Saving Newborn Lives
STORIES FROM THE FIELD
Save the Children
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Saving Newborn Lives Each year nearly 19,500 newborns die and 1,200 women die from complications related to pregnancy in Nepal. On track to meet Millennium Development Goal 4 for child survival, Nepal has made tremendous strides in improving outcomes for newborns over the past decade with 30 % decrease in newborn deaths from 2000 to 2010. Funded by Bill and Melinda Gates Foundation, Save the ChildrenÂ’s Saving Newborn Lives (SNL) program has supported the Government of Nepal to meet MDG 4, contributing to the development of several national policies and plans like National Health Strategy endorsed in 2004 which established policies to guide programs for newborns and mothers. SNL was one of the key partners of Ministry of Health and Population (MOHP) in initiating national roll out of Community Based Newborn Care Package (CB-NCP). It focuses on improving availability and quality of newborn care in the community, where most newborn deaths occur. It enhances skills of Female Community Health Volunteers (FCHVs) to provide newborn care in the community and link people to the health center. CB-NCP focuses on behavior change communication, promotion of institutional and clean delivery, postnatal care through home visits on days 1, 3, and 7, community-based infection management, low birth weight care, prevention and management of hypothermia, and community-based management of birth asphyxia with stimulation and resuscitation. The Government, Save the Children, Care, Plan and Unicef piloted CB-NCP in 10 districts initially. Findings from the pilot has been used to inform the scale up of the package, which is intended to reach all 75 districts by 2015. Save the Children overlooked implementation of CB-NCP in Bardiya, also a first pilot district. Here are glimpses of some of the successes from Bardiya.
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Hari Maya decides to go to the birthing centre Hari Maya (26) gave birth to her fourth child, a boy in the early hours of the morning in Saurahawa PHCC (Primay Health Care Centre). She went into labour late at night and her husband and some of his friends from the village carried her for over an hour to the birthing center on khatiya (a wooden bed post). When she was three months pregnant, she consulted her female community health volunteer (FCHV) Mathura as she was feeling discomfort, something she had not experienced in her first three pregnancies. Mathura advised her on care during pregnancy, safe delivery, and improving her diet. Hari Maya followed Mathura s advice took a lot of care during the pregnancy, taking her vitamins and irons on time, getting tetanus vaccination, and going for four mandatory check ups. Mathura visited her often and encouraged her husband Karna to take Hari Maya to the PHCC to give birth. When Hari Maya was brought into the birthing centre at around midnight, Mathura stayed by her side while a skilled birth attendant helped her give birth. When the baby was finally born, Mathura checked the baby s weight and helped her breast feed the baby. Hari Maya and Karna who have three children waiting for them at home Laxmi, 9, Arjun, 7, and Ganesh, 2, named the newborn Bivek, which means knowledge in Nepali. Resting after the sleepless night, Karna said, We didn t believe this baby will survive but we took her (Mathura s) advice and came to deliver the baby at the center.
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Hari Maya said, I had my first three children at home, and either he or I would cut the umbilical cord. This time I was scared. She (Mathura) told me that I should not carry any heavy load and eat well. She also encouraged us to come to the birthing center. I am happy I had my baby here. This place is much safer. Fifty-year-old Mathura is has been an FCHV for over 20 years. She has her first baby at 17 after a prolonged labor of seven days. She recalls, I still do not know how my baby and I survived . Inspired by her own difficult childbirth, she decided to become a FCHV. Women in her village seek her out for advice on childbirth, pregnancy, child care and family planning. Women trust her. For Mathura, this is her calling. She was with Hari Maya at five in the morning when Bibek was born and later in the evening, she visited her at home for a post natal visit to ensure that the baby and the mother was doing well. FCHVs like Mathura bring newborn care closer to the community.
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Asha s baby is saved When18-year-old Asha was expecting her first baby,she learnt about the benefits of nutritious food, vitamins, iron tablets and regular check ups from her female community health volunteer (FCHV) Syanumaya. The FCHV also advised her family to have the baby delivered at the health post. But she had a prolonged labor at home before she was brought to the health post where she gave birth to a baby girl with help from Pushpa, an auxiliary nurse and midwife at the health post. However, the baby didn t cry or breathe. Pushpa, who had just finished the seven-day community-based newborn care training, started stimulating the baby by rubbing her back. When there was no response, Pushpa used the dee-lee suction to initiate breathing. When both these methods didn t work, Pushpa used the bag and mask to resuscitate the baby. To everyone s relief, the baby started crying after a while. Since the baby was also underweight, her FCHV Syanumaya came to the house to check on the baby frequently and teach the family how to give skin-to-skin care known as Kangaroo Mother Care (KMC) to the baby. Asha, her husband and mother-in-law took turn in the first month after the baby s birth to provide KMC. A low cost method to save low birth weight babies, KMC has been proven very effective for low birth weight babies. It serves as a human incubator for the babies to maintain temperature and gain weight through frequent feeding which it promotes. Pushpa recalls, I have seen many babies born like that, not breathing. I didn t know how to save them. Now since the (CBNCP) training, I have already saved few babies with the bag and mask technique.
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Pusha became a health worker inspired by her own harrowing experience at child birth – She was only 16 and was hung on a tree for four days and asked to push the baby out. Now a mother of two, she is very happy to be able to help mothers bring their babies safely to this world. Asha remembers that she was very angry and sad when many attempt by the health worker to revive her baby failed. But when the baby finally started crying, she felt relieved and happy. She is grateful that a health worker saved her baby girl who turned one this year and is learning to walk. When hospitals are too far way for a women in labor, trained health workers like Pushpa can save lives right in the community, contributing to the country’s achievement in lowering child mortality.
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Kangaroo Mother Care helps Sunita's twin babies Sunita, an early childhood education facilitator, had her first baby when she was 21-yearsold but the baby died 43 days after birth. When Sunita at 23 became pregnant again, this time with twins, she and her husband decided to take every precaution possible. They contacted the female community health volunteer (FCHV) who came to her house frequently to advice her on taking iron tablets, tetanus shot, eating well and going for regular check ups. Sunita states, I was getting really big as my pregnancy progressed. We could guess that we will have twins so I went to get check up not just four but five times just to be safe . She was advised to go to the district hospital to get a video x-ray but she couldn t go as the hospital was almost over an hour way from bus. Sunita s FCHV visited her almost every day and advised her husband to make preparation to take Sunita to the health facility for birth. However, the babies were born on the way to the hospital. The traditional birth attendant who had accompanied them helped her through the birth and used the safe delivery kit which Sunita had kept ready on FCHV s advice. Sunita and Khushi Ram brought their twin babies back home. Their FCHV immediately visited them and found that both the babies had very low weight: weighing 1300 and 1500 grams each. She helped Sunita initiate immediate breast feeding and also taught the entire family on how to keep the babies warm on the chest by giving them skin-to-skin care round the clock called Kangaroo Mother Care. She also advised the new parents to immediately go to the hospital for further check up as the babies were not only born prematurely but were also low weight.
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Khushi Ram says, We immediately went to the Bheri Zonal hospital where the doctor kept the babies in observation for 13 days. I took turns with my mother and wife to keep the babies in Kangaroo Mother Care all the time. When Save the Children staff visited the babies at home 27 days after their birth, both babies had gained significant weight, weighing at 1600 and 1800 grams. Grateful for the care provided by the FCHV, Sunita says, I am very thankful that she advised us about taking the babies to the hospital and showing us how to do Kangaroo Mother Care. Both Saugat and Sandesh (the names of twins) are doing well and gaining weight now.
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There's nothing as good as mother's milk Like mothers everywhere, Hira has a lot of demands on her time and energy. She has three small boys to look after and her husband is away for months at a time working outside the country, so Hira has to manage on her own. Hira started breastfeeding all three of her children as soon as they were born, but she had difficulty continuing with the first two. With her husband away, she had to collect firewood and grass away from home, so she couldn t breastfeed as frequently as she wanted to. After about three months she did not think she had enough of her own milk to feed the boys, so she started giving them leeto (a porridge made of wheat, soy and gram flour). Both boys suffered frequent ailments such as common cold, coughs, fever, pneumonia and diarrhea. When Hira became pregnant with her third child she started getting help from the female community health volunteer in her village, a women named Bhagwati, who was trained by Save the Children on community based newborn care. Bhagwati counseled Hira about improving her diet, and taking vitamins and iron, so she could be stronger. She also explained why it is important to breastfeed exclusively for the first six months of a child s life, then to start introducing food like leeto after six months. I was not aware that the mother s milk is so good for the child, said Hira. That it protects children from disease and infection. Hira s third son, Sandesh, got nothing but breast milk for his first six months. Not even water, Hira says proudly. It is very easy to breastfeed. It doesn t take any preparation time. It is hygienic, and I feed anytime the baby needs it. My two older sons could not
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digest the leeto so early. Sandesh is much healthier. He has only been sick once. I took him to be weighed last week- he is up to 7.5 kilograms. Hira started complementary feeding Sandesh when he reached 6 months of age. Right now, I breastfeed him first hing in the morning. I just started feeding him leeto three times a day and he is able to digest it. I still breastfeed him at least six times a day. Hira says she plans to continue breastfeeding Sandesh for a few more years.
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This is why we need more health workers ! Banas Ram and his wife Khetrani were blessed with a baby boy after 20 years of marriage but their happiness had a complicated twist. Khetrani was brought to the hospital in a bullock cart from her village almost an hour away from the health post in Dhodari in Bardiya district where Save the Children has trained healthworkers in newborn care and survival. Her baby had suffocated and the placenta had already detached. Auxiliary Nurse Midwife Pushpa and Jhamkali, Maternal and Child Health Worker helped her give birth but the baby didn t breathe. While Pushpa worked on saving the mother, Jhamkali started cleaning the baby s wind pipe. After being assured that the mother will live, Pushpa and Jhamkali started resuscitating the baby with bag and mask and were not able to revive the baby after 20 minutes. But they didn t give up. With permission from the father who was waiting outside the labor room, Pushpa decided to try for 15 more minutes. The baby started breathing and crying after 35 minutes of resuscitating. They lit fire in the health post to keep the baby warm. The health workers said in unison, When we put the baby on the mother s chest, our happiness knew no bound. They initiated breastfeeding but the baby could not suck the milk. In addition the baby was underweight (1700 grams), so the two health workers immediately called an ambulance to avert any danger to the baby. Pushpa went along with the mother and father to the Bheri Zonal Hospital, the biggest hospital in the region at one in the morning, admitted the baby at the Neonatal Intensive Care Unit to make sure that the baby gets the best possible chance at living.
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Both Pushpa and Jhamkali went to visit the baby after the return from stay at Neonatal Intensive Care Unit for a week and found that the baby was breastfeeding and gained 200 grams. Khetrani is also keeping the baby in Kangaroo Mother Care, a skin to skin method of keeping the baby warm which is proven to help low birth weight babies gain weight. Pushpa and Jhamkali are very proud to have saved babies who would have otherwise not survived. This is why we need more health workers, better trained in every village so that ever baby born has an equal chance of surviving. Save the ChildrenÂ’s Saving Newborn Lives program trained over 2000 doctors, nurses, health workers and female community volunteers in Bardiya and Nawalparasi districts and now starting training in Baitadi.
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Sarita and her twins Sarita s twin daughters Rahel and Rudh were born in Dhodhari health post in the presence of trained health workers. While Rahel was 2200 grams, her sister Rudh was only 1600 grams, didn t breathe or cry at birth. A health worker present at the health post felt Rudh s faint heart beat. They immediately started working on resuscitating her. Rudh started crying after a while. Sarita says, I thought I had lost one of my babies but the health workers brought her back to life. Rahel and Rudh are three years old now and are doing well.
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Tara goes to health facility Naresh and TaraÂ’s second baby Suman (see photo above) was the first one in their community to be born at a health facility. When Tara was having difficulty giving birth, FCHVs Uma and Asharani convinced Naresh to take her to the health facility where skilled birth attendants saved her asphyxiated baby. Following Naresh and TaraÂ’s example, their neighbor Laxmana (in green shirt) also took her daughter-in-law to the birthing center to have her baby.
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Indicators of Community-Based Newborn Care Package (CB-NCP)
% at Baseline (BL) % at Endline (EL) November 2008 July 2010 N=625 N=615
Use of newborn healthcare services and adoption of healthy practices/behaviours at scale ANTENATAL CARE (ANC) Women attended at least 4 times during their last pregnancy for ANC
57.8
81.3
Women informed of pregnancy complications
75.1
95.9
Women who received at least two doses TT during their last pregnancy
86.7
81.1
INTRAPARTUM CARE (IPC) Women whose last birth was attended by a skilled provider
30.2
74.6
Live births delivered in a health care facility
33.7
81.3
Newborns who received PNC within 2 days after birth
64.8
95.6
Newborns with PNC within 24 hours after birth
64.6
95.1
Newborns with at least three PNC checks in first 7 days after birth
Not Collected
42.1
POSTNATAL CARE (PNC)
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Indicators of Community-Based Newborn Care Package (CB-NCP)
% at Baseline (BL) % at Endline (EL) November 2008 July 2010 N=625 N=615
Last born children who were put to the breast =1 hour after birth
63.8
89.6
Newborns who were given colostrums
94.9
96.6
Children < 6 months exclusively breastfed
76.3
77.8
Newborns given skin-to-skin contact after delivery
Not Collected
75.9
Newborns dried as soon as baby is born
60.8
88.8
Newborns wrapped as soon as baby is born
66.6
85.4
Newborns with first bath delayed at least six hours after birth
42.6
94.1
Newborns with nothing immediately applied to cord
69.6
86.0
Women receiving ANC who were informed about birth preparedness
72.8
99.2
Women with a birth preparedness plan in last pregnancy
70.2
96.9
Demand for newborn services increased
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Far Western Region Mid Western Region
Western Region
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CB-NCP Program Districts Expansion Phase - 2011 (067/68) Piloting Phase - 2010 (066/67) S.N. 1 2 3 4 5 6 7 8 9 10
District Dhankuta Morang Palpa Doti Bardiya Dang Chitwan Kavre Parsa Sunsari
Central Region
Implementing Agency Government of Nepal Government of Nepal Government of Nepal CARE Nepal Save the Children UNICEF UNICEF UNICEF Plane Nepal Plane Nepal
S.N. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
District Terthum Sankhuwasabha Sarlahi Myagdi Kailalai Saptari Bajhang Banke Kapilvastu Arghakhachi Mohatari Salyan Dailekh Jumla Nawalparasi
Implementing Agency Government of Nepal Government of Nepal Government of Nepal Government of Nepal Government of Nepal UNICEF UNICEF Plane Nepal Health Right International Health Right International NFHP NFHP NFHP NFHP Save the Children
Expansion Phase - 2012 (068/69) S.N. 1 2 3 4 5 6 7 8 9
District Lamjung Humla Kanchanpur Taplejung Bara Baglung Dolpa Rautahat Baitadi
Implementing Agency Government of Nepal Government of Nepal Government of Nepal Government of Nepal Government of Nepal One Heart One Heart Plan Nepal Save the Children
Eastern Region Expected to start in 2013 (069/70) S.N. 1 2 3 4 5 6 7 8 9 10 11 12
District Achham Rukum Dhanusha Syangja Gorkha Okhaldhunga Jajarkot Bajura Udaypur Rupandehi Pyuthan Dadeldhura
Implementing Agency Government of Nepal Government of Nepal Government of Nepal Government of Nepal Government of Nepal Government of Nepal Government of Nepal Save the Children Save the Children CNC CNC CARE Nepal
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Save the Children Nepal Country Office G.P.O. Box 3394 Airport Gate Area, Shambhu Marg Kathmandu, Nepal Tel : +977-1-4468130 / 4464803 Fax : +977-1-4468132 post.nepal@savethechildren.org www.savethechildren.net