Every year there are 2.9 million neonatal deaths and 2.6 million stillbirths [globally], most of which occur in low and middle income countries. — Lawn JE et al. Lancet. 2014 Jul 12;384(9938):189-205
The red dirt road brings me back to these wards, these walls, these children. I’m about half way into my second six months in Rwanda working for Partners In Health/Inshuti Mu Buzima (PIH/IMB) as a district clinical advisor to two district hospitals — which is really just a fancy way of saying that I’m the (only) attending pediatrician on two government hospital wards. I walk into the neonatology unit and the nurses are bustling around, hooking babies up to CPAP, performing the first steps of life saving care for tiny (800-1500g, or 1.8-3.3 lbs.) premature babies who the doctors have not been able to come see yet because they are busy in the other wards with other critically ill patients.
Rwanda is unique in that almost 90 percent of births take place in facilities. But despite that fact, two-thirds of neonatal deaths still occur within the first 7 days of life while babies are still receiving facility-based care. It’s taken three years of facility-level mentorship — delivered through PIH/IMB nurse mentors and physicians — on basic neonatal protocols, Kangaroo Mother Care, Helping Babies Breathe and systems level advocacy to allow nurses in Rwanda to be trained and work in one clinical area (rather than being forced to constantly change wards). But they are now able to initiate life saving neonatal support (e.g., IV fluids, antibiotics, CPAP, oxygen support) as needed until a doctor can come. They are now the anchor of a neonatal team that is able to regularly save babies born around 1000g.
I’m called to come over to the Pediatric Development Clinic (PDC) — an outpatient clinic that follows at-risk infants (the majority of whom are preemies and low birth weight infants) after they are discharged from the neonatology unit — to consult on a case. In a country where the reality until quite recently was that you only went to the hospital if you were acutely ill, the concept of a clinic that routinely follows the growth and development of at-risk children is truly unique. The fact that the clinic’s no-show rate is less than 10 percent when these women have so many other demands on their time and resources never ceases to amaze me.
I walk in and see mothers sitting with their babies, babies who used to be patients on our neonatology unit — playing with blocks, talking to their children, trouble-shooting feedings together while they wait for the doctor to assess their babies’ weight and development. Some of these babies are 6 to 12 months old now: fat and laughing and terrified of the muzungu (white) doctor who just walked in. They cringe a little at the unfamiliar sight and start making a beeline — whatever that might mean at their given age — back towards their mothers, who just smile and shake their heads.
And I pause, with awe that resonates as a deep ache and wells to leave me on the edge of tears. People said this couldn’t be done, accepted a reality in which low birth weight infants and preterm infants born in the resource limited world would die because the level of training, investment and equipment that would be needed to change that reality was unimaginable — too overwhelming, too hard. They accepted the idea that some lives are worth less than others by the simple virtue of where you were born.
There’s no magic or new machine or revolutionary medical treatment that made this happen. It’s just nurses and a few doctors equipped with basic supplies and support who believe in a new reality and refuse to give up.
But these babies, born prematurely, are now playing on blankets with their mothers and growing into healthy young children — this is justice. This is a miracle. A miracle that has grown out of 5 years of grit, heartache, frustration and hard work on the part of PIH/IMB, the Rwandan Ministry of Health and so many others at every level of the district hospital. A miracle that began with neonatal protocol development. With showing up over and over again to help nurses and doctors implement those protocols. Until they could finally see and believe with their own eyes that these tiny babies they had watched die their entire lives, these tiny babies they at first believed only survived in developed world hospitals they would never see, who don’t even get named until they’re 7 days old because you’re trying to emotionally protect yourself from a child who is likely to be die.
These babies can live. They are living. They are thriving, laughing and stealing blocks from each other on a blanket in the PDC.
And there’s no magic or new machine or revolutionary medical treatment that made this happen. It’s just nurses and a few doctors equipped with basic supplies and support who believe in a new reality and refuse to give up. Who show up to give these babies antibiotics, oxygen, IV fluids and nasogastric tubes. Who understand how to feed them until the babies can do it for themselves.
Rwandans are making this happen despite high staff turnover, supply chain interruptions, high patient burdens and the emotional toll of working in a unit where we still lose children more often then we should. And there is more work to be done. But today I stand in awe and celebration of a miracle that grew from a tenacious dream, and of which I have had the privilege to be a small part.
Jennifer Werdenberg, MD, is a fellow in the Global Health Program at Boston Children’s Hospital as well as a graduate MPH student at the Harvard T.H. Chan School of Public Health. She spends 6 months each year in Rwinkwavu, Rwanda, working with Partners in Health/Inshuti Mu Buzima. There, she teaches and works side-by-side with local General Practitioners, interns and nurses and as a member of the team implementing and evaluating the All Babies Count initiative (ABC). ABC is a comprehensive, intensive 18-month intervention across 25 facilities serving 500,000 individuals aimed at decreasing neonatal deaths through a combination of clinical mentorship and system-level improvements including district-wide learning collaboratives. Before joining Boston Children’s, she was a global pediatric resident at Baylor College of Medicine, where she provided care in Lesotho as part of the Baylor International Pediatric AIDS Initiative.