Role of health system strengthening (HSS) in reducing neonatal mortality in Bangladesh: A document review

Policies and strategies for newborn health

The Government of Bangladesh recently implemented measures that place a high priority on improving neonatal health. Bangladesh adopted a National Neonatal Health Strategy in 2009, which marked a significant step forward in the country's newborn health. Since then, newborn health measures have been taken through a series of discussions with stakeholders, experts, and development partners, with the National Technical Working Committee for Newborn Health playing a key role. Bangladesh issued a “call to action” in July 2013, pledging to eliminate child deaths from preventable causes by 2035. This declaration aimed to improve existing neonatal therapies while also introducing new evidence-based, internationally acceptable newborn health interventions. Bangladesh has begun developing its national strategy, BENAP, as part of the global Every Newborn Action Plan (ENAP).⁶

Newborn health service delivery

Traditional healers, neighborhood clinics, and hospitals are among the health-care professionals available to Bangladeshis. Government agencies, non-governmental organizations (NGOs), and the private sector may all be involved in providing services.

Government sector

The Ministry of Health and Family Welfare (MOHFW) is solely responsible for providing health services and formulating national policies, guidelines, and action plans within the government. The Directorate General of Health Services (DGHS) is a division of the ministry that provides general preventive and curative health care as well as technical help to the ministry as it launches on new programs and interventions. Family planning and reproductive health services are provided by the Directorate of Family Planning (DGFP). In collaboration with, or under the administration of, the department of Maternity, Neonatal, Child, and Adolescent Health, both directorates provide maternal, newborn, and child health services at various levels of care (MNCAH).³

Private sector

In Bangladesh, the private healthcare industry is rapidly expanding. Particularly in metropolitan regions, the private sector offers a major percentage of healthcare services. The private sector is mainly unregulated, and it offers services through both official and non-formal, untrained providers, such as traditional birth attendants and healers.¹⁹

Health workforce

Critical shortages, an insufficient skill mix, and an unequal geographic distribution of the health personnel are key roadblocks to attaining the health-related Millennium Development Goals (MDGs) in the majority of developing nations. This is also the situation in Bangladesh, where a lack of health workers makes it difficult to offer a continuum of care for women and babies.⁷ Bangladesh has a significant lack of public-sector health personnel, as well as a skewed distribution. There are about 0.58 employees per 1000 people, which is significantly below the WHO's cut-off of 2.28 workers per 1000 people.²⁰ Bangladesh's health worker shortage is worse than in other South and Southeast Asian countries. Only 0.5 physicians and 0.2 nurses are available per 1000 people.²¹

Though there are standardized training for midwives, community level workers are also getting training on “Essential Newborn Care (ENC)” still there some barriers like shortage of health professionals in low density population, difficulty in retaining trained person in hard to reach areas, higher number of vacancies in remote areas, weak recruitment transfer and posting system, weak supervision system of health worker, in appropriate ratios of health professionals in the facilities. These problems can be overcome by taking some steps like proper advocacy on filling and recruitment of vacant positions, training for NGO and government health workers etc.³ These could only be possible when our health system would be stronger. So, strengthening health systems is important to ensure proper human resource for the service delivery of newborn.²²

Evidence-based newborn care initiatives

Essential newborn care

Both the mother's and the newborn's health are dependent on the initial few minutes following birth. More than three-quarters of infant fatalities occur within the first week, with up to half occurring within the first 24 hours.⁸ Essential Newborn Care (ENC) is a set of basic treatments provided by healthcare providers to increase the odds of a newborn's survival after birth. Birth attendants, family members, relatives, and volunteers trained in ENC techniques should give ENC interventions soon following delivery³ (Table 3).

Application of chlorohexidine in newborn care

The importance of clean umbilical cord care in the prevention of newborn infections has been demonstrated. Invasive bacteria can enter the body through freshly cut umbilical cord stumps, causing neonatal sepsis, a leading cause of death in the first week of life. Cord infection is frequently linked to cultural customs of putting various substances to the cord, as well as a lack of sanitary precautions.

Until 2013, the recommended intervention for preventing neonatal infections was dry cord care. Based on compelling new data from three studies performed in Bangladesh, Nepal, and Pakistan, the World Health Organization (WHO) has now changed its advice. These investigations, which took place between 2007 and 2013, found that cleaning the umbilical cord with chlorhexidine digluconate (CHX) decreased both newborn mortality and infection. In a pooled analysis of these three studies, CHX usage was linked to a 23% reduced risk of death when compared to dry cord care. Based on this new evidence, policymakers, national experts, and stakeholders in Bangladesh conducted a meeting to recommend that a 7.1 percent CHX solution be applied to the newborn umbilical cord stump as a single application at birth, followed by dry cord care for all newborns, whether they were born in a facility or at home.⁹

Though necessary steps have been taken to increase use the CHX like CHX application has been incorporated in national policy, DGDA has been issued license for the production of this drug, local pharmaceutical companies are producing it at a low cost but still there are some draw backs in this intervention like it is not available countrywide, insufficient resource for the implementation, HMIS does not keep relevant information about it etc. If the following actions are taken like ensuring availability of the drug with adequate dose and application guideline in market and facilities, initiation of CHX use at all level of service delivery, including it in “National Essential Medicine List (NEML)” then it can reduce mortality.³ By strengthening our health system, we can easily take these measures to ensure CHX for newborn care.²²

Role of post-natal care in reducing child death

Because the majority of newborn fatalities occur during the first few days and weeks, Bangladesh's National Neonatal Health Strategy (NNHS) Guidelines highlight the significance of urgent and early postnatal check-ups for both family and providers. Family members must recognize health risk indicators early in order to receive timely assistance from qualified professionals or at appropriate institutions. Four scheduled post-natal visits are important according to the NNHS guideline: Within 24 hours following birth, on the third day, between seven and fourteen days, and within 42 days. Among these four visits, the first three are very important for the survival of neonates. In Bangladesh, as in many other low-income nations, most mothers give birth at home. Many parents encounter financial, social, and other obstacles when it comes to taking their newborns to a healthcare institution, especially in the crucial first week after birth.¹⁰ In 2009, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) issued a joint statement urging home visits by health experts or trained community health workers during a baby's first week of life. In high-mortality settings, where many deliveries occur outside of health facilities, research suggests that home-based newborn care treatments can avert between 30 and 60 percent of newborn fatalities. WHO and UNICEF urge that all women and their babies be examined by medical experts shortly after birth, regardless of where the birth occurs, and that mothers and newborns have a regular schedule of follow-up appointments. If their baby shows particular danger symptoms, such as a high temperature and seizures, mothers should seek medical help at once.¹¹

Though postnatal care (PNC) services are improving, desired coverage has not been achieved. Only 32% newborn achieve PNC by skilled health professionals within 48 hours of birth.

Some factors are responsible for this poor coverage like high proportion of home deliveries creates obstacle to receive services, reluctance of family member regarding taking the child to facilities for health care, unpreparedness of facilities for providing PNC services, women's access to facility-based PNC and ENC is hampered by high out-of-pocket costs, health personnel have insufficient knowledge and counseling skills when it comes to basic infant care, insufficient necessary logistic supply and there is no indicator for assessing ANC PNC progress which is important for decision making. Increased resource allocation to ensure quality of service and increased awareness of good maternal and infant care practices, as well as readiness to seek appropriate care which are a part of strengthening health system could enhance the coverage PNC service.^3,22

Management of birth asphyxia

Only around 5% to 10% of infants require immediate assistance to start breathing after delivery,¹² and only a small percentage of them require more sophisticated treatments like heart massage, intubation, or medications. A neonatal evaluation, as well as drying and tactile stimulation for the infant, are the initial steps in treating asphyxia.¹³ All health personnel, particularly those who attend births, should be able to assist babies in starting to breathe, according to the NNHS. Since 2011, the National Scaling-Up of HBB (Helping Babies Breath) Programs has provided instructions and tools (a bag and mask, as well as a sucker) to almost all government and non-government medically trained delivery care workers, including Community-Based Skilled Birth Attendants (CSBAs).¹⁰

HBB has been adopted in government curriculum to train CSBAs during their service training and this training was initiated. HBB training is started and managed by the Ministry of Health and Family Welfare (MOHFW) where trainers are from national level and district level. But due to some reasons this initiative could not reduce desired number of mortality. Some of the drawbacks of this initiative are lack of adequate information necessary for scaling up this intervention, the SBAs (Skilled Birth Attendant) do not include enough information on skill retention and practice, lack of resources to conduct the program and HBB monitoring is not integrated in HMIS.³ A strong health system can address these gaps and take strategic actions to save more newborn life.²²

Use of Antenatal Corticosteroid (ACS) for the prevention of complication related to preterm

The single most effective strategy for improving neonatal outcomes among preterm newborns is antenatal corticosteroid (ACS).¹⁶ Near-universal coverage of ACS for suspected preterm delivery might result in up to 40% fewer baby deaths due to prematurity-related complications.¹⁴ The World Health Organization supports ACS as a first-line strategy in the treatment of preterm labor to avoid respiratory distress syndrome (RDS).¹⁸ According to a Lives Saved Tool (LiST) study, ACS may save over 400,000 lives each year.¹⁵ Although the highest effect is obtained 48 hours after the initial injection, even partial or incomplete regimens can offer some benefit. ACS should be initiated as soon as the detection of preterm birth because it is difficult to predict the time of delivery.¹⁷ Although the National Newborn Health Strategy 2009 highlighted preterm as a major cause of avoidable neonatal mortality, it did not include explicit recommendations on ACS usage. Several programs, notably ACS, promoted expanding of innovative neonatal treatments in 2013. The National Technical Working Committee on Newborn Health (NTWCNH) recommended that ACS (dexamethasone) be used in premature labor both in institutions and in the community to minimize problems from preterm deliveries, particularly respiratory distress syndrome. Giving priority to this intervention national guideline and protocol have been developed. Besides local pharmaceutical companies are also producing and marketing to increase the coverage.¹⁰

Unavailability of required amount of ACS, tendency of not following standard protocol in facilities, late arrival of women at the facility for delivery that decrease efficiency of ACS, lack of knowledge of health professionals regarding administration of this drug, unawareness of people about the danger signs of pregnancy are some of issues creating obstacles in this intervention. Finalization and distribution of national protocol and guideline on usage of ACS, production of ACS in a 6 mg dosage with proper indication that is listed on the National Essential Medicines List (NEML) for premature deliveries, proper training of professional on administration of ACS and proper logistic management are some of the outcomes of effective health system necessary to reduce neonatal mortality.^3,22

Kangaroo Mother Care

In Bangladesh, Kangaroo Mother Care (KMC) is a cost-efficient, practical, and successful technique to preserve preterm and low-birthweight babies. KMC refers to the mother's (or mother substitute's) early, extended, and continuous skin-to-skin contact with her infant, both in the hospital and after discharge. It involves assistance to mothers with baby positioning, feeding (preferably exclusively breastfeeding), and the prevention and treatment of infections and respiratory problems. KMC should be given to all clinically stable infants weighing fewer than 2,000 grams, according to the evidence. It is most beneficial if it is begun within the first week of life. Understanding the value of KMC it is increasingly recognized in policy statements with proper guideline. But still there are problems like scarcity of trained nurses as they are frequently transferred from KMC, lack of proper instruction for the implementation of KMC through health system. As a part of well-organized health system identification of key champion for KMC in Bangladesh and support the Ministry of Health and Family Welfare's national level planning for scale-up and integration of KMC into its sector planning MOHFW could be the ways to increase the acceptance as well as the coverage of KMC to reduce child death.³