Insights from Uganda on how to fight the scourge of child mortality

When a child is born, especially in underserved settings, the first minute of their life can too often be their last.

In 2019, it was estimated that worldwide, 17.5 neonates per every 1,000 live births died, a figure that has come down significantly from 1990, when it was 36.6, but that still remains too high. As troubling, of the 47 percent of every under-five death in the world, one third occur on the day of birth. In low- or middle-income countries, like my native Uganda, where infections like malaria or syphilis are common and labor and delivery conditions are not always adequate, those averages are even higher.

Ensuring a safe birth is an essential part of preventing neonatal mortality. Deliveries in facilities with skilled birth attendants and enabling environments to provide high quality care can save newborns and facilitate care in high impact interventions (such as safe cord care, early initiation of breastfeeding, kangaroo mother care), circumvent complications (via the receiving of antibiotics for infections), and navigate emergencies (via newborn resuscitation) – all elements that, left unmitigated, can lead to neonatal deaths.

In low- and middle-income countries, preventing neonatal deaths to achieve the Every Newborn Plan SDG targets of less than 12/1000 live births by 2030 will not be easy. Unlike with older kids, where much progress has been made based on what could be termed “simple” interventions (immunisations, use of insecticide treated bed nets, control of diarrhea, etc.), reducing neonatal deaths will require improved clinical services because a baby who is not breathing can die within a minute. Thus, to save babies will require clinical systems that are able to respond “within a minute”. In other words, reducing neonatal deaths to achieve SDG targets is the real test of the performance of health systems in low- and middle-income countries. Therefore, systems must be well managed, very responsive and coordinated in order to be institutionalized for effective care, to give newborns a better fighting chance. That also means systems that are more affordable, less complex and offer better intervention design, putting women at the center.

Health systems in LMICs are not always managed to optimal efficiency. The centralization of care can create economies of scale, but too often the trade-offs are gaps at the district and local level, where delivery mechanisms become bottlenecked or fragmented and the continuum of care – from antenatal through postpartum – is interrupted. Resources, both capital and human, are often mismanaged, focusing disproportionately on delivery – as it’s regularly deemed the most important intervention. However, in settings like Uganda this is not enough. Here, we have a high burden of diseases in women (malaria, malnutrition, anemia, syphilis, and NCDs) which increase the risk of neonatal deaths (via stillbirths, low birth weight, prematurity, and birth asphyxia). In addition, circumstances often make women come late for delivery care. Thus, antenatal care is as important as care at birth. In addition, even after a successful delivery, many babies die following discharge because of poor postnatal care. It is therefore important that high quality care be provided throughout the continuum of care from antenatal, through delivery and postnatal care, including respectful care.

Empowering women

Women, who are inherently at the center of neonatal health, are not always fully empowered to seek proper care. This begins with proper family planning to both enable women to only have babies they seek, but also help systems remain unconstrained. It expands to prenatal care, to ensure women arrive at delivery facilities long before labor puts their child at risk. And it extends to caring for babies post-delivery, to ensure they can thrive in the critical first 28 days, in their first five years of life, and beyond.

Another challenge for newborn care is implementation fragmentation. Whereas as of recent there has been an increase in resources for newborn care and research, we see a total lack of coordination leading to project pressure on districts and hospitals in what we call “pilotitis”. This uncoordinated implementation puts pressure on the already overstretched human resources (such as midwives) and creates waste and lack of focus to deliver critical care where it’s needed most. Compounding that are global targets that are often established with optimistic ambition, but yet inadequate support to deliver on them especially at country and local level, given each country’s unique local context.

It is true that we need projects, but to be effective, they must be well designed and well implemented. Our work at the Makerere University’s Maternal Newborn Child Health Centre of Excellence has found that too often, failed institutionalization is what causes poor program implementation. Maintaining adequate supplies, lack of supervision, motivation and reporting, as well as poor stewardship, conflicting guidelines, lack of accountability, and limited autonomy at the local level often lead to programs’ poor performance – negatively impacting neonatal health.

From 2006 to 2020, we implemented the Maternal and Newborn Scale-Up project, aiming to improve newborn care in six hospitals that served four million people over a five-year period. To test our hypothesis, our program operated on key institutionalization tenets: the promotion of strong leadership involvement and engagement; the emergence of champions; the alignment to policy and structures; the use of mainly local resources, such as hospital space, no additional health workers, commodity availability from the hospital’s own resources, and routine data systems; the capitalization on health workers’ and community’s demand and perceived benefit; and the undertaking of implementation over a long period (five years) with full local staff and leaders’ involvement. The result was good governance. Good management. And ultimately, institutionalization with better care for newborns.

But like this example from Uganda, there are many others from LMICs that show how capacity, as well as stewardship and autonomy within health systems are essential to creating change for the health of newborns. Systems that are effective may help guarantee the sustainability of that change. It’s why we need national governments in LMICs to lead and invest in better systems, ensuring donors are mobilized for additional resources while also fostering alignment and shared accountability. Because as defining as any child’s first 60 seconds can be, the timeline that leads to them – and that predicts their outcome – starts long before a mother goes into labor and concludes long after a baby is born. Creating resilient healthy systems is one of the best ways we can give those 60 seconds for newborns in Uganda and beyond, their best shot.

This article first appeared on Exemplars in Global Health, a new initiative incubated by Gates Ventures and its partners to research positive outliers in global health so that other countries might learn from them and improve health outcomes.