Improving Early Neonatal Development in Conflict-affected Countries

Improving Early Neonatal Development in Conflict-affected Countries There have been substantial improvements in the provision of maternal and newborn healthcare in fragile and conflict-affected countries such as Afghanistan, Yemen and the Central African Republic in recent years [1, 2]. However, conflict-affected countries still have unacceptably high newborn mortality, estimated as 40 per 1000 live births in Afghanistan in 2018 [1]. Understandably, fragile countries focus on the ‘child survival agenda’ [3]. However, because of the evidence of the benefits of early childhood development (ECD) [4–8], there is increasing interest in the implementation of ECD programmes. The focus is on primary prevention and health promotion rather than neurodevelopmental screening and referral because there are no secondary or tertiary neurodevelopment services to refer to. Globally, there is increasing recognition of the importance of the ‘golden’ minutes and hours after birth for resuscitation, thermal care and breastfeeding [9–11]. The importance of fostering attachment and development of the neonate over this time through responsive stimulation, play and communication is also increasing [12–14]. There is clear evidence that the nervous system has great plasticity during the neonatal period and that neonates are not simply ‘reflexive’ and ‘subcortical’ but have important communication and social behaviours especially eye contact, visual locking, auditory responses and self-quieting behaviour [12–14]. By the end of the first month of life, neonates respond to language, look at bright contrasts, movement and colour. Healthy neonates regulate their physiological states by self-soothing, habituate to repeated sensory inputs and respond to social speech [12–15]. These observations led to the development of the Brazelton Neonatal Behavioural Assessment Scale [15, 16], and the inclusion of neonatal early childhood development, ‘neonatal ECD’, in the WHO UNICEF ‘Care for Child Development’ package of responsive caregiving and stimulation (see Box below) [17–19]. The ‘Care for Child Development’ package is targeted at community health workers and other primary care providers and includes clear play and communication messages to be used by community health workers and families in the first week of life. The ‘Care for Child Development’ package has been carefully evaluated and important impacts on children’s long-term neurodevelopmental and educational outcomes have been reported in the Lancet and other publications [7, 8, 17, 20, 21]. The ‘Care for Child Development’ package has also been incorporated into health service delivery in many low- and middle-income countries [17]. WHO/UNICEF Care for Child Development. ‘Newborn up to 1 week. Your baby learns from birth. Play. Provide ways for your baby to see, hear, move arms and legs freely and touch you. Gently soothe, stroke and hold your child. Skin to skin is good. Communicate. Look into your baby’s eyes and talk to your baby. When you are breastfeeding is a good time. Even a newborn baby sees your face and hears your voice’ [18, 19]. In Afghanistan, the community health worker programme was recently shown to have a statistically significant impact on enhancing demand and use of health facilities for facility delivery and antenatal care [22]. However, each woman only received an average of 2.2 home visits throughout the antenatal and postnatal periods. A total of 72% of women received a visit within 48 hours after birth but only 13% received a fourth antenatal visit and 5% received a fourth visit on day 28 after birth [22]. ‘Dropout’ after initial engagement is a well-known part of ‘real world’ maternal and child health (MCH) service delivery [23–25]. Analyses of Demographic and Health Surveys conducted in Pakistan, Uganda and Ethiopia describe coverage of 70–80% at the first antenatal care visit declining to 10–20% by the fourth visit [23, 26, 27]. Coverage of community health worker home visits (50–70%) in ‘real world’ programmatic settings is also substantially lower than experimental research sites (95–100%) [8, 28, 29]. In the Afghanistan study, the ‘drop out’ in community home visiting was because of the increasing village-level insurgency and withdrawal of permission for the community health worker to enter the house once the birthing ‘danger’ period had past. It is encouraging however that the uptake of home visits was as high as 70% in the first 2 days postnatal period [22]. For these reasons, the Afghanistan Ministry of Public Health has developed an enhanced package of community-based newborn care focusing on the ‘golden first day’ for resuscitation, breastfeeding and thermal care. For the first time, this package will include the WHO UNICEF Care for Development Programme and will focus on neonatal ECD as described in the Box above. The Afghanistan Ministry of Public Health together with Unicef Afghanistan is planning to test the golden first day package and assesses effects on mother and community health worker knowledge and attitudes and children’s long-term neurodevelopmental outcomes. We believe it is important for Ministries in other conflict-affected countries to review their community-based packages and consider implementation of neonatal ECD. References 1. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) . 2018 . http://www.childmortality.org/index.php? r=site/graph#ID=AFG_Afghanistan (9 March, date last accessed). 2. Countdown to 2030 Collaboration . Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health . Lancet 2018 ; 391 : 1538 – 48 . CrossRef Search ADS PubMed 3. United Nations . Every Woman Every Child (EWEC). Global Strategy for Women’s Children’s and Adolescent’s Health . New York, NY : United Nations , 2015 . 4. Shonkoff JP , Boyce WT , McEwen BS. Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention . J Am Med Assoc 2009 ; 301 : 2252 – 9 . Google Scholar CrossRef Search ADS 5. Engle PL , Black MM , Behrman JR , et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world . Lancet 2007 ; 369 : 229 – 42 . Google Scholar CrossRef Search ADS PubMed 6. Grantham-McGregor S , Cheung YB , Cueto S , et al. Developmental potential in the first 5 years for children in developing countries . Lancet 2007 ; 369 : 60 – 70 . Google Scholar CrossRef Search ADS PubMed 7. Yousafzai AK , Rasheed MA , Rizvi A , et al. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker Programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial . Lancet 2014 ; 384 : 1282 – 93 . Google Scholar CrossRef Search ADS PubMed 8. Daelmans B , Black MM , Lombardi J , et al. Effective interventions and strategies for improving early child development . BMJ 2015 ; 351 : h4029 . Google Scholar CrossRef Search ADS PubMed 9. Doyle KJ , Bradshaw WT. Sixty golden minutes . Neonatal Netw 2012 ; 31 : 289 – 94 . Google Scholar CrossRef Search ADS PubMed 10. Helping Babies Breathe . The Golden Minute. https://www.healthynewbornnetwork.org/partner/helping-babies-breathe/ (17 March 2018, date last accessed). 11. Smith ER , Hurt L , Chowdhury R , et al. Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis . PLoS One 2017 ; 12 : e0180722 . Google Scholar CrossRef Search ADS PubMed 12. Nagy E. The newborn infant: a missing stage in developmental psychology . Infant Child Dev 2011 ; 20 : 3 – 19 . Google Scholar CrossRef Search ADS 13. Werker JF , Hensch TK. Critical periods in speech perception: new directions . Annu Rev Psychol 2015 ; 66 : 173 – 96 . Google Scholar CrossRef Search ADS PubMed 14. Sroufe LA. Attachment and development: a prospective, longitudinal study from birth to adulthood . Attach Hum Dev 2005 ; 7 : 349 – 67 . Google Scholar CrossRef Search ADS PubMed 15. Brazelton TB , Nugent JK. Neonatal Behavioral Assessment Scale . 3rd edn. London : McKeith Press , 1995 . 16. Barlow J , Herath NI , Bartram Torrance C , et al. The Neonatal Behavioral Assessment Scale (NBAS) and Newborn Behavioral Observations (NBO) system for supporting caregivers and improving outcomes in caregivers and their infants . Cochrane Database Syst Rev 2018 ; 3 : CD011754 . Google Scholar PubMed 17. Lucas JE , Richter LM , Daelmans B. Care for child development: an intervention in support of responsive caregiving and early child development . Child Care Health Dev 2018 ; 44 : 41 – 9 . Google Scholar CrossRef Search ADS PubMed 18. WHO, UNICEF . Care for child development. In: Improving the Care of Young Children . Geneva, Switzerland : World Health Organization , 2012 . 19. WHO, UNICEF . Care for the Child’s Healthy Growth and Development . Geneva, Switzerland : World Health Organization , 2014 . 20. Jeong J , Pitchik HO , Yousafzai AK. Stimulation interventions and parenting in low- and middle-income countries: a Meta-analysis . Pediatrics 2018 ; 141 : e20173510 . Google Scholar CrossRef Search ADS PubMed 21. Gowani S , Yousafzai AK , Armstrong R , Bhutta ZA. Cost Effectiveness of Responsive Stimulation and Nutrition Interventions on Early Child Development Outcomes in Pakistan . Ann N Y Acad Sci 2014 ; 1308 : 149 – 61 . Google Scholar CrossRef Search ADS PubMed 22. Edmond KM , Yousufi K , Anwari Z , et al. Can community health worker home visiting improve care seeking and maternal and newborn care practices in fragile states such as Afghanistan? A population based intervention study . BMC Med 2018 , in press. 23. Anastasi E , Borchert M , Campbell OM , et al. Losing women along the path to safe motherhood: why is there such a gap between women's use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda . BMC Pregnancy Childbirth 2015 ; 15 : 287 . Google Scholar CrossRef Search ADS PubMed 24. Mohan D , LeFevre AE , George A , et al. Analysis of dropout across the continuum of maternal health care in Tanzania: findings from a cross-sectional household survey . Health Policy Plan 2017 ; 32 : 791 – 9 . Google Scholar CrossRef Search ADS PubMed 25. Singh K , Story WT , Moran AC. Assessing the continuum of care pathway for maternal health in South Asia and Sub-Saharan Africa . Matern Child Health J 2016 ; 20 : 281 – 9 . Google Scholar CrossRef Search ADS PubMed 26. Iqbal S , Maqsood S , Zakar R , et al. Continuum of care in maternal, newborn and child health in Pakistan: analysis of trends and determinants from 2006 to 2012 . BMC Health Serv Res 2017 ; 17 : 189 . Google Scholar CrossRef Search ADS PubMed 27. Yaya S , Bishwajit G , Ekholuenetale M , et al. Timing and adequate attendance of antenatal care visits among women in Ethiopia . PLoS One 2017 ; 12 : e0184934 . Google Scholar CrossRef Search ADS PubMed 28. Mbuagbaw L , Medley N , Darzi AJ , et al. Health system and community level interventions for improving antenatal care coverage and health outcomes . Cochrane Database Syst Rev 2015 ; CD010994 . 29. Kirkwood BR , Manu A , ten Asbroek AH , et al. Effect of the newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial . Lancet 2013 ; 381 : 2184 – 92 . Google Scholar CrossRef Search ADS PubMed © The Author(s) [2018]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Tropical Pediatrics Oxford University Press

Improving Early Neonatal Development in Conflict-affected Countries

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0142-6338
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Abstract

There have been substantial improvements in the provision of maternal and newborn healthcare in fragile and conflict-affected countries such as Afghanistan, Yemen and the Central African Republic in recent years [1, 2]. However, conflict-affected countries still have unacceptably high newborn mortality, estimated as 40 per 1000 live births in Afghanistan in 2018 [1]. Understandably, fragile countries focus on the ‘child survival agenda’ [3]. However, because of the evidence of the benefits of early childhood development (ECD) [4–8], there is increasing interest in the implementation of ECD programmes. The focus is on primary prevention and health promotion rather than neurodevelopmental screening and referral because there are no secondary or tertiary neurodevelopment services to refer to. Globally, there is increasing recognition of the importance of the ‘golden’ minutes and hours after birth for resuscitation, thermal care and breastfeeding [9–11]. The importance of fostering attachment and development of the neonate over this time through responsive stimulation, play and communication is also increasing [12–14]. There is clear evidence that the nervous system has great plasticity during the neonatal period and that neonates are not simply ‘reflexive’ and ‘subcortical’ but have important communication and social behaviours especially eye contact, visual locking, auditory responses and self-quieting behaviour [12–14]. By the end of the first month of life, neonates respond to language, look at bright contrasts, movement and colour. Healthy neonates regulate their physiological states by self-soothing, habituate to repeated sensory inputs and respond to social speech [12–15]. These observations led to the development of the Brazelton Neonatal Behavioural Assessment Scale [15, 16], and the inclusion of neonatal early childhood development, ‘neonatal ECD’, in the WHO UNICEF ‘Care for Child Development’ package of responsive caregiving and stimulation (see Box below) [17–19]. The ‘Care for Child Development’ package is targeted at community health workers and other primary care providers and includes clear play and communication messages to be used by community health workers and families in the first week of life. The ‘Care for Child Development’ package has been carefully evaluated and important impacts on children’s long-term neurodevelopmental and educational outcomes have been reported in the Lancet and other publications [7, 8, 17, 20, 21]. The ‘Care for Child Development’ package has also been incorporated into health service delivery in many low- and middle-income countries [17]. WHO/UNICEF Care for Child Development. ‘Newborn up to 1 week. Your baby learns from birth. Play. Provide ways for your baby to see, hear, move arms and legs freely and touch you. Gently soothe, stroke and hold your child. Skin to skin is good. Communicate. Look into your baby’s eyes and talk to your baby. When you are breastfeeding is a good time. Even a newborn baby sees your face and hears your voice’ [18, 19]. In Afghanistan, the community health worker programme was recently shown to have a statistically significant impact on enhancing demand and use of health facilities for facility delivery and antenatal care [22]. However, each woman only received an average of 2.2 home visits throughout the antenatal and postnatal periods. A total of 72% of women received a visit within 48 hours after birth but only 13% received a fourth antenatal visit and 5% received a fourth visit on day 28 after birth [22]. ‘Dropout’ after initial engagement is a well-known part of ‘real world’ maternal and child health (MCH) service delivery [23–25]. Analyses of Demographic and Health Surveys conducted in Pakistan, Uganda and Ethiopia describe coverage of 70–80% at the first antenatal care visit declining to 10–20% by the fourth visit [23, 26, 27]. Coverage of community health worker home visits (50–70%) in ‘real world’ programmatic settings is also substantially lower than experimental research sites (95–100%) [8, 28, 29]. In the Afghanistan study, the ‘drop out’ in community home visiting was because of the increasing village-level insurgency and withdrawal of permission for the community health worker to enter the house once the birthing ‘danger’ period had past. It is encouraging however that the uptake of home visits was as high as 70% in the first 2 days postnatal period [22]. For these reasons, the Afghanistan Ministry of Public Health has developed an enhanced package of community-based newborn care focusing on the ‘golden first day’ for resuscitation, breastfeeding and thermal care. For the first time, this package will include the WHO UNICEF Care for Development Programme and will focus on neonatal ECD as described in the Box above. The Afghanistan Ministry of Public Health together with Unicef Afghanistan is planning to test the golden first day package and assesses effects on mother and community health worker knowledge and attitudes and children’s long-term neurodevelopmental outcomes. We believe it is important for Ministries in other conflict-affected countries to review their community-based packages and consider implementation of neonatal ECD. References 1. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) . 2018 . http://www.childmortality.org/index.php? r=site/graph#ID=AFG_Afghanistan (9 March, date last accessed). 2. Countdown to 2030 Collaboration . Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health . Lancet 2018 ; 391 : 1538 – 48 . CrossRef Search ADS PubMed 3. United Nations . Every Woman Every Child (EWEC). Global Strategy for Women’s Children’s and Adolescent’s Health . New York, NY : United Nations , 2015 . 4. Shonkoff JP , Boyce WT , McEwen BS. Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention . J Am Med Assoc 2009 ; 301 : 2252 – 9 . Google Scholar CrossRef Search ADS 5. Engle PL , Black MM , Behrman JR , et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world . Lancet 2007 ; 369 : 229 – 42 . Google Scholar CrossRef Search ADS PubMed 6. Grantham-McGregor S , Cheung YB , Cueto S , et al. Developmental potential in the first 5 years for children in developing countries . Lancet 2007 ; 369 : 60 – 70 . Google Scholar CrossRef Search ADS PubMed 7. Yousafzai AK , Rasheed MA , Rizvi A , et al. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker Programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial . Lancet 2014 ; 384 : 1282 – 93 . Google Scholar CrossRef Search ADS PubMed 8. Daelmans B , Black MM , Lombardi J , et al. Effective interventions and strategies for improving early child development . BMJ 2015 ; 351 : h4029 . Google Scholar CrossRef Search ADS PubMed 9. Doyle KJ , Bradshaw WT. Sixty golden minutes . Neonatal Netw 2012 ; 31 : 289 – 94 . Google Scholar CrossRef Search ADS PubMed 10. Helping Babies Breathe . The Golden Minute. https://www.healthynewbornnetwork.org/partner/helping-babies-breathe/ (17 March 2018, date last accessed). 11. Smith ER , Hurt L , Chowdhury R , et al. Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis . PLoS One 2017 ; 12 : e0180722 . Google Scholar CrossRef Search ADS PubMed 12. Nagy E. The newborn infant: a missing stage in developmental psychology . Infant Child Dev 2011 ; 20 : 3 – 19 . Google Scholar CrossRef Search ADS 13. Werker JF , Hensch TK. Critical periods in speech perception: new directions . Annu Rev Psychol 2015 ; 66 : 173 – 96 . Google Scholar CrossRef Search ADS PubMed 14. Sroufe LA. Attachment and development: a prospective, longitudinal study from birth to adulthood . Attach Hum Dev 2005 ; 7 : 349 – 67 . Google Scholar CrossRef Search ADS PubMed 15. Brazelton TB , Nugent JK. Neonatal Behavioral Assessment Scale . 3rd edn. London : McKeith Press , 1995 . 16. Barlow J , Herath NI , Bartram Torrance C , et al. The Neonatal Behavioral Assessment Scale (NBAS) and Newborn Behavioral Observations (NBO) system for supporting caregivers and improving outcomes in caregivers and their infants . Cochrane Database Syst Rev 2018 ; 3 : CD011754 . Google Scholar PubMed 17. Lucas JE , Richter LM , Daelmans B. Care for child development: an intervention in support of responsive caregiving and early child development . Child Care Health Dev 2018 ; 44 : 41 – 9 . Google Scholar CrossRef Search ADS PubMed 18. WHO, UNICEF . Care for child development. In: Improving the Care of Young Children . Geneva, Switzerland : World Health Organization , 2012 . 19. WHO, UNICEF . Care for the Child’s Healthy Growth and Development . Geneva, Switzerland : World Health Organization , 2014 . 20. Jeong J , Pitchik HO , Yousafzai AK. Stimulation interventions and parenting in low- and middle-income countries: a Meta-analysis . Pediatrics 2018 ; 141 : e20173510 . Google Scholar CrossRef Search ADS PubMed 21. Gowani S , Yousafzai AK , Armstrong R , Bhutta ZA. Cost Effectiveness of Responsive Stimulation and Nutrition Interventions on Early Child Development Outcomes in Pakistan . Ann N Y Acad Sci 2014 ; 1308 : 149 – 61 . Google Scholar CrossRef Search ADS PubMed 22. Edmond KM , Yousufi K , Anwari Z , et al. Can community health worker home visiting improve care seeking and maternal and newborn care practices in fragile states such as Afghanistan? A population based intervention study . BMC Med 2018 , in press. 23. Anastasi E , Borchert M , Campbell OM , et al. Losing women along the path to safe motherhood: why is there such a gap between women's use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda . BMC Pregnancy Childbirth 2015 ; 15 : 287 . Google Scholar CrossRef Search ADS PubMed 24. Mohan D , LeFevre AE , George A , et al. Analysis of dropout across the continuum of maternal health care in Tanzania: findings from a cross-sectional household survey . Health Policy Plan 2017 ; 32 : 791 – 9 . Google Scholar CrossRef Search ADS PubMed 25. Singh K , Story WT , Moran AC. Assessing the continuum of care pathway for maternal health in South Asia and Sub-Saharan Africa . Matern Child Health J 2016 ; 20 : 281 – 9 . Google Scholar CrossRef Search ADS PubMed 26. Iqbal S , Maqsood S , Zakar R , et al. Continuum of care in maternal, newborn and child health in Pakistan: analysis of trends and determinants from 2006 to 2012 . BMC Health Serv Res 2017 ; 17 : 189 . Google Scholar CrossRef Search ADS PubMed 27. Yaya S , Bishwajit G , Ekholuenetale M , et al. Timing and adequate attendance of antenatal care visits among women in Ethiopia . PLoS One 2017 ; 12 : e0184934 . Google Scholar CrossRef Search ADS PubMed 28. Mbuagbaw L , Medley N , Darzi AJ , et al. Health system and community level interventions for improving antenatal care coverage and health outcomes . Cochrane Database Syst Rev 2015 ; CD010994 . 29. Kirkwood BR , Manu A , ten Asbroek AH , et al. Effect of the newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial . Lancet 2013 ; 381 : 2184 – 92 . Google Scholar CrossRef Search ADS PubMed © The Author(s) [2018]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Journal of Tropical PediatricsOxford University Press

Published: May 11, 2018

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