Maternity ward in a Cape Coast hospital. (Peter Lewenstein)
[Photo credit: bbcworldservice]
The following press release is really heartening. It’s so good to hear positive news about childbirth safety in Africa where, in many countries, maternal and child mortality is so high.
Dramatic improvements in provision of neonatal health care in Ghana increase the prospects for reducing child mortality.
Seventy Percent of Newborns, in Innovative Campaign in Rural Northern Ghana, Receive Postnatal Care in the First Week of Life
Cambridge, MA – July 15, 2010 – The Institute for Healthcare Improvement, the National Catholic Health Service, and the Ghana Health Service are working together to address the tragically high child mortality rate in Ghana. Following a decade of stalled progress in improving neonatal mortality, a breakthrough in delivering care to newborns in the first week of life offers new hope that child mortality can be reduced significantly in the near future.
Child mortality is a major problem in Ghana. Current estimates are that 80 children per 1000 live births die by the age of five. Of these deaths, 40% occur in the first month of life, otherwise known as the newborn period. And about half of newborn deaths occur on the first day of life, while an additional 25% occur by the end of the first week. The majority of these deaths are from preventable causes such as asphyxia, infections, and inappropriate care of premature babies. For that reason, focusing on providing health care to newborns in the first week of life offers the potential for dramatic reductions in child mortality. Two of the most critical interventions to address this problem were recently instituted by the Ghanaian government: first, in July 2008, national health insurance was made free for maternity and early infant care throughout the country and subsequently, in October 2008, the Ghana Health Service introduced a new policy that required two surveillance visits for newborns within the first week, replacing a policy that had required one visit by the 10th day of life. Project Fives Alive! was asked to help test the implementation of the new neonatal care policy before it was spread nationwide.
Project Fives Alive! is a partnership between the Institute for Healthcare Improvement and the National Catholic Health Service to assist and accelerate Ghana’s faith-based and public health services to achieve Millennium Development Goal 4 (a 66% reduction in mortality in children under five years of age, by 2015) and to disseminate effective large-scale models to improve health care delivery in Ghana and beyond. The project is funded by the Bill & Melinda Gates Foundation.
Innovations
Using Quality Improvement methods that are increasingly being deployed worldwide to improve health care delivery, Project Fives Alive! worked with the frontline health staff in three districts and one Catholic diocese in the Northern Sector of Ghana to introduce changes, to firstly encourage pregnant women to deliver with skilled health staff such as midwives, and secondly ensure that the newborns and their mothers were provided with preventive care twice during the first week after birth. The project team assisted the health staff to test, evaluate, refine, and re-test several change ideas to make sure as many newborns as possible were being provided with reliable postnatal care within the required time. The ideas that were tested to improve newborn survival can be summarized into three major categories:
For women who delivered at health facilities – women and neonates were kept at the facility for 24 hours after delivery. If there was no space at the clinic or the woman’s home was close by, the women and newborns were discharged after six hours if they were stable, and visited at home the following day.
For women who delivered at home without skilled health staff – news of the delivery was immediately communicated (by cell phone or bicycle) by family or community members to health staff who then visited the home within 48 hours of birth.
Reminder systems were developed at community and clinic levels to prompt a follow-up home or facility visit by the seventh day after birth.
Results
At the start of the intervention, only 10% of newborns in the catchment area, with 760 expected deliveries per month, were receiving postnatal care within 48 hours and none were receiving a second visit during the critical first week of life. Within 18 months of the start of the campaign, on average, 70% of newborns received first postnatal care within 48 hours, and 70% received a second postnatal visit on Day 6 or 7. While complete newborn survival data for each district are not yet available, the death rates for neonates in health institutions (as distinct from those who die in the community) fell from 7.9 to 3.6 per 1000 deliveries over the same time period. These improvements were achieved through innovations in the way care for new mothers, and their newborns, was organized in the hospitals, clinics and communities. Frontline health staff and their district managers worked closely together to redirect existing human and financial resources to implement the new policy.Project Fives Alive! summarized the strategies found to be successful in implementing this new policy into a simplified set of interventions and is now scaling it up throughout the Northern Sector of Ghana through an improvement collaborative network of peer health staff and district health leaders. As of June 30, 2010, implementation of the new policy had been spread to 31 of the 38 districts in the Northern Sector.
“What’s especially impressive about this increased health care coverage,” said Dr. Nana Twum-Danso, the Harvard-trained Ghanaian physician who directs the project for the Institute for Healthcare Improvement, “is that these improvements were achieved through novel ideas generated by the frontline health staff themselves and tested within the existing health care resources. This was made possible primarily because the goals for neonatal survival were ambitious, explicit, and shared amongst all levels of staff.” She added, “Another important reason for this success, I think, is that all staff – from the level of the district directors, to the midwives, to the community health nurses, and the health extension workers – reviewed their postnatal care and newborn survival data regularly to determine if the changes they were making were leading to improvements. If so, they developed systems to sustain those changes; if not, they made adjustments or tried new changes that they believed could get them closer to their goals.”
Mr. George Adjei, Acting Executive Secretary of the Department of Health of the National Catholic Secretariat, remarked, “Project Fives Alive! has showed that it’s possible to use a Quality Improvement approach that engages frontline staff to rapidly test new ideas in a ‘real life’ health system with support from leadership before large-scale implementation. The key lesson here is that new policies should undergo local testing, learning and adaptation to guide implementation plans and practices at the local level.”
“This initiative implements Quality Improvement methods proven to be effective in other settings,” said Dr. Isabella Sagoe-Moses, National Programme Manager for Child Health of the Ghana Health Service. “The main questions we wanted answered in this initial pilot-test were feasibility, effectiveness, and scalability. We are now satisfied with all three and are implementing the policy more broadly with the expectation that it will have a profound impact on neonatal survival in Ghana. The success of this project has implications not only for Ghana but far beyond.”
Project Fives Alive! began on a small scale in the north in mid-2008 and plans to spread to the entire country by 2012, with Quality Improvement methods to improve neonatal survival as well as survival in older infants and children.
About the Institute for Healthcare Improvement
The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action. IHI’s Developing Countries program supports health care improvement initiatives in Ghana, Malawi, and South Africa. More information is available at
http://www.ihi.org/IHI/Programs/StrategicInitiatives/IHIsWorkinDevelopingCountriesProjectFivesAliveinGhana.htmAbout the National Catholic Health Service
The National Catholic Health Service (NCHS) is an independent not-for-profit health care provider owned by the Catholic Church in Ghana. The service operates on the principles of subsidiarity, solidarity, and autonomy in its organizational and management arrangements. Through a network of 32 secondary-level hospitals and 66 primary health care clinics, organized in 20 Catholic dioceses, the NCHS system serves approximately 25% of the population in health care facilities spread throughout the country and located in primarily rural and deprived communities. The NCHS is closely integrated with the Ghana Health Service (GHS) and provides services consistent with policies and programs of the Ministry of Health (MOH) and GHS. NCHS is accredited for third-party payment through the National Health Insurance Scheme. NCHS is a member of the Christian Health Association of Ghana which is an Agency of the MOH.
About the Ghana Health Service
The Ghana Health Service (GHS) is an autonomous Agency of the Ministry of Health that is responsible for implementation of national health policies through its governing Council – the Ghana Health Service Council. The Director General of Health Services is a member of the Ghana Health Service Council and oversees the execution of policies and plans of the GHS. The mandate of the GHS is to provide and prudently manage comprehensive and accessible health service, with special emphasis on primary health care at community, sub-district and district levels, in accordance with approved national policies by directly providing health services or contracting out service provision to other recognized health care providers. Project Fives Alive! is implemented in GHS facilities through a memorandum of understanding between the National Catholic Health Service and Regional Health Directorates of the GHS in the participating regions.
Suggested Books (US)
- Whos Got the Power?: Transforming Health Systems for Women and Children (UN Millennium Project)
- Pregnancy: A continuing source of sorrow and pain for women in Sub-Saharan Africa
KOULOGO, 6 May 2009 (IRIN) – The first child Fatoumata Dio delivered in 1981 when she was 19 years old was before she ever received midwife training — or even knew what the words meant. She went from serving as a traditional birthing attendant to working as a midwife in her rural northern 
