"Newborn survival in Bangladesh: A decade of change and future implication"

Brig Gen ( Retd) Shahedul Anam Khan, Editor, Op-ED & Strategic Issues, The Daily Star
Newborn survival is very much related with Mothers' health. If we can ensure that no mother will die then we can also ensure no newborn will die.

Media can be a strong partner in promoting the newborn care issue. I think the government and NGOs should incorporate media in their strategy and media also have some strategies regarding such important issues.

Dr Sayed Rubayet, Project Manager, Saving Newborn Lives Program (SNL) & HBB
On behalf of the Saving Newborn Lives Program of Save the Children and the Daily Star, I would like to welcome you all to today's roundtable on newborn survival in Bangladesh. The round table has been organized in order to share the experience and exchange views on the trajectory of newborn survival and also to discuss about future progress.

Dr. Uzma Syed, Regional Advisor, Asia Region , Save the Children USA
In the world every year 3.1 million child die within one month of birth. Bangladesh statistics shows that the number of newborn death in Bangladesh was 83,000 in 2010. 20 more newborns will die over the end of our 2 hours long discussion. This is a silent tsunami.

Bangladesh is on track for achieving Millennium Development Goal 4, and has made more progress in reducing neonatal deaths than most other low-income countries. The neonatal mortality decline rate in Bangladesh in the last decade is double the regional and global averages (2.0% and 2.1% per year, respectively).

Over the last decade, extensive changes have occurred in health policy related to newborn care, including development of the National Neonatal Health Strategy. Civil society, development partners, academics and journalists have played key roles, alongside the government.

But, tragedy is still there. Every year, 32 newborns die per 1,000 live births which is 60 % of the under- 5 deaths. This high mortality rate is unexpected because their causes pf death are preventable. One example is Kangaroo mother care. Different researches show that thermal care is better than incubator. We can reduce low birth weight related neonatal death through skin to skin care of the newborn. We do not need any high tech infrastructure for this.

Another programme is Helping Babies Breathe (HBB). This is a very simple solution using a low price device to help the babies in breathing. Injectable antibiotics are also a good solution to prevent death due to infection.

We have to increase our investment in safe delivery and newborn health. It can come from both the government and donors. We have to implement all the suggestions of HPNSDP, and for that we need planning and budget; skilled birth attendants. Our health centres should be properly equipped and we should also ensure postnatal healthcare.

Another important issue is preventing still birth. We have to create awareness about birth preparedness so that every mother and family can know that.

Subrata K Bhadra, Senior Research Associate, NIPORT
In 2004, we first incorporated newborn health indicators in Demographic Heath Survey ( DHS). Now we are using information surveyed in 2007.

For the data of causes of childhood mortality in Bangladesh, we are, presently, using the 2004 survey data and are expecting new data from BDHS 2011, which will be available soon. According to 2007's survey report we used four indicators for surveying our newborn related practices drying, wrapping, delayed breathing and initiation of breast feeding. The percentage of drying and wrapping within 5 minutes after birth is only 5%

. We have been working with Save the Children, Brac and other organisations in the community level to promote these practices, and now the situation has improved a lot. For example in Nilphamari, which is a area for Postnatal care study, we find this practice rate is more than 90%.

The rate of initiation of breast feeding within 1 hour was 43% in 2007. Our DHS survey 2011 show that overall breast feeding has improved a lot as well as exclusive breast feeding; now it is 62%.

Birth notification is very helpful for increasing our newborn coverage. We have found in Modhukhali that with government setup we have reached to one third mother and child within 48 hours of birth. If we ensure birth notification withing 24 hours of birth we will be able to double the coverage, which almost 65-66%. We have to scale up these practices at national level.

NIPORT has incorporated newborn care in training materials of the health workers. If we can do it successfully then it will be easier to scale up the coverage.

Prof Mohammad Shahidullah, Pro- VC, BSMMU and President , BNF
First,I want to emphasise on clean delivery. If we simply use the delivery kits, we can reduce newborn mortality. The next thing is drying. It has two beneficial effects. One, it stimulates the baby so that it can breathe easily, and another thing it clears liquor and prevents heat loss through evaporation of the liquor. It has to be done immediately after receiving the child. Wrapping also prevents heat loss. Next is cord care. By cord care we mean keeping it safe from infection which is very important. The most important thing is breast feeding. It has some components. First is initiation of breast feeding within 1 hour. Even if the child gets some colostrum it will really help to its life. Then comes exclusive breast feeding. It should be continued up to six months. Next important thing is delayed bathing. Previously it was rampant getting the baby washed. Through efforts of different organisations we have prevented this immediate bathing. It is proved that delayed bathing has done a good job in reducing newborn death. I would suggest that it should done after 3 days of birth.

Early identification of danger sign comes next. Up to day 28 the baby is newborn. If anything goes wrong, sign and symptoms will appear and families have to identify those and take immediate steps to secure its life. Post natal care closely related with this care. Three times is better and two times of post natal care is must.

If pre-terms baby is born and suffers low weight then we should provide it kangaroo care or at least skin-to- skin care.

Dr.Md. Altaf Hossain, Programme Manager, IMCI, DGHS
Bangladesh government has taken the HPNSDP (Health Population Nutrition Sector Development Programme). It is a 5 year programme.It has started in July, 2011 and will continue up to June,2016. Previously it was called HNPSP. Government has initiated a separate operation plan for mother, newbron, child and adolescent. This is called MNCAH. We have prepared a neonatal strategy and guideline in 2009.

We know severe infection, birth asphyxia and low birth weight are three major reasons for newborn death. We have included neonatal focused trainings in our curriculum. This is also done in the community workers curriculum. We have trained persons in facilities to prevent infection but at the community level who will provide this service? This is a big challenge for us.

We are working for reducing death due to asphyxia. Save the Children, USAID and Unicef are helping us to scale up this programme nationally. We have signed a MoU with BSMMU. We will complete giving training to all skilled birth attendants (SBA)about asphyxia by next year.

We are also addressing low birth weight. We have some practice of kangaroo mother care(KMC). We have a plan to scale it up robustly.

Using chlorhexidine in cord care is also important. If professional bodies agree, the government will incorporate it in our national programme.

Postnatal care is the biggest challenge for us. It is well articulated in our operation plan, and we are giving training to community health workers. But the question is how to implement it. We are suffering from limited human resources.

Dr. Ziaul Matin, Health Specialist, Unicef
According to me, newborns have 5 rights- right to safe delivery, right to breathe, right to right temperature, right to breast feeding and right to be free from infection. If we can ensure these rights we will be able to reduce neo born death successfully.

We have some constraints. We have to cover a large area within a very short period. It is not possible to cover the whole country. So we need geographical targeting. We have data on which areas are more vulnerable like Sylhet and Noakhali areas where mortality is high.

We have to strengthen our community programme because there is lack of awareness amongst them. These programmes are very cheap and effective. We have achieved success through raising awareness in 32 districts. We need partnership.

My last point is identifying symptoms of illness and quick referral to doctors. This can be done through careful observation of the child. We also have to prepare our infrastructures to respond to these needs.

M.A.K Azad Chowdhury, Professor and Head of Neonatology, Dhaka Shishu Hospital
My first point is publicity of information on newborn care. Essential cares for neonatal are very simple. If we can make people aware we can easily ensure this cares.

Professional body can contribute significantly by sharing their experiences with the policy makers and disseminating simple information to people about newborn care. Because we learn from the ground and can suggest the best policy suited to our situation. In preparing National Neonatal Strategy (NNHS) we participated actively and government, also, considered our suggestions.

Another important contribution could be training. Senior professionals can disseminate their knowledge and experience to junior colleagues. We have suggested government to open neonatal training unit at district level.

Dr. Shams El Arefin, Director, Center for Child and Adoloscaent Health of ICDDR, B
In 2011's Demographic Health Survey ( DHS) we happily found that our TFR came down to 2.3. Practical implication of this result is that out of 10 at least 4 are the first child of the mother. The rate of first mother is increasing rapidly. We know that for the first delivery there are some complications. We have to take special care for them.

Media can play a great role here. Suppose media can promote breast feeding and other maternal and newborn care. But we are not caring about it or imposing self- censorship. Previously we found advertisement of condom in BTV but later it was banned. We do not know why this ban was imposed. We should come out of cocoons.

Another important issue is task shifting to nurses. We have increased number of nurses at the upazilla level from 5 to 11. We often face the problem that at the union level doctors who do not want to stay. We have to really think that whether there is any necessity of posting them there. Rather we can place them at higher level where they will be properly utilized. We should empower the nurses so that they can take over the charge at the lowest levels.

Professor Abid Hossain Mollah, Department of Pediatrics, Dhaka Medical College Hospital
In Bangladesh most of the health aids come for mothers and children but how much they get is a matter of question.

To provide efficient health care we need integration of three things- skilled health man power, parents who care for their babies and administration. If we look at the present medical undergrad curriculum we will find that pediatrics is simply nonexistent. 45 % of our population is children. So pediatrics is very much important in our context.

Dr.Md. Gias Uddin, Deputy Director, MCHS Unit, DGFP
We have recruited 800 FWVs and soon we will find them in the field. We have recruited 400 more for training. In the 60s we started with population control programme. Later we incorporated mother and child health. This incorporation has been giving us good results.

Attitude is very important. Our FWVs are focusing mainly on family planning. They fail to put proper emphasis on MCH. This is also our fault because once we suggested them to focus only on family planning. The name of MCH operation plan is MCARH (Maternal Child Adolescent and Reproductive Health Services). We are now also providing services to adolescents. This is important because early marriage is still rampant in our country. Early pregnancy and early child birth are result of early marriage which is also prone to maternal mortality and morbidity as well neonatal mortality. So we should focus on adolescent health issues.

We should increase the rate of institutional delivery. Skill birth attendant service should also be provided both in the community or institution. We have updated our 1500 field level institutions with man power and equipments.

Under the DGFP we organise satellite clinics. According to our calculation 30,000 satellite clinics should be organised every month. If we can disseminate MCH related information from top to down through these satellite clinics we will be successful.

Dr. M A Mannan, Associate Professor, Department of Neonatology, BSMMU
As nurses are the first contact point so their role in diagnosis of symptoms is the most important. So nurse training curriculum should incorporate modules on the three major three causes of neonatal death- asphyxia, low weight and severe infection.

Hand washing is another important issue. It is very simple but effective. We need just awareness. This practice should be followed not only in facilities but also at home level.

Dr. Arefin Amal Islam, Health Officer,Smiling Sun Franchise Programme
NGOs have been playing an assistive role in government efforts in both facility and community. NGOs do not have efficient health service provider at the community level. There is a perception that that we have done a lot at the community level and our policies should be shifted to the facility. But reality has not changed that much. I think we still should continue our programmes at the community level. Because still 70% delivery occurs at the community level and only 30% occurs in facilities. So we still need skilled delivery structure at the community level.

Dr. Rabeya Khatoon, Pediatrician
Maternal health is intrinsically related with newborn care. Early marriage and early pregnancy is still an issue here. We know adolescent mothers mostly give birth to low birth weight babies. If you address adolescent health, I think, we can address the newborn issue also. Majority of our population is adolescent so we have to seriously take care of them. I think media can play a great role in preventing adolescent marriage and adolescent pregnancy.

Quazi Ghiyasuddin Giasuddin, Deputy Country Director, Save the Children
Save the Children country strategy or approach is based on four things achieving result at scale that means we want to reach as many children as possible; driving innovation that means we continuously learn and use our learning to come with new ideas; voice for children that mean where children rights are violated we speak about realization of those rights; and working in partnership. Our partnership includes civil society organizations, government, UN, grass root level organization, media, children parents , schools teachers and many other stakeholders. We succeeded to institutionalize the newborn agenda in health and family welfare ministry. Through partnership we succeeded to formulate national core committee to deliver a national agenda for newborn. Today's roundtable is also part of the partnership where we get a forum to share our learning, experiences and views on newborn care. When such discussion will get public it will create awareness among them and they will create pressure on concerned organizations to do something meaningful to newborns.

Dr. Ishtiaq Mannan, Chief of Party, MCHIP
I want to emphasise on integration. Newborn care should be integrated with maternal health, family planning and child health. In our country parallel programme is not cost effective. Through integration we can also scale up coverage.

We need recounting and re-mapping of our human resources. We should recruit manpower in respect to our present population size. Our government is still counting on the needs of 1975 and trying to fill up those posts. I think here our government should take a bold step. Another issue is updating the job description. We have introduced new interventions but failed to change the job description.

We have to launch massive campaign programme in high mortality areas so that we can change the behaviour pattern of those communities. Once you can change behaviour pattern good result is just a matter of time.

My last point is quality of service. We have to create confidence among people on our facilities and for that our facilities have to provide quality services. It is a kind of market mechanism.

Dr Abdul Kuddus, Diabetic Association of Bangladesh
In our project we have found that mobilizing women group we can reduce neonatal deaths. So I think the community can play a role in reducing neonatal mortality. We found that our findings and mothers finding of the causes of neonatal death was synonymous. They are able to identify the leading causes of neonatal deathshould disseminate these knowledges to field level workers in easy and friendly languages.