” says Dr Kuppens quoting evidence from research. “Scale-up of cost-effective Kangaroo Mother Care to protect babies’ body temperatures through close body contact with the mother and maintaining nutrition along with full supportive care have the potential effect of reducing newborn death in high burden countries.”