International News - April

Midwifery 30 (2014) 387–390

Contents lists available at ScienceDirect

Midwifery journal homepage: www.elsevier.com/midw

International News April 2014 Elizabeth duff International News Editor

Ending newborn deaths: ensuring every baby survives Save the Children published this report on February 25 2014, with an introduction emphasising the numbers of families suffering the loss of their newborn babies across the world, and the association with births not attended by midwives:

 2.9 million – The number of babies who

   

 40 million – The number of mothers









 



across the world who give birth each year without any help from a midwife or other trained and equipped health worker. 2 million women report that when they last gave birth they were completely alone. 51% – The percentage of births in subSaharan Africa that were not attended by a midwife or other properly qualified health worker. This percentage is 41% in south-east Asia. 40% versus 76% – The percentage of deliveries attended by a skilled health worker in rural areas versus urban areas in the least developed countries. 950,000 – The number of newborn deaths that could be prevented each year if essential health services were more equitably distributed. This would reduce newborn mortality by 38%. 2025 – Universal coverage of skilled qualified birth attendance could be achieved by 2025 if we double the current rate of progress. If the rate does not increase, this would not be achieved until 2043. 2 million – The number of newborn babies who could be saved each year if we end preventable newborn mortality. 26.6 million – The number of children who died before their fifth birthday in 2012, most from preventable causes. This number has almost been halved since 1990, but still means that 18,000 children died every day.

http://dx.doi.org/10.1016/j.midw.2014.02.007 0266-6138

died within 28 days of being born in 2012. The number of deaths in this newborn period is four times higher in Africa than it is in Europe. 1 million – The number of babies who did not survive their first – and only – day of life in 2012. 1.2 million – The number of stillbirths in 2012 where the heart stopped beating during labour. 7.2 million – The global shortage of midwives, nurses and doctors. Increasing health expenditure by just US$5 per person per year could prevent the deaths of 147 million children and 5 million women, and 32 million stillbirths – and result in economic and social benefits worth up to nine times that investment by 2035.

In its recommendations to address the situation, Save the Children is calling on world leaders, philanthropists and the private sector to implement – this year – a five-point Newborn Promise to end all preventable newborn deaths:

 Governments and partners issue a









defining and accountable declaration to end all preventable newborn mortality, saving 2 million newborn lives a year and stopping the 1.2 million stillbirths during labour. Governments, with partners, ensure that by 2025 every birth is attended by trained and equipped health workers who can deliver quality care including essential newborn health interventions. Governments increase expenditure on health to at least the WHO minimum of US$60 per capita, to pay for the training, equipping and support of health workers. Governments remove user fees for all maternal, newborn and child health services, including emergency obstetric care. The private sector, especially pharmaceutical companies, should help address unmet needs by developing

innovative solutions and increasing availability for the poorest to new and existing products for maternal, newborn and child health. Governments of countries with high burdens of newborn mortality need to make significant policy changes in order to

 commit to addressing the newborn deaths and stillbirths as a top priority,

 commit to universal coverage of high-





 



quality care during birth, as part of integrated reproductive, maternal, newborn and child healthcare, increase budget allocations for health at least to meet the African Union Abuja target of 15% of government expenditure on health, address the health worker crisis through programmes to recruit, train, retain, deploy, support and appropriately remunerate health workers, including midwives with the skills and equipment to save newborns as well as mothers, remove and eliminate direct payments for maternal and newborn healthcare including emergency obstetric care, ensure that less than 20% of all national expenditure for health is from out-ofpocket payments. Governments must also tackle informal payments and other barriers such as transport and opportunity costs that deter the poor from using services, develop integrated national reproductive, maternal, newborn and child health action plans that ensure universal access to good-quality healthcare and lay out evidence-based paths to ending preventable maternal and child deaths.

The Every Newborn Action Plan – which should be presented to the World Health Assembly in May 2014 and lead to a global push – should have as its priorities:

 Ending all preventable newborn and child deaths and stillbirths. This should be achieved in all wealth quintiles and

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all segments of society with accountability mechanisms as part of Every Woman Every Child. Universal coverage of quality care at birth by 2025. Calling for the future monitoring and inclusion of stillbirths as an indicator in reproductive, maternal, newborn and child health frameworks. Endorsement of the principles of universal health coverage including eliminating financial and other barriers and establishing financial risk protection. Ensuring that underlying factors such as maternal nutrition, reproductive health and women’s empowerment are addressed to end all preventable newborn deaths. ensuring its targets are integrated within the post-2015 framework, so that they achieve global priority.

The post-2015 development framework must:

 contain targets for ending preventable





child, maternal and newborn deaths, using the targets of seven newborn deaths per 1,000 live births and a maximum of ten in every country, as well as 10 stillbirths per 1,000 total births in every country and every segment of society, endorse the principles of universal health coverage with specific metrics to measure it, including good-quality care at birth, set a target for ending impoverishment from healthcare costs. Civil society organisations should:

 campaign for and monitor government



commitments to end preventable newborn mortality and preventable stillbirths, including through universal health coverage, mobilise families and communities to address cultural and social barriers that drive newborn mortality.

Key issues include addressing girls' empowerment, the demand for goodquality healthcare, family planning and immediate and exclusive breast feeding. The private sector:

 should support the Every Newborn 

Action Plan by making commitments to support universal coverage of healthcare, should – especially pharmaceutical companies – help address unmet needs by developing innovative solutions and increasing availability for the poorest to new and existing products for maternal, newborn and child health,

 should support, respect and comply with regulations that protect the health of newborns and children, such as the Code of Marketing of Breastmilk Substitutes. The full report can be downloaded at /http://www.savethechildren.org/site/c. 8rKLIXMGIpI4E/b.8989373/k.E376/Ending_New born_Deaths_Ensuring_Every_Baby_Survives. htmS Safe abortion care and post-abortion care The World Health Organization has published the Clinical practice handbook for safe abortion care, intended to facilitate the practical application of the clinical recommendations from the second edition of Safe abortion: technical and policy guidance for health systems (World Health Organization [WHO], 2012). Although legal, regulatory, policy and service-delivery contexts may vary from country to country, the recommendations and best practices described in both of these documents aim to enable evidence-based decision-making with respect to safe abortion care. WHO states that the handbook is oriented to providers who already have the requisite skills and training necessary to provide safe abortion and/or treat complications of unsafe abortion. It is neither a substitute for formal training, nor a training manual. Guiding principles include: Providers should be aware of local laws and reporting requirements. Within the framework of national laws, all norms, standards, and clinical practice related to abortion should promote and protect: women's and adolescents' health and their human rights; informed and voluntary decision-making; autonomy in decision-making; non-discrimination; confidentiality and privacy. Some practical examples of how providers can apply these principles include:

 treating all women equally regardless of

     

age, ethnicity, socioeconomic or marital status, etc., in a prompt and timely fashion; ensuring that abortion care is delivered in a manner that respects all women as decision-makers; providing complete, accurate and easy to understand information; respecting the dignity of the woman, guaranteeing her privacy and confidentiality; being sensitive to the needs and perspectives of the woman; protecting medical information against unauthorised disclosures; being aware of situations in which a woman may be coerced into having an



abortion against her will (e.g. based on her health status, such as living with HIV); when dealing with adolescents, encouraging parents' engagement through support, information and education. Do not insist on parents' authorisation, unless it is a legal requirement.

The handbook can be accessed at /http://www.who.int/reproductivehealth/ publications/unsafe_abortion/clinical-practi ce-safe-abortion/en/S

Conscientious objection to the provision of reproductive health care Conscientious objection is when healthcare professionals or institutions exempt themselves from providing or participating in care on religious and/or moral or philosophical grounds. Although other barriers also hinder women’s right to obtain reproductive health services, conscientious objection is unique because of the tension existing between protecting and fulfilling women’s rights and health service providers' rights to exercise their moral conscience. A special supplement published in the International Journal of Gynecology & Obstetrics, with guest editor Dr. Wendy Chavkin, examines the prevalence, health consequences, and policy responses of conscientious objection and refusal to provide reproductive healthcare and includes commentaries on ethical and human rights obligations of States and service providers. Staff (and former staff) from WHO’s Department of Reproductive Health and Research (HRP) contributed a commentary on ‘Conscientious objection to provision of legal abortion’. The supplement is at /http://www.ijgo. org/webfiles/images/jouarnals/IJG/IJGO123_ Suppl3_final3_greyscale.pdfS

Low-risk pregnancy and normal delivery in four west European countries A recent article in the Archives of Gynecology and Obstetrics brings together an international meeting report and significant follow-up and discussion about the care of pregnant women who are at low risk of complications in childbirth. The 2012 ‘4 countries meeting’ of the French, Dutch, British and German Societies of Gynaecology and Obstetrics (CNGOF, NVOG, RCOG, DGGG) was dedicated to the topic ‘Low-risk pregnancy and normal delivery’. The objective was to compare how each country organises antenatal care and normal delivery. The discussion is outlined in the article and

International News / Midwifery 30 (2014) 387–390

provides new opportunities to learn from each other's strengths in order to provide a high level of care regardless of social, demographic, educational and clinical differences. In the round-up of the article the authors state ‘All four countries believe that women’s health care will be improved if multidisciplinary teamwork is made a priority between midwives and OG academics and clinicians – and between the four countries themselves … future training needs should be developed to reflect both the professional and personal development requests of all doctors, leading to resilient, flexible and adaptable specialists working to deliver high quality women’s health care’. The paper concludes: ‘meetings between the four countries provide new opportunities … to look for synergism between us. This will strengthen each nation to handle future changes in social, demographic, educational and clinical issues without forgetting that across Europe our patients continue to rightly expect the highest level of care we can deliver regardless of our Differences’. Schott S, van der Avoort I, Descamps P, et al. Four countries, four ways of discussing low-risk pregnancy and normal delivery: in France, Germany, The Netherlands, and the United Kingdom. Arch. Gynecol. Obstet. 2014;289(2):451–456.

A sharper focus on uncomplicated pregnancy may help develop and evaluate population interventions A recent editorial in the British Medical Journal (Knight, 2013) provided comment on a study entitled ‘Exploration and confirmation of factors associated with uncomplicated pregnancy in nulliparous women’ (Chappell et al., 2013), which drew information from a large cohort of nulliparous women in Australia and the UK to investigate factors associated with uncomplicated pregnancy. Marian Knight hailed the study with ‘This robust approach is welcome in the context of initiatives to step back from the medicalisation of pregnancy and provides useful information for women, clinicians, and policy makers’. Alluding to the 2011 ‘Birthplace’ project, she noted that ‘A recent study investigating safety of place of birth in low risk women clearly showed reduced rates of intervention in low risk women giving birth in midwife-led units compared with obstetrician-led units. Actions to promote delivery in midwife led settings may also help increase the likelihood of uncomplicated birth’.

She further wrote: ‘Public health and policy interventions, alongside prepregnancy care and counselling, will probably be needed. This is the key message for policy makers’. Importantly, ‘over a quarter of pregnancies are unplanned, so we must also develop and evaluate interventions designed to improve pregnancy outcomes within general populations of women, such as health promotion initiatives based in schools and communities’. Dr Knight concluded with ‘As Chappell and colleagues note, the most important next step is to replicate their approach, shift the focus of research from abnormality to normality, obtain clear evidence of causality, and start to build a robust evidence base to guide population interventions’. Knight M. Sharper focus on uncomplicated pregnancy. BMJ 2013;347:f6470 http://dx.doi.org/10.1136/bmj.f6470 Chappell LC, Seed PT, Myers J, Taylor RS, Kenny LC, Dekker GA, et al. Exploration and confirmation of factors associated with uncomplicated pregnancy in nulliparous women: prospective cohort study. BMJ 2013;347:f6398.

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‘Term neonatal deaths resulting from home births: An increasing trend’ and prepared by Drs Grunebaum and Chervenak. They highlighted the doctors' methodological approach of working retrospectively from birth certificates and advised that ‘birth certificate data do not allow researchers to accurately separate out planned vs. unplanned home births. We know that mortality rates are higher for unplanned home births, as they are more likely to involve emergency or urgent situations. The inability to distinguish between the two casts doubt on the findings’. News reported in the UK at /http://www. rcm.org.uk/midwives/news/us-home-birth s-on-the-up/#sthash.2Evmj19c.dpufS News from ACOG at: /https://www.acog. org/Resources_And_Publications/Commit tee_Opinions/Committee_on_Obstetric_Prac tice/Planned_Home_BirthS News from ACNM at /http://www.mid wife.org/acnm/files/ccLibraryFiles/Filename/ 000000003851/ACNM-SMFM-HomeBirth-Abstract-Response.pdfS

The World Breastfeeding Costing Initiative Home births in the US are now at their highest level since data collection on place of birth began in 1989 There has been considerable discussion in medical and midwifery circles about home birth in the United States of America. Published statistics on recent years appear to show that the level rose by 29% from 2004 to 2009, after 14 years of falling. Although the percentage looks like a dramatic increase, the number of home births in the US is still very low. Over the five years, the percentage of home births rose from 0.56% in 2004, to 0.72% in 2009. The statistics appear in the January 2012 National Center for Health Statistics Data Brief. The American Congress of Obstetricians and Gynecologists (ACOG) confirmed that ‘it respects the right of a woman to make a medically informed decision about delivery’, while warning of perceived risks. Unfortunately the ACOG statement relied on a study published by Wax et al. in 2010 which was widely criticised at the time for its flawed methodology (Midwifery: An international journal, 2010, Vol 26 (5), International News). The American College of Nurse Midwives (ACNM) then issued, as a preliminary statement, a response to a presentation given at the Society for Maternal-Fetal Medicine (SMFM) annual meeting on February 7, which was entitled

‘The Need To ‘Inve$t’ In Babies: The World Breastfeeding Costing Initiative (WBC) – A Global Drive for Financial Investment in Children's Health and Development through Universalising Interventions for Optimal Breastfeeding’ has been published by the International Baby Food Action Network (IBFAN) – Asia in partnership with the Breastfeeding Promotion Network of India (BPNI). In a preface, Dr Julie Smith of the Australian National University, writes: ‘The persistent failure of governments to invest significantly in breastfeeding is hard to comprehend’. ‘Ten years after staggering revelations showing more than a million infants and young children die annually from diarrhoea and related infections because they are deprived of the right milk – breastfeeding – around a million babies still die and government investment in breastfeeding remains minimal, or zero, in most countries’. ‘The benefits of human milk for human infants are so obvious, and so well-established, supported time and again by rigorous science that organisations like IBFAN should not need to gather yet more figures, or mount yet more arguments for investment in breastfeeding. The simple, stark facts are that breastfeeding saves lives; lack of human milk means human babies die’.

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She closes: ‘It must not be our generation, our governments, our institutions, which failed to act when we could’. ‘It is our responsibility - the global village that raises the child - to invest in scaling up breastfeeding, and this document shows the way’. /http://bpni.org/wbcitool/THE-NEEDTO-INVE$T-IN-BABIES.pdfS

of crime and referred to support services and the police, as appropriate. RCM, RCN, RCOG, et al. Tackling FGM in the UK: intercollegiate recommendations for identifying, recording and reporting London: Royal College of Midwives; 2013.

Tackling female genital mutilation (FGM)

The 2014 International Congress on stillbirth, SIDS and Baby Survival (the ISA/ ISPID Congress) is a call for global action to reduce perinatal and infant mortality. In 2014 the conference will be held in the Netherlands (co-hosted with ISPID), 18–21 September, at the Royal Tropical Institute (KIT), Amsterdam, The Netherlands. The aims of the 2014 ISA/ISPID Congress are to identify the ‘causes’ of sudden and unexpected baby deaths during pregnancy, labour or in the first year, and the actions to reduce them. Another major theme dominating the ISA/ISPID congresses since 2004 is the support of parents who lost an infant. At the Congress the aim is to exchange preventive measures and successful strategies that have been developed to prevent infant death. For perinatal mortality and SIDS prevention, measures need to be implemented and monitored continuously and progress towards achieving the aims should be measured the coming years.

A unique coalition in the UK of Royal Colleges, trade unions and Equality Now have launched in Parliament the report, ‘Tackling FGM in the UK: Intercollegiate recommendations for identifying, recording and reporting’. The ground-breaking report and collaboration recognises that implementing a comprehensive multi-agency action plan is urgently required to ensure that young girls at risk of undergoing FGM are protected by the existing UK legal framework (which has been in place since 1985). The report makes nine recommendations for tackling FGM in the UK and considers issues such as lack of consistent data collection about FGM in the NHS. The recommendations suggest that babies, children and young girls suspected of going to be cut or presenting with FGM should be considered as potential victims

Global action needed to address stillbirth

The International Stillbirth Alliance (ISA) is a global organisation which brings together researchers, clinicians, policy makers and parents to tackle the high rates of stillbirth around the world. The ISA research team authored the 2011 Lancet Series on Stillbirth /http:// www.thelancet.com/series/stillbirthS which has had a significant impact, focussing attention on the potential to avoid many stillbirths. Areas of interest and/or research by ISA include fetal movement, detection of poor fetal growth, modifiable risks, stillbirth work-up, stillbirth definition and classification, perinatal pathology and the economics of stillbirth. ISA holds an annual conference to bring together the latest research and thinking on stillbirth. No other conference has stillbirth as the central focus. It is an important opportunity to link health and research professionals with leading stillbirth experts from Australia, USA, and Europe. This conference is an opportunity to learn how other countries are managing to reduce stillbirth rates and to share some of the advanced research and stillbirth reduction work now under way. More information at /http://www. babysurvival2014.nl/S