Post by Cindy Turner-Maffei and Karin Cadwell
Last year Dr. Karin Cadwell, Healthy Children Project, Inc. (HCP) Executive Director was thrilled to plan a new project with our Egyptian colleague, Dr. Abla Alalfy. Together with other colleagues from the Egyptian Lactation Consultant Association, “Doctora Abla” and “the Mother of Egypt’s Children”, as she is affectionately known, had coordinated several earlier collaborative endeavors with HCP and Sweden’s Karolinska Institutet to train staff to implement Baby-Friendly Hospital Initiative (BFHI) and the PRECESS model, which supports hospital staff in practicing skin-to-skin contact after birth.
Now Drs. Abla and Karin were planning a way for HCP to support the Egyptian Members Association (EMA) of the Royal College of Paediatrics and Child Health (RCPCH), the Egyptian Ministry of Health & Population, the National Population Council, Kasr Alainy Faculty of Medicine, Cairo University, and Our Dream to expand resources for a 1,000 days campaign in Egypt. Because of the crucial importance of care and nutrition in this time period (spanning from conception through the second year), care providers needed training to better support the mother and child. Deficiencies in this time period are often irreversible in later life.
Egypt ranks 123rd of 182 countries on the Human Development Index (1). Although Egypt has made significant progress in reducing infant and child mortality, the World Bank Group reports that Egypt was expected to lose US$1.3 billion to chronic disease by 2015, with more than US$800 million lost in GDP each year due to vitamin and mineral deficiencies.
Many Egyptian women, especially those without the ability to afford care in a private hospital, do not have access to a companion of their choice during labor and birth, and the continuity of care model is not practiced. In 2017, Egypt reported a cesarean delivery of 62% (ranging from 30% to 85% in different areas of the country). Worryingly, the rate of Cesarean delivery is rising: estimated at 52% in 2014, it had increased to 62% by 2017, moving Egypt from the 42nd highest C/S rate to number one among the countries of the world.(2) For women delivering vaginally, episiotomies are common, and average length of stay is very short, often less than six hours.
Infant mortality rates are high in Egypt. UNICEF’s State of the World’s Children (2017) reports that approximately 2.5 million Egyptian children are born each year, of whom 19,000 died in infancy, while 23,000 died under the age of 5 in 2016. Egypt ranks 81st among other nations on Under-5 mortality (3). Life expectancy at birth in Egypt is 71 years. More than 1 in 5 Egyptian children experience stunting, which limits growth in height and cognitive development and increases susceptibility to infectious disease. More Egyptian maternal/child health statistics can be found in Box 1.
Improving maternity care practices, and optimizing nutrition and responsive care during the first 1000 days has the potential to dramatically decrease mortality and morbidity, saving lives, and improving future health. The hope of our collaboration is provide a cadre of community and hospital companions who will provide support and carry important health, hygiene, and nutrition education to the families of Egypt, especially in communities where disparity of care is highest. Specific areas of focus will be to increase healthy pregnancy, supportive childbirth practices such as companionship during labor, skin-to-skin in the first hours and establishment of exclusive breastfeeding and responsive feeding practices including cue-based feeding, support for continued breastfeeding through 6 months, addition of adequate, timely, safe and appropriate complementary foods at 6 months, and continued breastfeeding through at least 2 years.
Egypt experiences an inter-pregnancy interval that is shorter than the 24 months from birth of one baby to next conception recommended by WHO. This short interval potentially endangers the health and nutritional status of the infant or toddler, taking a toll on the mother’s future health and that of her subsequent children. Another goal of this project is to increase public awareness of the need for each child to have their full 1,000 days in order to grow healthier and more vibrant, carrying Egypt prosperously into the new millennium.
The 2018 WHO Intrapartum Care for a Positive Childbirth Experience(4) provides the template for the type of care our trainees will provide in the perinatal time:
- Support during pregnancy, labor and childbirth should be individualized and woman-centered.
- No intervention should be implemented without a clear medical indication.
- Only interventions that serve an immediate purpose and proven to be beneficial should be promoted.
- A clear objective that a positive childbirth experience for the woman, the newborn and her family should be at the forefront of labor and childbirth care at all times.
Over the past year, HCP faculty members have worked diligently in collaboration with EMA to create curriculum for two courses: one for health care workers who will provide education and support through labor and delivery and a second for health workers who will follow families in the community during the remaining 1,000 day period. This month, a team of HCP faculty, including Drs. Cadwell, Blair, and Brimdyr, Barbara O’Connor, Cindy Turner-Maffei and Donna Walls travelled to Egypt to conduct eight days of didactic and clinical training rotations in Stage 1, birth, postpartum, and NICU wards. Together with colleagues from EMA, including Dr. Abla, a dream team of supportive colleagues, stellar interpreters, and the support of Kasr Alainy’s Obstetrics and Gynecology Hospital, which provided training rooms and clinical rotation sites, we were able to train 85 hospital, and 105 community 1,000 Days counselors. Kudos to the participants who demonstrated great interest and commitment in seeking out and completing these arduous training programs.
Health system change will be necessary to support these shifts in maternal child care. In the next phase of the program, our colleagues will be working to scale up the project in keeping with the WHO Intrapartum Care Model, and the WHO/UNICEF Baby-Friendly Hospital Initiative, with a focus on the first 1,000 days.
It is our great honor to support the birth of this new initiative drawing attention to the importance of a healthy, supportive, humane birth for every Egyptian mother and baby. Long may this initiative grow and flourish, Insha Allah!
- World Bank Group. Nutrition at a Glance: Egypt [Internet]. [cited 2019 Mar 21]. Available from: http://siteresources.worldbank.org/NUTRITION/Resources/281846-1271963823772/Egypt.pdf
- AlAlfy A. Birth Statistics. 2019.
- UNICEF, editor. State of the World’s Children | Children in a digital world, 2017. New York, NY: UNICEF; 2017. 205 p. (The state of the world’s children).
- World Health Organization. WHO recommendations: Intrapartum care for a positive childbirth experience [Internet]. 2018 [cited 2019 Mar 21]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK513809/
UNICEF’s State of the World’s Children reports the following statistics for Egypt (3):
- 13% low birthweight rate
- 27% early initiation of breastfeeding
- 40% exclusive breastfeeding <6 months
- 77% of infants introduced to complementary foods between 6 and 8 months
- 23% of infants receive minimal acceptable diet between 6 and 23 months
- 20% breastfeeding rate at age 2
- 22% moderate/severe stunting
- 16% moderate/severe overweight
- 10% moderate/severe wasting
- 5% severe wasting
- 29% of children living in poverty by national standards
Regarding prenatal care, UNICEF reports that of Egyptian pregnant women (3):
- 90% have at least 1 antenatal care visit
- 83% have at least 4 care visits
- 92% of births are attended by skilled care attendants
- 87% of births occurred in a clinical setting
- 52% of births occurred via Cesarean delivery
- 14% of newborns had a health check within 2 days after delivery
- 82% of mothers had a health check within 2 days of delivery
- 49 maternal deaths per 100,000 births (adjusted 33)
- Lifetime risk of maternal death: 1 in 810