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Source: United Nations Children's Fund (UNICEF)
1 May 2012

Every year, an estimated 1,600 babies die in the first four weeks of their life in the occupied Palestinian territory (oPt). More than half die in their first week.

Most of these newborns deaths could be prevented if mothers and newborns’s health was systematically checked, and if young mothers received advice on how to best care for their children. This is why UNICEF developed a strategy that promotes widespread access to antenatal care, skilled birth attendance and early postnatal care. This is the most efficient way to contribute to reduce maternal and neonatal mortality worldwide.

To improve newborn survival, UNICEF supported the Ministry of Health (MoH) in revitalizing the postnatal home visits programme for new mothers and infants in Gaza.

Postnatal home visits are conducted by nurses and midwives who visit the mother three times within the first 42 days of delivery, with the first visit taking place immediately after birth. During each visit, they:

Improving skills for the sake of infants

Because most child deaths occur at home and due to late detection of danger signs by their caregivers, fatalities are best prevented by improving child health through the community. This idea is at the core of the strategy called “Integrated Management of Childhood Illness” (IMCI), which focuses on improving health worker skills, improving health systems and improving family and community practices.

Through IMCI, primary health care workers are trained by UNICEF to identify children who have symptoms of the most prevalent illnesses. Sick children are assessed according to their symptoms and signs. Severely ill children are urgently referred to hospital, while moderately ill children get specific treatment at primary health care level and at home. UNICEF trains health workers on case management skills through classroom work and hands-on clinical practice.

With UNICEF support 44 out 54 primary healthcare clinics (PHCs) in Gaza are now implementing IMCI. In addition, UNICEF conducts supervisory visits in those PHCs as a follow-up, to ensure compliance with IMCI standards and the implementation of in-service training when necessary. All PHCs in Gaza will be scaled up to implement IMCI by the end of 2012.

Making hospitals baby-friendly

The Baby Friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF in 1991 to encourage hospitals, health care facilities and particularly maternity facilities to adopt practices that fully protect, promote and support exclusive breastfeeding from birth.

A maternity facility can be designated 'baby-friendly' when it doesn’t accept free or low-cost breast milk substitutes, feeding bottles or teats, and has implemented 10 specific steps1 to support successful breastfeeding. Since the BFHI began, more than 15,000 facilities in 134 countries have been awarded Baby-Friendly status. In many areas where hospitals have been designated Baby-Friendly, more mothers are breastfeeding their infants, and child health has improved. The expected results are improved nutrition status, growth, development, health and ultimately the survival of infants and young children.

In Gaza, UNICEF supported the Ministry of Health in selecting three major hospitals where the BFHI will be implemented. After initial assessment of each hospital, a designating group has been formed in each of them to oversee the implementation of the initiative. Training on the 10 steps to successful breastfeeding has already started with the goal of reaching up to 80% of all health staff in these three hospitals.

On the long-term, this initiative should lead to an increase in the percentage of babies being on exclusive breastfeeding for the first six months of their lives, to a decrease in the number of children suffering from neonatal diarrhea and to a decrease in neonatal mortality (new-born dying before they reach one month).

Expansion of the Neonatal Intensive Care
Unit at Al-Nasser Pediatric Hospital

Al-Nasser Pediatric Hospital is the main pediatric referral centre in Gaza. Every year, it provides health care to approximately 90,000 girls and boys below 12 years of age in its emergency ward and inpatient units. Approximately 1800 critically ill infants receive care in the hospital’s 22-bed Neonatal Intensive Care Unit (NICU).

Although the current NICU is equipped with incubators, ventilators, and other lifesaving monitoring systems provided with the support of UNICEF, it is extremely crowded and below standards. Moreover, there is no dedicated space for infants who require isolation.

To respond to this critical need, and with support from the French National Committeee for UNICEF, UNICEF initiated a project to expand the NICU unit and provide it with much needed equipment and furniture. In addition, UNICEF will provide all needed technical support to hospital staff.

The expansion of the NICU unit will help doctors provide efficient services to the increasing number of pregnant women who face high risk deliveries as a result of congenital abnormalities, chronic disease, and who give birth under the stress of an environment marked by conflict. The expansion of the unit will also ensure that critically ill infants have access to timely and quality health care in Gaza.

Healthy eating for babies

UNICEF also continues to strengthen the capacity of the Ministry of Health’s Nutrition Surveillance System as part of its strategy to improve the nutrition situation in oPt, including that of babies and their mothers. The National Nutrition Surveillance System (NNSS) will ensure the availability and utilization of accurate and timely nutrition information. This will help bring about effective planning, design and implementation of curative and preventive nutrition programmes that will benefit young children and their mothers.

In Gaza, UNICEF supported the establishment of 15 nutrition sentinel centres in 15 primary health care clinics. The sentinel centers collect data about the nutritional status of mothers and children in highly vulnerable areas that require close monitoring, and analyze them on a monthly basis to obtain malnutrition trends.

In addition to nutrition surveillance, UNICEF works with the Ministry of Health and other partners to deliver essential micronutrients which will enhance the nutritional value of food and have a great impact on child’s development and mother’s health. Since 2010, UNICEF has delivered over 18 million micronutrient tablets in Gaza and now supplies three feeding centres in Gaza with therapeutic foods in partnership with the Near East Council of Churches.

To this day, no comprehensive study was completed in oPt that would help health authorities to fully understand the underlining causes of anemia and other micronutrients deficiencies which have long term impact on maternal and child morbidity and mortality. In order to bridge that gap, UNICEF is preparing a national micronutrient survey to assess the micronutrients status and explore the main causes of high anemia prevalence in oPt.

Visiting mothers and their new-born babies at home

Icelander Margrit Hafsteinsdottir works as Technical Advisor for UNICEF to help strengthen health systems.
A nurse, she writes about the postnatal visits she made to Gaza homes with UNICEF.

Finding our way was not easy. There are no street names in most of the Gaza Strip. The houses are known only by the family name, which turns every postnatal home visit into a little adventure. You end up meeting lots of people because you have to ask your way around the neighbourhood, and soon everyone is willing to help. You often reach the house you were looking for escorted by smiling children.

This house was like any other south of the Gaza Strip - no painting or wallpaper adorning the walls, only bare cement which is all families can afford. As usual, the rooms were almost empty, save for some rugs and pillows spread on the floor, and for children playing around.

In front of one of the rooms, we found numerous pairs of shoes of all sizes, neatly arranged. The door opened, revealing scores of women and children and a mother lying in bed with her new-born. The women had come to cook and clean for the new mother while she rested with her new child.

The nurses I had come with started asking questions to the mother. However before she had time to move her lips, other women and even some of the children began to speak, eager to help by answering any question we could have. We smiled and asked them politely to leave. Soon we were left only with the mother, her baby and a couple of children who had fallen asleep on the floor.

The 38-year-old mother had just given birth to her 14th child. She told us she has been married since she was 15 and had her first child one year later. She and her 15-year-old daughter were pregnant simultaneously, and went together to antenatal visits at the hospital. “I want my children to marry young and start having children immediately, like I did”, the mother told me, adding that marrying her children was also a practical way of making room in her house for the younger children. She said that seven of her children were already married, six girls and one boy. I calculated in my head that her oldest daughter must have been married at the age of 14.

“I don’t want anymore children”

The mother said this baby was her last child. “I am tired now, I do not want anymore children. My husband and I agreed that I would be sterilized at the hospital, at the same time I had a C-section.”

The mother said she had breastfed all her children, but that she had to wait five days before breastfeeding the new baby – he was bottle-fed in the meantime - as she was too tired. The nurses examined the C-section and changed the dressings, before examining the baby. Mother and child were found to be in good health but in need of rest. The whispers coming from the women standing outside the room, who had tried to follow every word we said, were replaced by laughs as the door burst open in front of relatives who brought us a tray of tea and sweets. No matter how poor people in Gaza may be, every visitor is greeted and every birth is celebrated with pride and love.

The new mother was only a teenager

Our next visit was to a 17-year-old mother who lived with her husband’s family in Gaza City. We were looking for a mother, we found a very unsecure teenager. Sixteen days had passed since she had given birth. She had been discharged from the hospital only one hour after the delivery, without receiving any education on breastfeeding. She had been trying for 16 days to breastfeed her baby, to no avail, and ended up following her mother in law’s advice to give the baby milk formula in a bottle.

At UNICEF we teach nurses and young mothers that they should exclusively breast feed newborns for six months, and continue breastfeeding up to two years, with supplementary feeding. Many mothers think it’s fine to give their newborns baby formula, or that breastfeeding for a couple of months is enough. There is still a lot of work to be done to extend our programme to all Palestinian clinics. We need to make sure no mother is left alone, and that every of them receives advice on their babies’s best start to life.

“The first days of life are crucial to save mothers and newborn lives”

Zeytun, Gaza, 4 January 2012 - It’s been only two days since 19-year-old Imane, from Zeytoun in Gaza City, gave birth to her first baby, a lovely boy called Quday. A midwife, employed by the Ministry of Health on a UNICEF post-natal visits programme, is already on her way to visit the mother and the baby, the first of three visits over the next 42 days.

“This is the first time I’ve seen Imane since she gave birth,” Fatma Darbali, the midwife, says. “I will check her blood pressure, sugar levels, her weight and the baby’s and check other indicators as well to see if everything is ok for both of them.”

Fatma’s job is to visit first-time mothers and mothers who have given birth in difficult circumstances or had high-risk pregnancies. A total of 25 midwives like her work from birth clinics across the Gaza Strip as part of a project supported by UNICEF. Imane, for whom this is the first pregnancy, is at home, waiting with her husband and mother-in-law. Two-day-old Quday sleeps comfortably in his mother’s arms as the midwife enters with her toolkit.

“It’s great to have this kind of support,” Imane says soon after Fatma has concluded her check-up. “I learnt a lot in this visit and it put my mind at rest since now I know my baby and I are fine.”

In Gaza, many Palestinian women marry at a young age and bear children shortly after, despite the reported harmful health effects of teenage pregnancies for mothers and their babies. Another problem is short birth spacing; more than one-third of Palestinian women give birth at intervals shorter than 18 months. Palestinian doctors report that the main causes of infant deaths in Gaza are prematurity, low birth weight and congenital malformations. Many infants are afflicted by congenital diseases such as cerebral palsy or eye defects, the most probable cause being consanguinity. Intrafamilial marriages remains a predominant feature of Palestinian life in Gaza to this day - around one-third of women are married to a first cousin.

The importance of following up on mothers and their new-borns cannot be understated. It is an extremely effective tool to fight infant mortality and postnatal
complications. Last year, UNICEF supported nearly 5,000 home visits to new mothers and their infants. “Mothers are supplied with a range of tools that help
them face the challenges of the first crucial days of their babies’ lives,” said Dr Sawsan Hamad, Director of the Mother's Health Department at the Gaza Ministry of Health.

Midwives do a systematic check-up on the mothers they visit while detecting and providing support to those sufferering from post-natal depression. They impart useful information on breastfeeding, check babies for potential complications and teach best practices to raise newborns in the earliest days of their lives.

The UNICEF project also provides mothers with a log book in which the visiting midwives record the mothers’ and babies’ health progress over the first weeks.. The transparent and informative file is kept by the mothers.

“Post-natal home visits are a safety net”

“These visits are really important to help us make sure we raise our children in the best way possible from the first days. They also help us feel that we’re not alone,” says Imane’s husband, Mohammed. “It’s great for mothers to realise there is professional help out there and support,” adds his sister, 28-year-old Suad.

Over the last decade, stunting in the Gaza Strip has increased substantially – an indication of chronic malnutrition and a risk factor in poor cognitive development for children. Increased food insecurity since the beginning of the blockade has not contributed to solve the problem. Anaemia ranks as the most
prevalent nutrient deficiency among children in Gaza. “Capturing this kind of data early on after childbirth is essential to ensure that any health problems are tackled immediately,” Dr Haman said. “After the first check-up, midwives can refer the mothers and their babies to a doctor, and send them for further hospital checks if necessary. This ensures that all mothers and children at risk are within a safety net from the very first days of motherhood.”

For Imane and Quday, the check-up had resulted in very positive results. Both mother and child are healthy. “The things that I have learned from this visit are invaluable,” Imane says. “I can now focus on my baby, knowing that I’m doing all the right things.”


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