A roundtable meeting titled 'Every newborn must be saved' was organized by Prothom Alo on February 6, 2018. This special supplement provides a summary of the speeches of the discussants who participated in the meeting.
Abdul Qayyum, Associate Editor, Prothom Alo
Although we usually didn't think much about newborn health, we are now ascribing considerable importance to reduction of newborn mortality and ensuring survival and a good life for every newborn in the current situation.
In the Sustainable Development Goals, there is a target on reducing newborn mortality and providing quality health care to newborns. Today's discussion is about what we need to do in order to reduce newborn mortality rate and save every newborn.
Md. Shahidullah, Former Pro-VC and Head of Neonatology, Bangabandhu Sheikh Mujib Medical University
There are three main reasons behind newborn mortality, namely: birth asphyxia, preterm birth and infection. Due to these three reasons newborns are dying mainly during the 28 days after birth.
At present, half of the newborns that are dying in our country die within 24 hours of birth, and 73% of those dying in 24 hours of birth die at home. That is, when a child is born at home, if any complication arises, since there are no facilities at-home to tackle such a complication, the newborn dies.
The rate of delivery at health care centers has almost doubled in our country over the years. But the growth is not satisfactory in our public hospitals. In 2010, 10% births would take place in public hospitals and health care centers. Now it has grown to 14%. On the other hand, births at private hospitals have grown from 11% to 29%.
There is wide disparity between the rich and the poor in terms of births at health care centers. At present, 93% of the pregnant mothers from rich families are taking pregnancy care services, but for poor families the rate is only 51%.
78% of the rich families have the delivery through skilled birth attendants, but only 25% of the poor take recourse to skilled midwives. We need to eradicate this huge disparity among the rich and the poor families.
It was a goal of the government to establish special care newborn unit or SCANU in every district hospital of the country. So far, the SCANU facility has been established in 44 district hospitals. It should be established in the remaining 20 districts quickly.
Md. Abdul Mannan, Chairman, Department of Neonatology; Secretary General, Bangladesh Neonatal Forum
There are three main reasons for newborn death: if the newborn doesn't cry at birth, if the infant is born underweight, and if there is sepsis. In our country's context, we need to adopt low-cost easy solutions to prevent newborn mortality due to these three reasons.
We already have an effective low-cost and easy solution, which is kangaroo mother care. Underweight newborn cannot maintain body temperature. Immediately after birth the underweight newborn should be placed at the center of its mother's chest in order to transmit heat from the mother's skin to the newborn's body. This is called kangaroo mother care.
Through kangaroo mother care we can save the underweight newborns and protect them from sepsis as well. Hence, we don't need very costly technology and treatment facilities to reduce newborn mortality within 24 hours of birth.
We need kangaroo mother care right after birth, feeding them mothers' breast-milk, delaying the newborn's bath, and six step hand-washing according to the guidelines of World Health Organization. If we follow these general and simple procedures, we can reduce newborn mortality by almost 75%.
Khaleda Islam, Director, Primary Health Care, Directorate General of Health Services
We are working in three steps in the national newborn health care program. In three phases we are trying to tackle the challenges bedeviling reduction of newborn mortality and providing better health care to newborns.
First, we are trying to raise awareness among pregnant mothers and their families on an area-wise basis. Through various publicity tools and advisory support, we want to create an environment in all areas so that family members themselves will take the pregnant mothers to the hospital or health center.
In the second phase, we want to ensure primary health care for pregnant mothers in all parts of the country. We want to make at least one health center properly equipped in each area where pregnant mothers can get primary health care and health advice. We are also working to ensure the conditions so that in the event of any complications they can be quickly taken to better hospitals.
In the third phase, we want to prepare at least one hospital at the district level with advanced facilities where we can provide treatment for any pregnancy complication. As part of that we are working to establish SCANU facility in every district hospital of the country.
Farid Uddin Ahmed, Deputy Director, Services and Program Manager (Newborn and Child), MCH Services Unit, Directorate General of Family Planning
Although the Directorate of Family Planning has been working on the protection of mother and child since 1975, for the first time, this year the issue of newborn healthcare has been added in the activities of the department.
To reduce the rate of newborn mortality, it is necessary to create awareness among the pregnant mothers and their family members at the local level. Since only if the pregnant mother and her family members become aware, we can ensure safe delivery at the health centers. In order to raise awareness at the local level, we are running awareness programme through the FP inspectors and other field workers.
In light of the national newborn health program, we at Family Planning Directorate have adopted a work plan. We have already begun work to create necessary work force. We have specially trained 154 physicians on newborn treatment and additional 144 are receiving training.
We are running extensive awareness-building campaign in order to inform common people about the danger signs related to newborn health and to sensitize them about newborn health care. Through the awareness campaign, we want to encourage common people to take care of newborns.
Zahera Khatun, Director, Nursing and Midwifery Service
In saving newborn's life, a nurse or midwife plays a very important role. If a midwife plays her role seriously, she can quickly identify complications related to breathing of a newborn and take necessary steps. A midwife is provided with training for this work.
Whether an newborn is born at home or at health center, it needs certain care right after birth. A skilled midwife provides that care. The midwife carries out responsibilities like checking the breathing of the newborn right after birth, making arrangements for proper cleanliness for preventing sepsis, checking the body temperature of the newborn, and above all after all the checks, arranging for breast-feeding of the newborn by its mother.
A mother often struggles to provide immediate newborn care including breast-feeding right after birth. Hence she needs a skilled trained midwife by her side. In order to reduce newborn mortality rate, we need to ensure presence of a skilled midwife during every delivery.
Government of Bangladesh has already begun the process of recruiting skilled and trained midwife in every health center around the country. With a joint initiative by Government of Bangladesh and UNFPA, the training and deployment of midwives has begun.
Ahmed Ehsanur Rahman, Assistant Sceintist, ICDDRB
Since 2017, 4th Health Sector programme started in Bangladesh. At the beginning of this program, the Health Ministry needed to know the amount of funding required to reduce death rate of infants down to 12 per thousand. ICDDRB with support from WHO, UNICEF and other partners have tried to provide an estimate on behalf of Health Ministry.
In our estimate, we saw that additional BDT 7.2 billion is needed to reduce newborn mortality rate to the desired level. Thus, if additional BDT 7.2 billion is allocated to the health sector, it would be possible to successfully implement the Bangladesh Every Newborn Action Plan (BENAP) adopted by the government to save every newborn.
Based on this estimate, the government has already allocated BDT 3.5 billion to the Directorate General of Health Services (DGHS) to work on reducing newborn mortality rate.
Around BDT 1.5 billion is already allocated in other projects and programs of the government in the health sector. Since newborn health is also reflected in other operational plans of the health sector, hence we think that the national newborn health programme could collaborate with other programs and use that money as well in reducing newborn mortality rate.
We have already come to know that newborn mortality rate is higher in the poor families. Hence, in spending the almost BDT 5 billion allocated by the government, priority should be on creating awareness among the poor community about the importance of having child birth at hospitals and enhancing the facilities in the rural public hospitals and health centers to provide newborn care.
Sabbir Ahmed, Program Director, Newborn and Child Health, Mamoni MHS Project, Save the Children
Since more than 50% are home births, local community volunteers can play a role here in reducing newborn mortality rate.
In community clinic infrastructure that exists in our country, there is a provision for raising awareness among local people about primary health care through community support groups. On the other hand, in the sector plan of DGHS and Directorate General of Family Planning also there are provisions to create awareness among local people by community volunteers. Hence in ensuring essential services for newborns and bringing the pregnant mothers to the health centers at the local level, we can utilize the community members. In our polio elimination program, we have seen that community members can play a very effective role in creating awareness at the local level.
Abu Sayed Mohammad Hasan, Technical Officer, United Nations Population Fund
Although the rate of child marriage has been reduced in Bangladesh compared to earlier times, it is still too high. Moreover, due to various social reasons, it will be difficult to completely eliminate child marriage. Child marriage is directly related with newborn mortality rate.
According to data from the Demography and Health Survey 2014, 31% of the married adolescent girls aged 15 to 20 are pregnant or have given birth. It is clear from this data that a large part of the pregnant mothers of the country are adolescent girls. When girls at an early age get pregnant, various complications arise for newborns, which is dangerous for both the mother and the infant.
The rate of early pregnancy is higher in rural areas compared to urban areas and more in poorer families compared to rich ones. Hence, in order to reduce newborn mortality rate, broader awareness needs to be created among the rural poor community of the country.
When a girl gets pregnant at an early age, she does not come to the health center for various family and social reasons. Even for delivery she is not taken to the hospital. This creates risk of death for both mother and the newborn.
Firoza Begum, General Secretary, OGSB
One of the main reasons of newborn death is birth defects, whose main cause is lack of adequate nutrition of the pregnant mother during pregnancy. Since most of our country's mothers get pregnant at an early age, these underage mothers have serious nutritional deficit, which leads to death of the newborn and the mother.
Probably we won't be able to prevent early marriage easily and quickly due to various social and religious obstacles. But we can delay the pregnancy of adolescent mothers. Community level awareness should be built so that even if a girl gets married at 18, she doesn't get pregnant before 20.
Besides, we can make effective use of technology to encourage pregnant mothers at rural areas to come to health centers during pregnancy and delivery. We can identify pregnant mothers area-wise and send mobile SMS to the mother, her husband, and family members that it is time for the pregnant mother to come to the health center to get the tests done.
Our public hospitals and health centers are not that much woman-friendly. The government is working to establish separate unit for the pregnant mothers in every hospital. This initiative should be continued. If the service quality is improved in the hospitals, the pregnant mothers will automatically be encouraged to come to the hospitals.
MK Azad Chowdhury, Member Secretary, Bangladesh Perinatal Association
In 2009, a policy was developed on our newborn health care. In this policy, all the relevant issues related to providing health services to an newborn have been mentioned in detail. Besides, detailed guidelines have been provided on how, when, to whom, and what kind of training should be provided to reduce newborn mortality rate.
List of the blood groups of pregnant mothers are not preserved in the public health centers. It is a very important matter for the pregnant mothers and newborns. Steps should be taken for preserving the list of blood groups of the mothers in the public health centers. In the public health centers there are provisions for sufficiently high level of services. Still, pregnant mothers are not going to the public hospitals for delivery. It is to a great extent due to the syndicates of unscrupulous agents in the public hospitals. In many cases, pregnant mothers may be brought to the public hospitals, but due to the influence of those agents from the gate of the hospitals, they are going to the private hospitals. Such pernicious actions of the agents need to be curbed.
Ziaul Matin, Health Manager, UNICEF
This year for the first time, around BDT 3.5 billion has been separately allocated for only newborn health sector. This is certainly a huge matter for us. We have limited resource. We needed to use our limited resource in the optimum manner to reduce newborn mortality rate. For that purpose, there is no alternative to quality health service.
In last few years we have already established the standards and guidelines for ensuring quality health care for mothers and newborns. Now we need to ensure quality health care in all the health centers and hospitals according to these standards and guidelines.
Every year in Bangladesh around 62,000 newborns die after birth. But around 83,000 are those who die after 28 weeks until birth. This is often missed in our discussion. Besides reducing rate of newborn death, we have to work towards reducing rate of stillborn.
Especially through ensuring proper quality of services during delivery, we can reduce rate of stillborn children, because it is due to various complications during the delivery that most of the stillborn children are born. Hence, besides ensuring pregnancy and post-delivery health care, we need to ensure that mothers come to the health centers for delivery in order to reduce stillbirths and newborn mortality.
Maya Vandenent, Chief of Health, UNICEF
At first, I want to congratulate the Government of Bangladesh for success in reduction of child mortality and newborn mortality rate. Bangladesh is one of the few countries that have been able to achieve the fourth Millennium Development Goal.
From UNICEF, we are emphasizing on reduction of newborn mortality rate, because such deaths most often remain outside our view. We often don't think much about the issue of newborn mortality. At least seven newborns have died during the length of time for which we are discussing the issue here. Probably another seven are stillborn. But we easily fail to take notice of such a serious problem.
UNICEF along with the government and other stake-holders are launching a global campaign "Every Child Alive" on February 20, 2018 in 10 countries including Bangladesh where there are high burden of newborn deaths. The main goal of the global campaign that we launching for reducing newborn mortality is to highlight this problem to everyone. The issue of newborn mortality is not an affair for the health ministry only. Each of us may know someone who is pregnant or would be pregnant in the coming days. For that pregnant mother or to-be pregnant mother known to us, the issue of newborn mortality is a big problem. Hence all of us should think about it.
From UNICEF we want that all members of society should be concerned for reducing newborn mortality and think how it can be eliminated. Only general awareness could significantly reduce newborn mortality.
Md. Shahidullah, Former Pro-VC and Head of Neonatology, Bangabandhu Sheikh Mujib Medical University
It is important to create woman-friendly environment in hospitals. Especially attention should be given to the situation that prevails after noon in the district and Upazila public hospitals.
We need to take care so that all the health centers have facilities for delivery according to the guidelines for quality service. Besides, we don't get skilled manpower for running the SCANU facilities that have been established in the district hospitals. We need to take notice of these issues urgently.
Abul Kalam Azad, Director General, Directorate General of Health Services
The Ministry of Health of Government of Bangladesh regularly holds discussion and consultation with government, private sector and NGOs, international development organizations and all relevant stakeholders to solve any problem in the health sector. It is due to this that Bangladesh has been able to make huge improvement in the health sector with limited resources.
There are questions about the service quality in our public hospitals. One thing that needs to be pointed out is that the same doctors who see patients in public hospitals also see patients in private hospitals as well.
They behave one way when they are in public hospitals; and their behavior changes significantly when they go to private hospitals. In order to improve service quality in public hospitals we also need to improve our mentality.
In the fourth sectoral program we have adopted the plan of recruiting 65,000 multi-purpose community volunteers around the country, with 5 in each community clinic. These volunteers will go from house to house in each area to check the health status of pregnant mothers, newborn children and all people and if needed, advise them to go to the health centers.
We may not be able to keep a mother in the community clinic for 24 hours, but if the delivery takes place there, then we can keep the updates of the mother even when she goes home. For any problem, we can quickly move her to the hospital.
Zahid Malik, MP, Hon'ble State Minister, Ministry of Health and Family Welfare
A main reason for newborn mortality is the underage pregnancy of adolescent mothers. When a mother gets pregnant at an early age, the child cannot be fully developed in the womb, and many complications arise after birth. On the other hand, poverty is one of the main reasons of early marriage. Mothers also suffer from malnutrition due to poverty. Hence, many issues are related to newborn mortality and maternal mortality. Hence, if solving other issues can contribute to reduction of maternal and newborn mortality.
If we can educate and empower the mothers, that would also play a role in reduction of newborn mortality. Because if women are educated and empowered, they will be able to make decisions.
In our country, the disparity between village and city and between rich and poor is very wide. Such disparity is not at all desirable in the health sector. We need to remove the disparity. But social system, education and poverty are also related to the disparity.
Our mothers need to come more to health centers for delivery. We have created the facilities for providing delivery-related services in community clinics to this end. But it is found that due to lack of awareness mothers are not coming to the health centers. Therefore, awareness among mothers and their families have to be raised.
We have very limited resources. We work with only 1% of our GDP in the health sector. Even our neighboring countries get 3 to 4% of GDP allocated to health sector. Yet, with these limited resources we have been able to surpass them. In this regard, international and non-government development partners like UNICEF have played an important role beside the government.
Considerable progress has been made in infrastructure development in our health sector. But we don't have the same level of skilled work force. Without skilled work force, it is not possible to deliver quality service. We now need to focus on improving service quality, and infrastructure, skilled work force and mentality are related to that.
Ministry of Health has already established SCANU in 44 districts with support from UNICEF for sick newborn care. We have plan to establish SCANU in all 64 districts by this year.
Hence, we should all work together in a coordinated manner to ensure quality service in the health sector of the country. If we put our efforts from respective positions, I am hopeful that we will be able to reduce newborn and maternal mortality rate within the stipulated time and achieve the SDGs.
Abdul Qayyum, Associate Editor, Prothom Alo
Media has an important role in encouraging mothers for ensuring newborn health care and having delivery at health center. As a media organization, we at Prothom Alo will take the necessary measures to reduce newborn and maternal mortality rate.
I express my cordial thanks and gratitude to all for taking part in the discussion.