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Dr. Paul Robinson (International Medical Corps, USA) submitted the following

comment, on 28 February 2014:

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ENAP Feedback

Section 6 in ENAP text

Comment

While the ENAP responds to the resolution WHA64.13 and specifically aims to increase access

to high quality and safe health services, the draft plan appears to be too medically focused.

Besides direct strengthening of health services it will be important to also include non-medical

strategies that are known to contribute to lowering newborn mortality. These evidence-based

broader social determinants include, for example:

Education for women and girls.

Poverty alleviation.

Training and involvement of midwives and TBAs.

Section 10 in ENAP text

Comment

Although the action plan recognizes the fact that countries with high burden of newborn

mortality have experienced conflicts, it is important to point out the flip side of the issue--that

countries and populations which are in conflict, including internally displaced persons and

refugees experience higher than usual newborn mortality rates and maternal mortality ratios.

Section 26 in ENAP text and Comment Box # 1 (Guiding Principles)

Comment

There are five guiding principles for ENAP. One more principle should be considered:

Knowledge Management and Dissemination: Country specific findings from M&E as well as

from the in-country consultations and activities should be documented and disseminated

appropriately for learning and replicating in other countries and regions.

This principle is important because adopting a rigorous Knowledge Management and

Dissemination strategy will enable countries to widely share the lessons learned from ENAP

implementation, so that in other countries and regions these can be adapted, and pitfalls avoided.

This would be also in keeping with the discussion under Section # 54 in the ENAP text.

Comment Box # 2 (Vision)

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Comment

The vision is well articulated. Suggest replacing the phrase “social and economic potential” to

“full human potential.” This replacement keeps the possibilities of growth and development open

for all facets of life, and avoids restricting the development to just the social and economic areas.

Successful growth of a newborn into adulthood, and living a full life should not be measured

merely in social and economic terms.

Section # 30 in ENAP text

Strategic objective 1: Strengthen and invest in care during labor, childbirth, and the first day and

week of life.

The strategic objectives (and activities) are focused on the timing of birth, immediate newborn

and postnatal care. It would be useful to include at least one objective around antenatal care (or,

treat this as part of SO 1), since adequate health services during pregnancy (and even during pre-

conception stage) are critical for positive outcome with delivery and newborn health. The SO 1

can be rephrased simply as: “Strengthen and invest in care during pregnancy, labor, childbirth,

and the first day and week of life.” The list of activities under this SO 1 would then include those

key ones related to ANC.

Section # 38 in ENAP text

Here, as in other parts of this draft plan, an assumption seems to have been made that

interventions with facility-based deliveries will improve newborn health, which in turn will

contribute to positive national level statistics. We believe this assumption needs re-thinking.

Facility-based deliveries are only a sub-set of all the deliveries that take place in a developing

country (particularly LMICs). Most of the deliveries still occur in the households. The plan

acknowledges this fact in Section # 56. Without significant inputs at the household levels the

overall goal (to achieve equitable and high-quality coverage of essential, referral and emergency

care for every woman and every newborn within every country) will likely remain unattainable.

There is no mention of TBAs in this action plan. Although training and using TBAs are sensitive

topics, it is undeniable that TBAs freely function in most developing countries, and are

influential in their communities. The TBAs can be trained and utilized to at least promote

appropriate referrals and newborn care even at the household level.

Section # 76 in ENAP text

The role of fathers as mentioned in this section and in other sections is commendable. The

decision-making role of mothers-in-law influencing newborn and postpartum care is significant

in most developing countries. It would be important for the plan to also discuss how the mothers-

in-law can be educated and utilized, so they can contribute to positive outcomes for newborn

health.

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Appendix # 3, Indicator # 2

Birth companion of choice and skilled attendant at birth

This indicator is unlikely to measure “respectful care” as intended. In its place, an indicator that

captures the mother’s own impression (for instance, reported in a postpartum survey) about

respectful care during delivery will be more appropriate. Numerator: no. of mothers reporting

they received respectful care; denominator: all live births.

General Comments

The draft ENAP is a good first step toward formulating a strong action plan for significantly

improving newborn health. The inclusive and consultative process is highly appreciated.

Congratulations to everyone involved in formulating this plan. Below are a few general

comments, more detailed comments have been offered above.

Pagination, crisper language and shortening of the document will make it more easily

readable.

Community awareness, provision of contraceptives, and influencing community norms are

not emphasized. These should be highlighted in the plan.

Pre-service and in-service training for relevant cadres of health staff need to be emphasized.

The plan heavily focuses on the biomedical approach to preventing newborn mortality.

Equal, if not greater emphasis must be given on improving social determinants that often are

the root causes for newborn, maternal and child deaths. These are the key barriers for not

using skilled attendants at childbirth. Unless the plan intentionally addresses these non-

biomedical factors the goal of lowering newborn mortality is unlikely to be attained.

TBAs are conspicuously missing from this plan. Although in some settings there is

sensitivity about using them for assisting in delivery, the TBAs can be trained to play key

roles in promoting Kangaroo Mother Care, providing cord care, detecting newborn illnesses,

undertaking awareness and education initiatives, and helping with referrals and other areas of

newborn health.