What does it take to ensure that premature or sick babies born in rural Tanzania get the care and attention they need to survive and thrive? The ‘No Baby Left Out‘ initiative shows how a set of simple interventions can make all the difference.
Seventeen-old Eli lives in the poor area of Moka in southern Tanzania, a three-hour journey on rough roads from the closest hospital in Lindi. When she went into labour the only health facility was a poorly equipped local dispensary, where her baby girl was born prematurely, weighing only 940 grams. With only the most basic facilities and lack of personnel trained in in newborn care, the chances of such a tiny baby surviving would normally be very small, but Eli and baby Musna were lucky: Staff at the Moka dispensary had received training under Tanzania’s innovative No Baby Left Out initiative. After receiving the appropriate basic care and being stabilised, mother and baby were referred to Lindi Regional Hospital’s Newborn Care Unit for further management and care. Thirty days later Musna’s weight had increased to 1590 grams and she was well enough for Eli to take her home.
The first 28 days of life are crucial
Not all new babies have such a fortunate start in life. Although much progress has been made in reducing under-five mortality, the fourth of the eight Millennium Development Goals, it has become increasingly clear that neonatal mortality remains a huge challenge: Worldwide, nearly half of deaths in children under five occur in newborn babies. The minutes and hours immediately after birth is a very vulnerable time for babies, and if there are problems, it is often a matter of life or death. Nearly three million newborn babies a year die from largely preventable causes, and a further 2.6 million die in the last three months of pregnancy or are stillborn, according to newly published research conducted by The Lancet’s Every Newborn series.
Neonatal infections, low temperatures and breathing or feeding difficulties are big killers – but many of these deaths could be prevented by adopting simple and timely interventions. As a result, the World Health Assembly launched a global Action Plan on neonatal health in June.
Experiences from Southern Tanzania
For babies like Musna, the strategies adopted in southern Tanzania by the Tanzanian-German Programme to Support Health (TGPSH) have proved highly effective in reducing preventable neonatal deaths.
The No Baby Left Out initiative started in 2011 in some parts of Tanzania’s southern regions of Lindi and Mtwara – some of the poorest areas of the country, with the highest rates of child mortality. It is part of a comprehensive German supported health sector programme which supports Tanzania’s health system also in the fields of social health protection and health financing, quality improvement of health services, decentralized health governance, cooperation with the private sector and strengthening civil society.
Although modest in scale, the initiative has seen impressive results in a short time. When it first launched Lindi’s Regional Hospital had a neonatal mortality rate of 35/1000 live births. As a result of measures implemented, fatality rates amongst newborn babies admitted to the hospital’s Newborn Care Unit decreased from a baseline of 32% in 2011 to under 10% in 2012. (The mortality rate remained stable in 2013, as more babies requiring complex or delayed treatment were referred from peripheral health facilities to the Regional Hospital.)
How has this been achieved?
Whereas most bilateral cooperation programmes now tend to focus on advising ministries at national level, this bilateral German cooperation programme includes – in addition to ministerial policy advice – a more old fashioned “hands-on” approach. Physicians from Germany and the British Voluntary Service Overseas (VSO) work very closely with their Tanzanian partners and colleagues on the ground to train healthcare workers to ensure timely interventions and better care for newborn babies.
The No Baby Left Out initiative has developed this comprehensive approach for newborn care by focusing on three key elements: better training of staff, standardised screening of newborn babies and timely referral of babies with problems.
Starting with fairly small-scale interventions in Lindi regional hospital in 2011, the initiative has gradually expanded to neighbouring Nyangao and Masasi District hospitals. These three centres now provide improved services and training for neonatal health, which has also been extended to around 73 peripheral medical centres throughout the region, including the Moka dispensary where Eli gave birth.
Around 220 doctors and nurses in the region’s health centres and dispensaries have been trained in total. This training, conducted over two-and-a-half days, is very much on the job, as well as theoretical, says Dr. Mallomo, the Tanzanian clinical officer in charge of co-ordinating outreach training.
Tanzania has a shortage of health workers, particularly in rural areas, where there is a high turn-over of health professionals, so the training needs to be constantly reinforced and refreshed. So whevenever possible – rainy season and transportation allowing – Dr. Mallomo and her team conduct outreach follow-up visits two months after the initial training and then every four months to supervise how the initiative is progressing, and provide on-going support and encouragement.
Although the Ministry of Health is encouraging more women to give birth at health facilities, many babies are still born at home, without proper medical care, so Dr. Mallomo and her team have also been training traditional midwives to spot and refer potential complications in pregnancy or newborn babies.
For example, new mothers are advised on breastfeeding and staff are trained to implement “kangaroo mother care (KMC)” – where premature or underweight babies such as Musna are kept warm through skin-to-skin contact with their mothers in facilities where no incubators are available.
The aim of the initiative is to keep things as simple as possible for rural health workers who may have little formal education, whilst focusing on standardising care for key problems.
Like all new babies, Musna was also allocated a Newborn Triage Checklist on which the health workers record the results of three screening sessions within the first 24 hours after birth – immediately after birth, four- to eight-hours after birth and before discharge. These cards have a list of standardised questions and a “traffic light” system that help health workers to identify whether a baby has any problems: if all the boxes on the green area of the card are ticked, everything is fine, yellow means the baby needs special observation and red means that the baby – as in Musna’s case – should immediately be referred from the local health facility to hospital.
Referral is a crucial and important part of the process, says Dr. Mallomo. “It makes a lot of difference, because if we observe this child in the first minutes of life, and see that this child has a problem and refer this child in time, then the survival rate for these children is very high.”
Early referral ensures more babies survive
As a result of these screening cards, Lindi Regional Hospital has seen a steady increase in the number of babies referred, and now receives a stable 5 – 10 referrals a month from peripheral health facilities. In 2012 there were twice as many referrals as in 2011. The hospital also has a Newborn Care Unit and staff are trained to a higher level to care for at-risk babies like Musna. As a result, the number of neonatal deaths has reduced by two-thirds for the admitted and treated newborns since the initiative began.
Nevertheless, mortality rates remain higher amongst babies from distant facilities because of the difficult journeys many of them have to endure to get to a hospital and the time lost before their treatment can be started. Although the initiative has been promoting the use of ambulances and accompanying medical staff for critical referrals, providing it to all who need it remains a huge challenge.
Empowering and motivating health workers
The No Baby Left Out initiative has proved very effective and provides valuable lessons for the rest of Tanzania and elsewhere, but – at the current stage – it remains a small regional initiative. Scaling up and ensuring sustainability can be a challenge when the initiative is so heavily reliant on human resources, says Dr. Martti Koehler, the GIZ paediatrician working alongside Tanzanian and VSO partners in Lindi.
According to the Ministry of Health, many rural health clinics operate with fewer than half the staff they need, and some have none at all. Severe personnel shortages and poor facilities, combined with shortages of basic supplies such as drugs, mean that motivation and morale of health workers is often very low. One of the main strengths of the No Baby Left Out initiative is that it also ensures that no health worker is left out. It not only provides proper training for staff, but provides constant supervision of guidelines to ensure quality control – and this in turn provides support for isolated rural health workers, helps to build teamwork and ownership of the process, and makes the initiative more sustainable in the long-run.
“This largely depends on human resources – individuals who serve individuals,” says Dr. Martti Koehler, “But obviously facilities and equipment are important too — oxygen therapy needs electricity or generators, and babies need medicines. So there are many challenges.”
Such a labour-intensive approach is of course expensive and funding is crucial. But, asks Dr. Koehler, “is there another way?” Better neonatal care, he says, also impacts on a baby’s prospects in later life, so could save money and resources in the long run.
As the initiative has expanded and consolidated, says Dr. Koehler, it has also become clear that neonatal programmes need to be better integrated with maternal health programmes, as a baby and mother’s health are so closely linked. More attention also needs to be paid to mother and child nutrition.
Hoping to save more and more children
Eli and baby Musna are now back home in the village, but receiving regular check-ups at Lindi hospital and the local dispensary. “If we want to avoid death in the first day or days or weeks of life, then we have to be continously active in that field,” says Dr. Koehler.
As we look beyond the Millennium Development Goals and consider priorities for the next 20 years, reducing newborn mortality remains an important challenge. With the launch of the World Health Assembly’s global action plan, newborn care is now high on the global agenda and the Tanzanian government is now treating it as a priority, too. Although the Tanzanian-German No Baby Left Out initiative is currently still a small regional project, Dr. Koehler emphasizes that it shows what can be achieved with motivated, trained staff and simple interventions.
By Ruth Evans.