Ghana has seen tremendous improvement in newborn mortality rates over the last two decades, thanks to efforts by its Ministry of Health, the Ghana Health Service, PATH, Kybele Inc., and a whole community of partners.
Together, this community has implemented the Making Every Baby Count Initiative (MEBCI)—a nationwide effort to shape policies, train health care workers, and secure equipment to help small and sick newborns grow into healthy children.
As MEBCI approaches ten years of action in Ghana, we spoke to four PATH experts to learn about the initiative’s impact and what comes next:
- Dr. Patience Cofie, Chief of Party for the Ghana Country Program
- Dr. Cyril Engmann, Neonatologist and Senior Director for Quality and Program Impact and Professor of Pediatrics and Public Health
- Ellen Browder-Long, Project Administrator for Maternal, Newborn, Child Health and Nutrition
- Patience (Patti) Dapaah, Senior Advocacy and Communications Advisor for Medical Devices and Health Technologies
Q: How did the Making Every Baby Count Initiative come about?
Dr. Cyril Engmann: PATH staff in Ghana have been studying newborn mortality since 2003. Very early on, we noticed a critical lack of training for nurses and midwives in caring for newborns who were not breathing.
As we began looking at the national policy for newborn care, we found that small and sick newborns were being overlooked altogether. Child health services assumed newborn care was under the purview of maternal health services—and maternal health services assumed newborn care was under child health services. There was just a stark lack of information, attention, and quality care for newborns. Consequently, PATH and our partners worked to advocate for policy and program change.
When the Every Newborn Action Plan was endorsed at the global level in 2014, Ghana was one of the first countries to adapt and integrate the guidelines into national policy. The political support—and PATH’s decade of experience in Ghana working in and researching newborn health—created the perfect foundation for launching the Making Every Baby Count Initiative. Since then, we have conducted two phases: MEBCI 1.0 and MEBCI 2.0.
Q: What was the focus of MEBCI 1.0?
Dr. Patience Cofie: We first implemented MEBCI in a subset of districts in Ghana working toward a goal where 90 percent of newborns in those areas had access to high-quality care. For MEBCI 1.0, we pursued three main approaches:
- Strengthening the national leadership capacity to develop and implement policies that improve care for newborns.
- Expanding the knowledge base of health care providers working with mothers and newborns in health facilities across the country to improve the quality of care.
- Improving advocacy, communications, and resource mobilization for newborns in Ghana.
We started MEBCI 1.0 to help the Ministry of Health and Ghana Health Service develop guidelines and policies to effectively implement best practices for newborn care. This included updating important newborn indicators in the District Health Information Management System (DHIMS 2), the national database that captures health data. Updating these indicators made it easier to identify which issues would have the biggest impact—and together we prioritized those through policy.
To ensure the policies were effectively implemented, we developed a curriculum to train health care workers who would then train others working in maternal and newborn care. PATH often uses a “training-the-trainers” approach to help cascade knowledge through all levels of a health care system—and this method has proven highly effective. By the time MEBCI 1.0 concluded, we had trained more than 4,000 nurses, midwives, and doctors working in district hospitals and larger health centers in four of the nation’s ten regions at the time.
MEBCI 1.0 also focused on building community champions to help shift traditional beliefs and practices around newborn care to help reduce deaths. By working with traditional leaders like queen mothers, chiefs, religious leaders, and other local influencers, we were able to share information about newborn care from trusted sources in the communities. As communities learned more about how to care for small and sick newborns, it helped to build citizen demand for improved services in the health facilities.
Q: What was the focus of MEBCI 2.0? Why was it needed?
Dr. Cyril Engmann: We quickly realized that while the trained providers in health centers and district hospitals were better able to identify very sick infants or those struggling to breathe, they lacked the equipment or operational structure to manage these cases.
Second, when the providers were able to help a newborn with asphyxia to breathe, the newborn required advanced care to prevent long-term consequences. Providers had to refer these cases to higher levels of care, specifically regional hospitals. Sadly, upon referral of these babies to higher-level regional hospitals, providers there similarly lacked the knowledge base or equipment to care for such sick babies. We had to ensure that these higher-level regional hospitals could provide better care for newborn babies in the country.
So, for MEBCI 2.0, we focused on ensuring that regional health facilities had the equipment they needed to care for more acute cases. And, equally important was ensuring that they had the systems required to maintain this equipment—a significant and complex challenge in Ghana. That meant setting up a system for purchasing and regularly servicing specialized equipment, training clinical staff on best practices to use equipment and maintain longevity, and facilitating training by manufacturers for hospital engineers to ensure they could handle equipment malfunctions.
In addition to equipping the referral hospitals, we continued to train providers on newborn care best practices and updated operational and referral guidelines. We also developed community messages about newborn and maternal care to educate parents—on seeking care for their small and sick newborns and on continuing to care for them at home after discharge. As part of this effort, we developed videos with Premier Productions Limited, a media production company. We also obtained educational videos from the Global Health Media Project and translated them into local languages for use in hospitals, clinics, and communities.
Q: What impact has been seen so far? How are things different for providers and patients?
Patti Dapaah: Since 2014, the Ghana Health Service’s efforts, which include MEBCI and other initiatives, have helped reduce newborn mortality by half. When we started, 32 newborns (per 1,000 live births) were dying each year. Now, that number has decreased to 17 newborn deaths per 1,000 live births. By halving neonatal mortality rates, tens of thousands of newborns are now surviving every year because of these improvements in care.
“…tens of thousands of newborns are now surviving every year as a result of these improvements in care.”
By working with traditional leaders, we have been able to help build the advocacy skills of passionate and outspoken community members. We have also amplified their voices as they demand more from their government and seek to ensure that government commitments to newborn care are fulfilled.
Thousands more health care providers are now trained in small and sick newborn care. Health care centers, district hospitals, and regional hospitals are better equipped to provide lifesaving care without referring patients to other facilities. We have made operational changes in those hospitals to help families see a trained nurse sooner. And we are reaching families—in their local languages via community health care workers—with critical information about newborn care.
Q: Who are the partners who have made this work possible?
Ellen Browder-Long: Many, many partners have invested in improving newborn health outcomes in Ghana and have worked alongside the MEBCI program. The Ghana Health Service has been the primary partner, while PATH has been working through MEBCI to support the government in implementing its vision for better access to and quality of newborn health services in the country.
Funded by the Children’s Investment Foundation Fund, MEBCI brought together PATH and Kybele Inc. We have also worked alongside public and private sector partners like African Health Supplies, the Pediatric Society of Ghana, Premier Productions, and the American Academy of Pediatrics, who have all contributed materials to our training curriculum.
Other partner government agencies investing and implementing programs in Ghana, like the US Agency for International Development and the Japan International Cooperation Agency, have also played a major role in shaping Ghana’s overall health care environment.
Q: What is next for newborn care in Ghana?
Dr. Patience Cofie: Ghana has made great progress in reducing maternal and newborn deaths, with strong momentum and sustained commitment from the government and stakeholders to reach the ambitious goals the country has set for itself. MEBCI 1.0 and 2.0 were only operating in a handful of regions due to Ghana’s redemarcation into 16 regions. There are still nine regions in the country yet to be covered. If we can stretch a little further and adapt our strategy to include even a small portion of these other regions, we could see the annual newborn mortality rate heading to single digits in just a few years.
This of course requires continued leadership from the government of Ghana to prioritize the care of all mothers and their newborns, especially those born small and sick. This will require newborn-specific budget lines and tackling the key challenge of workforce attrition so that highly trained nurses, midwives, and other health providers who are trained in providing care to mothers and babies remain in Ghana.
Nurses are the bedrock for health in Ghana, so the nurses who have been trained in small and sick newborn care stay in Ghana in health care positions where that training can be put to use. Strengthening the education curriculum around maternal and newborn health for nurses and midwives when in training schools before graduation (preservice training) will also be a very economical approach to scaling knowledge, as well as ensuring the population better understands and recognizes when a baby is well versus when sick. Our vision at PATH is that every baby born in Ghana lives, thrives, and has a productive life.
