Key Interventions on Pregnant Mothers Improve the Survival of Preterm Babies
Obstetrician Dr. Mark Hathaway—a trainer for USAID’s flagship Maternal and Child Health Integrated Program (MCHIP)—still remembers the empowering story a midwife told him during a training in Cambodia on the use of antenatal corticosteroids (ACS) to prevent respiratory complications of preterm birth.
“A woman arrived at the hospital late in the evening and had a clear story of ruptured membranes,” Dr. Hathaway recalls her saying. “She could tell that the pregnancy was too early and that the woman might deliver a preterm baby.” The doctor was not there, so the midwife administered the first of two doses of dexathemasone, the most commonly available ACS.
In the morning, a colleague said she would administer the second dose, and when the midwife returned to duty two days later, the woman had already delivered.
“She went to the nursery and saw the [premature] baby under some warming lights,” Dr. Hathaway says of the midwife. “Except for some oxygen, the baby was breathing on her own.” The midwife was very surprised, and quietly told the nurse what she had done. “Soon the pediatrician came over and told her she’d probably saved the baby’s life. She felt so happy and relieved having done the right thing by giving the dexamethasone.”
ACS are one of the most effective interventions for improving preterm survival, reducing death by 31% by augmenting the maturation of the premature fetus’ immature lungs. However, dexamethasone only works when given to the mother by injection prior to birth, requiring action by maternal care providers to reduce perinatal mortality.
This Cambodian midwife’s experience demonstrates how newborn and maternal health providers can work together to facilitate the use of ACS. By adopting a perinatal approach to care—where communication and protocols are developed between maternal and newborn care providers—the outcomes are better for both mothers and babies. However, even in facilities where maternal care providers and pediatricians work under the same roof, they often lack clear mechanisms for communication.
A pediatrician may not hear of a 30-week premature infant until called to attend the birth, thus missing the potential for improved outcomes through collaborative care, mutual support and reinforcement with the obstetrician throughout the labor. Strengthening the connections between different providers in the same hospital, or teams of providers at different levels of a health system, creates a collaborative mechanism that can help both do their jobs better, and improve outcomes for fragile preterm infants.
Complications of prematurity are now the number one cause of newborn deaths globally, resulting in more than 1 million deaths per year; they are also the second cause of mortality in children under five years of age. Although the administration of dexamethasone before birth is a fundamentally beneficial intervention for improving newborn outcomes among women who give birth prematurely, until now it has been underutilized in most low- and middle-income countries.
Therefore, MCHIP, in partnership with Survive & Thrive, has created two new training modules under the Helping Babies Survive series: one focusing on a holistic perinatal approach to the management of preterm birth[1]; and a simpler “mini-module” focusing explicitly on ACS[2]. These training materials will use the same approach as Helping Babies Breathe to improve the capacity of providers to manage preterm births using a perinatal team approach—an approach characterized by communication and collaboration in care decisions among newborn and maternal health providers[3].
In addition, our maternal and newborn health teams have developed and disseminated technical briefers and job aids designed to increase the use of dexamethasone. Notable among these is an advocacy briefer—developed in collaboration with the World Health Organization (WHO), the Bill & Melinda Gates Foundation, Survive & Thrive, and “Born too Soon”—which addresses how and why dexamethasone administration should be scaled up in developing countries and highlights its value as an effective intervention to save newborn lives. A related technical briefer describes the proper clinical use of dexamethasone to improve outcomes for preterm newborns.
Further shedding light on how to increase the use of ACS at facilities, MCHIP is conducting an innovative implementation research study in three Asian countries—Cambodia, Indonesia and the Philippines—to provide evidence around the key elements and potential barriers to successfully expanding the use of dexamethasone.[4] The hope is that the promotion of a collaborative perinatal approach to care will eventually expand the use of this simple intervention by more peripheral frontline providers working in hard-to-reach, isolated communities, thus increasing access to this lifesaving practice.
Improving newborn health outcomes will succeed only when the health of mothers and newborns is considered before, during and after birth. MCHIP Senior Technical Advisor and obstetrician Dr. John Varallo perhaps said it best: “Babies don’t appear out of the blue. We have to be ready!”
[1] Under current development, to be launched sometime in 2015
[2] ACS Before Every Preterm Birth will be finalized in August 2014
[3] Other components of this perinatal team approach include standard treatment protocols that are understood, agreed upon, and followed; a perinatal audit system; and regular meetings of the perinatal team to review progress and share individual patient outcomes.
[4] Findings from this study will be disseminated in summer 2014.