The implementation of early essential newborn care in the Gaza Strip to decrease neonatal mortality rates 

Childbirth in Gaza is particularly fraught with danger, and mothers and their babies are beset with challenges, including overburdened hospitals and a lack of health care support pre- and post-childbirth. 

In 2016, newborn deaths represented 68% of infant deaths in the country, a figure that only highlights just how risky being born in Gaza is – and why childbirth care can be critical, and lifesaving. 

Within the framework of the “Every newborn action plan”, WHO and its partners – including UNICEF, the United Nations Population Fund, The United Nations Relief and Works Agency for Palestine Refugees in the Near East, MAP-UK – are promoting and supporting early essential newborn care, a package of evidence-based life-saving interventions during delivery and the early newborn period. 

The work began by coaching 12 national facilitators from the Ministry of Health, who subsequently continued to scale up coaching around the Gaza Strip for hospital staff, including 455 midwives and nurses and 192 doctors. Target indicators included immediate skin-to-skin contact, immediate uninterrupted skin to skin, early breastfeeding, early and exclusive breastfeeding, newborn observation rates, newborn admission rates, sepsis fatality rate, asphyxia fatality rate, prematurity fatality rate and neonatal mortality rate. 

According to WHO, adopting these interventions, and eliminating potentially harmful practices, could effectively reduce the risk of infection and sepsis, asphyxia, and complications for an estimated 45 000 newborn boys and girls in Gaza, including for pre-term and low-birth-weight babies. 

Facilitators were also trained in quality assessment coaching, enabling self-monitoring and planning. An annual implementation review is also in place to assess the impact of the programme through measuring the above target indicators. 

In addition, practice improvements were supported by updated clinical guidelines, including the national neonatal guidelines 2019 and the local early essential newborn care pocket guide. Hospital policies were also adjusted, such as allowing the mother to bring a companion into the labour room, and supporting breastfeeding before discharge. There was a reorganization of work and the provision of basic supplies, including mother’s gowns and newborn caps. 

Early essential newborn care hospital teams were established and in January 2020 6 of these hospitals teams were coached in quality improvement tools and methods. Baseline data on early essential newborn care hospital practices, policies and impact indicators were collected. 

Challenges included a generally low quality of health-facility level data, both from aggregated facility level records and from administrative sources. Operational definitions were not unified in all facilities, and occasionally did not meet WHO core definitions. A chronic emergency context and persistent fragility of the social environment stops decision-makers maintaining long-term solutions and discussing gaps in services. 

Nevertheless, results were positive. Comparisons of baseline, early implementation, full implementation and annual implementation review data showed significant improvements in the above-mentioned targets. According to one early essential newborn care annual implementation review for Gaza, average clinical practice scores rose from five out of 42 (12%) to 16 out of 42 (38%) and 24 out of 42 (57%). 

In 2019 and 2020, 7 additional hospitals providing childbirth care for most of the remaining 35 % of births in Gaza endorsed early essential newborn care, and began implementation. These were: Al Harazin (Ministry of Health), Al Awda (operated by an NGO), Kamal Odwan (operated by Ministry of Health), Al Karamah (NGO), Asdekaa Al Marid (NGO), Al Ahli Hospital (NGO), and Public Services Hospital (NGO). A 2-day clinical coaching course was provided to 91 staff in the maternity and neonatal units, covering 85% of the total staff. 

The Early Essential Newborn Care Annual Implementation Review was conducted to assess progress in the 4 main Ministry of Health hospitals and in 5 of the 7 hospitals that began early essential newborn care in 2019. The remaining have requested not to be evaluated during the year 2021, because they have only just started the programme. 

It is hoped that the early essential newborn care programme will continue to support mothers and their babies on the Gaza Strip, with a view to providing comprehensive health care throughout women’s birth journeys.