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MAMI reflections on the Lancet Small Vulnerable Newborns series

By Marie McGrath on 7 June 2023

The recently launched Lancet Small Vulnerable Newborns (SVN) Series comprised three hearty papers of evidence and analyses and a call for action to prevent babies being born dead, too early and too small.

Figuring out the care of these ‘wee’ babies and their mothers has been my primary angst and professional interest for the past 14 years so I dived in with interest. Here are a few of my gut reactions – never one to say less when I can say more, sorry it’s a bit of a long read.  Pop out for a breather when you need!

Connecting SVN and wasting actions: don’t miss this trick

Reducing SVN burden will reduce malnutrition caseloads. The new SVN conceptual framework shared in Figure 2 of Paper 1 reflects how the small vulnerable newborns of today are the wasted, stunted and underweight babies of tomorrow. Paper 4, estimates that increased coverage of the eight proven health and nutrition interventions examined in the Series would reduce stunting by 2.9% in 81 countries by 2030. Why not extend the analyses for wasting and underweight too? This would help hammer home that SVN prevention is critical to achieving nutrition targets and really help join forces with the nutrition world.  In fact, you’ll be pushing on an open ‘nutrition’ door – one of the targets of the UN Global Action Plan on Child Wasting is to reduce incidence of low birth weight (LBW) to reduce wasting prevalence to less than 3% by 2030 (SDG 2.2).  Reduction in LBW is one of four critical outcomes around which core targets, priority actions, population groups and budgets are identified as part of national operational plans or “roadmaps” to translate these international commitments into national action. Development of twenty-one national roadmaps is well underway, supported by UNICEF. This process offers a great and critical window for multi-speciality co-action around women’s and infant’s health and nutrition. A bit more data, you’ll be invited right in!

35 million small vulnerable babies: acting now to mitigate risk

The focus of the SVN Series is on critical prevention. While we act to prevent, what to do with the estimated 35 million SVNs already (and continuing to be) born is something we need to also address right here, right now. They are at increased risk of death, poor growth and development. How do we handle that? We’re already trying through the MAMI Global Network, an established global community of practitioners working together for more than ten years to figure out how to find and best target risk-mitigation care for small and nutritionally at risk (in other words, vulnerable) infants under six months and their mothers.  

To fill a critical gap in ‘how’, we collectively developed the  MAMI Care Pathway Package, an adaptable framework and resources to guide integrated continuity of care across maternal and child systems of health and nutrition.  It is being piloted/programmed around the world with implementation experiences and research helping build a critical evidence base. The MAMI approach involves enrolling small vulnerable infants under 6 months and their mothers in community-based care to 6 months of age to provide targeted support, keep a watchful eye and enable prompt action. LBW is included as an independent enrolment criterion and prematurity an added marker of risk.

Through MAMI we aim to prevent as much as ‘treat’; these babies’ troubled start to life may well be fuelling subsequent malnutrition episodes, relapse and failure to respond to treatment later on. We always consider the mother-infant pair – a vulnerable baby may often mark a vulnerable woman. Systems and services to manage small and vulnerable babies offer a critical entry point to cater for long-neglected women’s health and nutrition.

Lightening can strike twice: targeting prevention

The SVN Call for Action has challenged me to think more deeply on what we can do on the preventive side for small vulnerable infants under 6 months and their mothers who we identify for care in the MAMI approach.  Starting life as a small vulnerable baby is catastrophic for an individuals life chances. To prevent it happening again, we could target preventive action to those already affected. On this front, multiple micronutrient supplementation feels like a low hanging fruit. The authors of Paper 4 conclude that evidence supports the provision of multiple micronutrient supplements (MMS) instead of just iron and folic acid for women in low and middle income countries (LMICs). Broadening WHO recommendations from the use of multiple micronutrient supplements in the context of research, to use for all women in LMICs could result in substantial reductions in small for gestational age (SGA) births, stillbirths, and neonatal deaths.

This makes me think; if a woman already has a small vulnerable baby, shouldn’t she be a prime candidate for MMS supplementation? Should we be more directive on MMS in the MAMI Care Pathway? We’ll be examining this in our ‘Mothers in MAMI’ review planned for later this year.

If we don’t look, we don’t see

Small vulnerable babies and their mothers are everywhere, in some places more than others. We often don’t see them because we don’t look for them. Through our MAMI approach we are trying to change that.  In January this year, I visited a health clinic in Ethiopia where LSHTM, ENN, Jimma University and GOAL are conducting a randomised control trial and process evaluation of the MAMI Care Pathway Package integrated within outpatient health clinics in Jimma Zone and Deder Woreda.  A very underweight baby and her mother were enrolled in the trial and came for follow-up support to an outpatient clinic while I was there.  Identified as severely underweight through screening at first vaccination as part of the trial, it transpired this 4 month old was one of triplets, born premature at 28 weeks and the sole survivor. Without proactive screening, this mother and baby would not have been picked up unless they presented sick or malnourished.  

When we look, it’s still hard to see

The Series aims to bring much greater visibility to the nature of the SVN burden beyond what LBW offers. Prematurity and SGA are the 'driving pathways for vulnerability' which informed the development of the ‘SVN’ umbrella term and the accompanying conceptual framework. This focus on functional outcomes resonates with the direction of travel in MAMI and in the world of nutrition - whether a child is small or tall doesn’t matter, whether they survive and thrive and live long and fruitful lives does.  

Reflecting the drive for data depth, the authors set an ambitious call and target for premature and SGA data collection at health facilities worldwide.  I worry such depth of data in routine services will not be feasible anytime soon. Our experience through MAMI is even birth weight is not available in many contexts, making it difficult to exactly identify these babies for follow up care. So while we strive for the ideal, I think we need Plans B, C and D to handle the many realities, with interim pragmatic options and target care to identify those infants most at risk of dying. For example, we have found that weight-for-age and mid-upper arm circumference, measured at six week vaccination, pick up infants at higher risk of death (critical to know) that includes LBW infants (good to know). These indicators won’t give the visibility on SVNs that the Series is seeking, but at least will help us swoop up these babies and their mothers into care.

Working together is not easy but so worth it

SVNs are a result of mal-nutrition, mal-health, mal-development, mal-you name it. We all need to be on the case. Collaboration isn’t easy. It involves negotiation, brokerage and willingness to compromise.  Paper 2 dug into collaboration with an insightful analysis of the four main challenges that global health networks tasked with LBW reduction face in generating attention and resources.  These findings resonate with our experiences at the MAMI Global Network. Here’s some of what we’re doing and have learned along the way;

Different definitions and fragmented guidelines are two of the challenges that have hindered clarity and action on LBW reduction. This also hinders co-action across nutrition and health. Our definitions create obscurity - one person's small and sick newborn becomes someone else’s underweight 6 week old who becomes someone else’s wasted 7 month old.  Yet we are all talking about the same baby. This makes it a nightmare to ‘join up the dots’ across initiatives and creates headaches for advocates trying to herd us all into simple, shared messages to galvanise attention and resources. 

With this exact problem in mind, ENN is in the throes of a scoping review of global health and nutrition guidance relevant to the care of small and vulnerable babies under six months and their mothers. We are working to unravel concepts, definitions and development processes to identify synergies, gaps and practical opportunities to work together. Opportunities already leaping out at us include implementation guidance development for WHO updated guidelines on wasting management (imminent release) and on premature and LBW infants (2022). It’s madness if we don’t make that happen.  For the review, we are collaborating across agencies including UNICEF, WHO and with partners in the Healthy Newborn Network, and across disciplines, and welcome any offers to join in, help shape our work, or to invite us to contribute to your efforts.

When we developed our MAMI Global Network 5-year strategy, we scrutinised the strategies, visions, and objectives of health and nutrition initiatives, including the Every Newborn Action Plan. We called out common ground to help connect.  But making this happen takes a lot more work. We’ve found that it really helps to have something practical to convene around, rather than some well-meaning but vague intent to ‘work together’. We’ve had positive experience of this with the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) Maternal and Newborn Health Sub working Group, contributing a MAMI take on ‘Success Depends on Collaboration: Cross-Sector Technical Brief on Maternal and Newborn Health and Nutrition in Humanitarian Settings’.  

Throwing collaboration into the already busy mix may well slow things down and brings complexity.  But from 25 years of experience of this at ENN I can say, it is so worth it. A great example is the update of the MAMI Care Pathway Package that we completed in 2021.  We originally planned to update it in six months. It took 16 months.  Why?  We engaged nutritionists, neonatologists, and specialists across nutrition, early childhood development, maternal mental health and child health in the process. Committed individuals somehow found the time to review, suggest and appraise content to generate a completely revamped version 3.  What resulted was so much stronger, not only in terms of relevance and content, but also shared ownership and buy-in.  This was only possible for us to do through the strong relationships with individuals we had nurtured though our networking over the years, and through flexible, intelligent funding from Irish Aid and the Eleanor Crook Foundation who saw the value of collaboration, trusted us, and invested in a process whose value is way beyond what can be measured in monetary terms. I’m happy to say, the Bill and Melinda Gates Foundation is now supporting our network in a similar vein.

We know what to do but do we know how to do it?

The Lancet Series has clearly identified what to do and why to prevent SVNs. They’ve rubber stamped the case on ‘what’ we need to do. But at the Cape Town launch I did sense an air of disappointment that there was nothing new in the package of interventions proposed for scale. I’m worried this will prompt a hunt for that elusive magic bullet missing from our repertoire. Rather, we need to turn our attention to the ‘how’. “We know what to do but we don’t know how to do it” has been a refrain for many years now. We need to take that particular “bull by the horns”, embrace the complexity of real life and invest in implementation capacity and research. Why do interventions work or not, how, for whom and in which contexts? How do we lessen the load of overburdened systems of health?  Otherwise, we will be still scratching our heads in 2030 when we have failed to come even close to SDG targets.

Recognising this longstanding evidence gap, BMJ Global Health is now encouraging submission of implementation science articles as a sign of their commitment to the 2016 Ottawa Statement to achieve “more and better implementation research”. Perhaps The Lancet would consider joining this movement to help bring rigour and attention and catalyse investment in research to this underappreciated wing of evidence generation? This would be a great dimension to feature in the future Lancet Series planned on the management of the sick and vulnerable newborns. Given our efforts on this front, we would love to contribute by tapping into the rich body of implementation evidence on the ‘how’, accumulating through the MAMI Global Network.

We hear your rallying cry loud and clear!

The smallest babies have the quietest voice. The Lancet SVN series has raised the volume, generated clamour and is make noise on their behalf.  We hear you, we’re acting, and we are keen to join forces in whatever shape or form collaborators may come in.

Forewarned is pre-armed; we will come knocking on various doors. Please let us in! The favour is returned; our door is always open. Come in and pull up a chair.  

Please do contact us at mami@ennonline.net and find out more about us here.

Marie McGrath is a Technical Director with Emergency Nutrition Network (ENN). She is ENN’s technical lead on the Management of small & nutritionally At-risk Infants under six months & their Mothers (MAMI) and Co-Chair of the MAMI Global Network. On the MAMI front, she is also undertaking a part-time PhD at the London School of Hygiene and Tropical Medicine to investigate implementation experiences during a randomised controlled trial of the MAMI Care Pathway Package within health services in Ethiopia (involving ENN/ LSHTM/ Jimma University/ GOAL Ethiopia).

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