Infusing traditional culture with western medicine to reduce newborn mortality
One of Stanford’s newest faculty members, Gary Darmstadt, MD, knows it’s possible to save the lives of hundreds of thousands of newborn babies worldwide without building hospitals or dispensing pricey drugs. In a groundbreaking endeavor, his team worked with communities to slash newborn mortality by 54 percent in less than two years in a large, impoverished area in northern India called Shivgarh.
Their strategy was simple, in principle: embrace the local culture, seek to understand its newborn-care practices, and partner with the community to translate evidence-based recommendations into meaningful communications — metaphors, songs — that could change behavior.
Even more strikingly, their method wasn’t really medical. The team’s most technical recommendation was to sterilize sickles used to snip umbilical cords.
But despite its success, the spillover from the Shivgarh study — conducted in 2004 and 2005 — has been difficult to discern. Nearly 3 million newborns still die each year, according to a 2014 Lancet study, and many global health experts remain focused on more highly technical interventions. Yet Darmstadt and his colleagues know that many of these babies could be saved using the team’s community-based tactics. They’re continually refining their methods, looking to improve the principles they developed a decade ago in rural Shivgarh. They published their guiding framework in 2010 and additional details this summer in Seminars in Perinatology.
Thanks to their community approach, they do more than just save babies; they also empower women and those in lower social classes, and improve maternal health. These principles have been adopted as part of Indian health policy, and they inform current World Health Organization recommendations on newborn care.
A traditional beginning
The Shivgarh project started small, just two men, one truck and a bit of funding. Darmstadt had teamed up with Vishwajeet Kumar, a public health researcher he met while both were at the Johns Hopkins Bloomberg School of Public Health. Kumar, who has an Indian medical degree known as an MBBS, is charismatic and effusive, while Darmstadt is reflective and empathetic. They had both been pondering a 1999 study that showed a 62 percent reduction in newborn mortality in a community in western India due almost entirely to interventions provided in homes, not in a medical setting. They wondered whether these findings were replicable. And what were the key ingredients that led to such a significant reduction in mortality? Could mothers, families and communities be empowered to save their newborn babies without medical intervention?
To them, Shivgarh was the obvious choice for their public health experiment, which was funded by the United States Agency for International Development (better known as USAID) and by Save the Children US via a grant from the Bill & Melinda Gates Foundation. The population was poor and rural, with female literacy rates under 40 percent, an 8 percent neonatal mortality rate and deeply ingrained beliefs in the omnipotence of spirits and gods. Shivgarh’s loose coalition of villages, with about 100,000 residents, encapsulated the health-care challenges posed by communities across southeast Asia. “It was the epicenter of public health challenges,” Darmstadt says. “If you could crack a problem here, you had really achieved something and it’s likely what you had learned could have some impact elsewhere.”
The duo first arrived in 2003, venturing into villages surrounded by rice and mango fields, where the winter fog penetrated with a chilling dampness. With a small team of local social scientists and public health professionals, they spent hours meeting with mothers and their families, traditional providers of village health care, community leaders, priests, elders and anyone else willing to talk with them, explaining their goals, asking questions and, most importantly, listening. They worked with community members to develop village maps and depictions of community systems of health care, and gathered statistics about pregnancies and childbirth practices — practices that to a Western mind screamed for change.
For generations, pregnant women in Shivgarh have labored in rooms lined with cow dung, giving birth squatting above the floor. They leave the baby on the ground until a domin, a woman from the lowest caste, arrives to cut the umbilical cord — a wait that can extend for hours, especially for nighttime births. She snips it with a sickle (unsterilized) and wraps the babe in dirty rags. Only the domin, it is thought, is not tarnished by the “pollution” of childbirth.
The mother and the child spend the next several days cloistered in a dark, damp storage room called a saur. Such isolation, community members believe, keeps evil spirits at bay and protects the child from neighbors who might give the newborn baby the evil eye. The mother’s first milk, the immunity-boosting colostrum, is considered unclean and discarded. Instead, the baby is fed goat’s milk, water and honey from a cotton wick (also unsterilized). Only another lower-class woman, called a naun, is allowed into the saur to massage and bathe the baby. The naun uses harsh, potentially toxic oils like mustard oil and scrubs the baby vigorously, leaving the skin vulnerable to infections. She stokes a fire, which is thought to protect against the bad spirits, leaving the room filled with dense, choking smoke.
Before the mother begins breastfeeding the baby, families consult the village priests. These priests check the stars to select an auspicious starting date, usually around the third day after birth. If the baby gets cold and turns blue, or struggles to breathe, or shows any other warning signs of illness, the family must weigh the risks of leaving the saur, thereby exposing the child to evil spirits, or remaining isolated and relying on traditional remedies.
If the baby lives through its first week, mother and baby leave the saur and rejoin the community, where the baby is welcomed with a ceremony, given a name and dressed in clean clothes.
It takes a village
To most Westerners and physicians, these practices seem nonsensical, even shocking: They leave their babies in cow dung?! But for Darmstadt and Kumar, the locals were “donors of knowledge,” equal partners rather than research subjects irrationally attached to harmful practices.
Team members had to vigilantly check their biases. “We had to continually remind ourselves to ‘Go out there and empty your mind,’” Darmstadt says. “It was really important to suspend that sense that you know something about what you’re observing until you’ve spent quite some time there.”
By asking probing, yet respectful questions, they learned that most of the practices surrounding childbirth in Shivgarh were developed to cleanse the baby from the perceived pollution of the womb and to protect babies from evil spirits, the supernatural forces thought by the largely Hindu population to be responsible for a variety of hardships. That insight made the villagers’ seemingly counterproductive behavior appear quite logical.
“Many of the things they do are driven by the same fears,” Kumar says. “We look for the cause of the cause and the cause of the cause of the cause, until we get just a handful of things, and that’s where we hit.”
The team set to work developing interventions that capitalized on the community’s belief system and could help its newborns. A breakthrough came when Darmstadt, Kumar and their team realized the practices that could lead to infections were also linked to hypothermia. Cold itself was dangerous, yet the community, though well-versed in other temperature-based concepts, lacked an understanding of, and a word for, hypothermia. Infection, which posed greater risk to the newborn, was even more elusive.
“The concept of germ theory per se was meaningless to them,” Darmstadt says. “The way we ended up providing the same concept was through an analogy.”
Villagers knew they had to stick their utensils in flames and clean their hands before making yogurt or paneer, or else the curd would spoil, Darmstadt says. Similarly, the team explained that babies needed the same treatment, or else they too would “spoil.”
“We tried to identify the path of least resistance to behavior change,” Darmstadt says. Their messages had to be believable; otherwise, they wouldn’t be adopted by community members and could even be seen as unnecessarily risky.
To address risks from both infection and hypothermia, the team worked with the community, which coined the term thandā bukhār, which translates as “cold fever.” The team made a list of desired interventions that addressed the risk factors for newborn deaths that they were seeing, and then translated each into a culturally tailored message. These messages typically were framed as metaphors that connected new practices for newborns with familiar concepts drawn from village life. For example, to encourage mothers to dry the baby after birth, they said: “When you come out after a dip in the pond, if you just wipe your face, won’t you feel cold? Similarly, if you just wipe the face of the baby, the baby will feel cold and develop thandā bukhār.” They enlisted the help of community leaders; for example, after learning of the importance of breast milk, local priests agreed to advise mothers to begin breastfeeding immediately after birth. They also trained local health-care workers, as well as the domins and nauns, on the benefits of using clean equipment and how to recognize common danger signs of illness, giving them new skills and increasing their value to the community.
Pregnant women and mothers-in-law, who play a critical role in perpetuating the community’s childbirth traditions, were shown how to provide skin-to-skin care, a simple practice that involves placing the bare-skinned baby on the caregiver’s skin, providing love, warmth and access to nourishment. The practice produces immediate, tangible benefits: It improves babies’ color and temperature, and reduces crying and startle responses. The villagers interpreted these signs as the absence of evil spirits, reinforcing their willingness to embrace the change.
With the groundwork set, the team was ready to launch a formal study. Kumar and Darmstadt divided the community into three groups with between 5,200 and 8,000 households each. One group was the control — they continued birthing and caring for children as they had for centuries. One group received a package of interventions the team called “essential newborn care,” which included home visits from trained workers and community meetings sharing the new behavior-change messages the team had developed with members of the community. Some of those meetings also featured folk songs, specially written by community members to communicate practices they had learned to protect the babies. The third group received the same set of “essential newborn care” practices, but they also were provided a liquid crystal hypothermia indicator called a ThermoSpot. The team tracked each of the group’s pregnancies (about 4,000) over a 16-month period (January 2004 to May 2005).
The results, published in the Lancet in 2008, were definitive: The interventions reduced newborn mortality by 54 percent. The benefit of ThermoSpot was minimal — it was the changed practices such as skin-to-skin care and breastfeeding, rather than technology, that saved babies’ lives.
Zulfiqar Bhutta, PhD, MBBS, co-director of the Centre for Global Child Health at The Hospital for Sick Children in Toronto and one of Darmstadt’s frequent collaborators, called the work pioneering.
“At the time, there was not a lot of evidence this could work at scale,” Bhutta says. “This study also proved the point that you could make a huge impact on mortality.”
Now, nearly a decade later, the Shivgarh study is recognized for making significant advances in newborn care. Its principles informed a 2009 World Health Organization/UNICEF strategy document on the importance of home visits for newborns. The state of Uttar Pradesh, which counts Shivgarh’s residents among its population of about 200 million, drew on the study to develop guidelines for its health-care workers, and some of the principles even made their way into India’s national health policy. Darmstadt finds it particularly rewarding to hear the term thandā bukhār while traveling in the region — evidence the dangers of hypothermia for newborns have infiltrated the health-care community and become common knowledge in villages. Darmstadt hopes other researchers will be inspired by their approach, but he recognizes one size does not fit all; each public health endeavor presents particular challenges that require customized adaptations.
In Shivgarh itself, the infant mortality rate continues to drop and the newborn care practices Darmstadt and Kumar introduced have taken root. Kumar now directs the Community Empowerment Lab, a Shivgarh-based nonprofit that promotes community-based global health interventions. In Shivgarh, his team is now focusing on childhood health and what Kumar calls “thrival,” rather than simply survival.
Yet challenges remain.
“Behavior change can happen rapidly, but it really is not an easy process to make it simple, appealing and scalable, and lead to change in social norms,” says Darmstadt, who joined Stanford earlier this year as a professor of pediatrics. To enact change, public health experts must immerse themselves in the local culture, a time-consuming effort that requires special skills — the ability to bridge cultures without sacrificing key scientific standards.
And government agencies, which are often responsible for health-care efforts, are more inclined to adopt policies that provide technologies, infrastructure or drugs, rather than behavior change, Darmstadt says.
“In public health, we’ve often tended to look for that silver bullet or what we think might be a more rapid route or a simpler route,” he says.
The ripples from Shivgarh continue to spread. Kumar and Darmstadt are working on a project to encourage the adoption of skin-to-skin care in other parts of India, using the same community-based principles they developed in Shivgarh. And Darmstadt has integrated the emphasis on community systems and culture into his more recent work on promoting gender equity and empowering women and girls. One example, says Darmstadt, is a project with the Inter-American Development Bank and the government in Honduras that sought to reduce maternal deaths by having women give birth in hospitals or clinics. Yet the team realized they needed to broaden the scope of efforts to include nutrition, family planning and girls’ education, rather than simply urging pregnant women to head to the hospital.
“As I’ve gone along in my career, I’ve increasingly felt the importance of taking a holistic approach to people’s lives, to developing an understanding of the ecosystem in which people live and what it is that’s important to them, and using that to develop solutions with them, rather than coming in with preconceived ideas about what the problems are and what the solutions are,” he says.
But he knows that one piece currently missing in many efforts to help newborns is a focus on gender equity — because the rampant marginalization and neglect of women and girls is not only a rights issue, it’s a health issue for women and men, girls and boys.
During the Shivgarh project, the team was silent about gender, hoping that by treating each infant equally they would model gender-neutral behavior and thus improve care for girls, who are often neglected. This did happen, but Darmstadt says he has since realized that’s not enough. Gender inequality can be as blatant as female infanticide, but it can also involve more subtle distinctions such as feeding girls differently or taking them to less qualified or less costly health-care providers, he says. To ensure that all babies are treated equally and slash the newborn mortality rate, women and girls must be empowered. That may include formal education, literacy training, information about family planning, working with men and boys on equitable decision-making and control over resources, and more. “It’s really important that we address those inequalities to see major advances in maternal health as well as in many other areas of health and community development,” he says.
David Stevenson, MD, a professor of pediatrics at Stanford who worked to recruit Darmstadt, agrees. “If you make a change that is impactful for girls and women of childbearing age, then you can impact the values of the entire society.”
And to truly help every newborn, efforts will have to penetrate into some of the world’s most dangerous areas, Darmstadt says. These countries — Democratic Republic of the Congo, Pakistan, Sudan, Afghanistan and others — have the world’s highest rates of newborn deaths, but their public health problems have been overshadowed by ongoing conflict and instability. Without a community-centric focus, projects to help newborns in these countries are bound to fail — and could endanger health-care workers, he says.
“The real lesson is the program has to be matched to the local situation and local needs,” Darmstadt says. “In public health, we often don’t take enough care in that design process.”