In this interview, Dr Rebecca Nantanda says Uganda’s struggling newborn indicators can be improved once the responsible gaps are identified and fixed.
Knowing the weight of the baby at birth is good practice but in Uganda only half of the newborns are weighed. How can the country improve this?
First of all we need to find out why the babies are not weighed. Is it that the people who deliver those babies do not know the importance of weighing? I have come across those units where they may be willing to weigh the baby but they don’t have the appropriate scales. And for newborn care we must have a neonatal scale or maybe they have the scale but don’t know how to calibrate it or it has broken down. So we need to find out; is it a knowledge gap? Is it because they don’t have the equipment? Or if the equipment is there, is it that everybody doesn’t use it or some people use it or don’t use it consistently? So it all comes to why is it that we don’t have all our babies weighed?
It is important to know the first weight of the baby at birth to be able to do appropriate growth monitoring. When the baby is brought back for immunisation, I will know the baseline of where we came from. Knowing the weight also helps for example to determine if this baby is too small for gestational age. What are the things I am thinking about as a paediatrician, for example the complications that might arise even when I think this baby is okay for now? But also from the mother’s perspective, it is just so important to know the weight of your baby.
When it comes to preterm babies, we retain them in the hospitals because we need to care for them. We give them prophylactic antibiotics. We need to know how much to give them depending on their weight. But secondly, when it comes to feeding, we need to know how much to give and all that depends on the weight. But at the same time if you are looking at the preterm weight improvement every day, you must know what the baseline weight was. If there is no weight gain, what is the cause? Is it a problem with the baby? Is it a problem with the way I am [health worker] doing things? Are there some complications I am not looking at?
So how do we improve? Ideally weight measurement should be 100 percent in health facilities. Because once a mother has given birth in a health facility, they should have their baby’s weight taken for all those reasons I have given. So we need to look back and see why it is like this and act accordingly.
Just over half (53%) of the babies born in health facilities are initiated on breastfeeding in the first hour of birth. Does taking this to 100 percent require rocket science?
The situation is not the same everywhere and there are reasons why certain facilities failure to help mothers to initiate breastfeeding within an hour of childbirth. We have just been having a discussion on the heavy workload at Mulago National Referral Hospital. You have a situation a midwife is receiving the baby, the mother is supposed to be monitored somewhere, then another mother is coming in already in the second stage of labour. She should have had an opportunity may be if the load was not too high to help the mother start the breastfeeding process. Once you do not have that immediate opportunity to do that immediate support for the mother then it becomes very difficult. We have situations where the mother is waiting for the instruction from the doctor or the nurse. I think one of the ways we could improve that is through our antenatal care. The message should be that whether the midwife is there or not, mothers should immediately after birth start breastfeeding the baby. So we again need to go back and question ourselves regarding the health education we give during antenatal clinics. What are the key messages we need to give? That will impact both the care during antenatal and the immediate post-partum period so that the mother can be empowered to take decisions by herself and do it well knowing the benefits of that intervention.
Why does postnatal care for newborns within two days stand at a meagre 11% yet the number of women giving birth in health facilities has gone up?
It could be a whole lot of things. It could be the system. It could be the mothers themselves or the environment surrounding the mother. I think the ideal should have been the integration newborn care into the VHT [village health team] programmes. And therefore you would expect that after discharge the VHT would visit the mother to do the first postnatal visit. There are clear things that the VHT should be looking out for and if a mothers needs to visit a health facility they are referred or supports the mother on things like cleaning the cord. So that’s a systems issue. How are the health facilities linking to the Village Health Team and vice versa? How much communication is there? Does the VHT even know that this mother has delivered and even been discharged? I had an opportunity to visit Ethiopia where they have Health Extension Workers. They actually have a system of calling the VHT and letting them know about who has delivered, how and their condition, and so on.
One of the reasons why we are looking at health from the VHTs is because not every mother will come back to the health centre for review. They may have social and economic issues. They may not have the money, or there is 3 year old she has left home and needs to take care of them or she is too weak. There may be so many issues surrounding her and therefore she may not be able to come back. So if there is someone who can assist with assessing her and take a decision then it would be great.
For the few who may decide to come back, what are the hindrances at our health units? I am coming and there is this long line yet I have just had a delivery. Are there priorities in the system as they come to the health centre? Are there ways of making postnatal mothers not to wait for a long time? So all these could be hindrances to mothers getting back. But also the experiences matter. Time and again we have had some people having bad experiences in some of our health units. So it’s many factors which could contribute to that. We have to examine each of them.
How can communication between health workers and newly delivered mothers be improved?
First of all we need to understand that communication is more than talking. Many times we think when we tell a mother to breastfeed their baby within the first hour we have communicated. But the right thing would be to as well tell the mother the benefits that come with breastfeeding. In other words we need to improve their health literacy because if somebody appreciates something they will be able to do it. Humanly, we usually don’t want to take instructions. So the communication in terms of how and what is said to the mothers and or their attendants is very important. But also communication within the health system for example between the health workers and community health workers is also important. If for example the two would communicate say via telephone it would go a long way in terms of helping out the mothers.
We have no policy on safe oxygen use yet it is very critical in the management of newborns
First I must say oxygen is a lifesaving commodity regardless of one’s age. When you need it you must have it. But again for the newborn even more of a lifesaving commodity. Looking at our newborns, it can save life but if not used appropriately, can cause harm. If you give inappropriate doses of oxygen, they can easily end up with blindness. And therefore for the newborns, particularly the preterm, health workers should be able to know how much is needed, for how long and monitor response. When should we start oxygen? What is the best method of giving it? What should I be looking out for? Luckily enough, early this year, we got guidelines from WHO about oxygen use in paediatrics. But going forward, we need to disseminate these guidelines further down to health facilities. But we also need formal training for the health workers to appreciate these guidelines. I have interacted with health workers in some areas in Uganda but many do not know when to start giving oxygen, they don’t know how to monitor oxygen, and they don’t know what the different values mean. An eye opener for us was when these health workers were given pulse oximeters which are not readily available in many health centres yet one needs them to find out if a baby needs oxygen. In one of the facilities a midwife said she did not know that even when a baby looks well they could actually be having low oxygen saturation. What I am saying here is that for the newborns, a health worker doesn’t need to wait for the signs, they must make use of the pulse oximeters to establish if there is a problem.
***By Kakaire Ayub Kirunda