2018 PROGRESS REPORT:REACHING
EVERY NEWBORNN ATIO NAL
2020 MILESTONESMARCH 2018

2018 PROGRESS REPORT:REACHING
EVERY NEWBORNN ATIO NAL
2020 MILESTONESM A R CH 2018

About the Every Newborn Action Plan
In 2014, at the Sixty-seventh World Health Assembly, 194 Member States of the World Health Organization (WHO)endorsed Every Newborn: an action plan to end preventable deaths (Resolution WHA67.10), a road map of strategic
actions to end preventable newborn mortality and stillbirths and contribute to reducing maternal mortality and morbidity.
The Every Newborn Action Plan presents evidence-based solutions and sets out a clear path to 2020 with eight specificmilestones for what needs to be done differently to reduce mortality rates and improve maternal and newborn health by2030. Member States requested that the WHO Director-General monitor progress and report periodically to the Health
Assembly up to 2030.
Achieving the targets set out in the Sustainable Development Goals and the UN Secretary-General’s Global Strategy for
Women’s Children’s and Adolescent Health (2016-2030) is underpinned by achieving the Every Newborn milestones
by 2020. For the Seventy-first World Health Assembly in 2018, progress on the Every Newborn resolution is included
under reporting on the Global Strategy.
To complement that report, the present document provides a detailed look at progress in country leadership and action
toward the Every Newborn milestones. It presents a compilation of data collected through use of the Every Newborn
Tracking Tool in 2017, adopted by 75 countries, it highlights examples of specific country activity for each national
milestone as well as relevant progress towards global milestones.

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Contents
1. Executive summary....................................................................................................4
2. Introduction ..............................................................................................................6
3. ENAP Strategic objectives and national milestones.....................................................7
4. Methodology .............................................................................................................8
5. Tracking country progress towards Every Newborn 2020 national milestones.............9
5.1 Every Newborn milestone: National plans........................................................10
5.2 Every Newborn milestone: Quality of care........................................................20
5.3 Every Newborn milestone: Investment in health workforce...............................42
5.4 Every Newborn milestone: Health workforce capacity and support..................43
5.5 Every Newborn milestone: Community engagement........................................48
5.6 Every Newborn milestone: Parents’ voices and champions..............................51
5.7 Every Newborn milestone: Data......................................................................54
5.8 Every Newborn milestone: Research and innovation........................................60
6. Regional and global support to countries to accelerate progress towards
Every Newborn 2020 milestones..................................................................................64
7. Emerging areas .......................................................................................................66
8. Discussion ..............................................................................................................68
Acknowledgements ....................................................................................................70
Annexes .....................................................................................................................71
Annex 1: Simplified progress tracking tool for 2018 reporting .......................................71
Annex 2: Tables on progress (75 countries, 2017-2018) of selected ENAP milestones .... 78
Annex 3: List of indicators for maternal and newborn health (under discussion) ............98
List of Acronyms .......................................................................................................100
References ...............................................................................................................1023

1. Executive summary
Improving newborn health and preventing
stillbirths are critical to achieving the Sustainable
Development Goals (SDGs). This year, 2018, marks
the fourth year since the launch of the Every Newborn
Action Plan: an action plan to end preventable deaths(ENAP) at the Sixty-seventh World Health Assembly.
Commitments made by national governments,
the scaling-up of evidence-based interventions,coordinated international efforts and increased
attention to improving newborn health in countries areleading the world towards significant progress. The
progressive uptake of the Every Newborn Tracking Tool
has reached 75 countries: 22 in Asia, 45 in Africa andeight in the Middle East. This is a substantial increase
from 51 countries in 2016.
Newborn survival is firmly embedded within the
SDG targets, and the UN Secretary-General’sEvery Woman Every Child (EWEC) monitoring
framework includes both neonatal mortality andstillbirths. Visibility of the issue of newborn survival
has been increased by the recent launch of the Qualityof Care network, by the United Nations Inter-Agency
Group for Mortality Estimation (IGME) 2017 report onChild Mortality that focused on newborn survival andby the launch of the “Every Child Alive” campaign,
spearheaded by UNICEF.
Compared to previous years, more countries
requested assistance in developing operational
plans for improving newborn survival and reducing
stillbirths. There were also increased numbers ofrequests for technical assistance to build capacity andscale up newborn-specific interventions such as early
essential newborn care, Kangaroo mother care (KMC),
management of newborn infections, relevant healthmanagement information systems (HMIS) indicators,
and implementation of the revised guidelines on
Managing possible serious bacterial infection (PSBI) in
young infants when referral is not feasible.*Given the increasing demand from countries
for guidance on improving the availability andquality of inpatient care for newborns, there wascoordinated action to develop concepts and tools
for a multi-country situation assessment of carefor small and sick newborns. Efforts to strengthen
implementation in humanitarian settings also led to areview of data on the use of a WHO tool for hospitalassessment of maternal and newborn care in countries
and the development of the revised guidance manualon “Newborn Care in Humanitarian settings”.
4There was also an increased focus on building
capacity and sharing experiences on KMC andon Maternal and perinatal death surveillance andresponse (MPDSR). Regional efforts were sustained inSouth and East Asia, the Middle East and North Africa,
and West and Central Africa while new multi-country
events were organized for the Eastern and Southern
Africa region as well as the European and Central Asia
regions. Findings from the use of the Every Newborn
Tracking Tool show incremental, steady progress
between 2016 and 2017 (see Table 1).
As more countries develop their costed newborn
action plans, challenges are becoming apparent
in settings that are fragile or have ongoing
humanitarian crises. These include challenges
in implementing maternal and newborn healthprogrammes and in securing adequate, sustainablefinancing through both domestic and development
partner resources. The Global Financing Facility (GFF)
helps to mobilize additional funds and better target
existing resources to health services. Expansion of
the GFF to ten additional countries could be a good
opportunity to link national newborn action plans withthe country investment cases. Consistent indicatordefinitions and better data to measure and monitor
progress and ensure quality of care (QoC) are crosscutting needs for all newborn health programmes.
ENAP progress tracking has revealed some key
lessons. Countries that conducted the bottleneck
analysis in 2013 were early adopters, and theexercise helped to build consensus amongst key
partners in the initial years of implementation.
Knowledge management through the Healthy Newborn
Network, opportunities for south to south learning, andregional workshops have proved useful in building capacity
in countries. UNICEF’s support at headquarters, regionaland country levels for compilation of information fromcountry progress tracking has stimulated organizational
ownership and accountability. Technical assistancerequests from countries have allowed global partners toalign their support to actual country needs. Availabilityof some catalytic funding proved useful in responding
swiftly to country requests. Routine progress tracking
on an annual basis has meant that areas with the least
progress, for example, target setting for stillbirth rates,
newborn indicators in health management information
systems (HMIS) and the inclusion of newborn healthin emergency preparedness plans could be identified
promptly, and this information can be used to advocate
for change in countries.

* http://apps.who.int/iris/bitstream/handle/10665/181426/9789241509268_eng.pdf?sequence=1

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Table 1: ENAP milestones achieved between 2016 and 2017
ENAP milestones achieved

2016

2017

Total number of countries reporting on ENAP progress tracking tool51

75

Countries that have developed a national Every Newborn action plan24

44

Countries with “newborn component” included in emergency preparedness plans

718Countries with a defined Neonatal Mortality Rate (NMR) target

43

56

Countries with a defined Stillbirth Rate target

10

17Countries that have a costed Every Newborn plan21

40Country quality improvement programmes that have a specific focus on maternal andnewborn health (MNH)

26

40Countries that have adopted policies on maternal death notification

34

61

Countries implementing maternal death surveillance and response

44

67Countries with perinatal death review systems in place

23

38

Countries with policies on home based postnatal care

32

44Countries with insurance schemes to cover maternal and newborn care, including sicknewborn care

32

54Countries that have included indicators for all four newborn-specific interventions in
national HMIS

2

3Countries with all essential commodities in national essential medicines list (NEML)

26

41

Countries with all essential commodities in logistic management information systems(LMIS)

12

22

Countries with MNH-related communication plans or community engagement strategies

27

37

Notes: NEML and LMIS exclude chlorhexidine as it is not a policy in all countries due to WHO recommendations, as well as ambu
bags and masks, which may be listed under equipment/supplies rather than drugs in some countries.
Source: Every Newborn Tracking Tool

Going forward, a greater focus will be required
to remove financial barriers to institutionalchildbirths and management of obstetric andnewborn complications, including improving
the availability of and access to quality
inpatient care. More emphasis is also needed toinclude a strong newborn component in emergency
preparedness and response plans. Country targetsetting, particularly for stillbirth rates, needs to besupported further. Scaling up neonatal resuscitation,
infection management and care of preterm and low
birth weight infants, including KMC, as well as further
research to explore effective models for reducing
preterm mortality are required.

The response to findings of maternal and perinatal
death reviews needs to be strengthened and linked
to facility and district level quality improvement
plans with broad health system support. Continued
global- and national-level advocacy and community
engagement strategies, including greater parental
involvement, are critical for achieving an enabling
environment for ENAP implementation. Disparities
in access to high-quality inpatient care for small andsick neonates is a particular concern. The increasing
contribution of the private sector to sick newborn care
globally poses both challenges and major opportunities
for ensuring that populations have access to affordable,
equitable and high-quality newborn care services infuture. The tracking tool needs to be simplified, since
many ENAP milestones have already been achievedin countries and there is need to capture coverage
indicators to monitor progress.
52. Introduction
The Every Newborn Action Plan, a comprehensive
multi-partner initiative launched in 2014 to prevent
newborn mortality and stillbirth, estimated that the
lives of 3 million women, newborns and stillborn
babies could be saved each year by improving carearound the time of birth and providing special care forsmall and sick newborns.[1]The ENAP targets, aligned with the SDG target 3.2
and the Every Woman Every Child (EWEC) monitoring
framework are:• 12 or fewer neonatal deaths per 1000 live births inevery country by 2030.
• 12 or fewer stillbirths per 1000 total births in every
country by 2030.
To achieve these targets, a global Average Rate ofReduction (ARR) of 4.2% is needed, and 56 countries
will currently need to double their ARR.[2] This will
require a renewed and focused emphasis on research,
programmes, policies and financing.[3]Figure 1: Mortality rates and numbers of deaths, 1990-2016
15

93

12.6

80
60
40

41

37

20
0

10

1990 1995 2000 2005 2010 2016

11.3
9.9
8.3

5

19
0

5.1

4.5

7.0
5.6

4.0

3.5

3.1

2.6

1990 1995 2000 2005 2010 2016

Under-five mortality rate

Under-five deaths

Newborn mortality rate

Newborn deaths

Source: United Nations Inter-agency Group for Child Mortality Estimation, 2017

6

Deaths (millions)

Mortality rate (deaths per 1000 live births)

100

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

3. ENAP Strategic objectives andnational milestones
Countries and development partners have developed
and adopted the Every Newborn Tracking Tool to 1)
measure progress towards the strategic objectives
and 2) track the processes of country ownershipand action for key facets of newborn health, as set
out in the Every Newborn 2020 national milestones(Table 2).
The Strategic objectives for ending preventablematernal and neonatal mortality and stillbirths [4] are:

2. Strengthen health systems to optimize theorganization and delivery of care through theworkforce, commodities and innovation.
3. Reach every woman and newborn by minimizing
inequities in access to and coverage of care.
4. Harness the power of parents, families andcommunities, and engage with society.
5. Improve data for decision-making and accountability.

1. Strengthen and invest in care around the time ofbirth, with a focus on improving the quality andexperience of care, while ensuring full integrationof services for women and babies across thecontinuum of care.

Table 2: Every Newborn 2020 National Milestones
National plans

Review and sharpen national strategies, policies and guidelines
for reproductive, maternal, newborn, child and adolescent health(RMNCAH) in line with the goals, targets and indicators in the ENAP,
including a clear focus on care around the time of birth and on smalland sick newborns.

Quality of care

Adopt standards of quality and indicators for assessing quality ofmaternal and newborn care at all levels of the health system and ensure
access to essential commodities for RMNCAH.

Investment in healthworkforce

Develop or integrate costed human resources for health strategy into
RMNCAH plans and ensure sufficient financial resources are budgeted
and allocated.

Health workforce capacity
and support

Ensure the training, deployment and support of health workers, inparticular midwifery personnel, nurses and community health workers.

Community engagement

Involve communities, civil society and other stakeholders to increasedemand and ensure access to and coverage of essential maternal andnewborn care.

Parents’ voices andchampions

Parents’ voices and champions shift social norms so that it is no longer
acceptable for newborns to die needlessly, just as it has become
unacceptable for women to die when giving birth.

Data

Count every newborn by using and improving programmatic coveragedata including equity and quality gap assessments. Institutionalize civil
registration and vital statistics, adapt and use a minimum perinatal
dataset, implement maternal and perinatal death surveillance andresponse.

Research and innovation

Develop, adapt and promote access to devices and commodities
to improve care for mothers and newborns around the time of birth,and agree on, disseminate and invest in a prioritized and coordinatedresearch agenda for improving preterm and newborn health outcomes.
Particular focus is required on stillbirths, which have often been left out
or left behind.
7

4. Methodology
The Every Newborn Tracking Tool, in use since
October 2014, was initially applied in 20 countries
having high rates of neonatal mortality and gradually
expanded to others. Data collection is supported
by in-country partners who populate the tool with
inputs from the focal point in the ministry of health(MoH) when possible. The information is compiled
through existing coordination mechanisms, such as aTechnical Working Group (TWG) or a national steeringcommittee for maternal and newborn health.
Findings are communicated to and discussed withpartners. Once the Tracking Tool has been completed,and the validity and consistency of data have beenchecked by UNICEF and WHO country offices, it issubmitted by UNICEF country and regional offices forcompilation at the global level. The complete tool canbe found in Annex 1.

8Case studies highlighted in this report were collectedfrom annual reports provided by UNICEF country
offices and partner organizations (USAID, Save theChildren, WHO, London School of Hygiene andTropical Medicine [LSHTM], Maternal and Child
Survival Program [MCSP]). A literature review was
conducted to identify promising interventions forscale-up as well as newborn care innovations overthe past year. Data sources used for this report
include national RMNCAH strategies, plans andpolicies, national guidelines and standards, periodic
programme reports, country reviews, and existing
project survey data. Information on progress was
also obtained from programme managers at the MoH
and partners working in country.

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5. Tracking country progress towards
Every Newborn 2020 national
milestones
This section presents an overview of the adoption of
the Every Newborn Tracking Tool and the compilationof data for each of the eight milestones. It spotlights
specific country activity, as well as regional and global
efforts that support national progress.
There has been a steady increase in the number ofcountries reporting use of the Every Newborn Tracking
Tool, from ten countries in 2014 to 18 in 2015, to 51
in 2016 and 75 in 2017 (see Figure 2). In 2016, theincrease was attributed to the uptake in the UNICEF
regions of West Africa and the Middle East and North
Africa. In 2017, twenty-four countries were added,
mostly from the UNICEF regions of Eastern andSouthern Africa, Europe and Central Asia and East
Asia and the Pacific. This increase has been catalysedby regional meetings in those areas.

The 75 countries that report having completed
use of the Every Newborn Tracking Tool in 2017
are Afghanistan, Angola, Armenia, Azerbaijan,
Bangladesh, Benin, Bhutan, Botswana, Burkina
Faso, Burundi, Cameroon, Chad, China, Comoros,
Côte d’Ivoire, Democratic Republic of the Congo,
Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Georgia,
Ghana, Guinea, Guinea-Bissau, India, Indonesia, Iran,Iraq, Jordan, Kazakhstan, Kenya, Kyrgyzstan, Lao
People’s Democratic Republic, Lebanon, Lesotho,
Liberia, Libya, Madagascar, Malawi, Maldives, Mali,
Mauritania, Morocco, Mozambique, Myanmar,
Namibia, Nepal, Niger, Nigeria, Pakistan, Palestine,
Philippines, Rwanda, Senegal, Sierra Leone, Somalia,
South Sudan, Sri Lanka, Sudan, Swaziland, Syria,
Tajikistan, Timor-Leste, Togo, Tunisia, Turkmenistan,
Uganda, United Republic of Tanzania, Uzbekistan, Viet
Nam, Yemen, Zambia and Zimbabwe.

Figure 2: Progressive adoption of the Every Newborn Tracking Tool in countries

2014
2015
2016
2017
No data available

95.1. Every Newborn milestone:
National plans
5.1.1. Status of developing national newborn action plans
Of the 75 countries, 44 reported having developed a national newborn action plan. Seven countries,
including several that are affected by humanitarian crises and conflict situations (Sierra Leone, South
Sudan, Syria and Yemen) reported that work was under way. However, 22 countries, 19 of which are in
Africa, still do not have a national newborn plan.

Table 3. Countries reporting having developed national newborn action plans, 2017
Indicator

National
newborn
action plandeveloped

2017 (n=75)*
Yes (n=44)

Afghanistan, Armenia, Azerbaijan,
Bangladesh, Bhutan, Burkina Faso,
Cameroon, Comoros, Egypt, Ethiopia,
Georgia, Ghana, Guinea- Bissau, India,
Indonesia, Iran, Iraq, Jordan, Kazakhstan,
Kenya, Kyrgyzstan, Lao PDR, Lebanon,
Madagascar, Malawi, Maldives, Morocco,
Myanmar, Namibia, Nepal, Niger, Nigeria,
Pakistan, Palestine, Papua New Guinea,
Philippines, Rwanda, Sri Lanka, Sudan,
Tajikistan, United Republic of Tanzania,
Uzbekistan, Viet Nam, Zambia

In process (n=7)

Botswana, Chad,
Democratic
Republic of theCongo, Sierra
Leone, South
Sudan, Syria,
Yemen

No (n=22)

Angola, Benin, Burundi,
China, Cote d’Ivoire,
Eritrea, Gambia, Guinea,
Lesotho, Liberia,
Libya, Mali, Mauritania,
Mozambique, Senegal,
Somalia, Swaziland,Togo, Tunisia,
Turkmenistan, Uganda,
Zimbabwe* Of the 75 countries having used the Every Newborn Tracking Tool, only 73 provided information on thestatus of newborn action plans

10

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Case study: Ghana conducts a comprehensive review of its
national newborn health strategy and action plan. he India
Ghana has made consistent progress in improving maternal and newborn health indicators since thelaunch of its National Newborn Health Strategy and Action Plan (NNHSAP) in July 2014.
Deliveries by skilled birth attendants increased from 51% in 2013 to 56% in 2015.
The proportion of first postnatal visits within 48 hours increased from 60% to 79% in the same time
period, and there was a slight reduction in the institutional neonatal mortality rate (NMR), from 6 to 5
per 1000 live births. However, recent estimates indicate that the population NMR is 29 per 1000 live
births, with most newborn deaths occurring outside facilities.
The 2018 NMR target is 21 per 1000 live births, in order to be on track to achieve the 2030 targetof 12 per 1000 live births.
The Ghana Health services and partners conducted a comprehensive review of the NNHSAP in July
2016 to assess progress in implementation.
The review uncovered many gaps in the implementation of newborn care interventions. These
included a lack of roll-out of standardized perinatal death audit guidelines, a lack of KMC scale-up,
the absence of key newborn health indicators in the District Health Information System-2 (DHIS2),
fragmentation of partner support and problems in the training on information management systems.
Strategic recommendations to address these gaps were discussed and finalized during stakeholder
consultations, and progress is visible: KMC has been rolled out to all regional hospitals and perinatal
death audits have started to be conducted.

11

Case study: Defining ‘N’ in
RMNCAH he India
In 2017, a user guide and costing toolkit entitled“Defining ‘N’ in RMNCAH” was designed tosupport countries in applying the latest available
planning and costing tools when developing
their national newborn action plans. This toolkit
synthesises implementation experience andknowledge gained from forerunner countries
that have been successful in strengthening
newborn health in their national plans, policies,
programmes and systems. The user guide aims
to further accelerate progress so that mothers
and newborns everywhere receive high quality
care when they need it. The toolkit is available
at:https://www.healthynewbornnetwork.org/
hnn-content/uploads/ENAP-toolkit_layout-004_
pages.pdf

5.1.2. Status of ENAP integration into national health strategies
In 2017, 47 of the 75 countries using the Every Newborn Tracking Tool reported that newborn health
had been strengthened in national RMNCAH plans. This included the high-population and high burdencountries with the exception of Indonesia. Twelve countries reported that work was under way tostrengthen the newborn component. Nine countries (Gambia, Iran, Kyrgyzstan, Malawi, Somalia,
Swaziland, Togo and Tunisia) reported that no work has been done yet to strengthen newborn healthin RMNCAH plans.

5.1.3. Progress in preparing national plans in countries with thehighest burden and rates of newborn mortality
Countries where urgent action is required can be identified by looking at currently available data on
stillbirths and neonatal deaths. It is encouraging that two very heavily populated countries, India andNigeria, have targets for both stillbirths and neonatal deaths included in their national ENAP. However,given the high numbers of stillbirths and neonatal deaths and the sub-national disparities in thesecountries, scaled up actions that focus particularly on the poorest and most marginalized will be
critical.
South Asia has the highest absolute number of newborn deaths, while West and Central Africa has
the largest number countries with high NMR. Conflict and humanitarian emergencies are posing thegreatest challenge to newborn survival in Iraq, Libya, Syria, and Yemen. There are many countries,
particularly in sub-Saharan Africa, that figure among the most fragile states. In these countries, crises
including conflict and natural disasters, coupled with political instability and poor governance often
hamper health systems and the ability of policymakers to formulate and implement policies that improve
the quality of maternal and newborn care.

12

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Table 4. Numbers and rates of stillbirths and neonatal deaths in high burdencountries, and progress in adding national targets in the Every Newborn Action Plan
Neonatal Deaths
Country

Number ofneonataldeaths(2015)

Neonatalmortality
rate target
included in
the ENAP

Neonatalmortality
rate (per1000 live
births)Stillbirths
Number ofstillbirths(2015)

Stillbirthrate target
included in
the ENAP

Stillbirthrates (per1000 totalbirths)Afghanistan

46 00040

20 10026.7

Bangladesh

74 40023

83 10025.4

CentralAfricanRepublic

7000

42.3

5 800

34.4

Chad

22 00035.1

25 200

39.9

China

93 4006

122 300

7.2

Côte d’Ivoire

32 00036.6

22 80026.7

Democratic
Republic of
the Congo

94 30030

87 80027.3

Ethiopia

87 40028

96 50029.7

GuineaBissau

3 000

38.2

2500

36.7

India

695 900

28

592 100

23

Indonesia

73 90014

73 400

13.2

Lesotho

2000

38.5

1 200

19.5

Mali

27 00035.7

24 40032.5

Nigeria

240 10034

313 700

42.9

Pakistan

244 70046

242 600

43.1

Somalia

24 00038.8

16 40035.5

South Sudan

17 00037.9

13 40030.1

Source: Neonatal estimates: United Nations Inter-Agency Group for Child Mortality Estimation, 2017. Stillbirth estimates: Lawn et al. Lancet 2016

As shown in Table 4, many high burden and low-resource countries still need to define their stillbirth rate
targets. National data is essential to track the burden of stillbirths, existing coverage of interventions
to prevent stillbirths and the quality of those interventions. It is crucial to focus on intrapartum or fresh
stillbirth rates, as the majority of stillbirths can be prevented with improved care at the time of birth.
[5]
Therefore, there needs to be greater investment in collecting usable data that drives national level
action to close gaps in coverage, quality and equity.

13

Case study: Launching ENAP in Iraqhe India
Newborn deaths make up an estimated 56% of the under-5 mortality rate in Iraq, and the NMR has
reduced more slowly than infant mortality rates. According to MICS 4 estimates, the NMR in Iraq
is 20 per 1000 live births, however, broad disparities exist across different governorates ranging
from 32 per 1000 live births in Kirkuk to and 13 per 1000 live births in Missan.
In response, UNICEF Iraq supported a desk review, a rapid survey of health facilities to assess
Quality of Care and a bottleneck analysis workshop in 2016. These were followed by a series ofnational consultations to develop and finalize the Iraq Every Newborn Action plan (IENAP) in 2017.
The IENAP is expected to serve as the roadmap that redefines and focuses on national and subnational strategies and activities until 2020, when Iraq will review the progress achieved and revise
its plan accordingly. It is a vital step towards ensuring accessibility and availability of high-quality
MNH services in Iraq and will move the country towards achieving the global ENAP targets by
2035.

5.1.4. Status of setting targets for reducing newborn mortality andstillbirths
As shown in Table 5, 56 countries reported having defined a target for reducing newborn mortality intheir national newborn or RMNCAH plan in 2017; this is up from 43 in 2016. Sixteen countries reported
that they did not have such an explicit target. Progress for setting a stillbirth reduction target wasmuch slower: only 17 countries reported having a defined stillbirth target in their national newborn
or RMNCAH plans in 2017 compared to ten countries in 2016. Of note, in 2017, 54 countries andterritories that reported not having a specific target included countries with the highest numbers ofstillbirths such as China, Democratic Republic of the Congo, Niger and Pakistan.

14

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Table 5. Setting targets for reducing newborn mortality and stillbirths
Indicator

Countries

Defined anewbornmortality
reduction
targetAfghanistan, Angola, Armenia, Azerbaijan, Bangladesh, Bhutan, Burkina Faso, Burundi,
Cameroon, China, Comoros, Côte d’Ivoire, Democratic Republic of the Congo, Egypt, Ethiopia,
Georgia, Ghana, Guinea, Guinea Bissau, India, Indonesia, Iraq, Kazakhstan, Kenya, Lao
People’s Democratic Republic, Lesotho, Liberia, Libya, Madagascar, Malawi, Mali, Mauritania,
morocco, Myanmar, Namibia, Nepal, Niger, Nigeria, Pakistan, Palestine, Papua New Guinea,
Philippines, Rwanda, Sri Lanka, Sudan, Syria, Tajikistan, Timor -Leste, Turkmenistan, Uganda,
United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe (56)
Botswana (1)Benin, Chad, Djibouti, Gambia, Iran, Jordan, Kyrgyzstan, Mozambique, Senegal, Sierra Leone,
Somalia, South Sudan, Swaziland, Togo, Tunisia (17)Defined astillbirth
reduction
targetAzerbaijan, Bangladesh, Bhutan, Ethiopia, Georgia, India, Indonesia, Iraq, Kenya, Madagascar,
Malawi, Namibia, Nepal, Nigeria, Sri Lanka, United Republic of Tanzania, Yemen (17)Cameroon (1)Afghanistan, Angola, Armenia, Benin, Burkina Faso, Burundi, Chad, China, Comoros, Côte
d’Ivoire, Democratic Republic of the Congo, Djibouti, Egypt, Eritrea, Gambia, Ghana, Guinea,
Guinea-Bissau, Iran, Jordan, Kyrgyzstan, Lebanon, Lesotho, Liberia, Libya, Madagascar, Mali,
Mauritania, Morocco, Mozambique, Myanmar, Niger, Pakistan, Palestine, Papua New Guinea,
Philippines, Rwanda, Senegal, Sierra Leone, Somalia, South Sudan, Sudan, Swaziland, TimorLeste, Togo, Tunisia, Turkmenistan, Uganda, Uzbekistan, Viet Nam, Zambia, Zimbabwe (52)Yes

In process

No5.1.5. Status of developing newborn plans at the sub-national level
Implementation of national newborn plans requires conforming to the centralized or decentralized governanceand budgeting processes. Many countries are opting for regional or district-specific plans to increase efficiency
and enhance accountability. Amongst the 75 countries that reported on the Every Newborn Tracking Tool, 23(Afghanistan, Cameroon, China, Democratic Republic of the Congo, Egypt, Ethiopia, Ghana, India, Indonesia,
Iran, Iraq, Kazakhstan, Kenya, Morocco, Namibia, Niger, Pakistan, Palestine, Rwanda, Sudan, Syria, United
Republic of Tanzania and Zimbabwe) said that they had developed a sub-national plan for newborn health.
Three countries (Bangladesh, Comoros and Sri Lanka) reported that work to develop a sub-national newborn
health plan was under way.
Figure 3 depicts the trend of country progress on planning and costing from 2014 to 2017 among countries that
submitted data. Once national newborn action plans are completed, countries use available tools to completea costing exercise for scaling up newborn care. Forty countries reported that their plan had been costed; thisis almost double compared to 2016 (21 countries). Afghanistan was the only country in 2017 that reported thatwork on costing was under way.

Figure 3. Country progress on planning and costing (n=75)

40

0

2
National newborn
action plandeveloped

29
18

12

12

20

40

31

24

30

10

47

43

50

8

0

2014

Total countries with both
NB and Strengthened
RMNCAH plans

2015

21

1

0

Newborn component
strengthened in
RMNCAH plan

13

2016

8

16

23

0
Newborn
Action Plan
costed2017

Sub-national
Newborn Action
Plan developed

15

Case study: Government of Bangladesh starts
implementation of a national newborn health programmehe
The Government of Bangladesh endorsed the first National Strategy for Neonatal Health in 2009,
which emphasized the importance of rapidly accelerating and expanding life-saving, cost-effective
newborn health interventions. Up to 2012, the focus of newborn care was primarily throughcommunity-based initiatives in rural areas. The government has now successfully scaled up two of
the priority newborn health interventions throughout the country: Helping Babies Breathe (20112014) and application of 7.1% chlorhexidine solution to the newborn umbilical cord (2015-16).
With support from the USAID-funded MaMoni Health Systems Strengthening Project, the Ministryof Health and Family Welfare (MOHFW) trained over 30 000 skilled birth attendants on Helping
Babies Breathe and more than 85 000 health providers, supervisors and managers on essential
newborn care, including the use of chlorhexidine.
Political commitment for ending preventable newborn deaths was reinvigorated through “A Promise
Renewed: Child Survival Call to Action” in 2013. There was a growing need to develop effectivemodels of service delivery through the MOHFW infrastructure, with an emphasis on generating
local evidence to overcome operational challenges. In 2014, a comprehensive newborn carepackage (CNCP) was developed where essential newborn interventions – both tested and new –were defined, agreed and implemented. The CNCP was adopted for implementation at scale in
the National Newborn Health program (NNHP), and costing was completed for scaling up. Under
the leadership of the Government of Bangladesh, pro-active partners successfully advocated formobilizing resources for the costed NNHP. Finally, the 4th Health, Population Nutrition Sector
Programme 2017-2022 incorporated a costed NNHP with an allocation of US$ 50 million, which
includes support from major development partners. For the first time in Bangladesh, dedicated
Newborn Care Programme Managers have been deployed in the Directorate General of HealthServices and the Directorate General of Family Planning to lead and manage implementation. The
NNHP is a huge leap towards achieving the targets envisioned in the Bangladesh Every Newborn
Action Plan.

16

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.1.6. Status of inclusion of specific activities for ENAP milestones
and scaling-up of newborn-specific interventions in RMNCAH
In 2017, 34 countries, up from 16 in 2016, reported that they had specific activities for all ENAP milestones
added to RMNCAH plans, including the scale-up of newborn-specific interventions. Seventeen countries (Benin,
Côte d’Ivoire, Democratic Republic of the Congo, Gambia, Georgia, Guinea-Bissau, Lesotho, Mali, Mauritania,
Nigeria, Senegal, Sierra Leone, Somalia, Tajikistan, Togo, Tunisia and Uzbekistan) did not have activities alignedwith the ENAP milestones.

5.1.7. Status of positioning a focal person for newborn care at thenational level
There has also been a steady increase in the number of countries reporting the presence of a focal person
for newborn care. Forty-two countries reported having a newborn health focal person in 2017, compared to
28 countries in 2016. Having a dedicated focal person for newborn health ensures that research, advocacy,programme and policy efforts to support newborn health are prioritized.

5.1.8. Status of inclusion of newborn care within national plans for
emergency preparedness
Humanitarian emergencies are challenging for all people living in affected areas, but are particularly difficult for
pregnant woman and newborns. These emergencies may be rapid onset, slow onset or caused by a combinationof complex and interrelated circumstances. They encompass situations of epidemic outbreaks, acute or chronic
situations of conflict, war or civil disturbance, natural disasters, food insecurity and other crises. Health systems
are at risk of collapsing during these times, along with governance mechanisms and other local and national
infrastructure, resulting in the need for international assistance and aid by humanitarian organizations. Recent
examples include the conflicts in the Democratic Republic of the Congo and South Sudan, the 2010 earthquake
in Haiti, the 2010 floods in Pakistan, the 2015 Nepal earthquake and the Rohingya crisis, all of which resulted
in massive population displacement, distress and casualties. Mothers and newborns are particularly vulnerable
during these situations and their health requires special attention. Historically, care during labour and childbirthand care for neonates is often missing in emergency response assessments, supply kits, intervention packages
and monitoring efforts. Rebuilding health facilities and systems, providing emergency care and training healthworkers form critical components of any humanitarian response, and maternal and newborn health services
should be an important priority.
Eighteen countries (Armenia, Bangladesh, Burundi, Democratic Republic of the Congo, Iraq, Lesotho, Liberia,
Madagascar, Myanmar, Nepal, Niger, Nigeria, Pakistan, Sri Lanka, Sudan, United Republic of Tanzania, Yemen
and Zimbabwe) have to date reported including newborn care within their emergency plan. This is a significant
increase since the previous year where seven countries reported having done so. China was the only country in2017 that reported that work was under way to develop an emergency plan.

17

Case study: Newborn health in a humanitarian setting: thecase of South Sudanhe
Despite the steady reduction in NMR in South Sudan, from 67 per 1000 live births in 1990 to 39
per 1000 live births in 2015, the rate remains high. This may be attributed to low rates of skilled
birth attendance, inadequate access to emergency neonatal care interventions, early pregnancies,
high malnutrition rates among pregnant women, and other sociocultural issues. In addition, longstanding, continuous conflict has had a detrimental impact on maternal and newborn health.
Health systems analyses show that newborn health in South Sudan has not received adequate
political, policy and programme attention. Newborn health was mentioned in the country’s Health
Sector Development Plan 2012 – 2016 (HSDP), but there were no national targets to reduce neonatal
mortality. The Reproductive Health Strategic Plan (2013 – 2016) did not address newborn health.
The Emergency Obstetric and Neonatal Care (EmONC) assessment report conducted by the MoH in2013 also revealed high intrapartum and very early neonatal mortality rates for all facilities (28.2 per1000 deliveries), with huge disparities across states.
Piloting of the Newborn Health in Humanitarian Settings: Field Guide in South Sudan in 2015-2016
and the dissemination of findings sparked government interest in developing a national newborn
health plan. A stakeholder workshop in September 2017 served to identify key bottlenecks to
newborn health interventions and potential strategies to overcome them. These were compiled to
inform the Every Newborn Action Plan for the country. The coverage of nine tracer interventions wereclassified as good, needs some improvement, needs major improvement, and inadequate (see Table
6).

Community
participationand ownership

Healthinformation
systemHealth service
delivery

Medicalproducts

Healthwork force

Healthfinancing

Health system building blocks

Leadershipandgovernance

Table 6. Overall findings from bottleneck analysis of maternal andnewborn health interventions in South Sudan

Preterm birth
Skilled birth attendance
Basic emergency obstetric careComprehensive emergency obstetric care
Basic newborn care
Kangaroo mother care
Severe infection
Inpatient care

Good

Some Improvements

Major Improvements

Inadequate

Reflecting the country’s commitment to newborn health, South Sudan’s health policy 2016 – 2025
holds the MoH to the following objective: ensure reduction of maternal and neonatal mortality andmorbidity through effective delivery of maternal, sexual and reproductive health services and rights
with particular attention to vulnerable populations. In addition, the inclusion of newborn health in
the revised RMNCAH Strategic Plan offers an important opportunity to increase the availability andaccessibility of quality life-saving services at the facility and community level. Reaching the SDGs
by 2030 will require considerable investment in South Sudan’s health system, and the addition of
newborn health into national level policies is a significant first step.
18

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.1.9. Status of policies supporting free maternal and newborn care
The global drive for Universal health coverage (UHC) provides a unique opportunity to advocate for free maternal
and newborn health care services that include referral and care for mothers and newborns experiencing
complications. Care of sick neonates often require significant out-of-pocket expenditures in many low- andmiddle-income countries (LMICs) where such services may be limited. This can be a major deterrent for poorfamilies. Fifty-four countries reported having policies on free maternal and newborn care including care of sicknewborns in 2017, up from 34 countries in 2016. Seventeen countries reported not having such insurance
schemes or policies in place, while Burkina Faso, Eritrea and Nigeria reported that work was under way.

Table 7. Policies for free maternal and newborn care
Indicator

Yes (n=54)

In process (n=3)

No (n=17)

National healthinsurance scheme/
free policy in place
covering maternal
and newborn careincluding sicknewborn care

Afghanistan, Angola, Armenia, Azerbaijan,
Bangladesh, Bhutan, Botswana, Burundi,
China, Côte d’Ivoire, Egypt, Ethiopia,
Gambia, Georgia, Ghana, Guinea-Bissau,
India, Indonesia, Iran, Iraq, Kazakhstan,
Kenya, Kyrgyzstan, Lao People’s
Democratic Republic, Liberia, Libya, Malawi,
Maldives, Mali, Mauritania, Morocco,
Myanmar, Nepal, Niger, Pakistan, Palestine,
Philippines, Rwanda, Senegal, Sierra Leone,
Somalia, South Sudan, Sri Lanka, Sudan,
Syria, Tajikistan, Timor-Leste, Turkmenistan,
Uganda, United Republic of Tanzania,
Uzbekistan, Viet Nam, Zambia, Zimbabwe

Burkina Faso,
Eritrea, Nigeria

Benin, Cameroon,
Chad, Comoros,
Democratic
Republic of theCongo, Djibouti,
Guinea, Jordan,
Lebanon, Lesotho,
Madagascar,
Mozambique,
Namibia, Papua New
Guinea, Swaziland,Togo, Yemen

19

5.2. Every Newborn milestone:
Quality of care
Quality of care is defined as “the extent to which health care services provided toindividuals and patient populations improve desired health outcomes.” In order toachieve this, health care needs to be safe, effective, timely, efficient, equitable andpeople-centred. [6]countries preparing plans that focus on including quality
improvement (QI) initiatives, updating policies requiredfor QoC improvements, authorizing health workers
at appropriate levels of care to administer life-saving
interventions and commodities, adopting policies formaternal death notification and developing policies on
postnatal care for the neonates (see Figure 4).

Quality of care is a key component of the “Right toHealth”, and the route to equity and dignity for every
women and child. Since 2014, countries have madesteady progress in establishing appropriate policies andplans to improve the quality of maternal and newborncare at all levels of the health system and ensure accessto essential commodities for RMNCAH. Between 2014
and 2017, there was a large increase in the number of

Figure 4. Country progress on national policies (n=75)
68
70

53

60

30
10
0

11

14

6

0

0

National Quality
Improvement
initiative included inpolicies

National QI
Programme has
specific focus on
MNH

Health workers
authorized toadminister life-saving
MNH interventions

2015

32
13

11

0

2014

20

34

26

40
20

44

43

40

40

50

61

2016

0

0

Policy adapted formaternal death
notification

Policy exists on
home-based
postnatal care2017

In 2017, 53 countries reported having national QI
initiatives included in their health sector policies, andtwo high-burden countries (Nigeria and Pakistan)reported that work was ongoing. Thirteen of the
17 countries that reported not having QI initiatives
included in their national policies were in sub-SaharanAfrica.

Sixty-eight countries reported that health workers at
appropriate levels of care are authorized to administerlife-saving interventions and commodities for MNH.
Six countries (Angola, Iraq, Jordan, Kazakhstan, Libya
and Papua New Guinea) reported that health workers
are not authorized to administer life-saving MNHinterventions, at their appropriate level.

Forty of the 53 countries reported that their QI
programmes had a specific focus on MNH. However,
22 countries, the majority of which were in subSaharan Africa, reported that QI activities did not havethis specific focus.

Legislation or policies on the notification of maternal
deaths within 24 hours was reported to have been
adopted by 61 countries, compared to 34 in 2016.
There remain 13 countries that still do not have a policy
on maternal death notification in 2017 (Table 8).

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Table 8. Countries that have adopted a policy for maternal death notification2017 (n=75 countries)
Indicator

Policyadopted formaternal
death
notification

Yes (n=61)

Afghanistan, Angola, Armenia, Azerbaijan, Bangladesh,
Benin, Bhutan, Botswana, Burkina Faso, Burundi,
Cameroon, China, Comoros, Cote d’Ivoire, Democratic
Republic of the Congo, Djibouti, , Egypt, Eritrea, Ethiopia,
Georgia, Ghana, Guinea- Bissau, India, Indonesia,
Iran, Iraq, Jordan, Kazakhstan, Kenya, Kyrgyzstan, Lao
People’s Democratic Republic, Lebanon, Lesotho, Libya,
Madagascar, Malawi, Maldives, Morocco, Mozambique,
Myanmar, Namibia, Nepal, Niger, Nigeria, Palestine,
Rwanda, Senegal, Sierra Leone, Sri Lanka, Sudan,
Swaziland, Tajikistan, Timor-Leste, Tunisia, Turkmenistan,
Uganda, United Republic of Tanzania, Uzbekistan, Viet
Nam, Yemen, Zimbabwe

In process(n=0)

No (n=13)

Chad, Gambia,
Guinea, Liberia,Mali, Mauritania,
Pakistan, Papua
New Guinea,
Philippines,
Somalia, South
Sudan, Syria,
Togo

Case study: An initiative for improving quality of hospital
services in Dominican Republic: The “Mothers and Babies
in Good Care” projecte
Despite high coverage of antenatal care and institutional deliveries, high maternal and neonatal mortality
rates point to poor QoC in health facilities in Dominican Republic. The Ministry of Public Health and
UNICEF used the Monitoring Results for Equity System (MoRES) methodology to identify and measure
the bottlenecks in hospital care for pregnant women and babies. Key bottlenecks were largely specificto context, service provision, demand and QoC. Based on the MoRES results, a joint action plan wasdeveloped for the initiative “Mothers and Babies in Good Care”.
The initiative was designed to reduce maternal and neonatal mortality through the continuous
improvement of quality and humanization of care for mothers and newborns. The major componentsof this initiative are (1) quality antenatal care, (2) mother-friendly care to reduce obstetric violence, (3)clean and high-quality delivery (4) immediate and early breastfeeding, (5) reduction of infections during
immediate newborn care and (6) in-house birth registry.
Implementation guidelines have been developed and tools for quality control, monitoring results andevaluation have been designed and aligned with national protocols and norms, including antenatal care,delivery, pre-and post-delivery care, newborn care, breastfeeding and birth registration. Monitoringdata from 2017 shows good progress in implementing standards of care, ranging from 70% in postdelivery care to 95% in antenatal care.
Having well-defined quality standards for each component helped to establish the baseline and wasessential for monitoring and evaluation efforts. Even if challenges are known, improvements requirea diagnosis and an improvement plan that has ownership from hospital staff and commitment
from managers at the hospital. Supportive supervision and ongoing monitoring are important toencourage and maintain the commitment of hospital staff. The leadership from the MoH is central
to ensure that any adopted policy is appropriate and integrated within the national systems for
quality control of hospitals.

21

5.2.1. Policy on home based postnatal care
Providing basic care to newborns in the home has been identified as a critical intervention in preventing newborn
deaths. In 2017, 44 countries reported having a policy on postnatal care home visits, up from 32 countries in2016. However, 26 countries reported not having such a policy.
ENAP [7] articulates a 2020 target of a 20% increase in postnatal care coverage within two days of birth, forboth the mother and the newborn, but progress is slower than expected in many countries. There is some
improvement but the median coverage for postnatal care visits for babies (36%) lags behind postnatal care formothers (62%).[8] Available data show that compared with other elements of the continuum of care, such asantenatal care or skilled care at birth, the coverage and quality of postnatal care for mothers and newborns
tend to be relatively poor[9],[10] due to a variety of health system, socioeconomic and user related factors. For
example, a substantial proportion of women leave the health facility too soon after delivery to allow adequate
postnatal care during the first 24 hours.[11] Evidence also indicates that in LMICs the use of postnatal services
remains highly inequitable and varies with socioeconomic status and between urban and rural residents.[3]Greater rates of facility deliveries in many countries provide a unique opportunity to provide pre-discharge
postnatal counselling and care. This has been noted in multiple districts of Bangladesh, Ghana and the United
Republic of Tanzania.

Case study: Postnatal home visits for active case detection
for management of possible serious bacterial infection he
Serious bacterial infection remains one of the major causes of newborn deaths in low income settings.
Addressing neonatal infection requires strategies that result in timely case detection and prompt
initiation of definitive treatment. A diagnosis of neonatal infection in low-resource settings is usuallybased on the presence of clinical signs, using the Integrated Management of Childhood Illness (IMCI)
guidelines. The revised 2017 WHO/UNICEF guidelines for Managing PSBI are available at: http://apps.
who.int/iris/bitstream/handle/10665/181426/9789241509268_eng.pdf?sequence=1
Recently, a cluster randomized trial in Ethiopia[12] evaluated thesenewborn sepsis treatment guidelines at the most peripheral
health facility level. In both arms of the study, volunteers andgovernment-employed Health Extension Workers (HEWs)
conducted home visits to pregnant and newly delivered
mothers. They assessed newborns and counselled caregivers
on preventing newborn illness, recognizing danger signs andseeking care. Volunteers referred sick newborns to healthposts for further assessment while HEWs referred newborns
with PSBI signs to health centres. In the intervention arm only,
HEWs treated newborns assessed identified as having PSBI
with intramuscular gentamicin and oral amoxicillin for 7 days at
health posts when referral to health centres was not possibleor acceptable to caregivers. Intervention communities were
informed of treatment availability at health posts to encourage
careseeking.
The results from this trial showed that despite considerable
support, it was difficult to achieve and sustain adequate home
visitation coverage and manage the volume of careseeking for possible newborn infections. Home
visitation by community health workers may seem like a simple, low-tech approach to improving
maternal and newborn outcomes, but doing it successfully takes considerable programme effort.
Therefore, health sector planners and policy makers need to make a realistic determination of thecircumstances in their settings, the availability of newborn care services, access to health centres,
likelihood of attaining high coverage of postnatal home visits and whether or not active case detection
strategies are feasible in their context.

22

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.2.2. Country progress on quality improvement
It is encouraging to note the increased number of countries that report having national QI guidelines andimplementation plans for maternal and newborn health (Figure 5). Similarly, there has also been a steady increasein the number of countries reporting to have maternal death surveillance and response (MDSR) mechanisms
implemented. The weakest areas for QI appear to be the availability of appropriate plans to implement QI
guidelines and the establishment of perinatal death review systems. These two areas will need greater emphasis
in 2017-2018.

Figure 5. Country progress on quality improvement (n=75)
67
70
60

27

40
30
20
10
0

44

42

50

0

8

National QI
guidelines for MNH
are available

24
0

17

8

11

4

Plan available toimplement the MNH
QI guidelines

2014

38

33

2015

13

1
MDSR
mechanismin place

2016

Perinatal Death
Review system in
place

2017

In 2017, 42 countries reported having national QI guidelines available for maternal and newborn health; this isa significant increase from the 27 countries that reported in 2016. However, amongst these countries only 33
reported having an implementation plan. The launch of the Quality of Care network co-led by WHO, UNICEF
and UNFPA has provided a platform for cross-country learning and has developed a standardized monitoringand evaluation framework for countries.

23

Case study: Within-24-hour paediatric hospitalization
practice in Kyrgyzstanhe
An assessment of the quality of hospital paediatric and neonatal care in Kyrgyzstan in 2012
revealed important gaps, for example in admission to hospitals without referral from primary healthcare facilities, lack of adequate care for sick neonates and children in the admissions department,
and unjustified hospitalizations. Furthermore, accuracy of the diagnosis of the admitted child
was found to be problematic and often the prescribed treatment was not in compliance withrecommended clinical protocols.
A technical working group established under the leadership of the MoH was tasked to decrease
the under-5 mortality rate by improving the quality of paediatric in-patient care and reducing
excess mortality attributed to practitioner errors. A situation analysis revealed that improving quality
would be possible by minimizing cases of late hospital admissions, reducing medically unjustified
hospitalizations, improving timeliness of service provision, shortening the average length of stay,
ensuring compliance with clinical protocols and improving mother/caregiver satisfaction.
In a participatory process, a pilot project was implemented in five hospitals through the establishment of“one-day care units”. In addition, to ensure quality of services, hospitals put in place continuous quality
improvement systems and practices. UNICEF provided technical support, supported staff training andparticipated in joint monitoring and evaluation. Since the project was deemed to be effective, it wasscaled up after one year with one-day care units established in 74 hospitals in all regions of the country.
An evaluation conducted in 2017 found that the project had managed to fully staff the hospitals byinternal rationalization of personnel without increasing the number of posts. It ensured improved accessto medicines and laboratory services and increased admissions with referrals from primary health carefacilities. Institutionalization of within-24-hour hospitalization practices resulted in a reduction of excess
mortality due to practitioner errors. The project also minimized unjustified hospitalizations. Timelinessof treatment initiation and QoC improved with increased compliance to treatment guidelines. Increased
satisfaction of caregivers with services received resulted in a drastic decrease of early discharges on
caregiver’s request. This initiative produced many important lessons: project success depended on
the political will, ownership and commitment of the MoH, actions needed to be integrated into existing
systems, and large-scale involvement of all hospital personnel including administrative, para-clinicaland clinical staff was essential. Implementation required the establishment of QI teams at hospitals,
targeted training of health workers and ongoing mentoring and supportive supervision.

24

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.2.3. Status of including essential medical products andtechnologies in the national essential medicines list
The addition of recommended essential medicines and commodities for high-impact interventions to the National
Essential Medicines List (NEML) has been an area with the greatest progress since the start of ENAP tracking.
In 2016, 26 countries reported having included all seven essential medical products and technologies in their
NEML, and this number increased to 41 in 2017. Figure 6 shows the summary of progress for the reporting
countries since 2014.
• Oxytocin, magnesium sulphate and injectable antibiotics have been incorporated in the NEML by all reporting
countries.
• Misoprostol was reported to be a part of the NEML in 65 countries. Eight countries that did not have Misoprostol
in the NEML were Comoros, Egypt, Georgia, Indonesia, Mauritania, Palestine, Philippines and Sri Lanka.
• Sixty-six countries reported that antenatal corticosteroids were included in their NEML. Seven countries(Cameroon, Georgia, Maldives, Mauritania, Myanmar, Papua New Guinea and South Sudan) reported not having
antenatal corticosteroids in their NEML.
• Sixty countries reported that newborn resuscitation devices were included in the NEML. In 2017, 13 countries(Burkina Faso, Cameroon, Ethiopia, Georgia, Lao People’s Democratic Republic, Madagascar, Maldives,
Mozambique, Myanmar, Nepal, Philippines and Sri Lanka) reported not having such devices in their NEML.
• 7.1% chlorhexidine digluconate was reported to be a part of the NEML in 55 countries in 2017.

Figure 6. Country progress on inclusion of essential medical products andtechnologies in NEML (n=75)

49

32

1
Newborn
resuscitation devices(Ambu bag and mask)
included in the NEML

1

6Chlorhexidine
included in the
NEML

73

49
38

18

17

13

12

2

2

2

1

Antenatal
corticosteroids
included in the
NEML

Injectableantibiotics includedin the NEML

Magnesium
sulphate includedin the NEML

Misoprostol
included in the
NEML

2014

74

65

48

39

12

25

0

55

38

50

73

66

60

75

2015

2016

2017

18
2
Oxytocinincluded in the
NEML

25

Case study: Chlorhexidine for cord carehe
A baby’s recently cut umbilical cord is a potential entry point for bacteria that can cause life-threatening
newborn sepsis. Optimal cord care at birth and in the first week of life, especially in settings with poor
hygiene, is important. People in many cultures also traditionally tend to apply various substances to a
freshly cut cord stump such as ash, oil, butter, spice pastes, or mud which may be harmful. In January
2014, WHO issued a new recommendation for umbilical cord care for newborns who are born at home insettings with high neonatal mortality (30 or more neonatal deaths per 1000 live births): the daily applicationof chlorhexidine (7.1% chlorhexidine digluconate aqueous solution or gel, delivering 4% chlorhexidine) to theumbilical cord stump during the first week of life. Clean, dry cord care is recommended for newborns bornin health facilities and at home in settings with neonatal mortality lower than 30 per 1000 live births. Overthe past decade, chlorhexidine has moved rapidly from research studies to a part of programme efforts.
Figure 7 shows the Chlorhexidine scale-up effort at initiation in 2011 and status in 2017. Further details areavailable at https://www.path.org/publications/files/DT_CHX_story_rpt.pdf.

Figure 7. Rapid expansion of chlorhexidine use, 2011 to 20172011

Implemenatation/scale-up
Pilot introduction and/or policy alignment
Expressed interest
Local chlorhexidine manufacturer whereCWG provided technical assistance

2017

Haiti

The chlorhexidine working group (CWG) has been crucial to accelerate the introduction and global scale-upof chlorhexidine for umbilical cord care.[13] A recent paper examined the effectiveness of the CWG and offersa very interesting case study on the effectiveness of such multiagency collaborative efforts in improving
newborn health. The case study is available at: https://doi.org/10.9745/GHSP-D-17-00380
26

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.2.4. Status of essential maternal and newborn commodities in
Logistics Management Information Systems
Including commodities in Logistics Management Information Systems (LMIS) is important to avoid stock-outs
and ensure timely and quality supplies to appropriate levels of care. Figure 8 shows that in 2017, 52 countries
reported having injectable antibiotics in their LMIS, and 51 reported having oxytocin and magnesium sulphate.
Misoprostol was regularly tracked in the LMIS system of 41 countries and antenatal corticosteroids in 42.
Chlorhexidine was reported as tracked by the LMIS in 36 countries and newborn resuscitation devices in 39
countries.

Figure 8. Country progress on inclusion of essential maternal and newborn
commodities in LMIS (n=75)
51

60

34

40

0

7

0

0

Oxytocinincluded in the
LMIS

Misoprostol
included in the
LMIS

42

34

32

27

8

20

52

51
41

8

8

4

0

0

0

Magnesium
sulphate includedin the LMIS

Injectableantibiotics includedin the LMIS

Antenatal
corticosteroids
included in the
LMIS

2014

2015

2016

39

36
26

25

17
0

2

Chlorhexidine
included in the
LMIS

8
0
Newborn
resuscitation devices(Ambu bag and mask)
included in the LMIS

2017

5.2.5. Standards for improving quality of maternal and newborncare in health facilities
In order to achieve UHC, it is essential to deliver health services that meet specific quality criteria. The WHO
QoC framework recognises that quality is a normative concept, therefore, standards for care are needed forassessment and improvement purposes.[14] In 2016, WHO published standards for improving the quality ofmaternal and newborn care in health-care facilities.[15] These standards place people at the centre of the careby improving both the provision of, and patients’ experience of health care, and they are a critical part ofstrengthening health systems.

27

Case study: National leadership for quality of care he
The Network for Improving Quality of Care for Maternal, Newborn and Child Health supported
by WHO, UNICEF, UNFPA and partners is bringing together countries and development partners
around the vision: “Every mother and newborn receives quality care throughout the pregnancy,
childbirth and postnatal periods”. This vision is underpinned by the core values of quality, equity
and dignity. Under the leadership of the ministries of health, the Quality of Care Network plans
to support implementation of national plans for quality improvement and pursue four strategic
objectives:
1. Build and strengthen national institutions and processes for improving QoC in the health sector.
2. Accelerate and sustain implementation of QoC improvement packages for mothers, newborns
and children.
3. Facilitate learning, knowledge sharing and generation of evidence on quality planning,
improvement and control.
4. Develop, strengthen and sustain institutions and methods for accountability for quality of care.
Ten months after the Network’s launch, representatives from the first member countries(Bangladesh, Côte d’Ivoire, Ethiopia, Ghana, India, Malawi, Nigeria, Uganda and United Republicof Tanzania) were joined by Kenya and Sierra Leone at a workshop in December 2017. Countries
shared their progress on introducing a national QoC strategy in selected districts and facilities,
establishing/strengthening quality of care management and response systems, and setting up
systems to support the improvement of quality of care from sustaining clinical skills, to optimizing
the use of resources, to motivating staff and equipping health workers to deliver respectful care.

Case study: Operationalizing the nine standards of quality
improvement for the “Every Mother, Every Newborn”
strategy in health facilities in the United Republic of
Tanzania
The United Republic of Tanzania, with support from UNICEF, is implementing an Every Mother
Every Newborn initiative that focuses on quality improvement to reduce preventable maternal
deaths, neonatal deaths and stillbirths. Project activities during the first year focused on
improving handwashing, ensuring the completeness and quality of documentation of clinicalrecords and improving the management of maternal and newborn complications. Externalmonitoring has shown significant improvements in adoption of standardized maternal andnewborn care protocols in the intervention facilities. All health facilities now have functional QI
teams. Availability of handwashing facilities and handwashing practices among health workers
have increased from around 50% to 100%. Improved infection prevention and control andhandwashing by health workers have reduced hospital-acquired infections amongst neonates.
In intervention facilities, completion of clinical records has improved from 14% to 90%. The useof partographs to monitor progress of labour has increased from 40% to 80%. Health workers’
perceptions and attitudes have improved, as shown by better interpersonal communication andefforts to ensure privacy and empathetic care to clients. Client satisfaction through self-reports
has improved, and the proportion of maternal and perinatal deaths reviews that are completed
has increased. Case fatality rates have improved for maternal complications. Further work is
ongoing to operationalize sick newborn care units and KMC services.
28

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Case study: WASH in in health care facilities -an importantcomponent of Quality of Care in Zambia he
In Zambia, the Millennium Development Goal initiative, funded by the European Union, aimed to
improve maternal and child health in Copperbelt and Lusaka provinces, primarily through its Infection
Prevention and Control (IPC)-centred water, sanitation and hygiene components. Project activities
focussed on reactivating infection prevention committees, on-site chlorine production and utilization,
waste management, promotion of handwashing with soap and decontamination practices of surfaces
and “hand-touch” sites. The project was piloted by UNICEF in 2015 in four selected public urban
health facilities. The endline surveys showed improved hand hygiene practices among healthcare staff,
an increased number of health services meeting “good hygiene” criteria and improved water quality
with low levels of microbiological contamination. This pilot phase provided the necessary evidence forscaling up the WASH-IPC package to a total of 55 health facilities. The establishment of an inter-sectoraltechnical working group for coordinating activities between government agencies and implementing
partners was important in generating ownership of the project. The project has shown that throughdedicated advocacy, it is possible to rally the government at the central and decentralized levels to
support IPC-WASH interventions.

5.2.6. Country progress on newborn-specific interventions
Essential newborn care for all infants is now mainstreamed in many national newborn programmes in LMICs,
and the priority is shifting towards increasing effective coverage and quality. The Every Newborn Milestones
concerning national plans and quality of care both call for specific action for small and sick newborns.
The Every Newborn Tracking Tool maps the ability of countries to determine whether four high-impact
interventions (neonatal resuscitation, treatment of serious neonatal infection, kangaroo mother care andantenatal corticosteroids) are monitored by the HMIS. It is important to note that these indicators require
further refinement. The ENAP metrics group is assessing the validity of capturing the coverage of facility-based
interventions and how these indicators can best be integrated within routine information systems.
Figure 9 shows the steady progress for all four indicators since 2014.

Figure 9. Country progress on newborn specific interventions (n=75 countries)
21
20

15

15

0

12

10

9

8

10
5

19

8

5
0
Eligible newborns
treated for neonatal
sepsis0

20

Eligible newborns that
benefited from KMC

2014

5

2015

0

Eligible newborns
receiving resuscitation

2016

1

Eligible mothers given
antenatal corticosteroids
for foetal lung maturation2017• Only three countries (Georgia, Guinea and India) reported having the four newborn-specific indicators
included in the national HMIS.
• Bangladesh reported that work was under way to include all four indicators in their national HMIS.
• Armenia, Ethiopia, Iran, Pakistan and Palestine reported having data on three newborn-specific interventions.
Armenia, Iran, Pakistan and Palestine did not have data on KMC, while Ethiopia did not have data capturing
the use of antenatal corticosteroids.

29

5.2.7. Use of antenatal corticosteroids
Despite the fact that 66 countries reported that antenatal corticosteroids were included in their national essential
medicines list, only eight reported having a relevant indicator in the national HMIS (Table 9). This is nonethelessan increase from previous years. In 2015 only one country reported tracking antenatal corticosteroid use, andin 2016 the number had increased to five.

Table 9. National HMIS includes an indicator for the use of antenatal corticosteroids
2017 (n=75 countries)
Yes (n=8)

In process (n=9)

No (n=57)

Armenia, Georgia, Guinea,
India, Iran, Jordan, Pakistan,
Palestine

Bangladesh, Ethiopia, Ghana,Iraq, Kazakhstan, Nigeria, Sri
Lanka, Tajikistan, Togo

Afghanistan, Angola, Azerbaijan, Benin,
Bhutan, Botswana, Burkina Faso, Burundi,
Cameroon, Chad, China, Comoros, Côte
d’Ivoire, Democratic Republic of the Congo,
Djibouti, Egypt, Eritrea, Gambia, GuineaBissau, Indonesia, Kenya, Kyrgyzstan, Lao
People’s Democratic Republic, Lebanon,
Lesotho, Liberia, Libya, Madagascar,
Malawi, Maldives, Mali, Mauritania, Morocco,
Myanmar, Namibia, Nepal, Niger, Papua
New Guinea, Philippines, Rwanda, Senegal,
Sierra Leone, Somalia, South Sudan, Sudan,
Swaziland, Syria, Timor-Leste, Tunisia,
Turkmenistan, Uganda, United Republic of
Tanzania, Uzbekistan, Viet Nam, Yemen,Zambia, Zimbabwe

5.2.8. Neonatal resuscitation
In 2017, 19 countries reported having integrated an indicator on newborn resuscitation into their HMIS (Table
10). This is an improvement from 11 countries in 2016 and includes high-burden countries such as India andPakistan. Bangladesh and Nigeria are among the 12 countries that reported ongoing work to include theneonatal resuscitation indicator in their national HMIS, and 43 countries reported not having this indicator.

Table 10. National HMIS includes an indicator for the performance of resuscitation2017 (n=75 countries)30

Yes (n=19)

In process (n=12)

No (n=43)

Afghanistan, Armenia,
Bhutan, Democratic Republicof the Congo, Ethiopia,
Georgia, Guinea, India,
Iran, Kyrgyzstan, Malawi,
Mozambique, Pakistan,
Palestine, Rwanda, Senegal,
Uzbekistan, United Republicof Tanzania, Zambia

Bangladesh, Eritrea, Ghana,Iraq, Kazakhstan, Nigeria,
Papua New Guinea, Sri
Lanka, Sudan, Tajikistan,Togo, Uganda

Angola, Azerbaijan, Benin, Botswana,
Burkina Faso, Burundi, Cameroon, Chad,
China, Comoros, Côte d’Ivoire, Djibouti,
Egypt, Gambia, Guinea-Bissau, Indonesia,
Jordan, Kenya, Lao People’s Democratic
Republic, Lebanon, Lesotho, Liberia, Libya,
Madagascar, Mali, Mauritania, Morocco,
Myanmar, Namibia, Nepal, Niger, Philippines,
Sierra Leone, Somalia, South Sudan,
Swaziland, Syria, Timor-Leste, Tunisia,
Turkmenistan, Viet Nam, Yemen, Zimbabwe

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.2.9. Kangaroo mother care
Kangaroo mother care is an approach to the care of preterm and/or low birth weight infants, which engages
and empowers mothers and families as the main providers of the biological (warmth and food) and psychoemotional (contact, caring, bonding and comfort) needs of their newborn. The cornerstone of KMC is the
kangaroo position whereby the infant is placed and held upright in direct skin-to-skin contact on the mother’schest. KMC should be initiated early and performed more than 18 hours per day, but the initiation, continuity andduration may vary according to the stability of the infant and the context of care. Other key components of KMC
are support for exclusive and early breastfeeding and timely discharge from the hospital with appropriate followup. In 2017, only 12 countries (Table 11) reported that an indicator on KMC was included in the national HMIS
compared to 11 in 2016. Amongst high-burden countries, work to include the KMC indicator was reported
only in Bangladesh. In 2017, 51 countries including some with large number of neonatal deaths (Angola, China,
Indonesia and Pakistan) reported that an indicator for KMC did not exist as a part of their national HMIS.

Table 11. National HMIS includes an indicator for Kangaroo Mother Care2017 (n=75 countries)
Yes (n=12)

In process (n=11)

No (n=51)

Democratic Republicof the Congo, Ethiopia,
Georgia, Ghana, Guinea,
India, Malawi, Mali, Nigeria,
Rwanda, Senegal, United
Republic of Tanzania

Armenia, Bangladesh, Eritrea,
Iran, Kazakhstan, Liberia,
Papua New Guinea, Sri
Lanka, Sudan, Tajikistan,
Togo

Afghanistan, Angola, Azerbaijan, Benin,
Bhutan, Botswana, Burkina Faso, Burundi,
Cameroon, Chad, China, Comoros, Coted’Ivoire, Djibouti, Egypt, Gambia, GuineaBissau, Indonesia, Iraq, Jordan, Kenya,
Kyrgyzstan, Lao People’s Democratic
Republic, Lebanon, Lesotho, Libya,
Madagascar, Mauritania, Morocco,
Mozambique, Myanmar, Namibia, Nepal,
Niger, Pakistan, Palestine, Philippines, Sierra
Leone, Somalia, South Sudan, Swaziland,
Syria, Timor-Leste, Tunisia, Turkmenistan,
Uganda, Uzbekistan, Viet Nam, Yemen,Zambia, Zimbabwe

31

Case study: Introduction of KMC and reduction in newborn
deaths in Kenya he
In Kenya, approximately 188 000 babies are born too soon every year. There is limited capacity
to optimally manage preterm babies, due to health worker shortages, limited skills and lack ofinfrastructure including appropriate equipment, commodities and space. Where equipment isavailable, it is often inadequate and poorly maintained, or it cannot be used because the electricity
source is not reliable.
With funding from the Government of the United Kingdom, UNICEF supported the Kenya MoH toroll out KMC in selected high-burden counties, including Kakamega county. In early 2016, UNICEF
supported the training of 40 midwives in Kakamega in a 3-day skill-based workshop. The training
covered theoretical components of KMC (establishing KMC at health facilities, nutrition, physicaland emotional support, monitoring and evaluation, and essentials for scale up) and was followedby practical sessions in the newborn unit of a referral hospital. UNICEF and the Department of
Health subsequently supported the trained midwives in rolling out KMC at their respective healthfacilities, including through the provision of KMC beds, digital weighing scales, guidelines, andsupportive supervision.
KMC is now being practised in 20 health facilities in Kakamega county and shows promising
results. Three hundred preterm babies have benefitted from the intervention to date, with anaverage reduction in neonatal mortality of 52% across the 20 facilities and a high point of 67% at
one. Some of the benefits of KMC have gone beyond the newborn period, for example a monthly
mother’s support group meeting was formed in one health facility, where mothers discuss issues
affecting their children’s health including family planning, breastfeeding, and immunization.
Key lessons learnt from the implementation of KMC in Kenya include:
1. KMC introduction is facilitated by the presence of supportive health authorities at the county
level and in all facilities.
2. KMC introduction can be done without significant resources nor additional staff at healthfacilities.
3. Continued supportive supervision and mentorship from UNICEF field staff was critical to ensure
motivation and continued capacity building of health workers.

32

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Case study: KMC implementation expands heWar, population displacement and violence have dominated the news from the Middle East andNorth Africa. The ongoing humanitarian crises, destruction of existing hospitals and exodus oftrained health workers have meant that some countries in this region have reversed the positive
gains made in child survival over recent decades.
An estimated 454 000 neonates die annually in Middle Eastern and North African countries, withprematurity as the single most important cause. In September 2017, the first ever regional workshop
on KMC was organized in Beirut, Lebanon for country teams from Iran, Iraq, Sudan, Syria, plus
the Gambia. The workshop was part of regional efforts by H6 partners (UNAIDS, UNFPA, UNICEF,
WHO, UN Women and the World Bank) to reduce preventable newborn deaths.
The workshop included competency-based training where health workers learnt clinical skills on
managing preterm and low-birth-weight babies and ensuring that standards are met for quality ofcare. Country teams developed action plans for collecting facility-level baseline data, mobilizing
local support and resources, translating training materials to local languages and initiating KMC in
their respective hospitals. Participants also formed a social network group to exchange experiences
and foster collaboration. All workshop participants have begun implementing intermittent KMC
and used World Prematurity Day to raise awareness about the practice. Countries have requested
that training materials be translated into Arabic to facilitate wider use.

33

Case study: Integrating newborn indicators into national
HMIS: Experience with KMC in Malawi
Malawi has systematically scaled up KMC since
the intervention became national policy for careof preterm and low birth-weight (LBW) babies
in 2005. However, the absence of a national
system of standardized indicators, registers andreports resulted in limited, poor-quality routine
data for monitoring the availability and uptake of
KMC. A pilot register and reporting form had
been developed in 2011, but these were difficult
to fill in, included unnecessary data and were notwidely available or endorsed nationally.
Starting in 2014, the Malawi Reproductive
Health Directorate and Central Monitoring and
Evaluation Department with support from Save
the Children, began a process of developinga national routine reporting system for KMC,
including a simplified, user-friendly registerand reporting form. The process followed fourphases. In the first phase, five core indicators
were prioritized and the initial list of 32 data
elements was reduced to eight. In the second
phase, the KMC register and reporting form
were revised, with several improvements:
data standardization using pre-coded data
elements, page summaries to tally the subset of data elements required for reporting,
improved tracking to distinguish follow-up
from new cases, clarification of reporting for
facilities with or without inpatient services, anddetailed instructions on how to fill the registers
and reports. In the third phase, the system
was pilot-tested over a two-month period in
21 facilities across the country. In the fourthphase, the registers and reporting forms were
finalized based on feedback from the pilot test.
The full package was approved for national
scale-up in mid-2015.
The final version of Malawi’s national reporting
system for KMC captures eight data elements (sixfrom facilities with inpatient KMC and two fromfacilities without inpatient KMC) and five core
indicators (Box 1), which were incorporated into
Malawi’s DHIS-2 in 2015. By October 2015, all
KMC focal points in each district had been trained,
and facility-level orientations completed. Analysis
of DHIS2 data showed improved reporting, with
87% of hospitals submitting KMC reports in 2016
compared to 51% in 2014. Data completenessand timeliness remain a challenge. In 2016, anestimated 15 316 babies were initiated on KMC,
representing about 21% of expected cases
nationwide (calculated as 10% of expected live

34

births) and 44% of reported preterm or LBW
babies. The number of cases initiated on KMC
and the estimated coverage varied widely by
district.
The process revealed several importantlessons. First, leadership of the MoH and early
involvement of end-users (facility and HMIS
staff) are critical to gain approval and uptake.
Second, it is essential to prioritize indicators anddata elements suitable for routine reporting tominimize reporting burden. Finally, substantial
and sustained investment is needed to produce
useable, quality data.
Priorities for further
strengthening of the national routine monitoringdata for newborn health in Malawi include
institutionalizing regular data quality audits,
developing dashboards at national and districtlevel to facilitate data use, and harmonizing
routine data on maternal and newborn health.
Currently, facility-based providers are required tocomplete multiple registers capturing information
related to maternal and newborn health (labourand delivery, postnatal care, Helping Babies
Breathe, sick neonate register), in several caseswith overlapping data elements. The MoH andpartners need to work together to minimize theburden of data collection and reporting and tostrengthen data quality and use.

Box 1. Core KMC indicators in
Malawi HMIS
1. KMC initiation rate: # of babies initiated on
KMC (inpatient and/or ambulatory) per i) 100 live
births at health facility and ii) 100 LBW/prematurebabies identified at health facility
2. KMC referral completion: Proportion ofbabies who were initiated on KMC and referred
who completed referral and initiated on facilitybased KMC
3. Survival to discharge: Proportion ofbabies initiated on facility-based KMC who aredischarged alive
4. Death before discharge: Proportion ofbabies initiated on facility-based KMC who died
before discharge
5. Left against medical advice: Proportion ofbabies initiated on facility-based KMC who left
against medical advice or absconded

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.2.10. Treatment and management of severe neonatal infections
In 2017, 21 countries out of 75 countries reported having an indicator to capture the management of neonatal
sepsis in their national HMIS; this is an increase of six countries since 2016. Amongst countries with a large
burden of neonatal deaths, Angola, China and Indonesia were among the 43 countries that reported not having
indicators to track the management of neonatal sepsis. Nine countries, including Bangladesh and Nigeria
reported that relevant work was under way.

Table 12. National HMIS includes an indicator for the treatment and management ofsevere neonatal infections
2017 (n=75 countries)
Yes (n=21)

In process (n=9)

No (n=43)

Afghanistan, Armenia,
Burkina Faso, Democratic
Republic of the Congo,
Djibouti, , Ethiopia, Gambia,
Georgia, Guinea, India, Iran,
Namibia, Nepal, Pakistan,
Palestine, Senegal, Sudan,
Tajikistan, United Republic of
Tanzania, Uzbekistan, Zambia

Bangladesh, Eritrea, Ghana,Iraq, Kazakhstan, Liberia,
Nigeria, Sri Lanka, Togo

Angola, Azerbaijan, Benin, Bhutan,
Botswana, Burundi, Cameroon, Chad,
China, Comoros, Côte d’Ivoire, Egypt,
Guinea-Bissau, Indonesia, Jordan, Kenya,
Kyrgyzstan, Lao People’s Democratic
Republic, Lebanon, Lesotho, Libya,
Madagascar, Malawi, Mali, Mauritania,
Morocco, Mozambique, Myanmar, Niger,
Papua New Guinea, Philippines, Rwanda,
Sierra Leone, Somalia, South Sudan,
Swaziland, Syria, Timor-Leste, Tunisia,
Uganda, Viet Nam, Yemen, Zimbabwe

35

Case study: Characterizing appropriateness of care for sickyoung infants with PSBI in the private sector in Nepal
Possible severe bacterial infection is an important cause of neonatal deaths in Nepal. While outpatient
treatment for PSBI has been available through public health facilities since 2005, there is evidence
to suggest that the majority of sick young infants are treated in the private sector. Caregivers prefer
the private sector because of convenient opening hours, availability of drugs, and perceived better
quality of care. However, data on the quality and appropriateness of private sector care for sickyoung infants are limited. To address this gap, USAID Nepal and MCSP supported the MoH to
conduct a large, nationally representative survey to provide a more definitive picture. The study was
conducted between June and July 2017 in a representative sample of 25 districts, 400 medicine
shops and 82 physician-run clinics.
The results showed that physician-staffed private clinics were concentrated in urban and peri-urban
areas, whereas private medicine shops were more widespread, including in rural areas and werestaffed by qualified paramedics. Almost all providers surveyed reported giving oral antibiotics astreatment for PSBI with more than 20% also reporting the use of injectable antibiotics. Incorrect
dosing was common for both oral and injectable antibiotics. Use of age to determine dosages, andinaccurate weighing procedures, were common particularly in remote areas. Injectable treatment
regimens were often shorter than recommended due to the family’s failure to return to medicine
shops or their inability to pay for the appropriate treatment.
About 21% of physicians and 11% of medicine shop providers reported using injectable steroids fortreating sick young infants, most often “when the child has signs of critical illness.” In almost all suchcases, this is inappropriate and likely to increase the risk of neonatal death. Approximately half ofproviders reported routinely giving a pre-referral dose of oral antibiotics, but provision of pre-referral
injectable antibiotics was considerably less frequent (fewer than 5% of providers). Fewer than half ofall providers took action to check on infants who did not return for follow-up.
The study also uncovered some promising findings. The qualifications of providers in medicine shops
were equivalent to those working within the peripheral public health facilities. These private sector
health workers trusted the MoH and expressed an interest in using government treatment protocols
and participating in formalized social franchising networks for treatment of sick young infants.
In response to this assessment the MoH, with support from partners, is working to test and develop
strategies to address critical performance gaps among private sector providers. Improvements willaddress accurate weighing and dosing, avoiding harmful steroids, appropriate use of pre-referral
injectable antibiotics and strengthening of referral systems to facilitate timely referral for more criticallyill cases.

36

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.2.11. Inpatient care for small and sick newborns including familycare and follow up
Inpatient care for small and sick newborns is emerging as an important priority for countries. Although not
specifically tracked in ongoing global efforts due to lack of clarity on definitions and on what it entails, it can beconceptualized as being delivered across three levels at health facilities (see Figure 10). In a well-functioning
health system, all three levels of care for newborns should be available. The majority of small and sick newborns
will require special care at the secondary level whereas a small proportion will require neonatal intensive care,including ventilation support.
Global partners are undertaking multiple activities to advance the global agenda on small and sick newborn care.
These include (a) a landscape analysis, (b) review of hospital assessments of quality of maternal and newborn careservices conducted in 24 countries with WHO technical assistance, (c) a document to describe key systems issues
related to the care of small and sick newborns and (d) the definition of signal functions (see section 5.7.6). The
multi-country landscape analysis is looking at inpatient care for sick newborns and young infants in Bangladesh,
Ghana, Malawi, Nepal, Pakistan, Rwanda, Uganda and the United Republic of Tanzania. Results, expected in2018 and 2019, will provide a basis for strengthening care of small and sick newborns, building on the essential
newborn care platform.
The document describing the global gap, need, and solutions to strengthen care for every small and sicknewborn is expected to be launched on the 2018 World Prematurity Day, and will serve to galvanize the global
community to do more for this extremely vulnerable population.

Figure 10. Health system requirements for inpatient care of small and sick newborns
by level of care
• A special ward that includes neonatal care facilities

More complex care

Place • Incubators, resuscitaires• Space for kangaroo mother care and supporting breastfeeding• Nurses with specialized neonatal skills

People • High nurse-newborn ratio e.g. 1:1 in the UK• At least one doctor with specialised neonatal training
In addition to special care equipment and commodities (see below)

Equipment• Availability of Continuous Positive Airway Pressure, Intermittent
and Positive Pressure ventilation and monitoring equipment
commodities• Surfactant therapy for extremely premature newborns, if appropriate• 24 hour laboratory support

Support • Transport and safe referral if needed
system• Space for mother and family to stay close to their babyPlace

• A special room or specially allocated corner of a warm facility,with specific areas for resuscitation, stabilisation and space forkangaroo mother care
• Incubators/resuscitaires overhead heaters

People• Specialized nursing and midwifery staff• High nurse/midwife to newborn ratio e.g. 1:4 in United Kingdom• Feeding support with nasogastric tubes and intravenous fluids

Equipment• Infection prevention and management, including antibiotics
andcommodities • Some access to oxygen provision (with pulse oximetry), andeffective phototherapy for jaundice case management

Basic care

Support • Space and support for mothers including place to express breast
system milk
Place • Basic facility or home birth with skilled attendancePeople • Midwifery and nursing staff
Equipment and • Linen/towels for drying and wrapping and resuscitation bag andcommodities mask
Support • Warmth, cleanliness and breastfeeding support
systemFigure adapted from Moxon et al (2015) BMC pregnancy and childbirth [16}37Case study: Family-centred care in a neonatal intensive
care unit in north India
Family-centred care (FCC) for sick newborns is emerging as a useful approach at health facilities.
FCC seeks to transform traditional technology-driven, provider-centred care into a more clientcentred model, and to build a stronger partnership between health providers and families. Often
parental or family participation in caring and decision-making regarding the care of their babies islimited. In some settings family members, even mothers, are granted limited access to the inpatientcare unit. This leads to anxiety and stress among parents and family members and limits essential
practices such as KMC. In addition, there are widespread human resource shortages in hospitals inhigh-burden settings. Family-centred care for small and sick newborns seeks to develop and nurture
the family’s role in partnership with the care delivery team of doctors and nurses.
A randomized controlled trial conducted at the Post Graduate Institute, RML Hospital, New Delhi,
during 2010-2012 aimed to adapt the principles of family-centred care to overcoming the problemof human resource constraints and improving neonatal outcomes in the tertiary referral neonatal
unit. Researchers enrolled the accompanying parent or attendant of sick newborns to participate
in delivering care to babies in addition to that provided by nurses and doctors. The objectives of
the training, using developing culturally sensitive audio-visual training modules, were to improveawareness, educate, train and build capacities of accompanying parents or attendants in thedomains of personal hygiene, handwashing, identification of danger signs, reporting of adverse
events, feeding and KMC of low birth-weight or sick newborns.
The results of the trial were promising. There were no increases in infection rates, and better rates of breastfeeding
were achieved prior to discharge of the neonate. Health workers and families found this intervention to befeasible, well-accepted and safe. The Indian government plans to scale up this initiative to other sites, and the
FCC model has the potential of being useful in other low- and middle-income countries.

38

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Case study: Comprehensive integrated care of smalland sick neonates: Newborn Essential Solutions andTechnologies (NEST) and the MacArthur Foundation
Although a large proportion of African mothers
now give birth in hospitals, these hospitals
often lack the life-saving technologies needed
to provide comprehensive inpatient newborncare. These technologies are not available fortwo principal reasons: (1) equipment designed
for high-resource settings cannot withstandthe harsh environments of African hospitals,and (2) the distribution functions for medical
devices in Africa are poorly coordinated orunderstood.
The Newborn Essential Solutions andTechnologies (NEST 360°) project addresses
these gaps through three complementary
approaches: (1) Innovation: Providing a
package of rugged technologies for quality,
comprehensive newborn care, (2) Distribution:
Ensuring the affordable delivery, installation,and maintenance of NEST360° technologies
and (3) Measurement: Demonstrating costeffectiveness of NEST360° to unlock demandin the public and private sector hospitals.
NEST360° comprises a multi-disciplinary
team of clinicians, engineers, manufacturers,
distributors, and experts in newborn careprogramming and evaluation. Collaborators
are from Rice University, Northwestern
University, the University of Malawi, theLondon School of Hygiene and Tropical

Medicine and 3rd Stone Design. NEST 360°
builds on previous work done on expanding
bubble continuous positive airway pressure(bCPAP) in Malawi. In December 2017, theNEST team was awarded US$ 15 million
through the MacArthur Foundation’s inaugural
100&Change competition. Additional partners
have made commitments to this integrated
approach.
NEST360° identified five key insights critical for
scaling comprehensive newborn care in Africa:
1. A bundle of technologies is needed to end
preventable newborn deaths across Africa
2. A bundle of technologies is needed tosustain distribution across Africa
3. Rigorous evaluation of a bundle oftechnologies, including cost effectiveness
data, is required for global policy andcountry uptake
4. Providing financing for a bundle oftechnologies is critical for uptake, especiallyin private sector health facilities
5. Sustaining a bundle of technologies
requires collaboration with local clinical andtechnical training institutions

39

Spotlight: Safe and effective oxygenuse for inpatient care of small andsick newborns
Access to appropriate oxygen therapy can reduce deathfrom childhood pneumonia and neonatal respiratory
distress. Improved detection of hypoxemia and the safe
administration of oxygen has resulted in a 35% reductionin the risk of death from childhood pneumonia in highburden settings.[17] Historically, the administration anddelivery of oxygen with pressure that helps maintainlung inflation has resulted in a dramatic improvement insurvival of premature infants.[18] Oxygen therapy remains
an essential element in the treatment of newborn
respiratory distress, with specialized delivery methods
being increasingly used in low- and middle-income
countries.[19],[20] The requirements for safe oxygen use innewborns include:• Systems
fordelivering
different
oxygenconcentrations (blenders to provide 21% to 100%
oxygen);• Non-invasive systems for measuring oxygen levelsin the blood (pulse oximetry);• Adequate number of trained staff who understandthe importance of controlling oxygen levels.

40

Without proper monitoring, however, oxygen may
also be unsafe and cause harm. Injury may occur
from high levels of oxygen in the blood, regardlessof the administered oxygen concentration, and fromexposure of the lungs to high concentrations ofoxygen. The two main complications of oxygen use
in newborns are retinopathy of prematurity (ROP)and lung injury. ROP is the abnormal developmentof blood vessels in the retina of the eye. In its most
severe form, ROP can result in blindness. Exposure
to supplemental oxygen also produces complications
from direct oxygen toxicity to lung tissue. Chroniclung disease (also known as bronchopulmonary
dysplasia) is a serious consequence in extremely
preterm infants, but cumulative oxygen exposure also
leads to lung problems in infancy among moderately
preterm babies. [21]

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

What are the current evidence-based best practices?
• Prevention of unnecessary oxygen exposure:
Appropriate
administrationofantenatal
corticosteroids to women with threatened
preterm birth from 24 to 34 weeks of gestation
can reduce the incidence and severity of
respiratory distress syndrome among theirnewborn infants. [22],[23]• When oxygen therapy is required, duringresuscitation or later during inpatient care,minimizing the concentration and duration ofoxygen exposure through strict monitoring is
key to avoiding an increased need for oxygen
and resultant complications.
• Pulseoximetry
providesnon-invasive
monitoring of blood oxygen levels episodicallyor continuously.
• Involving parents in skin-to-skin contact anddevelopmentally supportive care of newborns
can reduce agitation and desaturation, and thus
limit unnecessary oxygen exposure.

• Nurses, midwives, physicians and other healthprofessionals who care for newborns receiving
oxygen therapy should have specific training
and skills in the safe delivery of oxygen.
Facility-specificstandard
operatingpoliciesand procedures, as well as clinical treatment
guidelines, and availability of blenders, pulse
oximeters, gas heaters/humidifiers are key toimproving the safe use of oxygen. Newborns who
are treated with oxygen need to be monitored withpulse oximetry and have oxygen saturations kept
in the safe range. Newborns who have received
oxygen therapy must be screened for evidence of
direct and indirect toxicity – specifically, lung injury
and ROP. Biomedical engineers are needed formaintenance of delivery and monitoring systems
for oxygen supplementation that require scheduledcalibration, cleaning, electrical safety checks andrepair/replacement of durable and consumableelements.

41

5.3. Every Newborn milestone:
Investment in health workforce
Investment in the workforce requires developing or integrating costed strategies on humanresources for health into RMNCAH plans and ensuring the allocation of sufficient financial
resources. In 2017, 41 countries reported that they had developed a human resource planor a strategy for skilled attendance at birth. This represents an increase of 11 countries
since 2016 (Table 13).

Table 13. Health workforce strategies

42

Indicator

Yes (n=41)

A humanresourceplan/strategy forskilled birthattendance isin place

Afghanistan, Angola, Armenia, Bangladesh,
Bhutan, Burkina Faso, Burundi, Cameroon,
Chad, Côte d’Ivoire, Democratic Republic of
the Congo, Djibouti, Egypt, Ethiopia, Ghana,
Guinea, Guinea-Bissau, India, Indonesia, Iran,Kazakhstan, Kenya, Lao People’s Democratic
Republic, Liberia, Libya, Morocco,
Mozambique, Myanmar, Nepal, Niger,
Pakistan, Palestine, Rwanda, Somalia, Sri
Lanka, Sudan, Syria, Turkmenistan, United
Republic of Tanzania, Viet Nam, Zambia

In process(n=6)

Eritrea, Jordan,
Namibia,
Nigeria,
Senegal,Zimbabwe

No (n=25)

Azerbaijan, Benin, China,
Comoros, Gambia,
Georgia, Iraq, Lebanon,
Lesotho, Madagascar,
Malawi, Maldives, Mali,
Mauritania, Papua New
Guinea, Philippines, Sierra
Leone, South Sudan,
Swaziland, Tajikistan,
Timor-Leste, Togo, Tunisia,
Uzbekistan, Yemen

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.4. Every Newborn milestone:
Health workforce capacity and support
Table 14 shows the reported policies in place to support health worker competencies andretention in 75 countries. In 2017, 28 countries reported that a retention policy was in place
for skilled birth attendance, compared to 18 countries in 2016 and 5 countries in 2015.
Sixty countries reported that competency and skill-based trainings for maternal and newborn
health were available in 2017 compared to 44 countries in 2016.

Table 14. Countries reporting policies to support health workers retention andcompetencies
Indicator

Yes

In processNo

A retention
Policy or
strategies forskilled birthattendants
or relevant
cadres inplace

Afghanistan, Burkina Faso, Burundi,
Cameroon, Egypt, Ethiopia, Gambia,
India, Iran, Kazakhstan, Kenya,
Kyrgyzstan, Malawi, Nepal, Niger,
Pakistan, Palestine, Rwanda, Senegal,
Somalia, Sudan, Tajikistan, United
Republic of Tanzania, Timor-Leste,
Uganda, Viet Nam, Zambia, Zimbabwe(28)

Armenia,
Bangladesh
Eritrea, Liberia,
Mozambique,
Nigeria (6)Angola, Azerbaijan, Benin,
Bhutan, China, Comoros, Coted’Ivoire, Djibouti, DRC, Georgia,
Ghana, Guinea, Guinea-Bissau,
Indonesia, Iraq, Jordan, Lao
People’s Democratic Republic,
Lebanon, Lesotho, Libya,
Madagascar, Maldives, Mali,
Mauritania, Morocco, Myanmar,
Namibia, Papua New Guinea,
Philippines, Sierra Leone,
South Sudan, Sri Lanka,
Swaziland, Syria, Togo, Tunisia,
Turkmenistan, Uzbekistan,
Yemen (39)Competency
and skillbased
service /training/
education
for MNH
available

Afghanistan, Angola, Armenia, Benin,
Bhutan, Burkina Faso, Burundi,
Cameroon, Chad, China, Cote d’Ivoire,
Democratic Republic of the Congo,
Djibouti, Eritrea, Ethiopia, Gambia,
Ghana, Guinea, Guinea- Bissau, India,
Indonesia, Iran, Iraq, Kazakhstan,
Kenya, Kyrgyzstan, Lao People’s
Democratic Republic, Lesotho, Liberia,
Libya, Madagascar, Malawi, Mali,
Morocco, Mozambique, Myanmar,
Namibia, Nepal, Niger, Nigeria, Pakistan,
Palestine, Senegal, Sierra Leone,
Somalia, South Sudan, Sri Lanka,
Sudan, Swaziland, Syria, Tajikistan,Togo, Tunisia, Turkmenistan, United
Republic of Tanzania, Uzbekistan, Viet
Nam, Yemen, Zambia, Zimbabwe (60)Bangladesh,
Lebanon (2)Azerbaijan, Comoros, Egypt,
Georgia, Jordan, Mauritania,
Papua New Guinea, Philippines,
Rwanda, Timor Leste (10)43Case study: Improving maternal and newborn healthservices in eastern Indonesia through a multifaceted
programme including perinatal mentorship he
Difficult geography, inequitable distribution of health personnel, infectious diseases such as malaria
and basic resource limitations make preventable maternal and newborn deaths higher in eastern
Indonesia than in other parts of the country.
In 2017, Indonesia embarked on three interrelated initiatives attempting to address thesebottlenecks. First, malaria screening was performed for more than one-half million pregnant womenattending antenatal care services, leading to the treatment of nearly 24 000 cases of malaria-inpregnancy. Second, a referral system was established between health facilities in remote areas
and urban areas, which led to a two-to-four-fold increase in appropriately managed obstetricand neonatal complications as well as shorter delays in accessing safe delivery services. Third,
the perinatology mentorship initiative paired specialist paediatricians and paediatric nurses frombetter-developed parts of Indonesia with more poorly developed hospitals in remote areas. This
led to enhanced capacity of health professionals in targeted perinatology units and increased
ability to manage major causes of neonatal deaths.
Several lessons were learnt in this process. Applying a bottom-up approach that included
designing a programme with local providers and health managers ensured that the method wasappropriate to the local context. Promoting stakeholder engagement early on resulted in strong
national and local ownership, enhanced effective implementation and facilitated programme
sustainability. The programme succeeded in improving public awareness on critical health issues,and enhanced community participation has contributed to the programme’s achievements.
National and subnational policy guidelines have been developed for MNH, and local, national andexternal resources have been secured to ensure sustainability.
Investing in data generation and continuous monitoring and evaluation have been important
not merely to measure programme achievements, but also to inform planning and to guide
implementation. Strengthening of health stewardship across all levels is critical to maintaining
programme sustainability and strategic direction.

44

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.4.1. Survey report on strengthening midwifery education
There is increasing evidence to indicate that a consistent barrier to improving maternal and newborn health has
been the failure to create an environment that enables midwives, nurses, doctors and other health workers toprovide quality care. A systematic mapping of barriers to the provision of quality care by midwifery personnel
revealed that poor midwifery education, often reduced to a matter of weeks without qualified faculty and lacking
in practical application, was a major constraint.[24] The State of the World’s Midwifery Report 2014 notes thatof the 73 countries from which data was gathered, only four had a workforce capacity to provide the careneeded by newborns and by women in their reproductive years. Moreover, many of the programmes lacked
basic training such as for infection prevention and for respectful care, leading to possible links between poor
education, poor clinical care, sepsis and mistreatment of women in facilities.[25]Efforts to improve the quality of education have been made by many partners under the leadership of theInternational Conference of Midwives (ICM), the International Federation of Gynaecology and Obstetrics
and the International Paediatrics Association, as well as through UN agencies, donors, foundations andmajor international and national NGOs. Much of this has focussed on curriculum development and training(short and long term). More recently attention has been given to the potential for mHealth and e-learning
opportunities. In 2015 WHO developed “Midwifery Educator Core Competencies”, which sets out 19
competencies for all educators (midwives, nurses or doctors). WHO also developed “Global strategic
directions for strengthening nursing and midwifery 2016-20”, which highlights education along with policy
development, leadership, intra- and inter-professional partnerships and greater investment in the workforce.[26]Yet educators remain challenged in providing learning opportunities that ensure that future practitioners acquire
the practical skills needed to deliver quality maternal and neonatal care. In response, Bharj et al (2016) set out a
new “Agenda” to improve the quality of education. This includes developing intensive, sustainable collaboration
between education programmes, practice settings, and government systems. WHO has identified midwifery
education as a priority and is leading work with UN agencies, professional organizations, academics and otherpartners to develop a global strategy for strengthening quality interprofessional midwifery education. Midwifery
will be the theme for the 2019 report to the WHO Executive Board on the UN Secretary-General’s Global
Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030), with potential for this to be a key issue
for discussion at the World Health Assembly.
45

5.4.2. Human resources for sick newborn care
The health workforce is a critical bottleneck for the provision of skilled care for mothers and newborns inmost countries. Shortages are most apparent in low-income settings, and are compounded by inadequate
deployment, poor retention and the misdistribution of health workers between urban and rural areas. Highly
skilled personnel such as obstetricians, paediatricians, neonatologists, anaesthetists and midwives tend to beconcentrated in urban areas or to migrate overseas to pursue better opportunities. Human resource shortages
are particularly evident for neonatal nurses, with no programmes for training these cadres available in lowincome settings. Other human resource challenges include a lack of supervision, poor salaries, low morale andmotivation.[27],[28]Effective human resource management requires strong leadership and comprehensive planning guided byneeds on the ground. Mapping exercises can reveal the distribution of staff with specific skills, and gaps inservice provision. The frequent transfer or rotation of specialty-trained staff can be detrimental to the qualityof sick newborn care. Staff that have participated in specialized training on sick newborn care and who haveexperience working in neonatal intensive care units should be protected from mandatory rotation to ensure thequality of care and the best use of resources. Given the frequent shortages of skilled health workers and thedisparities of skills available, task shifting has emerged as an important strategy in many settings to delegatetasks to lower level cadres by providing them focused training on key activities.[29] In many African countries, forexample, non-physician clinicians have been employed to provide emergency obstetric services.[30] Task shifting
is an important interim strategy, but needs to be implemented with regular supportive supervision and ongoing
mentoring.

Case study: Establishing special newborn care units run by
mid-level health professionals in Malawi
The NMR has decreased at a much slower pace than post-neonatal mortality rates inMalawi. Although 90% of women deliver at health facilities, the number of newborn deaths
remains high, suggesting poor quality of care. The common causes of neonatal deaths arebirth complications, prematurity and sepsis. In line with the ENAP, UNICEF worked with the
Paediatric and Child Health Association of Malawi to establish Special Newborn Care Units(SNBCU) in ten hospitals that are primarily run by nurses with support from clinical officers.
The initiative was designed and implemented to address four critical gaps in the care of sicknewborns: the absence of dedicated space, limited staff, limited protocols and poor data
capture.
In 2015 work began to identify rooms and staff in district hospitals who could be specifically
dedicated for sick newborns, to renovate units and provide necessary equipment. A training
package, Care of the Infant and Newborn (COIN), was developed to build capacity among
mid-level health workers in the care of sick neonates; this was complemented by neonatal
admission forms and other supporting tools.
Training was provided for 350 health workers and 43 pre-service lecturers. Nurse and midwife
curricula were reviewed, and mentorship and supervision were provided. The MoH-developed
newborn care register was printed and tested in the ten hospitals. All ten SNBCU are now fully
operational and provided care for 14 596 newborns last year, reducing the need for referraland saving thousands of lives. Death audits were undertaken for 56% of newborn deaths;
response actions contributed to improved care. The NMR in the ten hospitals has declined by
one third within a one-year period, twice as fast as predicted. The key lesson learnt from the
project is that tailored capacity-building interventions can be successful in enabling mid-level
health workers to independently provide a comprehensive package of inpatient care for smalland sick newborns.

46

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Case study: The Regional Learning Network, a model for
improving outcomes of maternal and newborn care in
UgandaAs facility births have increased in Uganda from 58% in 2011 to 74% in 2016, the MoH has
stepped up QI efforts to end preventable maternal and newborn deaths. Starting in 2016, theMoH piloted a Regional Learning Network (RLN) in Hoima, with support from Save the Children
and the University Research Company (URC). The RLN is a network of 14 health facilities,
including and within the catchment area of the regional referral hospital, linked to provide
newborn care services based on national standards and guidelines.
The RLN aims to: 1) employ a QI methodology that includes a training lab based at the regionalreferral hospital to address critical gaps in providing high quality MNH care: 2) produce newknowledge and learning on the best approaches to improving MNH care; and 3) spread, share,and document lessons with other regional referral hospitals and lower-level facilities. The URC
set up the training lab and carried out quality improvement activities, including plan-do-studyact cycles (PDSA), clinical coaching, and training of 137 frontline health workers. Save theChildren conducted core network-building activities such as learning sessions, maternal andperinatal death surveillance reviews, training on RMNCH scorecard use, district coordination
meetings, and quarterly data quality assessments. The early investment in and engagementof the local clinical leadership in this QI initiative served to support the sustainability andscalability of the RLN model.
Key changes made to improve the quality of care included establishing clinical mentorship andskill-building opportunities, fostering use of data for accountability, and ensuring the availabilityof appropriate communication, referral systems, supplies, commodities and infrastructure to
support essential obstetric and newborn services. After just 12 months, vast improvements
were seen including the availability of essential inputs, knowledge of evidence-based careamong health care providers, and delivery of key maternal and newborn health services that
improved the outcomes of mothers and newborns. The endline evaluation found that nearly all
staff assessed were able to correctly identify the necessary procedures for essential newborncare and that the number of staff able to accurately describe KMC doubled. All facilities had
an appropriate place for newborn resuscitation within the delivery room with functional Bag
Mask devices available; this had been only 21% at baseline. Delivery of essential newborncare improved, including handwashing, skin to skin contact and support to initiate earlybreastfeeding.
District coaches and midwife mentors led learning sessions and provided mentorship andsupportive supervision. Health care providers and district management staff involved in the
RLN found that the learning sessions served as a valuable network-building activity for sharing
learning and building rapport; this work can be carried on after the pilot project ends.
High quality maternal and newborn care can be achieved when facilities have theinfrastructure, personnel, equipment, drugs and skilled providers needed to follow evidencebased processes in a timely fashion for every patient, every time. Based on improvements inclinical outcomes, care processes, and shared learning under the RLN, the Uganda MoH cancontinue implementing mentorship and supportive supervision in Hoima and the 14 facilities of
the RLN to test a version of quality improvement that is not partner-funded. Because a skills
lab in Hoima has already been created, the main requirements to maintain quality improvement
activities are mentorship and supportive supervision, along with the continued engagement ofleadership.
47

5.5. Every Newborn milestone:
Community engagement
Involving communities, civil society and other stakeholders to increase demand andensure access to and coverage of the essential maternal and newborn care is an importantmilestone for ENAP. Fig 11 shows the progressive increase in the number of countries thathave strategies in place for MNH engagement and communication.

Figure 11. Country progress on communication strategy and community MNH
engagement
37
40

27

30

27

18

20
10
0

1

10

5

3

A national
communication strategy(advocacy, BCC/C4D) on
newborn health developed
2014

A community
engagement/
mobilisation strategy
in place

2015

2016

2017

In 2017, 37 countries reported that a community maternal and newborn health engagement/ mobilization
strategy had been developed, 33 countries reported that no such strategies were available.

Table 15. Status of national community maternal and newborn engagement
strategies that were available
Indicator
A community
MNH
engagement/
mobilization
strategy in
place

48

Yes (n=37)

Armenia, Bangladesh, Bhutan, Burkina
Faso, Cameroon, Cote d’Ivoire, Democratic
Republic of the Congo, Egypt, Eritrea,
Ethiopia, Ghana, Guinea, Guinea-Bissau,
India, Indonesia, Kazakhstan, Kenya,
Kyrgyzstan, Liberia, Malawi, Morocco,
Myanmar, Nepal, Niger, Nigeria, Rwanda,
Senegal, Sierra Leone, Somalia, South
Sudan, Sri Lanka, United Republic of
Tanzania, Timor-Leste, Uganda, Uzbekistan,
Yemen, Zambia

In process(n=2)

Palestine,
Swaziland

No (n=33)

Afghanistan, Angola,
Azerbaijan, Benin,
Botswana, Burundi,
Chad, Comoros, Djibouti,
Gambia, Georgia,
Iran, Iraq, Jordan, Lao
People’s Democratic
Republic, Lesotho,
Libya, Madagascar, Mali,
Mauritania, Mozambique,
Namibia, Pakistan,
Papua New Guinea,
Philippines, Sudan, Syria,
Tajikistan, Togo, Tunisia,
Turkmenistan, Viet Nam,
Zimbabwe

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Case study: MCSP conducts a multi-country assessment
on community engagement
In 2017, MCSP initiated a multi-county assessment on community engagement in Bangladesh,
Ethiopia, Guatemala, Haiti, Kenya, Malawi, Mozambique, Pakistan and Rwanda. The primaryobjective of this assessment, scheduled to end in late 2018, is to document what actions at
the community level have contributed to changes in practices in maternal and newborn healthand nutrition. Secondary objectives are: 1) to share and disseminate experiences and lessons
learned, 2) discuss the merits of institutionalizing the community health model and 3) promote
the use of participatory community capacity strengthening approaches to improve demand
creation and service uptake.

5.5.1. Every Child Alive: the urgent need to end newborn deaths
The Every Child Alive campaign is a joint effort launched by UNICEF and partners in February, 2018.
The campaign is an urgent appeal for strong cooperation between governments, businesses, health careproviders, communities, and individuals to fulfil the promise of universal health coverage and keeping every
child alive.
The campaign was launched with a global report that describes the challenges of ending preventable newborn
deaths. The report is available at: https://www.unicef.org/publications/files/Every_Child_Alive_The_urgent_need_to_end_newborn_deaths.pdf. This report received widespread coverage including a three-part featurefrom Japan, Malawi and India on BBC News at 10, which also ran online and across BBC News outlets
including BBC World, BBC Arabic, BBC Africa and BBC World Service. Al Jazeera aired multiple segments
and live interviews from the Central African Republic, as did AFP and RFI (radio and online). Additional
field reports came from Rwanda (Mail and Guardian) and Somalia (RTL Radio). Further coverage, includinginterviews with UNICEF spokespeople, included 52 newspapers such as the Times, The New York Times,
Daily Mail, The Guardian and others. Several outlets did multiple stories, including USA Today, TIME, BBC,Al Jazeera, CNN, and the Guardian. UNICEF placed an op-ed by UNICEF Goodwill Ambassador Serena
Williams on CNN, which generated more than 32 articles including the Telegraph, The Guardian, BBC Sport,
MailOnline, USA Today, E! News, Sports Illustrated, TMZ, ABC News, HuffPost, El Tiempo, Time Magazine,
Fox News, CNN, Sky Sports, El Pais , Huffington Post , El Tiempo , People, E!News, Entertainment Tonight
and more.
The campaign is making an urgent, global plea to invest in the “four P’s”: Places, People, Products andPower. Places means guaranteeing clean, functional health facilities with access to clean, running water,
sanitation facilities and electricity. People means recruiting, training and managing doctors, nurses andmidwives, and placing them where they are needed most. Products means making the top ten life-saving
drugs and supplies available for every mother and baby. Power means giving mothers the power to demand
and receive quality care at every stage of their children’s birth and development. These four Ps combinedwith a fifth P for “partnership” are vital to success. Governments, non-profit organizations, civil society,foundations, businesses, UN agencies, professional associations and parents’ groups all have to join hands
to reduce neonatal mortality.

49

Case study: EVERY NEWBORN: An advocacy toolkit andguidance manual for ending preventable deaths
This toolkit offers practical instruments to help country programmes and stakeholders support
advocacy for improving MNH and preventing stillbirths. It is especially important in countries witha high burden of newborn and maternal mortality. The document provides a repository of quickreferences and examples to show the user how to undertake advocacy and communication invarious national and local contexts. The toolkit supports the global ENAP initiative by providing
a wide range of options for outreach and advocacy activities tailored to specific audiences. It
includes key messages on MNH, as well as examples of letters to policymakers, briefs, press
releases, social media content and other relevant materials to make the case for improving thequality of care and scaling up interventions. Each country using the toolkit will need to updaterelevant data and adapt messages to its local context. The toolkit is available at the healthy
newborn network website: https://www.healthynewbornnetwork.org/hnn-content/uploads/
ENAP-A-toolkit-for-Advocacy-_0118_layout_002-2.pdf

Case study: Creating demand for MNCH services in
Ethiopia
Despite the increasing availability of services in Ethiopia, neonatal and child mortality rates remain
high, attributable in part to inappropriate recognition of illness and poor careseeking behaviours.
The Government of Ethiopia has committed to ending preventable newborn deaths by scaling up
Community-Based Newborn Care (CBNC), a package of preventive and curative services deliveredat the community level and within lower levels of the health system, close to communities.
In partnership with the Government, Save the Children and other partners developed a strategy
to increase demand for CBNC. The Demand Creation Strategy for Maternal, Newborn and Child
Health/Community-Based Newborn Care (MNCH-CBNC) addresses the barriers families face toseeking appropriate care and improving newborn care practices. The strategy aims to create
enabling social norms that support helpful MNCH-CBNC behaviours, improve MNCH-CBNCrelated household practices and increase timely careseeking for maternal and newborn illnesses.
The strategy was rolled out from 2015 to 2017 in 244 districts (Woredas) across 21 zones in four
regions of Ethiopia.
Results of an evaluation showed that the Demand Creation Strategy contributed to improvements
in MNCH by changing attitudes towards issues such as harmful traditional practices, breastfeeding
and appropriate care of the umbilical cord. The evaluation reported increases in male involvement
in decision-making and support for MNCH-related practices, including careseeking in communities
where stronger implementation of Kebele Command Posts occurred. The strategy also contributed
to supportive environments for earlier disclosure of pregnancies by women to family members,
and increasing awareness about the importance of antenatal care, institutionalized delivery, andcareseeking for sick newborns.
Implementation of the Demand Creation Strategy for MNCH-CBNC shows that increased community
capacity and mobilization can catalyse action around maternal and newborn health. Sustaining
the success of CBNC will require integrating the social and behaviour change strategy, community
empowerment approaches and involvement of public health structures such as primary healthcare units and woredas. Community capacity strengthening using a multiple component approachis important to increase demand for and appropriate use of MNCH services. More information
about this case study is available at https://www.healthynewbornnetwork.org/resource/demandcreation-mnch-cbnc-ethiopia/
50

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.6. Every Newborn milestone:
Parents’ voices and champions
Empowerment of communities, particularly parents and champions for newborn
health, can bring about lasting change, shift social norms around the acceptance of
newborn deaths, and keep health workers and governments accountable for providing
high quality care.

Parents and families suffer emotional distress when there is a newborn death, illness or stillbirth. Engaging
such parents and couples as advocates for better newborn care may be a way of shifting social norms awayfrom accepting that babies die needlessly. Newborns and stillborn children do not have their own voice.
Programmes thus need to cultivate champions who can be fierce advocates for newborn survival, such as
clinicians, members of parliament, ministers, parents, journalists, celebrities, donors, public health leaders
and researchers.
In 2017, 27 countries reported that they had developed a national communication strategy on newborn
health; 42 countries reported that no such strategy existed.

Table 16. Status of national communication/advocacy strategies
Indicator
A national
communication
strategy on
newborndeveloped

Yes (n=27)

In process (n=5)

No (n=42)

Afghanistan, Armenia,
Bangladesh, Benin,
Bhutan, Cameroon, Coted’Ivoire, Djibouti, Ghana,Kazakhstan, Liberia,
Madagascar, Morocco,
Nepal, Niger, Nigeria,
Pakistan, Rwanda,
Senegal, Sri Lanka, TimorLeste, United Republicof Tanzania, Uganda,
Uzbekistan, Viet Nam,
Yemen, Zambia

China, India,
Kenya, Palestine,
Swaziland

Angola, Azerbaijan, Botswana,
Burkina Faso, Burundi, Chad,
Comoros, Democratic Republic of
the Congo, Egypt, Eritrea, Ethiopia,
Gambia, Georgia, Guinea, GuineaBissau, Indonesia, Iran, Iraq, Jordan,
Kyrgyzstan, Lao People’s Democratic
Republic, Lebanon, Lesotho, Libya,
Malawi, Mali, Mauritania, Mozambique,
Myanmar, Namibia, Papua New Guinea,
Philippines, Sierra Leone, Somalia,
South Sudan, Sudan, Syria, Tajikistan,Togo, Tunisia, Turkmenistan, Zimbabwe

51

Spotlight: Honouring midwife and nurse
champions for newborns
Identifying and engaging strong leaders andchampions can be a powerful advocacy tactic usedin public health. As frontline health workers, nurses
and midwives play a central role in preventing
maternal and neonatal deaths and stillbirths. Save
the Children has been partnering with international
healthcare professional associations for over a
decade to recognize and celebrate midwife and nurse
champions for newborns. This includes two awards:• The International Midwife Award, establishedin 2005, to acknowledge midwives who havechampioned newborn survival. The award, given by
the ICM and Save the Children, is been presented
at ICM’s Triennial Congress, and recognizes two
exceptional midwives from countries with thehighest number of newborn deaths. Winners havecome from Afghanistan, Bangladesh, Ethiopia,
Malawi, Nigeria, South Africa and Uganda.
• The
International
NeonatalNursing
Excellence Award, established in 2010,
recognizes the commitment of nurses working
on the frontlines of newborn care in resourcechallenged countries. The award, given by theCouncil of International Neonatal Nurses (COINN)
and Save the Children, has been presented every
three years at the International Neonatal Nursing
Conference to two nurses working in newborncare in a low- or middle-income country where
the burden is highest. Winners have come from
Ghana, India, Kenya, Nigeria, Pakistan, and VietNam.
All of the midwife and nurse champions, as well as

52

the hundreds of nominees, have impressive stories
of dedication, determination and excellence. Awardwinners were provided the opportunity to attend theinternational midwifery or neonatal nursing conference
in order to receive their awards, network with othernurses and midwives and learn new skills. Awardwinners also received support on how to become
better spokespersons and advocates for maternal
and newborn health and were expected to leverage
the international attention to increase country-level
action at home.
Follow-up with some of these champions shows
how awards and recognition can support andencourage midwives and nurses in their workand elevate newborn health on political agendas.
Catherine Ojo, 2011 International Midwifery Awardwinner from Nigeria, has been a tireless advocate
for midwifery in Northern Nigeria and beyond. After
receiving the award, she met with the President of
Nigeria and multiple heads of state to advocate formore health workers. She also raised awarenessabout maternal, newborn and child health at theCommonwealth Youth Forum and has served on
many international panels. † Christine Sammy, 2013
International Neonatal Nursing Excellence Awardwinner from Kenya, received the presidential “Orderof the Grand Warrior of Kenya” and was profiled ona national television programme‡, thus increasingawareness about newborn health and the importanceof neonatal nursing. Future awards should be usedstrategically to drive change in countries by providing
extended support to the winners and their national
associations.

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Spotlight on midwife and nurse champions for newborns
Loveluck Mwasha, 2017 International Midwifery Award winner from the United Republic of Tanzania,
has been a steadfast advocate for and mentor to midwives through her work on the board of the Tanzania
Nursing and Midwifery Council, at the Aga Khan Hospital and the University School of Nursing andMidwifery. Loveluck’s mentorship and advocacy support important improvements in policy, funding, andthe practice of midwifery. “My work is an opportunity to advocate for better support and training of
midwives,” Mwasha said. “We work with stakeholders to help them appreciate midwives’ role in supporting
women’s reproductive health, from community groups to members of parliament.”
Learn more about Loveluck at www.healthynewbornnetwork.org/blog/international-midwife-awardwinner-fights-recognition-training-modern-facilities.
Nguyen Thi Minh Hong, 2016 International Neonatal Nursing Excellence Award winner from Viet Nam,works in the rural district of Tram Tau, where poor roads, local customs, and language barriers have
impeded access to and knowledge of good health practices around the time of birth. Ms Hong has
worked for the past 34 years, serving a primarily ethnic minority Hmong population.
“The work is hard, and travel is difficult,” Mrs. Hong says, “But I love this job. When a delivery is done I feelso happy to welcome a new baby. And if the baby is not well, we take care of them and they get healthy
after our care and I feel so honoured about that.”
Learn more about Nguyen at https://www.healthynewbornnetwork.org/blog/international-neonatalnursing-excellence-award-2016-nguyen-thi-minh-hong/†‡https://www.theguardian.com/global-development-professionals-network/2014/may/16/rights-women-girls-development 		
https://www.healthynewbornnetwork.org/blog/award-can-change-everything-neonatal-nurse-christine-sammy/

53

5.7. Every Newborn milestone:
Data
The urgent need to improve national data was one of the main messages during thedevelopment of the ENAP, in particular, data is needed to measure coverage of facilitybased interventions and to understand equity and quality gaps.

In addition, countries need to focus on collecting QoC indicators, to use innovative methods to collect data
and to use data for making decisions. Countries are increasingly collecting data that will improve estimates ofthe burden of stillbirths and newborn deaths. Unfortunately, in most high-burden countries, Civil Registration
and Vital Statistics systems (CRVS) are weak. In these settings, most stillbirths and up to half of all neonatal
deaths may not receive a birth or death certificate and are not registered.[32] An understanding of the true
number of deaths and their causes is essential for countries to improve the quality of care, prevent futurematernal and perinatal deaths, improve national vital statistics systems, allocate resources efficiently andtrack progress for reaching national, regional and global targets. A minimum perinatal dataset ensures thatall births and birth outcomes are in the HMIS and collated at higher levels. The ENAP specifies a minimum
set of six essential pieces of information to collect on each birth and death. These are maternal age, place ofdelivery, mode of delivery, birth weight, gestational age and birth outcomes.

5.7.1. Audits of stillbirths and neonatal deaths
Since 2014 there has been a steady increase in the number of countries that report having a perinatal death
review system in place: 38 in 2017 (Table 17), up from 23 in 2016, 11 in 2015 and just one in 2014. India
and Turkmenistan reported that work was under way to institute a perinatal death review system. There is
still a need to promote this system, since it is not in place in 31 countries, including Indonesia and Pakistan,
two countries with a high burden of neonatal mortality. Overall, more information is needed on the qualityof audits being conducted to promote links with counting maternal, neonatal and perinatal deaths andimproving quality of care.

Table 17. Countries reporting a perinatal death review system in place
Indicator
Perinatal death
review system in
place

54

Yes (n=38)

Angola, Armenia, Azerbaijan,
Bangladesh, Bhutan, Botswana,
Cameroon, Chad, China,
Democratic Republic of theCongo, Egypt, Eritrea, Ethiopia,
Gambia, Ghana, Indonesia, Iran,Kazakhstan, Kenya, Lebanon,
Lesotho, Madagascar, Maldives,
Morocco, Mozambique,
Myanmar, Namibia, Nepal,
Nigeria, Palestine, Rwanda, Sri
Lanka, , Togo, Tunisia, United
Republic of Tanzania Uganda,
Uzbekistan, Zimbabwe

In process (n=2)

India,
Turkmenistan

No (n=31)

Afghanistan, Benin, Burkina
Faso, Burundi, Comoros, Coted’Ivoire, Djibouti, Georgia,
Guinea, Guinea- Bissau, Iraq,
Kyrgyzstan, Lao People’s
Democratic Republic, Liberia,
Libya, Malawi, Mali, Mauritania,
Niger, Papua New Guinea,
Senegal, Sierra Leone, Somalia,
South Sudan, Sudan, Swaziland,
Syria, Timor-Leste, Viet Nam,
Yemen, Zambia

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Case study: Missing stillbirths means missing impact
An estimated 2.6 million stillbirths occur globallyeach year, yet the majority are preventable.
Half of these babies were alive at the onsetof the mother’s labour. Reducing stillbirths isa sound economic investment with a 10-25fold return in economic and social benefits, [33]and the full impact of investment is missed
if stillbirths are not tracked through nationaland global monitoring systems. Attention tostillbirths is increasing, but progress is slow
must be accelerated to reach the target of
12 or fewer stillbirths per 1000 total births by
2030. More than 60 countries need to at least
double their rates of progress.
Whilst LMICs carry the heaviest burden ofstillbirths (approximately 98%), the burden
in high-income countries is also important.
For example, the USA has more than 20 000
stillbirths per year, higher than the number ofbabies who die in their first year of life. The 2016
Lancet Stillbirth Series garnered international
attention, including media coverage in almost
100 countries. A recent Lancet film highlighted
actions taken.[34]• National targets: So far only 17 of the 75
countries tracked by the Every Newborn
Tracking Tool have set stillbirth targets
for 2030. Some countries are showing
ambition, largely driven by pressure
from parents. For example in the United
Kingdom, a target to halve the national stillbirth rate was brought forward from 2030 to2025, and the Health Secretary announced
an independent investigation into “Whatwent wrong and why?” for every stillbirth.
• Programme opportunities: The 1.3
million intrapartum stillbirths each year
could be prevented by better quality ofcare at birth, especially foetal monitoring

and rapid response. Major impact is also
possible through improved antenatal careaddressing non-communicable conditions,and infections, especially syphilis andmalaria. New research shows the potential
for a maternal group B streptococcus
vaccine to prevent stillbirths as well as
maternal and neonatal deaths within an
anticipated 5-year timeline.
• Burden of stillbirths on women andfamilies: The burden of stillbirths affects
women, families, caregivers, communities
and society. The burden of emotional,
psychological and psychosocial wellbeing
remains largely invisible and unrecognized.
Globally, at least 4.2 million women livewith depression associated with stillbirth.
Women often suffer grief, fear and isolationfrom the rest of their community – oreven overt stigma. In El Salvador recently
Teadora Del Carmen Vasques was freed
after serving almost 11 years in prison
for aggravated murder after experiencing
a stillbirth, and a teenage rape victim
sentenced to 30 years for murder after
suffering a stillbirth.
• Data: WHO has now requested countries
to regularly submit data on national stillbirthrates alongside reporting of deaths atother ages. WHO and UNICEF are working
together to improve the quality of data andestimates. In Mexico, the classificationof stillbirth was changed to increase theaccuracy of reporting. There is still a major
gap in national data for tracking intrapartum
stillbirths, even though these data arecollected in almost every hospital.

55

5.7.2. Maternal death surveillance and response (MDSR)
mechanism in place
In order to end preventable maternal deaths, accurate information is needed on how many women died,
where they died and how they died; this is currently not available from all countries. In 2017, 67 countries
reported having a MDSR mechanism in place, up from 17 in 2015 to 44 in 2016. Three countries (Djibouti,
Jordan and Pakistan) reported that work was under way. Five countries that are also fragile settings (Libya,
Mauritania, Somalia, Syria and Yemen) reported not having such a mechanism.

Table 18. Countries reporting that MDSR mechanisms are in place2017
Yes (n=67)

Afghanistan, Angola, Armenia, Azerbaijan,
Bangladesh, Benin, Bhutan, Botswana, Burkina
Faso, Burundi, Cameroon, Chad, China, Comoros,
Cote d’Ivoire, Democratic Republic of the Congo,
Egypt, Eritrea, Ethiopia, Gambia, Georgia, Ghana,
Guinea, Guinea- Bissau, India, Indonesia, Iran,Iraq, Kazakhstan, Kenya, Kyrgyzstan, Lao People’s
Democratic Republic, Lebanon, Lesotho, Liberia,
Madagascar, Malawi, Maldives, Mali, Morocco,
Mozambique, Myanmar, Namibia, Nepal, Niger,
Nigeria, Palestine, Papua New Guinea, Philippines,
Rwanda, Senegal, Sierra Leone, South Sudan, Sri
Lanka, Sudan, Swaziland, Tajikistan, Timor-Leste,
Togo, Tunisia, Turkmenistan, Uganda, United
Republic of Tanzania, Uzbekistan, Viet Nam, Zambia,
Zimbabwe

In process (n=3)

Djibouti, Jordan,
Pakistan

No (n=5)

Libya, Mauritania,
Somalia, Syria, Yemen

Case study: County mortality forums as a key step tostrengthening maternal and perinatal death surveillance
and response in Kenya
Maternal and perinatal death surveillance and response (MPDSR) is an important strategy
to reduce deaths. In Kenya, county mortality forums bring together the county leadership,
health managers, healthcare workers and development partners to synthesise qualitative andquantitative evidence on maternal and perinatal deaths and generate actions to prevent them.
Participants develop key advocacy messages that they can use to lobby county leaders toaddress the priority causes of maternal and perinatal deaths. County leaders then give focused
and actionable commitments to improve the situation. The participatory county mortality forum
is a promising strategy to institutionalize MPDSR at the county level. It empowers health workers
to demand action on persistent health system gaps, while at the same time giving leaders andpolicy makers a chance to better understand the key drivers of maternal and perinatal deaths
and priority actions to address them.

56

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Case study: Experience of Mozambique in implementing
MPDSR
Improving maternal and newborn health is a priority for the Government of Mozambique. In
2011, the MoH established Maternal, Perinatal and Neonatal deaths (MPND) review committees
at country, provincial, district and health facility levels. These committees are responsible forstudying the factors and circumstances behind maternal and newborn deaths. As a part ofthis process, appropriate tools for collecting data were developed, reproduced and distributed.
These included a notification record, a maternal and neonatal death data collection form andorientation guidelines to assist committees on how to collect, analyse and report on maternal
and neonatal deaths. The International classification of diseases for maternal mortality (ICD-10MM) was adapted and included in the orientation guidelines.
The rules and responsibilities of committees at national, provincial, district and facility levels arewell defined. The notification of all maternal and neonatal deaths occurring at health facilities ismandatory and the national committee must receive detailed information within seven days ofthe event. Although, the notification process initially started as a paper-based system, it is now
done as a part of the DHIS2 online database.
There has been good progress to date. For the first time, Mozambique is utilizing the informationand data provided by the provincial committees. Six out of the 11 provincial MPND audit
committees are reporting maternal and neonatal deaths and investigating the causes using
ICD-10 and reporting them in the HMIS systems. In 2017, the National MPND Audit Committee
produced its first annual report using routine data from the committees.
Some important lessons were also learnt from this implementation experience. First, it isessential to involve and get support from all partners to support national committees effectively.
Second, a dedicated officer is required for data management, communication and support
to the national MPND committees. Third, there needs to be ongoing technical assistance tosupport the national committees; lastly, the government needs to mobilize adequate resources
to support performance of the programme.
Some of the remaining challenges include limited availability of human resources, weak national
capacity, limited funding and resources, delayed response to gaps identified, poor follow-up ofrecommendations and the challenge of expanding these programmes to community and private
sector hospitals.

5.7.3. Improved estimates and improved input data
Work is under way to improve data on LBW babies and to develop systematic estimates. The LSHTM is
working in close coordination with WHO, UNICEF and the John Hopkins University to systematically review
LBW rate data sources, assess data quality, and refine methodologies to adjust survey-based LBW data.
National estimates and time trends will be estimated and published, with uncertainty ranges.
Registering all facility births with birth certificate and all deaths (stillbirths, neonatal and maternal deaths)
with death certificates would substantially increase data availability and timeliness. WHO is currently
coordinating work to improve stillbirth data, working with the UN Inter-agency Group for Child Mortality
Estimation and the LSHTM.

57

5.7.4. EN- INDEPTH STUDYHousehold survey data remain problematic for capturing stillbirth rates. With funding from the Children’s
Investment Fund Foundation (CIFF) and as part of The Every Newborn measurement improvement roadmap §,the EN-INDEPTH study, led by LSHTM and Makerere University School of Public Health is comparing two
household survey approaches, pregnancy history and birth history, in five sites capturing 75 000 births.
Results will be used to inform possible changes to the core Demographic and Health Survey (DHS) module.
The research has three objectives: 1) improve household survey capture of stillbirths and neonatal deaths interms of assessing pregnancy history compared to live birth history modules, 2) improve household survey
capture of birth weight and gestational age by assessing various methods for measuring these outcomes insurveys and 3) optimize the Health and Demographic Surveillance Sites (HDSS) data capture of pregnancy
outcomes (stillbirths, neonatal deaths, birth weight and gestational age) to link and compare with survey
data to examine who is missing and why.

5.7.5. Every Newborn-Birth Indicators Research for Tracking in
Hospitals (EN-BIRTH study)
EN-BIRTH is a large-scale observational research study that will capture information on 20 000 facility
births in Bangladesh, Nepal and the United Republic of Tanzania. This study is coordinated by the LSHTM,
is in line with the Ending Preventable Maternal Mortality and is a part of the Every Newborn measurement
roadmap. It aims to test validity of routine programme measurement (coverage, quality and safety) for
selected specific newborn and maternal care indicators. These indicators include: uterotonic use, Essential
Newborn Care, newborn resuscitation, KMC, treatment for neonatal infections and use of antenatal
corticosteroids. The validity of routine register records and maternal recall survey of maternal and newborncare at the time of birth will be assessed by comparison with a “gold standard” of direct observation.
Different denominator options for these coverage indicators will be compared. Content and QoC will be
evaluated focussing on timing of interventions as well as barriers and enablers to routine recording of these
indicators and the perceived utility of the data to improve decision-making, coverage and QoC at all levelsof the health system.

5.7.6 Signal functions for inpatient care of small and sick newborns
Standardized measurement of emergency obstetric care (EmOC) has improved tracking and accountability,
using indicators based on “signal functions” to monitor the availability and use of EmOC services. However,signal functions to track service readiness to provide inpatient care of small and sick newborns are notconsistently defined or routinely tracked. As an input for the ENAP metrics measurement improvement
roadmap, a global survey on signal functions and levels of inpatient care for small and sick newborns was
carried out in 2017 in collaboration with WHO, the LSHTM, Saving Newborn Lives, Save the Children,
Averting Maternal Death and Disability (AMDD) and UNICEF. The global survey was launched as a followup to an expert focus group held by the ENAP metrics group in April 2016 that identified 13 core newborninterventions that services should be ready to provide at an inpatient care level. The results of the global
survey will be available in the global report on inpatient care of small and sick newborns that will belaunched in November 2018. Signal functions for maternal health are also under revision in 2018 and 2019.

§58

The ENAP Measurement roadmap is available at: http://apps.who.int/iris/bitstream/handle/10665/184225/9789241509381_

eng.pdf;jsessionid=CB53107806057EC24C5B795CE2F64330?sequence=1

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.7.7. Mother and Newborn Information for Tracking Outcomes andResults (MONITOR)
In 2015, WHO established the technical advisory group Mother and Newborn Information for Tracking
Outcomes and Results (MoNITOR). MoNITOR is comprised of 14 independent global experts from a variety
of disciplines and regional representation, selected through a competitive process. The vision of MoNITOR
is to facilitate, harmonize and coordinate measurement and metrics for maternal and newborn health.
MoNITOR held two meetings in 2017 to review ongoing measurement efforts, map maternal and newborn
indicators and data sources, and assess gaps. Emerging issues include a lack of consistent definitions for
key indicators across varying data collection platforms. Over the next two years, MoNITOR will provide
recommendations for priority indicators, norms and standards for data collection platforms, a coordinatedresearch agenda, and will contribute to building regional capacity. WHO is also building a simpler, real-time,
integrated database for maternal and newborn indicators included in the UN Secretary-General’s Global
Strategy.

5.7.8. HMIS indicators workshop and other efforts by ENAP metrics
group
UNICEF, WHO, UNFPA, LSHTM, the Bill & Melinda Gates Foundation and USAID convened a joint workshop
on metrics for maternal and newborn care and HMIS in Kathmandu in 2017. Eighty participants from 12
countries met to discuss how existing national data systems can be improved to help end preventablematernal and newborn deaths. Robust measurement of programmes using validated indicators can help
accurately identify whether pregnant and postpartum women and their newborns are receiving effective
interventions. It can also support context-specific programming and targeted approaches that will lead tobetter programme measurement, improved tracking of progress and better evidence to support policymaking.
During the workshop, partners provided technical updates on progress on maternal and newborn metrics.
Countries shared their experience and best practices on HMIS and DHIS2 and developed follow-up actions
and monitoring and evaluation plans. Partners reaffirmed their commitment to facilitate technical assistanceto countries. A consensus was reached on a short list of MNH indicators for inclusion in HMIS, on arelevant concept note, and on next steps including further consultations by the ENAP Metrics group.
In addition, the Health Data Collaborative is developing a set of modules for strengthening routine healthinformation systems, including MNCH. The short list of maternal and newborn indicators discussed at theKathmandu workshop will be included in this module as well as recommendations for data analysis andvisualization.

59

5.8. Every Newborn milestone:
Research and innovation
A research agenda for MNH has been prioritized in 42 of the 75 countries in 2017,
compared to 28 countries in 2016. However, research on stillbirths still needs greater
traction at the country level particularly in high burden settings. In 2017, 21 countries
reported that they were conducting research focused on stillbirths compared to 14
countries in 2016 (Figure 12).

Existing
knowledge
gaps
includeeffective
interventions to prevent stillbirths, focusing on
what works in low-resource and conflict settings,
for marginalized groups in all settings, and inunderserved populations. More support andinvestment are needed in implementation researchand robust monitoring and evaluation of programme
activities, ensuring integration of stillbirth outcomesas well as other pregnancy and birth outcomes. In
high-burden settings, it is extremely important todevelop research capacity to assess the needs ofwomen and families that suffer from pregnancy andchildbirth complications including neonatal deaths
and stillbirths.

Lastly, there needs to be a better understanding of
how best to support health workers affected by careof women undergoing stillbirths.
The 2016 Lancet Stillbirth Series identified thefollowing as priority actions to prevent stillbirths:(1) intentional leadership, especially from policy
makers, which is identified as the biggest challenge,(2) increased voice, especially of women,(3) implementation of integrated interventions
with commensurate investment, (4) indicators tomeasure the effect of interventions and to monitor
programmatic progress and quality of care and(5) investigation into crucial knowledge gaps.

Figure 12. Country progress on the research agenda
42
40

28
21

30

14

20
10
0

0

10

2

0

Research focussing on
stillbirths planned by country

2014

2015

Research agenda (asreferenced in ENAP)
prioritized by country
2016

2017

5.8.1. Every Newborn- Simplified Measurement Integrating
Longitudinal Neurodevelopment & Growth (EN-SMILING)
This study follows up newborns observed in the EN-BIRTH study and exposed to newborn interventions.
Since many existing early childhood development (ECD) tools are complex and require specialists to usethem, this study will test simplified ECD tools to be applied at 3 months, 3 years and 5 years of age. The
study offers an important opportunity to answer priority questions such as child developmental outcomes
after basic resuscitation.
60

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.8.2. Estimates for Group B streptococcus published in Clinicaland Infectious diseases
A series of 11 papers (https://academic.oup.com/cid/issue/65/suppl_2) were published in the Clinical andInfectious diseases journal funded by a grant from the Bill & Melinda Gates Foundation. The researchers
found that Group B Streptococcus (GBS) is present among pregnant women in all regions of the world, with21.7 million pregnant women colonized worldwide. This translates to a global average of 18%, or nearly
one in five pregnant women, most of whom are unidentified and untreated. Regionally, this ranges from
11% in eastern Asia to up to 35% in the Caribbean. In 2015, the highest numbers of colonized pregnant
women were found in India (2.5 million), China (1.9 million), Nigeria (1.1 million), the USA (0.9 million)
and Indonesia (0.8 million). There are multiple GBS-related health outcomes, for women themselves aswell as infants including, stillbirth, neurodevelopmental impairment, prematurity, neonatal sepsis, neonatal
encephalopathy and neonatal death.
These are the first-ever estimates of the worldwide burden of GBS infection in pregnant women. This work
has more than doubled previously available data, through comprehensive systematic reviews as well as
the use of previously unpublished data from collaborators worldwide. Gaps remain, notably for stillbirths(especially in Asia), disability (especially after GBS sepsis), and maternal GBS disease. Evidence of theassociation of preterm births with maternal GBS colonization also needs further work.
Currently, GBS prevention focuses on providing antibiotics to women in labour, aiming to reduce early onset
infections in newborns. At least 60 countries have a policy for this, however, implementation varies aroundthe world and would not be feasible for many low-income countries where the burden is highest. There issome modelling to suggest that a GBS maternal vaccination with 80% efficacy and 90% global coverage
could prevent 231 000 infant and maternal GBS cases, 41 000 stillbirths and 66 000 infant deaths annually.
Work is planned to develop an effective maternal GBS vaccine and a comprehensive evaluation of costeffectiveness.

61

5.8.3. PREgnancy Care Integrating translational Science
Everywhere (PRECISE) network
PRECISE is a collaborative network of researchers, policy actors and advocates for the global women andchildren’s health community. The Network is funded by the Research Council UK Global Challenge ResearchFund, and aims to build global, interdisciplinary research and policy partnerships to better understandplacental disorders of pregnancy, in particular hypertension, foetal growth restriction and stillbirth.
The first phase of PRECISE will establish a cohort of 12 000 pregnant women in the Gambia, Kenya
and Mozambique. Biological samples and information about the women’s lives, contexts and stories will
provide a unique and holistic data set that will be analysed to inform future research questions, clinical andcommunity interventions and evidence-based policy to improve their lives.
The primary objectives of PRECISE are to:• Develop a unique cohort of pregnancies affected by placental disease and assess the prevalence of these
disorders in women attending antenatal care in centres representative of urban and rural communities
in three sub-Saharan African countries;• Develop cohorts of women with normal pregnancies, and non-pregnant women of reproductive age, forcomparison;• Investigate sociocultural and health system barriers preventing access, effective management and carepathways;• Investigate the potential for introducing novel methods to assist with diagnosis and management ofplacental disorders in sub-Saharan Africa;• Support skills and capacity development for researchers and institutions collaborating in The PRECISE
network.

5.8.4 Child Health and Mortality Prevention Surveillance (CHAMPS)
There is limited information about the specific causes of neonatal and under-five mortality in high-mortality
geographic regions, due largely to a lack of primary data and dependence on inaccurate tools such asverbal autopsy. Better approaches are needed to determine specific causes of death so that prevention
and treatment interventions can be strengthened and focused. Minimally invasive tissue sampling (MITS)
is a technique that uses needle-based post-mortem sampling, followed by advanced histopathology andmicrobiology to definitely determine cause of death.
The Bill & Melinda Gates Foundation is supporting a new surveillance system called the Child Health andMortality Prevention Surveillance (CHAMPS) network, which will determine causes of death using MITS
in combination with other information, and yield cause-specific population-based mortality rates in up
to 15 sites in sub-Saharan Africa and south Asia. [35] Each site will determine the causes of childhood
death using MITS, verbal autopsies and medical record abstractions, within demographically defined
populations. Comprehensive anthropological work will be carried out to promote community engagement
and sensitization, and to increase the likelihood that MITS is welcomed by the communities and healthcare
providers, as well as religious, cultural, and political leaders.

62

Staff of the MoH and/or National Public Health Institute at each CHAMPS site will be engaged in implementation,
analysis, and reporting to maximize the use of evidence for public health policy decision-making. Local
laboratory and pathology capacity will be built and supported to enable long-term sustainability andexpansion. Protocols will be standardized across sites, and data will be uploaded to cloud-based servers
for rapid dissemination. In addition, CHAMPS seeks to integrate with existing surveillance by aligning
protocols and combining data with complementary systems, such as sample registration systems and
HMIS to provide a current, comprehensive, and statistically valid view of childhood mortality. CHAMPS iscoordinated by Emory University in association with the International Association of National Public HealthInstitutes, U.S. Centers for Disease Control and Prevention, and the Public Health Informatics Institute of
the Task Force for Global Health.

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONESBEMPU Hypothermia alert device
Hypothermia is an important cause of neonatal deaths. The Hypothermia Alert Device is a band worn on theinfant’s wrist for the first four weeks after discharge from the hospital. . The bracelet alarm signals low bodytemperature. As part of the education around the innovation, parents are taught how to respond to the lowtemperature through KMC. If the device continues to alarm despite KMC, the parents are instructed to seek
medical attention. The current cost of the device is approximately US$ 29.
Independent evaluations of the BEMPU are being carried out by the Government of Papua New Guinea
and by UNICEF Benin. These assess KMC performance and careseeking behaviour (seeking early clinicalattention and adherence to hospital follow-up) in low birth-weight and preterm neonates, as well as healthoutcomes at four weeks post-discharge (weight, length, head circumference, hospital admission, death).
Several states in India will also pilot the device.

63

Case study on implementation of the bubble continuous positive
airway pressure (bCPAP) in Malawi
Malawi has the world’s highest estimated preterm birth rate, with nearly 1 in 5 babies born before 37 weeks
of gestation.[36] However, the solutions needed to address complications associated with prematurity areoften unavailable due to technical complexity and prohibitive costs. Through the collaborative efforts ofRice University in Texas, USA, and the Queen Elizabeth Central Hospital in Blantyre, Malawi, a low-cost
bubble continuous positive airway pressure (bCPAP) device was developed to address the high mortality innewborns attributed to respiratory distress.
After encouraging results from a clinical trial in 2012 at the Queen Elizabeth Central Hospital[37] and withfunding from USAID and ELMA Philanthropies, the device has been rolled out to 36 district, central
and mission hospitals across the country under the guidance of the MoH. The implementation process
comprises training, mentorship, supervision, technical support, monitoring and evaluation to ensure thatclinical users are conversant with the administering of bCPAP therapy and that biomedical technicians onsite have the capacity to maintain and repair the devices.
With the introduction of bCPAP, health workers in Malawi now have a more clinically effective alternative to
low-flow nasal oxygen therapy, which is the standard of care for newborns in respiratory distress in most lowresource settings. Preliminary evaluations revealed that despite the countrywide availability of the life-saving
technology, there remained significant gaps in the health system’s overall capacity to effectively improvenewborn outcomes. Gaps included the lack of conducive spaces for the care of sick newborns, a lack ofessential newborn technologies to address other complications such as jaundice and hypothermia, as well
as staffing shortages and high turnover rates. Recent efforts have supplemented bCPAP implementation
with the provision of separate and equipped spaces to treat sick newborns, improved newborn careguidelines and protocols, and increased allocation of staff to neonatal units. To ensure sustainability of
the learning process, bCPAP has been integrated into pre-service training in 15 of Malawi’s leading healthtraining institutions.
By the end of 2017, 3629 babies had benefitted from the bCPAP device, 1035 health workers had been
trained and mentored on the management of babies on bCPAP, and 70 technicians were trained on themaintenance of bCPAP and other essential equipment. The launch of Malawi’s ENAP has generated
growing interest in innovative strategies to improve the management of sick newborns, including but notlimited to bCPAP.

64

A nurse at the Queen Elizabeth Central Hospital putting a baby on bCPAP

Nursing students at the Kamuzu College of Nursing undergoing bCPAP
pre-service training

Neonatal unit in a district hospital before renovations

Neonatal unit in a district hospital after renovations

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

5.8.5 Other newborn health research conducted by the World
Health Organization
WHO has a broad research agenda on priorities to improve the quality of care for every woman and every child.
An evidence map on social, behavioural and community engagement interventions for RMNCH was completed
and disseminated in 2018, and work is ongoing to define priorities for MNCH research in humanitarian settings.
Other research includes the Alliance for Maternal and Newborn Health Improvement (AMANHI) bio repository
study, an Antenatal corticosteroids (ANCS) trial, the Early intervention for optimal linear growth and development
trial, the Enhanced management of pneumonia in community (EMPIC) study, the Healthy Life Trajectories
Initiative (HeLTI), , and studies on Improved management of high-risk pregnancies, Improving quality of carefor mothers and newborns, Possible serious bacterial infection (PSBI) and Primary prevention parameters
evaluation (PREPARE).
The World Health Organization has also initiated several studies to bridge some of the evidence gaps aroundKangaroo Mother care and improve quality of care for every newborn. These include:• Scale up KMC study: KMC coverage remains dismally low globally. To address this, the WHO Scale up KMC
study involves 7 populations of about a million each in different geographic regions of Ethiopia and India. It aims tounderstand barriers to KMC implementation and addresses them systematically. The goal is to develop the bestmodel to ensure implementation of facility initiated KMC at scale to reach population coverage of at least 80%.
• Immediate KMC (iKMC) Study: Most previous studies initiated KMC only after the newborns were stablewith the average age at initiation >3 days. The iKMC study is a large individually randomized controlled
trial in Ghana, India, Malawi, Tanzania and Nigeria (sample size 4200) to study the efficacy of KMC initiatedimmediately after birth, including in unstable LBW babies (1 to 1.8 kg) in reducing neonatal mortality.
• Community initiated KMC (cKMC) Study: There has been considerable interest in KMC initiated outside
health facilities for LBW babies born at home or discharged early. Currently, there is insufficient evidence
to support initiation of KMC in the community. The cKMC study is a big (sample size 10500) individuallyrandomized controlled trial in Haryana, India to study the impact of KMC initiated at home in LBW infants<48 hours old on mortality at 1 and 6 months. The early learnings form the study shows almost universal
acceptance with average KMC duration of about 9.5 hours per day.

5.8.6 Research on midwifery
International maternal and newborn health stakeholders, in collaboration with WHO and the global Partnershipfor Maternal, Newborn, and Child Health (PMNCH) have used the Child Health and Nutrition Research Initiative(CHNRI) process to identify the following three maternal and newborn research priorities arising from the Lancet
Series on Midwifery†, that hold the potential to improve the quality of care for every woman and every child‡.
1. Evaluate the effectiveness of midwifery care as defined by the Quality Maternal & Newborn Care Frameworkand the contribution of its components, when compared to other models of care across various settings,
particularly on rates of maternal/foetal/infant death, preterm birth, and low birth weight, and access to andacceptability of family planning services.
2. Identify and describe aspects of care that optimize, and those that disturb, the biological/physiological processes
for healthy childbearing women and fetus/newborn infants and those who experience complications.
3. Determine which indicators, measures, and benchmarks are most valuable in assessing quality maternal andnewborn care across settings, including the views of women, and develop new ones to address identified gaps.
A meeting of researchers was held at Ryerson University, Canada in 2017 to begin developing concepts
for the specific research need to address each priority. These concepts were discussed during a technicalconsultation on midwifery convened by WHO. Global leaders, practitioners, researchers, advocates andfunders strategized the next steps towards implementing the research.

†
Kennedy HP, Yoshida S, Costello A, Declercq E, Dias MA, Duff E, Gherissi A, Kaufman K, McConville F, McFadden A, Michel-Schuldt M. Asking different
questions: research priorities to improve the quality of care for every woman, every child. The Lancet Global Health. 2016 Nov 1;4(11):e777-9.
‡

The Lancet midwifery series is available at http://www.thelancet.com/series/midwifery

65

6. Regional and global support tocountries to accelerate progress
towards Ever y Newborn 2020
milestones
Support provided at the regional and global levels includes an interagency meeting to share experiences andupdated tools, advocacy at the global level, accountability, and technical assistance.

6.1. Interagency meeting on
neonatal health for the Easternand Southern Africa Region
UNICEF, WHO, USAID and partners convened aregional meeting on newborn health in Entebbe,
Uganda in September 2017. The four-day meetingbrought together 103 participants from twenty
countries including the fragile states of Somalia andSouth Sudan.
The technical sessions spanned topics relevant
to MNH in the region: updated WHO guidelines,
quality of care, clinical mentoring, birth registration,
advocacy and community engagement, sicknewborn care, surveillance of birth defects, perinatal
death reviews and newborn care in emergency
settings. Of particular interest were a panel
discussion on KMC, the country poster session anda market place that introduced new technologies
and approaches such as the Hypothermia alert
device wristband and training devices such as
Mama Birthie. Country group work sessions
allowed participants to identify country-specificchallenges and opportunities for prioritizing action
for newborn survival and develop draft operational
plans. Further information regarding this meeting isavailable at www.healthynewbornnetwork.org/blog/
regional-interagency-meeting-neonatal-health-eastsouthern-africa-region/.

6.2. Global advocacy efforts
The UN Secretary-General’s Global Strategy for
Women’s, Children’s and Adolescents’ Health(2016–2030) calls for accelerated progress,
increased commitments and better alignment
across sectors and among partners. To ensure
strongermutualaccountability
mechanisms,
partners developed the 2020 Every Women Every
Child Partners’ Framework. This covers six focus
areas: quality, equity, dignity (QED) in services,
early childhood development, adolescents’ health66

and well-being, sexual and reproductive healthand rights, empowerment of women, girls andcommunities, humanitarian and fragile settings.
The framework was endorsed unanimously by theHigh-Level Steering Group in April 2017. Advocacy
roadmaps have been developed for each focus
area,** with measurable milestones to be monitored
through the Unified Accountability Framework.
While newborn health cuts across the focus areas,
the Every Newborn partnership has primarily been
engaged in the development of QED, which iscommitted to ensuring that all women, children
and adolescents in all settings have equal accessto quality, affordable and respectful health careand services. This provides an important platform
for advocacy and programming, particularly in thepartnership’s efforts to support the Network for
Improving Quality of Care for Maternal, Newborn
and Child Health †† (www.qualityofcarenetwork.
org), the development of costed national plansto achieve universal coverage of essential healthservices for women, children and adolescents andthe promotion of respectful care in all settings.

6.3. Accountability efforts
EWEC has mobilized continued support fromgovernments and nongovernmental stakeholders,
and their 2017 progress report ‡‡ shows thatcommitments
haveincreased
since
2015.
These commitments may be financial, in-kind or
shared value interventions (for example policy
or advocacy). Between September 2015 andDecember 2016, the 215 commitments made to
the EWEC Global Strategy totalled US$ 28.4 billion(excluding the value of non-financial commitments,
which is considerable but difficult to quantify).
Commitments by LMICs reached an estimated
US$ 8.5 billion – more than half the sum committed
by high-income countries. Of all commitments, 42%referenced newborn health or mortality and 5%
referenced stillbirth specifically.

** http://www.everywomaneverychild.org/advocacy-roadmaps/††
QUALITY, EQUITY, DIGNITY Launch of the Network to improve Quality of Care for Mothers, Newborns and Children 14 – 16 		
February 2017. http://www.who.int/pmnch/media/events/2017/lilongwe_conceptnote.pdf?ua=1‡‡
http://www.who.int/pmnch/activities/advocacy/globalstrategy/2016_2030/gspr/en/index2.html

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

6.4. Technical assistance requests
Figure 13 shows the various types of technical assistance (TA) requests submitted by countries to the
ENAP working group. The greatest proportion of requests concerned the development of plans, policies,
costed plans and investment cases for MNH (30%). This is followed by requests for assistance on QoC(28%), for example conducting QoC assessments, developing guidelines and action plans, training on
PDSA cycles, quality improvement approaches at facilities, development of indicators for outpatient andinpatient obstetric and neonatal care, establishment of quality assurance systems, and adaptation of
paediatric quality assessment tools and standards. There were 17 requests from countries for help onhuman resources for maternal and newborn health (24%), including in-service and pre-service training
on MNH, developing appropriate training materials and conducting training of trainers. There were 13
technical assistance requests to support MPDSR work in countries (18%).

Figure 13. Technical assistance requests for newborn health

24%

30%

Development of plans, policies andcosting, investment cases
Quality of care for MNH
Maternal, perinatal deathsurveillance and response

18%

Human resource, trainings andother requirement for MNH

28%

Additional TA requests for specific topics are shown in Figure 14. Most of these requests concerned early
essential newborn care and KMC (43%). Assistance on other newborn-specific interventions such as PSBI,
infection presentation, chlorhexidine and specialized topics in neonatology comprised 18% of the requests.
The third most frequent request was on research and innovation (13%) to identify research priorities for
MNH, operations research on newborn health, development of costed research plans and strengthening
national capacity for research on newborn health.

Figure 14. Technical assistance requests on newborn interventions

13%

5%

Newborn specific interventions(ENC and KMC)

41%

11%

Other newborn specific interventions(PSBI protocols, CHX, IPC, PMTCT,
Obstetric and neonatology related
Research and Innovations
Nutrition related activities

12%

M&E and HMIS related

18%

LMIS related activities677. Emerging areas
Topics of new or increased focus include early childhood development, surveillance of birth defects, Zika virus
disease and newborn care in humanitarian settings.

7.1. Early childhood
development
Children that get nurturing care reach their fullpotential, are healthier, have better growth andachieve better grades at school. It is essential that
all countries, particularly low-income countries
that suffer disproportionately from the burden ofunfulfilled human potential, prioritize investments inearly childhood development.
Services provided by health workers during themother’s pregnancy and the first three years of achild’s life are appropriate channels to address
ECD. During antenatal care visits, health workers
can help to ensure that pregnant women are getting
adequate nutrition to support brain development.
Giving birth with the assistance of trained healthworkers at facilities that offer good quality services
can reduce the risk of complications. Early initiationof breastfeeding and exclusive breastfeeding for six
months supports a child’s mental development.
The way mothers, fathers and other caregivers
nurture and support children in the early years isamong the most decisive factors for healthy childdevelopment, with lifelong and intergenerational
benefits for health, productivity and social cohesion.
Nurturing care means providing stable environmentthat ensures children’s good health and nutrition,
protects them from threats, and gives opportunities
for early learning, through interactions that areemotionally supportive and responsive. Contacts
with health services, such immunization visits,
can be opportunities for promoting nurturing care;other sectors, including nutrition, education, social
welfare and child protection sectors also have a roleto play. WHO and UNICEF, in collaboration with the
PMNCH, the ECD Action Network (ECDAN) andothers, are leading a process to develop a Nurturing
Care Framework for early childhood development.

7.2. Surveillance of birth defects
Because neonatal mortality due to infections andbirth asphyxia is decreasing, the relative contributionof congenital defects to death and disability is
growing. There is limited availability of reliable,
nationally representative data on birth defects, thus
the burden of birth defects in countries remains
largely unknown. Surveillance of birth defects will68

help identify the occurrence and factors associatedwith birth defects and put in place interventions
to address those that are preventable.
Suchinterventions include vaccination against rubella,testing and treatment for syphilis in pregnancy,and folic acid supplementation before and during
pregnancy.

7.3. Zika virus disease
The Zika virus affected 75 countries in Africa, Asia,
Latin America and the Caribbean, and continues tothreaten the well-being of women and children. It
is primarily transmitted by the Aedes mosquito, but
sexual transmission also occurs. Climate change,
weather phenomena and natural disasters arethought to contribute to outbreaks. There is now
consensus that Zika virus is a cause of microcephaly
and the Guillain-Barré syndrome. Links to otherneurological complications and long-term effects
are being investigated.
Protection against mosquito bites is a key means ofpreventing Zika virus infection. Travellers and thoseliving in affected areas should protect themselvesfrom mosquito bites. Special attention and help
should be given to those who may not be able toprotect themselves adequately, such as young
children. WHO recommends that sexually active
men and women be appropriately counselled andoffered a full range of contraceptive methods, inorder to make an informed choice about whether
and when to become pregnant and to prevent
possible adverse pregnancy and foetal outcomes.
In 2016, WHO declared an end to the international
Zika emergency. However, the world needs to remain
vigilant on efforts to control Zika virus. Crucial
questions remain unanswered, particularly related
to the safety of pregnant women and neonates after
Zika virus infection.

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

7.4 Newborn care in
humanitarian settings
Despite improvements in newborn health globally,
relatively poor outcomes persist in countries plaguedby conflict or political instability. Newborn healthservices are often neglected during humanitariancrises and are largely missing from emergency
response assessments, supply kits, intervention
packages, and monitoring efforts.
The particular vulnerability of women and children
during humanitarian crises indicates that maternal
and newborn health services should be one of thefirst priorities. Setting up temporary health outposts
or facilities as close as possible to the crisis affected
communities may be the only option. Other potential
strategies include using mobile health units to reachpregnant and recently-delivered women and theirnewborns or using community health workers thatmake household visits when the security situation
allows. Health workers should be provided with the
supplies, commodities and equipment they need inorder to provide essential newborn care to every

newborn, and high-quality and timely treatment tosmall and sick neonates. Workers should be trained
to recognize danger signs, treat life-threatening
newborn conditions to the greatest extent possible,
and transfer women and newborns to referral
facilities (or hospitals) when possible.
Integrating newborn care into a humanitarian
response plan requires prioritization, planning andpersistence on the part of the government andpartners. Training on newborn health must bepractical, and management of common neonatal
conditions should be incorporated in other training
curricula such as IMCI, Safe Motherhood andintegrated Community Case Management. There
are a range of resources available at the global
level which can be used in such contexts. These
include Newborn Health in Humanitarian Settings:
Field Guide, the Minimum Initial Service Package
for Reproductive Health in Crisis Situations (MISP)
and the Inter-Agency field manual For Reproductive
Health in Crisis Situations (IAFM).

69

8. Discussion
The increased uptake of the Every Newborn Tracking
Tool, 75 countries in 2017 as compared to ten
in 2015, is encouraging. Progress is noted in allreported areas with a few exceptions where global
guidance and consensus building need more effort.
The launch of the Network for Improving Quality ofCare for Maternal, Newborn and Child Health hasprovided an additional opportunity for all countries tobenefit from mutual learning and available resources
for implementing WHO standards on maternal andnewborn health. With two years remaining to reach
ENAP targets for 2020, countries need to further
intensify their actions. The coverage of evidencebased key interventions (antenatal corticosteroids,
resuscitation, management of infections, KMC andinpatient care of small and sick newborns) as wellas rates of postnatal care and early initiation ofbreastfeeding need to be improved. This will require
renewed political attention at the global, regional andnational levels.
The number of countries reporting having included
a newborn component in their emergency
preparedness plans has increased but remains very
low. Urgent attention is needed to disseminate andimplement Newborn Health in Humanitarian Settings:
Field Guide, and to build the capacity of humanitarian
actors.
With country ENAP plans and budgets in place,further efforts are required to ensure adequate
resource mobilization and financing. Countries arealso encouraged to assess whether they are making
progress towards achieving national targets set for
2020.
The Every Newborn Tracking Tool will be progressively
replaced by an increased focus on results monitoring.
A simplified tool for country reporting in 2018
can be found in Annex 1, and a list of suggested
indicators for HMIS reporting can be found in Annex
3. Measurement improvements should focus on
strengthening country vital statistics at both central
and decentralized levels, understanding what drives
changes in coverage and obtaining better data on
perinatal and neonatal deaths. Achieving the SDG
mortality targets will also require investments totarget those families most at risk, including theincreasing proportion of newborn deaths occurring infragile humanitarian settings. To address inequities,
political commitment is crucial. Programmes willneed to understand underlying issues and barriersand determine the best equity strategies to target
underserved areas and groups.
70

Research efforts need to focus on improving
understanding of the causes of maternal, perinatal andneonatal deaths. This also includes the developmentof new interventions and context-specific approaches
to preventing mortality and morbidity. Implementation
research in countries is needed to improve quality ofcare at birth, prevent stillbirths and care for small andsick newborns.
Substantial weaknesses have been noted in national
HMIS data, including data that is incomplete or ofpoor quality, data duplication and overload, gaps
in data management and lack of utilization. Hencenational and subnational information systems need to
be strengthened considerably, particularly as a partof results-based financing and mechanisms such as
the GFF for quality improvement.
As the risk factors are similar for maternal, perinatal
and neonatal deaths, and they tend to occur within thesame time frame (around the time of birth), integrationof maternal and newborn health interventions along
the continuum of care is logical. Successful andfeasible interventions are well-known, however, much
more attention is needed to ensure the coverage andthe quality of obstetric and neonatal care services(especially for the sick and small newborn). Althoughchallenges vary amongst countries, a multi-faceted,health-systems approach supported by an enabling
policy environment holds promise.
Accountability efforts have received increasing
attention and ensuring accountability for the provisionof quality care should remain central in programmaticefforts. Mechanisms at the global level such as the
UN Secretary-General’s Global Strategy for Women’s,
Children’s and Adolescents’ Health and the seriesof Countdown reports have proven to be useful intracking progress and identifying inequities andgaps. At the national level, stakeholders including
civil society, independent researchers, academics,
champions and influential persons need to exert
continuous pressure and work with government toensure the provision of high-quality services. These
accountability efforts will be strengthened whencombined with local outreach and civil society
activities such as citizens’ reports cards and public
hearings that help draw attention to the performanceof the health sector.
An important factor in changing the trajectory of
newborn survival is access to the most recent dataon neonatal mortality, coverage of interventions,funding trends and human resources. The Numbers

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

page (https://www.healthynewbornnetwork.org/
numbers/) of the Healthy Newborn Network aims
to improve the understanding and use of data inmaking decisions about strategic newborn healthinterventions. It provides a central location of themost recently published data relating to newborn
survival and health, including mortality estimates,
causes of death, coverage, contextual indicators,
human resources and financing indicators. Numbers
provides a comprehensive database that can be
downloaded with an extensive list of indicators for
197 countries. It also includes an interactive toolfor data visualization that allows users to easily andquickly make graphs. The multi-dimension query
functionality of the tool makes it easy to selectmultiple indicators and countries. The heat maps
visually demonstrate cross-country comparisons of
indicators across countries. Easy access to suchdata by health workers, public health practitioners
and researchers in high-burden countries will be
crucial for ensuring data-driven decision making,accountability and progress towards newborn healthtargets.

Inadequate financing for health systems is a common
bottleneck in low-income settings. A strong healthsystem depends upon numerous factors suchas trained and motivated health workers, a wellmaintained infrastructure and a reliable supply of
medicines and technologies. These must be backed
by adequate funding, strong health plans andevidence-based policies. Specific budget lines formaternal health, newborn health and stillbirths areoften missing from national and subnational healthbudgets, and care for small and sick newborns israre in financial protection schemes. Strong politicalcommitment can ensure that the limited resourcesthat do exist are invested judiciously to build strong
health systems that prioritize MNH.
The GFF is one of several initiatives designed tosupport efforts to ensure dedicated investments for
RMNCAH. Improving stillbirths, maternal health andnewborn health by strengthening health systems mustbe central in investment cases for GFF support in
high-burden countries. The GFF can play a catalyticrole in bringing together multiple financing sources formaternal and newborn health in a synergistic, countryled way that closes the funding gap for maternal
health, newborn health and stillbirths by 2030.

71

Acknowledgements
Writing: This report was written by Dr Gaurav Sharma and Dr Nabila Zaka. We are grateful to colleagues who
contributed content to this report: ministries of health, the headquarters, regional and country offices of WHO and
UNICEF, UNFPA, the World Bank, USAID, USAID’s Maternal and Child Survival Program, Every Preemie Scale,
Global Alliance to Prevent Prematurity and Stillbirth, London School of Hygiene and Tropical Medicine, Makerere
University, the All India Institute for Medical Science, Save the Children, World Vision and the members of the Every
Newborn Management Team.
Editing: Cathy Wolfheim
Design and Layout: Simon Paton and Miracle Interactive, Cape Town
Photo credits: UNICEF, Save the Children, Rice University and USAID

72

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Annexes
Annex 1: Simplified progress tracking tool for 2018 reporting
ENAP
SIMPLIFIED COUNTRY IMPLEMENTATION TRACKING TOOLCountry name:Partner completing the form: (Name, Agency):
Date Form completed (dd/mm/yyyy):
Date Form submitted (dd/mm/yyyy):
SECTION 1: COUNTRY CONTEXTNo.

Question

Response

100

Ministry of Health focal point
for newborn health?

Yes............................................................. 1No............................................................. 0

101

102

103

Is there a Ministry of Healthfocal point for newborn healthat sub-national level?
Is there a national technicalworking group for maternal
and newborn health?

How often does the national
technical working group meet?

Skip

Yes

............................................................. 1No............................................................. 0

Maternal health only....................................... 1

Newborn health only....................................... 2

Maternal and newborn
health only....................................... 3

SRMNACH combined....................................... 4

No technical working
group....................................... 0

Other....................................... 8

Monthly.................................................. 1

Twice a Year.................................................. 2

Annually.................................................. 3

Other (Specify).................................................. 8201

SECTION 2: EVERY NEWBORN 2020 NATIONAL MILESTONES
National Plans
No.

Question

Response

201

Does your country have a
National Newborn Action
Plan?

Yes

202

Date of finalization

Skip.......................................................... 1

In Process .......................................................... 2No.......................................................... 0203__ __ / __ __ __ __M M/ Y Y Y Y

203Is the National Newborn
Action Plan integrated with a
Reproductive and Maternal
Health National Plan?

Yes............................................................. 1No............................................................. 0

73

No.

Question

Response

204

Does your country have anadequately strengthened
RMNCAH strategy/plan for
implementation at scalewith focus on maternal andnewborn health?

Yes

Date of finalization__ __ / __ __ __ __

205

Skip
.......................................................... 1

In Process .......................................................... 2No.......................................................... 0206

M M/ Y Y Y Y

206

207

208

209

210

211

212

213

214

Was the National plan
formulated in coordination withother sectors?

YesNo.......................................................... 0

Does the national plan
mandate community
participation in decisionmaking, delivery of healthservices, and monitoring andevaluation?

Yes.......................................................... 1No.......................................................... 0

Has the national plan beencosted and budgeted?

Yes.......................................................... 1No.......................................................... 0

Have funds been expended tosupport the national plan?

Yes.......................................................... 1No.......................................................... 0

Does the country have subnational newborn action
plan/s?

Yes.......................................................... 1No.......................................................... 0

At what level are the subnational newborn action
plan/s?

Provincial.............................................. 1

State.............................................. 2

Urban.............................................. 3

Municipality.............................................. 4

Other.............................................. 8.......................................................... 1

In Process .......................................................... 2

In Process .......................................................... 2

Have the sub-national
newborn action plans beencosted/budgeted?

Yes.......................................................... 1No.......................................................... 0

Does your country hold routine
national health sector reviews
that include maternal andnewborn programs?

Yes.......................................................... 1No.......................................................... 0

Do these reviews include
broad stakeholder
participation, including civilsociety organizations?

Yes.......................................................... 1

In Process .......................................................... 2216

In Process .......................................................... 2No.......................................................... 0

Quality of Care

74

No.

Question

Response

215

Does your country have a
National Quality improvement
program or initiative?

Yes

Skip
.......................................................... 1

In Process .......................................................... 2No.......................................................... 0

218

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

No.

Question

Response

Skip

216

Date of finalization__ __ / __ __ __ __M M/ Y Y Y Y

217

218

219

220

Does this National Quality
Improvement program orinitiative include maternal andnewborn health?

Maternal health only....................................... 1

Newborn health only....................................... 2

Maternal and newborn
health only....................................... 3

SRMNACH combined....................................... 4

Other....................................... 8

List key elements that are
relevant to maternal andnewborn health1.

Does your country havenational quality improvement
guidelines for maternal andnewborn health?

Yes

Date of finalization__ __ / __ __ __ __2.
3.
.......................................................... 1

In Process .......................................................... 2No.......................................................... 0

221

M M/ Y Y Y Y

221Does your country have amaternal death surveillance
and response system in place?

Yes.......................................................... 1

In Process .......................................................... 2
No

222

Number of facilities conducting __________
routine reviews

223

Total number of facilities__________

224

Does your country have aperinatal death review system
in place?

Yes.......................................................... 0.......................................................... 1

In Process .......................................................... 2No.......................................................... 0.......................................................... 1

225

Number of facilities conducting
routine reviews

226

Total number of facilities

227

Does your country hold routine
national health sector reviews
that include maternal andnewborn programs?

YesNo.......................................................... 0

Do these reviews include
broad stakeholder
participation, including civilsociety organizations?

Yes.......................................................... 1

228

224

In Process .......................................................... 2

227

229

In Process .......................................................... 2No.......................................................... 0

Investment in Health Workforce and Health Workforce Capacity and Support
No.

Question

Response

229

Does your country have apolicy in place for adequate
skilled health workers formaternal and newborn healthaccording to global standards?

Yes

Skip
.......................................................... 1

In Process .......................................................... 2No.......................................................... 0

232

75

No.

Question

Response

Skip

230

Date of finalization__ __ / __ __ __ __M M/ Y Y Y Y

231

232

List key elements that are
relevant to maternal andnewborn health1.

Does your country have apolicy in place for adequate
skilled health workers formaternal and newborn healthaccording to global standards?

Yes

2.
3.
.......................................................... 1

In Process .......................................................... 2No.......................................................... 0

Community Engagement and Parents’ Voices and Champions
No.

Question

Response

233

Does your country havea national advocacy/communication strategy formaternal and newborn health?

Maternal only....................................... 1

Newborn only....................................... 2

Maternal and newborn....................................... 3

No Strategy....................................... 0

List key elements that are
relevant to maternal andnewborn health1.

Does your country havea national community
engagement / mobilization
strategy in place for maternal
and newborn health?

Maternal only....................................... 1

Newborn only....................................... 2

Maternal and newborn....................................... 3

No Strategy....................................... 0

List key elements that are
relevant to maternal andnewborn health

1.

No.

Question

Response

237

Does the national HMIS
include an indicator for use ofantenatal corticosteroids for
foetal lung maturation?

Yes
No.......................................................... 0

Does the national HMIS
include an indicator for
newborn resuscitation
performed?

Yes.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for
newborns that benefited from
KMC?

Yes

.......................................................... 1

234

235

236

Skip

235

2.
3.

237

2.
3.

Data

238

239

76

Skip
.......................................................... 1

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2No.......................................................... 0

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

No.

Question

Response

240

Does the national HMIS
include an indicator fortreatment of neonatal sepsis?

YesNo.......................................................... 0

Does the national HMIS
include an indicator on
newborns with documented
birth weight?

Yes.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for predischarge neonatal mortality
rate?

Yes

.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for
newborn deaths by cause
using ICD-PM?

Yes.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for
immediate breastfeeding?

Yes.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for low
birthweight?

Yes.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for
preterm birth?

Yes.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for content
of pre-discharge postnatal
care?

Yes

.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for birth
registration?

Yes.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator forneonatal death registration
with Civil registrar?

Yes.......................................................... 1No.......................................................... 0

Does the national HMIS
include an indicator for
perinatal death reviews?

Yes.......................................................... 1

241

242

243

244

245

246

247

248

249

250

Skip
.......................................................... 1

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2

In Process .......................................................... 2No.......................................................... 0

Research and Innovation
No.

Question

Response

251

Does your country have aprioritized research agenda for
newborn health?

Yes

Skip
.......................................................... 1

In Process .......................................................... 2No.......................................................... 0

254

77

No.

Question

Response252

Status of process

Identification.......................................... 1

Development/review.......................................... 2

Implementation.......................................... 3

Dissemination.......................................... 4253

Does the research agenda
include issues related tostillbirths?

Skip

Yes

.......................................................... 1No.......................................................... 0

Health Financing
No.

Question

Response

254

Does your country have freematernal care policy in place?

Yes

255

Does your country have freenewborn care policy in place?

257

258

259

.......................................................... 1

In Process .......................................................... 2No.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
No

256

Skip

.......................................................... 0

Is this a stand-alone policy or
integrated with free maternal
care?

Standalone....................................................... 1

Integrated....................................................... 2

Other....................................................... 8

Does your country havenational health insurance formaternal and newborn care?

Maternal only....................................... 1

Newborn only....................................... 2

Both Maternal andnewborn....................................... 3

No national healthinsurance....................................... 0

Does the national healthinsurance include sicknewborns?
Date of finalization

Yes.......................................................... 1No.......................................................... 0

257

260

__ __ / __ __ __ __M M/ Y Y Y Y

Commodities
No.

Question

260

Are the following life-saving maternal and newborn health commodities included in the
National Essential Medicines List (NEML)?

ResponseA

Oxytocin

Yes

Skip

.......................................................... 1

In Process .......................................................... 2
B

MisoprostolNo.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
C

Magnesium sulfateNo.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2No78.......................................................... 0

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

No.

Question

Response

D

Injectable antibiotics

Yes

Skip
.......................................................... 1

In Process .......................................................... 2
E

Antenatal corticosteroids

No.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
F

ChlorhexidineNo.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
G

Newborn resuscitation (Ambu
bag and Mask)

No.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2No.......................................................... 0261

Does your country have a Logistics Management Information System (LMIS) for the following
life-saving MNH commodities?

A

OxytocinYes.......................................................... 1

In Process .......................................................... 2
B

MisoprostolNo.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
C

Magnesium sulfateNo.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
D

Injectable antibioticsNo.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
E

Antenatal corticosteroids

No.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
F

ChlorhexidineNo.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2
G

Newborn resuscitation (Ambu
bag and Mask)

No.......................................................... 0

Yes.......................................................... 1

In Process .......................................................... 2No.......................................................... 0

Additional Comments

79Country

Afghanistan

AngolaArmenia

Azerbaijan

Bangladesh

Benin

BhutanBotswana

Burkina Faso

BurundiCameroon

Chad

China

Comoros

Cote d’Ivoire

Djibouti

DRC

Egypt

Eritrea

Ethiopia

GambiaGeorgia

Ghana

GuineaGuinea-Bissau

India

Indonesia

Iran

Iraq

JordanKazakhstan

Kenya

Kyrgystan

LebanonLesothoLiberia

Libya

Madagascar

Malawi

Maldives

Mali

Mauritania

MoroccoMozambique

80

MyanmarSub-national plandeveloped

A dedicated full-time
position for newborncare at national levelavailable

Newborn action plancostedEmergency
preparedness for
newborn care in
emergency includedin planSpecific activities for
all ENAP milestones
added, including
scale-up of newbornspecific interventions
in RMNCAH plan

Stillbirth rate target
defined in newborn or
RMNCAH plan

Newborn mortality
rate target defined innewborn or RMNCAH
plan

Newborn component
strengthened in
RMNCAH plan

National newborn
action plan developed

Annex 2: Tables on progress (75 countries, 2017-2018) of selected
ENAP milestones

National Plans

Country
Sub-national plandeveloped

A dedicated full-time
position for newborncare at national levelavailable

Newborn action plancostedEmergency
preparedness for
newborn care in
emergency includedin planSpecific activities for
all ENAP milestones
added, including
scale-up of newbornspecific interventions
in RMNCAH plan

Stillbirth rate target
defined in newborn or
RMNCAH plan

Newborn mortality
rate target defined innewborn or RMNCAH
plan

Newborn component
strengthened in
RMNCAH plan

National newborn
action plan developed

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Namibia

Nepal

Niger

Nigeria

Pakistan

Palestine

PNG

Philippines

RwandaSenegalSierra Leone

SomaliaSouth Sudan

Sri Lanka

Sudan

Swaziland

Syria

Tajikistan

Tanzania

Tomor-Leste

Togo

Tunisia

Turkmenistan

UgandaUzbekistan

Vietnam

Yemen

ZambiaZimbabwe81

Quality of Care

Country
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan82

National Quality
Improvement Initiative
included in policies

National QI programme
has specific focus on
MNH

Health workers
authorized toadminister life-saving
MNH interventions

Policy adopted formaternal death
notification

Policy exists on homebased postnatal care

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONESCountry

National Quality
Improvement Initiative
included in policies

National QI programme
has specific focus on
MNH

Health workers
authorized toadminister life-saving
MNH interventions

Policy adopted formaternal death
notification

Policy exists on homebased postnatal care

Palestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe83

Data Availability

Country
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan

84

Eligible mothers given
antenatal corticosteroids for
foetal lung maturation

Eligible newborns receiving
resuscitation

Eligible newborns that
benefited from KMC

Eligible newborns treated forneonatal sepsis

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONESCountry

Eligible mothers given
antenatal corticosteroids for
foetal lung maturation

Eligible newborns receiving
resuscitation

Eligible newborns that
benefited from KMC

Eligible newborns treated forneonatal sepsis

Palestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe

85

QI guidelines and mechanisms

National QI guidelines for
MNH are available
Country
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan

86

Plan available to implement
the MNH QI guidelines

MDSR mechanism in place

Perinatal Death Review
system in place

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

National QI guidelines for
MNH are available

Plan available to implement
the MNH QI guidelines

MDSR mechanism in place

Perinatal Death Review
system in place

Country
Palestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe

87

Investment in free Maternal and Newborn Care and Services

Free maternal care policy/national healthinsurance/incentive schemes in place
Country
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan

88

Free newborn care policy/national healthinsurance in place

National health insurance scheme/freepolicy in place covering maternal andnewborn care including sick newborns

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONESFree maternal care policy/national healthinsurance/incentive schemes in place
Country

Free newborn care policy/national healthinsurance in place

National health insurance scheme/freepolicy in place covering maternal andnewborn care including sick newborns

Palestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe89

Health workforce strategies

A human resource plan/strategy for SBAs
in place
Country
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan90

A retention policy/strategies for SBAs or
relevant cadres in place

Competency and skill-based service/training/education for MNH available

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

A human resource plan/strategy for SBAs
in place

A retention policy/strategies for SBAs or
relevant cadres in place

Competency and skill-based service/training/education for MNH available

Country
Palestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe91

National Essential Medicines List (NEML)

Oxytocinincluded in the
NEMLCountry
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan

92

Misoprostol
included in the
NEML

Magnesium
sulfate includedin the NEML

Injectableantibiotics
included in the
NEML

Antenatal
corticosteroids
included in the
NEML

Chlorhexidine
included in the
NEML

Newborn
resuscitation
devices (Ambu
bag and mask)
included in the
NEML

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Oxytocinincluded in the
NEMLCountry

Misoprostol
included in the
NEML

Magnesium
sulfate includedin the NEML

Injectableantibiotics
included in the
NEML

Antenatal
corticosteroids
included in the
NEML

Chlorhexidine
included in the
NEML

Newborn
resuscitation
devices (Ambu
bag and mask)
included in the
NEMLPalestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe93

National Essential Medicines List (NEML)

Oxytocinincluded in
LMIS
Country
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan

94

Misoprostol
included in
LMIS

Magnesium
sulfate includedin LMIS

Injectableantibiotics
included in
LMIS

Antenatal
corticosteroids
included in
LMIS

Chlorhexidine
included in
LMIS

Newborn
resuscitation
devices (Ambu
bag and mask)
included in
LMISREACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Oxytocinincluded in
LMIS
Country

Misoprostol
included in
LMIS

Magnesium
sulfate includedin LMIS

Injectableantibiotics
included in
LMIS

Antenatal
corticosteroids
included in
LMIS

Chlorhexidine
included in
LMIS

Newborn
resuscitation
devices (Ambu
bag and mask)
included in
LMIS

Palestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe

95

Research agenda

Research agenda (as referenced in ENAP) prioritized by country
Country
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan

96

Research focusing on stillbirths planned by country

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

Research agenda (as referenced in ENAP) prioritized by country

Research focusing on stillbirths planned by country

Country
Palestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe97

Community ownership and partnership

A national communication strategy (advocacy, BCC/C4D) on
newborn developed
Country
Afghanistan
AngolaArmenia
Azerbaijan
Bangladesh
Benin
BhutanBotswana
Burkina Faso
BurundiCameroon
Chad
China
Comoros
Cote d’Ivoire
Djibouti
DRC
Egypt
Eritrea
Ethiopia
GambiaGeorgia
Ghana
GuineaGuinea-Bissau
India
Indonesia
Iran
Iraq
JordanKazakhstan
Kenya
Kyrgystan
LebanonLesothoLiberia
Libya
Madagascar
Malawi
Maldives
Mali
Mauritania
MoroccoMozambique
MyanmarNamibia
Nepal
Niger
Nigeria
Pakistan98

A community MNH engagement/mobilization strategy in place

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

A national communication strategy (advocacy, BCC/C4D) on
newborn developed

A community MNH engagement/mobilization strategy in place

Country
Palestine
PNG
Philippines
RwandaSenegalSierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
Swaziland
Syria
Tajikistan
Tanzania
Tomor-Leste
Togo
Tunisia
Turkmenistan
UgandaUzbekistan
Vietnam
Yemen
ZambiaZimbabwe99

Annex 3: List of indicators for maternal and newborn health (underdiscussion)
Interim Maternal and newborn health HMIS Indicators (under discussion)
Indicator (all facility-based)

Numerator

Denominator (Facility level)

Outcome indicators
1. Maternal deaths

Number of maternal deaths infacility

2. Maternal deaths by cause

Number of maternal deaths
classified by cause (ICD-MM)

3. Newborn deaths by cause

Number of neonatal deaths
classified by cause (ICD-PM)

4. Stillbirth rate (disaggregated by
fresh and macerated)

Total Births
Number of newborns born in a
facility with no signs of life and bornweighing at least 1,000 grams orafter 28 weeks of gestation

5. Pre-discharge neonatal death
rate (disaggregated by in-born &out-born)

Number of newborns born live in a
facility who die prior to discharge
from facility

Live Births

6. Obstetric Case Fatality Rate
(disaggregated by direct andindirect causes when feasible)

Number of women who develop acomplication in facility who die due
to an obstetric complication

Number of women with obstetriccomplications attended in thehealth facility

7. Proportion of women who
were screened for syphilis during
antenatal care

Number of women screened forsyphilis during antenatal careFirst ANC visits

8. Proportion of womenadministered immediate
postpartum uterotonic (for PPH
prevention)

Number of women administered
immediate postpartum
uterotonic to prevent postpartum
haemorrhage

Total Births

9. Placeholder for treatment ofmaternal complication

TBD

TBD

10. Proportion of newborns
breastfed within one hour of birth

Number of newborns breastfed
within one hour of birthLive Births

11. Proportion of newborns with
documented birthweight

Number of newborns with
documented birthweight in recordor register

Total Births

12. Proportion of newborns on
KMC

Number of newborns initiated in
KMC (or admitted to KMC unit if
separate unit exists)

Live Births

13. Proportion of newborns
resuscitated with bag and mask

Number of newborns resuscitatedwith bag & mask

Total Births

14. Proportion of newborns treatedfor neonatal Infection

Number of newborns treated with
antibiotics

Live Births

15. Low Birth Weight

Number of newborns withbirthweight <2500 grams

Live Births

16. Pre-Term Birth

Number of newborns born <37weeks estimated gestation

Live Births

17. Caesarean Section(disaggregated by elective andemergency)

Number of births via caesarean
sectionTotal Births

Output/Coverage indicators

100

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

18. Placeholder for content of
postnatal care for woman

Number of women who received xx Total births
service for postnatal care prior todischarge

19. Placeholder for content of
postnatal care for newborns

Number of newborns who received
xx service for postnatal care prior
to discharge

Live births

20. Birth Notification

Number of births with notification
submitted to Civil Registrar

Total Births

21. Maternal death registration

Number of maternal deaths
registered with Civil Registrar

Number of Maternal Deaths

22. Neonatal Death registration

Number of neonatal deaths
registered with Civil Registrar

Number of Neonatal Deaths

23. Proportion of maternal deaths
reviewed

Number of maternal deaths
reviewed in MPDSR Programme

Number of Maternal Deaths

24. Proportion of perinatal deaths
reviewed

Number of perinatal Deaths
reviewed in MPDSR Programme

Number of Perinatal Deaths

101List of Acronyms

102

AMDD

Averting Maternal Death and Disability

ARR

Average Rate of Reduction

BCC

Behaviour Change Communication

bCPAP

Bubble Continuous Positive Airway Pressure

C4D

Communication for Development

CHAMPSChild Health and Mortality Prevention Surveillance

COIN

Care of the Infant and Newborn

COINN

Council of International Neonatal Nurses

CNCP

Comprehensive Newborn Care Package

CRVS

Civil Registration and Vital Statistics Systems

CIFF

Children’s Investment Fund Foundation

CWG

Chlorhexidine Working GroupDHIS2District Health Information System- 2

EN-BIRTH study

Every Newborn-Birth Indicators Research for Tracking in Hospitals

ECD

Early Childhood Development

ENAP

Every Newborn Action Plan

EmOC

Emergency Obstetric Care

EmONC

Emergency Obstetric and Neonatal Care

EWEC

Every Woman Every Child

GBS

Group B Streptococcus

GFF

Global Financing Facility

HEW

Health Extension Worker

HMIS

Health Management Information Systems

HNN

Healthy Newborn Network

HSDP

Health Sector Development Plan

IAFM

Inter-Agency Field Manual for Reproductive Health in Crisis Situations

ICM

International Confederation of Midwives

ICD-10 MM

International Classification of Diseases for Maternal Mortality

IGME

Inter-Agency Group for Mortality Estimation

IMCI

Integrated Management of Childhood Illness

KMC

Kangaroo Mother Care

LBW

Low Birth-Weight

LMICs

Low- and Middle-Income Countries

LMIS

Logistic Management Information Systems

LSHTM

London School of Hygiene and Tropical Medicine

MCSP

Maternal and Child Survival Programme

MDSR

Maternal Death Surveillance and Response

MISP

Minimum Initial Service Package for Reproductive Health in Crisis Situations

MITS

Minimally Invasive Tissue Sampling

MNCH

Maternal, Newborn and Child Health

MNH

Maternal and Newborn Health

MoH

Ministry of Health

MOHFW

Ministry of Health and Family Welfare

MoNITOR

Mother and Newborn Information for Tracking Outcomes and Results

MoRES

Monitoring Results for Equity System

MPDSR

Maternal and Perinatal Death Surveillance and Response

MPND

Maternal, Perinatal and Neonatal Deaths

REACHING EVERY NEWBORN NATIONAL 2020 MILESTONES

NEML

National Essential Medicines List

NMR

Neonatal Mortality Rate

NNHP

National Newborn Health Program

PRECISE

Pregnancy Care Integrating Translational Science Everywhere

PSBI

Possible Severe Bacterial Infection

PDSA

Plan-Do-Study-Act Cycles

PMNCH

Partnership for Maternal, Newborn & Child Health

QI

Quality Improvement

QoC

Quality of Care

RLN

Regional Learning Network

RMNCAH

Reproductive maternal newborn child adolescent health

SNBCU

Special Newborn Care UnitsTA

Technical Assistance

TWG

Technical Working Group

SBR

Stillbirth rates

SDG

Sustainable Development Goal

UHC

Universal Health Coverage

UN

United Nations

UNICEF

United Nations Children’s fund

UNFPA

United Nations Population FundUNAIDS

Joint United Nations Programme on HIV and AIDS

URC

University Research Company

USAID

United States Agency for International Development

WHA

World Health Assembly

WHO

World Health Organization

103

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