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Q&A with Dr. Stephen Atwood, UNICEF Child Survival Specialist: Hundreds of thousands of children in this region do not survive the first three days of life!

© UNICEF Malaysia/2005/Jothiratnam

Q&A with Dr. Stephen Atwood, UNICEF East Asia and the Pacific Regional Advisor for Health and Nutrition

Despite considerable progress in reducing mortality among children younger than 5, some 3,000 children continue to die daily in the East Asia and Pacific region. Of them, an estimated 32 per cent die within the first three days of life. This proportion actually increases, however, in areas where under-5 mortality decreases. Globally, neonatal deaths occur because of infections (36 per cent), birth asphyxia (23 per cent), complications due to premature birth (28 per cent) and congenital anomalies (8 per cent). Earlier this year, Dr. Stephen Atwood and experts at the World Health Organization (WHO) brought together other colleagues from their respective organizations along with a myriad of government officials from Asia and the Pacific to discuss a strategy, called the Essential Perinatal Care Package, to confront the crisis of life among newborns. Dr. Atwood, who recently received a Lifetime Achievement Award from the American Dartmouth College for his international public health work, explains the need for the strategy and what can be done in even the most basic and remote situations.

Q:  Why does the drop in under-5 mortality seem to reach a plateau at a certain level and become difficult to change?

A:  In this region, we’ve improved our rates of infant and under-5-year-old mortality by improving coverage rates of childhood immunization and treatment of the common childhood diseases. But we really haven’t touched deaths in the neonatal period – the first 28 days of life. Now, neonatal deaths – and particularly early neonatal deaths – have become the biggest cause of infant and child mortality. So much is happening in the first three days of life: the risk of dying at birth or in the first day is three to four times higher than on day two or three. And the first 24–48 hours are when the most maternal deaths occur in most areas of the region, at around 45–48 per cent.

To improve the chances of survival of mother and child in this crucial period, maternal nutrition and care throughout pregnancy, including the months or years before and the crucial first trimester, are very important. Most programmes usually reach women in the second or third trimester when it may be too late to correct anaemia or to treat or prevent infections that may affect the mother and her baby. Anaemia alone – particularly moderate and severe anaemia – has an impact on maternal survival. Some infections during pregnancy can affect both the mother’s and the baby’s health. We know that a deficiency of folic acid at the time of conception can cause birth defects of the spinal cord and brain of the newborn baby. So our goal is to make sure that women enter pregnancy well nourished and disease free, that they maintain good health throughout the pregnancy and to improve care during delivery. This includes increasing the likelihood that the baby will be delivered by a skilled birth attendant.

© UNICEF Myanmar/2004/Noorani

Q: Have those first few days been overlooked? 

A:  They have always been seen as critical. But the reality is that when infant and under-5 mortality rates are high, it means that more children are dying in the first year of life or before they reach their fifth birthday than in the newborn period. The bigger problems in that situation, at least in this region, have been the vaccine-preventable diseases along with acute respiratory infections AND diarrhoea, which usually occur late in the first year or in the second to third year of life. Once those causes decrease, the neonatal period then emerges as the most important cause proportionately of deaths. This would be the case in countries that have brought their infant mortality rate down to 40 or 50. However, in those areas of the region where it’s 250, neonatal deaths are one problem among many – but not necessarily the biggest problem.

And where there have been decreases, the number of neonatal causes of death have remained the same because they’ve been untouched by any kind of programme. They’ve remained untouched because that period around birth is one of the more difficult times to reach women or for women to reach facilities: Complications are unpredictable, the birth usually occurs at home and there aren’t enough skilled birth attendants to prevent them or treat them.

Q: Why didn’t the programmes that brought down under-5 mortality protect the first few days of life?

A:  In some countries, such as Lao PDR and Cambodia, only 25–30 per cent of deliveries are in a hospital or health centre.  And of those, maybe only 35 per cent are attended by a skilled birth attendant. The other 70 per cent are giving birth at home with an unskilled attendant. Nearly one in four women in developing countries delivers alone, or with a relative, and that has not changed since the early 1990s. It’s been a policy of many organizations, including UNICEF, the United Nations Population Fund and the WHO, not to train unskilled or traditional birth attendants to manage complicated deliveries. The rationale has been that without equipment, referral systems and sufficient long-term training, they cannot intervene in a way that will help the mother, which is likely to put them in a very difficult position if she dies. Without midwifery training, the traditional birth attendants [TBA] cannot manage complicated deliveries. However, with training, the TBA should be able to handle the essential care – warming, early feeding of colostrums, clean care of the cord – of the newborn in the first 24 hours of life or recognize complications with the birth and urge any mother in distress to move quickly to a health care facility where a skilled attendant can provide the more adequate care.  Until recently, most UNICEF programmes focused on neonatal care in facilities, such as the baby-friendly hospital initiative, or with skilled attendants. This is obviously the ideal, but there remains the persistent reality in the region of home- or community-based births, where there are no supplies or medications and where access to a trained health worker is limited.

Certainly facilities are excellent interventions. But we believe that until the health care system in an area develops (so that every family can reach a well-supplied, well-staffed facility), a transitional emphasis on the home and community and on whomever is providing care in those places will save lives.
Also, our current  programmes – and the set-up of most health bureaucracies – tend to focus on either the mother or the newborn. For example, UNICEF’s Safe-Motherhood Project centres mainly on care of the mother and emphasizes skilled birth attendants and institutional deliveries. And our baby-friendly hospital initiative focuses on early breastfeeding – care of the newborn is actually a separate programme.  We need programmes that simultaneously confront the problems that occur with both the mother and the newborn.

© UNICEF Viet Nam

Q: Are births with unskilled attendants the biggest reason for neonatal deaths?

A:  It’s certainly a major part of the problem. But the problem itself starts before pregnancy – in the health and nutritional status of a woman before she conceives and certainly through the first trimester when the foetus is growing so rapidly in length and the nervous system is developing and throughout the rest of the pregnancy when the baby gains weight. One of the most important risk factors for early infant death is low birth weight, which is a result of conditions that placed a baby at risk before it was born. The skilled attendant can respond to this risk and can recognize when things are not going well. But many of the things that can be done to give a baby a good start in life can be handled by a non-skilled attendant. She can make sure that the baby breastfeeds early, is kept warm and is delivered in a clean environment with good care of the umbilical cord. She also can help the mother to be as healthy and well nourished as possible.

Where the skilled attendant is key is in the care of a mother in delivery: She makes sure that post-partum bleeding is reduced through active management of the third stage of labour – the delivery of the placenta and the contraction of the uterus to prevent bleeding. She also can cope with some breech deliveries or identify danger signs that signal the need to move quickly to a health facility. 

The essence of the Essential Perinatal Care approach is to make sure all attendants at birth are equally capable of managing the mother and the baby at the same time – to the best of their ability. This means that while we clearly advocate for and promote skilled attendants at birth, we also believe we must do something to improve the knowledge and skills of those attendants now delivering babies in remote villages – even if they are not skilled. They should at least be able to recognize when a mother is in trouble and be willing to urge her to go to a health facility without delay. We believe there should be a focus on community health providers during the transitional period between the real and the ideal.

Shortage of equipment skills and medicine greatly impact the chances of survival for malnourished children in DPR Korea

 Q. What’s preventing countries from providing sufficient skilled attendants to serve women in every community? 

Part of the problem here is the difference between scheduled and unscheduled visits. Scheduled visits – for immunization days or well-baby days – are inexpensive, easy to plan and require fewer staff. If a health clinic has an immunization day once a month per village, an outreach staff person goes to each village on a specified date and all children and women gather to be immunized.

But emergencies, sudden illness and curative care require unscheduled visits, and they are difficult to guarantee. If a health service intends to provide care for every woman and child whenever they fall ill or have an accident or for every birth, that means someone has to be available 24 hours a day, seven days a week (and within two or three hours of the onset of labour.) To provide one full-time staff person for an emergency room setting in hospitals in the developed world, four people have to be hired: Each works an eight-hour shift, and someone is always on leave or may be sick. Even if that is reduced to three people – how many community hospitals or health centres can provide that kind of coverage?  It requires enough people, training programmes and adequate salaries. This means that governments have to decide that this is a priority and dedicate the necessary resources – financial as well as human. In the meantime, we are left looking for ways to improve the situation temporarily.

Q: How is the regional strategy, the Essential Perinatal Care Package, going to make a difference?

A:  The strategy captures both the mother and the newborn. We start with pre-pregnancy with prevention, diagnosis and treatment. We hope to reach women in the three to six months before they get pregnant so we can discover if they are anaemic, have a urinary tract infection, tuberculosis, malaria, are well nourished or undernourished. The aim of the programme is to incorporate safe motherhood with child survival. If a woman cannot be identified and reached before she gets pregnant, we are emphasizing the importance of reaching her as early as possible – in the second month if possible – for antenatal care. We don’t want the ante-natal care to be too little, too late.

We have three levels of responses in the strategy:  Level one is what can be done by a non-skilled person in a non-health facility with very few supplies other than those locally available. The second level is what can be done by a non-skilled but trained person in a non-health facility with some supplies, and the third is what can be done by a more skilled person with supplies that require more capabilities such as intramuscular injections. We see this graduated approach as a way to deal with the vast un-met need in terms of care in difficult-to-access communities.

While we continue to advocate with governments about the importance of funding and training skilled birth attendants, we will focus on training non-skilled attendants and community health workers in interventions that match their skill and knowledge levels. We’re looking to develop home-based and community care and logistics systems that serve them, including the stocking of supplies nearby. We want to support what can be done with minor skills and minimal supplies. And we want to enhance perinatal care in the first week of life. We have to do something to increase the ability and knowledge of local women to provide the best kind of care that they are capable of providing. What we’re talking about is rather basic: warming the baby after birth, preferably  by putting the baby in its mother’s arms; strong emphasis on early feeding of colostrum; use of the “kangaroo method” for newborn care, which is having the mother wrap a low-birth-weight baby next to her skin between her breasts to use her own body heat to keep the baby the same temperature; delay the clamping of the umbilical cord  by two to three minutes so the baby is not anaemic in the first six months; and teaching more skilled attendants  how to do  manual extraction of a placenta with controlled  cord traction and using an oral drug to contract the uterus.  The oral drug can be used instead of an injectable one to make the uterine muscle contract so that it stops bleeding. 

Q: This kind of training could reduce neonatal deaths by how much?

A:  From studies done in other countries, it could be by as much as 30–40 per cent, particularly when community health workers were trained and allowed to administer antibiotics for sepsis management.

Q: It’s that simple?

A:  It’s never that simple! What makes it difficult? It’s all community based. UNICEF and many other agencies have always found it hard to work at the community level because it’s labour intensive and because we see our work so often as having more impact at the national or provincial level. We can do pilot projects on a smaller scale or work with an NGO in a localized area, but trying to set something up nationwide or province-wide is very difficult to do. Yet, we know that community ownership is important, that community collection of data is important, that community empowerment is important. We also know that there are always community obstacles that would prevent people from changing the ways they’ve practised for years and years and that these obstacles and the ways to overcome them can only be understood and developed by working with the community members.

© UNICEF China/Liu Yu

Q: How does the regional strategy address the community problem?

A:  To be honest, we haven’t gotten there yet. Ideas are being explored about creating more self-sufficiency among remote communities by training local people in easily mastered skills and interventions for taking care of newborns, treating diarrhoea, washing hands, using vaccines that can be kept for longer periods out of the cold chain and stockpiling key supplies for deliveries in the homes of community members instead of in a health centre.  These are not new ideas, they are just the extension of old ideas to new uses – it’s a revisit of David Warner’s Where There is No Doctor and Robert Chambers’ Rural Development: Putting the Last First.  Communities need to be re-empowered because with the “medicalization” of so much of public health, we’ve tended to disempower them.  Some of the things that can be done to save lives require very little input from the outside. 
However, having said this, we have to make sure that this is seen as a transitional solution – something to be put in place while the State develops the capacity to fulfil its responsibility to give services to all its people. The process of developing that capacity has to be pursued simultaneously.
We’re working now in some countries to develop this strategy; looking at ways that it can be incorporated into ongoing maternal and child survival programmes. We still have a long way to go, but the response of governments upon hearing these ideas has been very positive.



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