Improving Zambia’s Neonatal Death Rate with Healthcare Policy Proposal

Abstract

Adverse perinatal outcomes, particularly stillbirth, are significant issues in underdeveloped and developed nations. The World Health Organization (WHO) defines stillbirth as the death of a baby after at least 28 weeks of gestation. According to the WHO (2022a), based on epidemiologic research, approximately 3 million stillbirths occur globally each year. In Zambia, unfavorable pregnancy outcomes, including infant mortality, remain a serious public health concern. As per the United Nations Children’s Fund (UNICEF), Zambia’s neonatal death rate in 2020 was 24 per 1,000 live births.

In response, Zambia has implemented a comprehensive program of health sector devolution through several policies over the past few years, but no substantial improvements have been achieved. As such, there are calls for the INAP and MLCC to be combined, as has been done in India and Australia, to solve the problems of poor maternal healthcare in terms of services and healthcare workers’ underutilization. As the Minister for Health in Zambia, this proposal requests $2,000,000 to integrate the program and strengthen health service delivery and the workforce through training and education, aiming to achieve the MDG-4 goal.

Introduction

Adverse maternal and neonatal outcomes, notably stillbirth, are significant issues in developing and industrialized nations, according to the World Health Organization (WHO, 2022a). A stillbirth is the death of a baby in the weeks preceding birth or during the delivery process. According to the United Nations, the term varies from 16 to 28 weeks of pregnancy in various nations (UN, 2021). The WHO defines stillbirth as the mortality of an infant after at least 28 weeks of gestation (WHO, 2022a). As stated by the Centers for Disease Control and Prevention (CDC), stillbirth is defined as premature stillbirth (20–27 weeks) and delayed stillbirth (28–36 weeks of completed pregnancy term), with the latter having a better outcome through prevention (CDC, 2022).

As per epidemiologic research, over 3 million neonatal deaths occur globally yearly (WHO, 2022a). 67% of all stillbirths occur in rural homes, with 55% occurring in rural Sub-Saharan Africa and South Asia (WHO, 2020). There are 1.2 stillbirths worldwide during childbirth (intrapartum), and the risk is 24 percent higher for African women than for mothers in wealthy countries (WHO, 2022a).

Several underlying and conflicting variables contribute to fetal death. Furthermore, some illnesses, such as well-controlled diabetes mellitus, may be related to pregnancy complications without directly causing them. As a result, many infant deaths are difficult to pinpoint the specific reason for, and they are classified as unexplained by categorization systems for informing and establishing the probable cause of the infant’s demise (Housseine et al., 2021).

Due to the variety of categorization methods today, the fraction of stillbirths designated as unexplained ranges from 9.5% to 50.2%. (UNICEF, 2020a). Some infant deaths cannot be explained because not enough has been done to establish why they died. However, even after a thorough review, many neonatal deaths remain unsolved.

Considering that stillbirth and its complications are one of the primary causes of maternal death, the success of the Millennium Development Goal (MDG-4) is contingent on the accessibility of data on prevalence and incidence, as well as the size and risk factors of adverse neonatal outcomes. The proposed research study aims to evaluate the frequency and risk factors associated with stillbirth in Zambia and establish a plan that ensures best practices for quality healthcare delivery. Furthermore, Zambia has increased its efforts to meet the MDG-4 for maternal and child health. As a result, demographic data are essential for making policy and program decisions.

Evidence Review

Health Service Delivery

Providing high-quality healthcare is crucial to enhancing individuals’ length and quality of life worldwide. To achieve this, a country’s leadership must organize and resolve significant issues regarding structure and finance, as well as deliver high-quality public medical services to all citizens. Access to adequate health facilities is a fundamental human necessity.

If health is a resource and illness is a burden, safeguarding and promoting healthcare is critical to poverty reduction and ongoing human growth (World Bank, 2022a). Previous research, however, has demonstrated disparities in healthcare usage in favor of the wealthy. Furthermore, people in the greatest need of healthcare do not get a fair share. Although fairness in access is lauded in official documentation in Zambia, there is evidence that individuals in need of healthcare are not receiving their due.

Inadequate Healthcare Facilities

Zambia’s protracted socioeconomic strategic plan, Vision 2030, prioritizes health and ensures fair access to affordable, high-quality healthcare delivered as close to the community as possible. The Republic of Zambia’s administration is committed to enhancing the living standards of all Zambians. In recent years, considerable effort and resources have been invested in enhancing health facilities. Nevertheless, as in other Zambian communities, the endeavor to bring healthcare closer to the community has been challenging.

Zambia uses a pyramid classification scheme for healthcare delivery. Level 3 hospitals offer tertiary or specialist treatment, Level 2 hospitals give province-level care, Level 1 hospitals deliver district-level care, and health clinics and health posts offer local community services. The distribution of essential health services at lesser health facilities, such as health posts and clinics, is geographically constrained and supplemented by first-, second, and third-level referral hospitals.

In rural Zambia in 2018, 42% of expectant women delivered at home, while 56.3% gave birth in a healthcare facility (UNICEF, 2021). Public transportation to a health clinic is the responsibility of pregnant women and their families. The Lusaka system lacks a pyramid-based referral framework. In most cases, patients who should be treated at a level one hospital are sent straight to level three hospitals, reducing the quality of treatment.

Insufficient healthcare facilities cause healthcare congestion. Overload is caused by several issues, including insufficient infrastructure and a labor shortage (Sserwanja et al., 2021). Research revealed that congestion in healthcare facilities is a significant barrier to receiving adequate healthcare treatment (Miyoshi et al., 2019). People sometimes avoid visiting the facility due to the long lines and the time they spend there.

Socioeconomic Status

The connection between socioeconomic status (SES) and fetal death risk has been acknowledged for more than sixty years; however, its impact is incompletely defined. However, the wealthy in most nations do not have similar healthcare delivery challenges. As such, the healthcare delivery system disproportionately harms the poor more than it benefits the rich. The country’s Vision 2030 emphasizes the right of all citizens, irrespective of socioeconomic level, to universal access to and use of high-quality healthcare coverage (United Nations, 2022). However, inequality persists, and there is evidence that the inverse care law exists in African nations, notably Zambia.

Growing inequities can be traced back to 1991, when Structural Adjustment Programs (SAPs) were implemented, leading to the enforcement of user fees. The challenge led to a decline in healthcare utilization, particularly among individuals with low incomes (Cordero et al., 2019). As a result, the Zambian government implemented pro-poor policies and programs to increase healthcare utilization, improve health outcomes, and meet people’s needs while mitigating financial risks (Cordero et al., 2019).

The entire health system was devolved in 1995, and user fees were removed at all rural institutions in 2006. However, they were extended to all primary facilities nationwide in 2007 (Cordero et al., 2019). As a result, several health measures and the use of health services, especially at primary care centers, improved.

Healthcare Workforce

Attitude/Skilled/ Utilization of Healthcare Personnel

The attitudes of healthcare staff influence the interaction level between users and service providers. Negative attitudes among medical personnel can make patients hesitant to express themselves (Chavula et al., 2022). According to Chavula et al. (2022), the attitudes of health personnel may affect access to high-quality healthcare.

When speaking with patients, healthcare personnel have been accused of impolite and lacking civility. Low motivation levels might contribute to health personnel’s unfavorable attitudes. According to UNICEF (2021), health facilities are understaffed, and employees may have poor morale. The way the staff treats the users is influenced in part by the health professionals themselves.

Some of the critical factors for Zambia’s high maternal mortality ratio (MMR), which is now at 211 deaths per 100,000 live births, are limited access to healthcare facilities and poor utilization of professional birth attendants (UNICEF, n.d.-a). The lack of access to skilled personnel and variables such as women’s lack of decision-making ability, poor socioeconomic standing, and reliance on their husbands for financial assistance exacerbate the problem. When these circumstances are combined with the inadequate quality of care in rural Zambia, accessibility to facility-based delivery services is limited, and many women (53%) give birth at home (UNICEF, n.d.-a).

As a result, women seeking treatment face a barrier due to a lack of information about the need for professional attendants, particularly during delivery crises. According to Ota et al. (2020), understanding the number of stillbirths, their perceived causes, and potential remedies is crucial for developing effective prevention policies and programs. Risk factors for stillbirth include socio-demographic factors, medical problems during pregnancy, unsafe medicines, and problems after birth caused by a lack of access to qualified birth attendants.

Best Practices

Indian Newborn Action Plan Program

The Indian government has spent extensively on demand-side initiatives over the past century, resulting in an increase in skilled birth attendants and gains in emergency obstetric care enrollment. India sees a health system in which avoidable infant and stillbirth deaths are eliminated, every pregnancy is desired, every birth is cherished, and mothers, babies, and children prosper, flourish, and attain their full potential. The India Newborn Action Plan (INAP) initiatives were established to be consistent with the global Every Newborn Action Plan (ENAP). On the other hand, India intends to meet the global ENAP objectives by 2030—five years ahead of the global deadline—with all states achieving the goals independently by the end of 2035 (UNICEF, 2020b).

The INAP’s planned objectives are to reduce premature infant deaths and stillbirths to single digits by 2030, with intermediary goals for 2017, 2020, and 2025 (UNICEF, 2020b). The program would necessitate universal, egalitarian, and high-quality holistic care for all women and newborns nationwide (UNICEF, 2020b). The INAP was meant to be a plan for redefining and focusing national and subnational plans and activities.

However, India will assess how the initiatives perform and adjust its strategy as needed. INAP has further classified the neonatal/postnatal care element of the Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) continuum into four separate subgroups: immediate newborn care, healthy newborn care, small and sick newborn care, and beyond survival care for newborns (“National Health Mission,” 2022). Furthermore, the two phases influencing infant outcomes, including infant deaths, have been included: pre-conception and antenatal care, and care during labor and childbirth. The Indian concept aligns with the WHO’s principles and standards for the Every Newborn Action Plan (ENAP) (WHO, 2022b). For example, in 2015, 13 nations reported having produced a human resource strategy or program for skilled birth attendants within this framework (SBAs).

Except for Bangladesh, China, and Nepal, the same group of nations indicated the availability of a competence- and skill-based training program for healthcare facilities. Many nations have stated their intention to increase the number of educated midwives to meet the country’s current needs, particularly in remote and underserved areas, where a shortage of professional healthcare personnel is prevalent in public health facilities. With the system’s initiatives, India’s under-five mortality rate in 2022 is 32.6 deaths per 1,000 live births, compared to 46.2% in 2014, when the initiative began, showing a 29% decrease (UNICEF, n.d.-b). In this situation, the Indian approach is an excellent way to reduce stillbirths and health-related deaths in newborns.

Midwife-Led Continuity Care Practice (MLCC)

MLCC refers to a model of mother-and-newborn care in which services are provided by a single midwife or a small team of midwives throughout pregnancy, labor, delivery, and the postpartum period, with referral to specialized care if necessary (Bradford et al., 2022). MLCC is also a type of care offered by a specific professional group of midwives (WHO, 2021). Midwives should be thoroughly certified, regulated, and deployed solely as midwives.

In contrast, nurse-midwives are assigned nursing or midwifery tasks in many nations. In some HICs, MLCC has been associated with lower rates of preterm delivery (24% reduction) and fetal loss before and after 24 weeks (Perriman et al., 2018). MLCC has also decreased newborn mortality (16%), meaning mothers are less likely to lose their infants (WHO, 2021). Women are also less likely to receive therapies and have more positive patient experiences than men.

In Australia, the approach is utilized to provide community-based healthcare to pregnant women. The MLCC is active in this nation during prenatal, intrapartum, and postnatal periods, with continuity of care supplied by the same or a renowned provider certified by the Australian Government Department of Health and Aged Care. The Australian Department of Health integrates the concept with the Australian Nurse-Family Partnership Program (ANFPP), which assists pregnant women with an Aboriginal or Torres Strait Islander infant in becoming the best mothers attainable (“The Department of Health and Aged Care,” 2021). In this case, community nurses or midwives undertake home visits to advise from the beginning of pregnancy through the baby’s first year and even into the child’s second and third years (The Department of Health and Aged Care, 2021).

The concept has proven successful nationwide, especially during natural disasters such as floods, when women are unable to access healthcare facilities for childbirth and pregnancy. For example, a study of maternity care following major floods in Queensland found that MLCC mitigated the social and emotional consequences of the floods (Kildea et al., 2018). Another study in Australia discovered that MLCC resulted in fewer preterm births among Aboriginal and Torres Strait Islander women (Kildea et al., 2019).

The frequency of under-five male newborn maternal mortality has decreased from 4 per 1,000 live births in 2014 to 3.0 per 1,000 live births in 2020 since the model’s inception (World Bank, 2022a). It has remained constant throughout the years at 4 per 1000 live births for female neonates (World Bank, 2022b). These findings suggest that women at a greater risk of having an unsatisfactory neonatal outcome may benefit more from treatment continuation. Understanding how continuity can help close gaps in the health of mothers and babies remains a top research goal.

An MLCC model includes, but is not limited to, certain essential parts. Within healthcare systems, the paradigm is endorsed and applied. The model is accessible to all women, regardless of their personal or clinical conditions. Every woman needs the services of a midwife, and some also require the services of a doctor. Every woman is assigned a primary, designated MLCC midwife from the start of her pregnancy. The MLCC midwife accompanies a woman through all stages of pregnancy, delivery, and the postnatal period in various settings, including institutions and the community (“The Department of Health and Aged Care,” 2021).

When necessary, the midwife collaborates with additional healthcare specialists to provide comprehensive care that addresses the woman’s physical, emotional, psychological, social, and spiritual needs and expectations. During the midwifery program, the midwife represents the woman and her choices. Women are taught in an MLCC paradigm and are exposed to continuity of care.

Table 1. Comparison analysis of Zambian Mortality Rates from 2017-2020

Description

According to the table above (Table 1), the Neonatal Mortality Rates for the years 2017-2020 were 24.968, 24.688, 24.361, and 23.998, respectively. The infant mortality rate has also decreased slightly over the years, with rates of 45.562, 43.920, 42.873, and 41.664 for the years 2017-2022. Lastly, there has been a slight decline in the under-five mortality rates from 2017 to 2020, with rates of 64.629, 65.369, 64.089, and 61.378, respectively. However, neonatal mortality as a proportion of under-five mortality has been on the rise since 2017, with 0.395, 0.387, 0.390, and 0.402 for 2017 to 2020, respectively. The data points towards a general increase in neonatal deaths when the under-five-year-olds are factored in.

Framing the Optimal Strategy for Zambia

A combination of the best strategies from India and Australia has led to significant improvements in reducing infant mortality rates. As such, the program envisioned for use in the current research is a combination therapy built on two pillars.

The Program

The program was derived from the contextualization of the best strategy for Zambia. A conceptualized program is formed through the synergy of the Indian program INEP and the Australian program MLCC. The program is built and anchored on two pillars. The need for change with respective program implementations drives all four strategic drivers.

First pillar: Sanctioning and assembling individuals and midwives with their communities.

• Strategic Driver 1: Advance individual, household, and community conduct and standards:
  • Encourage programs that promote healthy motherhood and household habits, such as seeking care for uncomplicated pregnancies and deliveries, and treating abnormalities as soon as possible.
  • Boosting community engagement activities to make it easier for women, families, and communities to work together with health professionals and management to improve service quality and hold healthcare systems accountable.
• Strategic Driver 2: Expand equity of access to and utilization of services by the most susceptible:
  • Assisting in the changing of social and cultural norms in the maternal health environment via community-led initiatives and activities.
  • Promoting innovative financial changes to reduce economic barriers to maternal healthcare utilization.

Second pillar: Consolidating health systems and advancing quality.

• Strategic Driver 3: Strengthen and support health systems:
  • Encouraging public and private sector resource mobilization to facilitate the shift toward higher health system resilience.
  • Building the competence of health professionals and adopting policies, funding, and guidelines that meet the required skill mix, deployments, attrition, and motivating initiatives.
• Strategic Driver 4: Expand quality maternal and fetal healthcare:
  • Improving the referral system and responsiveness to complications and life-threatening situations.
  • Increasing the scope and scale of high-impact interventions for lethal complications.
  • Enhancing the acceptability, compliance, and quality of evidence-based treatments for the prevention and treatment of infectious illnesses and malnutrition in pregnant, laboring, and postpartum women.

Evaluation of the Success of the Program

In addition to evaluating progress on the outcome indicators listed below, the program will assist with the oversight and documentation of process indicators used to evaluate the coverage and quality of maternal and fetal interventions in major interventions nationwide. These criteria will include the provision of extensive and emergent obstetric and neonatal care, the facility’s preparedness to deliver excellent care, enough personnel, and 24-hour services. Furthermore, the program will support additional activities to assess unmet needs, near misses, and behavior modification interventions to increase demand for and utilization of life-saving treatments.

Evaluation Parameters

Table 2. Evaluation parameters for the synergized program.

From the table above (see Table 2), baseline and target analyses are provided to serve as evaluation markers in monitoring positive changes in the implementation of the synergized program.

Limitations of the Program

• Results may not be directly applicable to all situations, especially when MLCC and ENAP are integrated into the current maternity care payment system.
• While women value choice, it is essential to acknowledge that midwives at various life stages and those with childcare responsibilities may have distinct preferences for the program, which could impact future recruitment to the MLCC-integrated model.

Recommendations

This proposal seeks $2,000,000 in funding because:

1. Integrating a new Zambian strategy and interventions to address stillbirth and preterm birth takes time and resources.
2. Bolstering the referral system and response to manage health problems and life-threatening emergencies are required for the new program.
3. Training and education for community midwives and nurses are needed to increase the program’s uptake.

Pros

Regarding quality, the government should implement the Every Mother Every Newborn Quality Initiative (EMENQ) criteria and ensure the availability of commodities. The program will ensure that all the AEMENQ recommendations, standards, and improvement tools are used at all levels of the Zambian health system. To health workers, the government should provide training, mobilization, and assistance, particularly for midwives, nurses, and community health workers. The initiative can be established by counting the number of qualified birth assistants in healthcare facilities who have had basic training in emergency obstetrics and newborn care.

Cons

With a severe scarcity of human resources, especially when a qualified birth attendant is requested to attend training outside the health institution, the lack of grants will further restrict women’s access to timely maternity care. Based on the results, the on-the-job training of healthcare professionals will need to be better organized to prevent inconveniences and delays in service delivery. Improving human resources and ensuring the timely availability of all essential components of maternity care would guarantee the acceptance and quality of services in Zambia, resulting in a decrease in the incidence of maternal mortality. As a result, infant health outcomes will deteriorate dramatically, resulting in a rise in mortality attributable to unfavorable impacts.

Conclusion

In conclusion, although several reasons may impede mothers’ access to quality healthcare, health facility congestion, socioeconomic issues, staff attitudes, and a shortage of competent healthcare practitioners are the main reasons for stillbirths. Quality healthcare entails not only the service provider’s capacity to offer excellent services but also addressing the patient’s needs. Congestion at the clinic in Zambia affects mothers, resulting in lengthy lines and delays in the delivery of quality healthcare. The attitudes of health workers are also recognized as a factor influencing healthcare accessibility.

How patients are treated may impact whether they return to the hospital in the future. Economic and physical constraints also influence ease of access. The Zambian government has emphasized health through Vision 2030 and is dedicated to achieving equal access to cost-effective, quality healthcare as close to the family as possible. To reduce the number of stillbirths, the Zambian government needs to provide exemplary services that are easily accessible and affordable. As such, this informs the proposal for the MLCC-integrated model for use by the Zambians.

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