When Dr Elizabeth Nabiwemba decided to tackle the problem of neonatal mortality in Uganda, she knew it was a Herculean task. Nabiwemba is a lecturer at the school of public health at Makerere University in Uganda’s capital Kampala. She knew that Uganda health department had scant resources. So instead of looking at sophisticated – read, expensive – health technologies she decided to devise a method by which the health of infants can be gauged using just a measuring tape and a plastic ruler.

Neonatal mortality is defined as death within 28 days of being born. The main causes for neonatal mortality are premature birth and low birth weight, infection and birth asphyxia – the lack of oxygen caused by obstruction to the airways.

According to the Uganda Demographic and Health Survey 2010 -’11, the neonatal mortality is 27 for every 1,000 live births. Nabiwemba said that, in Uganda, 75% of neonatal deaths occur in the first week of life with 25%-45% of these occurring within the first 24 hours after birth.

Nabiwemba started off on her project in 2009 by looking at possible solutions to identify newborns with low birth weight. Identifying low birth weight is not a challenge for countries with robust health infrastructure but in Uganda where most women deliver their babies at home and where even hospitals do not have weighing machines, it poses a significant challenge.

“We found that 70% of the children are not even weighed at birth,” said Nabiwemba.

Low birth weight is defined as weight of less than 2.5 kg at birth. “It is a result of either prematurity or intrauterine growth restriction,” said Nabiwemba. Low birth weight babies are prone to birth asphyxia, hypothermia, hypoglycemia due to inadequate feeding and infections such as septicemia.

Nabiwemba wanted set up a mechanism to identify low birth weight babies so that they could be given the right care and improve their chances of survival.

Dr Elizabeth Nabiwemba, a lecturer at the school of public health at Makerere University in Uganda’s capital Kampala. ( Photo: Priyanka Vora)

Best foot forward

Nabiwemba and her colleagues conducted a study in Eastern Uganda’s Iganga and Mayuge districts, which are predominantly rural, to find the most sensitive anthropometric surrogate measure to identify low-birth weight babies. An anthropometric measurement is one that refers to the size, shape or composition of a part of the human body.

Two hospital-based midwives and one doctor were trained on how to measure a newborns’ foot length and circumferences of the head, chest, thigh and mid-upper arm. The health workers took measurements of more than 500 children within 24 hours of their birth. Nabiwemba’s team then decided to look for the measurement which best helped to identify a low birth weight baby.

“We found that measuring the foot length and chest circumference were the best tools to identify low birth weight,” she said.

Between the two methods, the research team decided to standardise the foot-length procedure since measuring chest circumference could expose the baby to the cold.

Once, the method was decided, Nabiwemba and her team devised a simple measuring tool.

“We decided to make a card with the healthy foot length and if the child’s foot was placed against the one drawn on the card, the health worker and mother could easily spot whether the child is low birth or not,” Nabiwemba explained.

Saving Shadiya’s baby

When she was only 18, Nakisige Shadiya delivered her second child prematurely. Shadiya went into labour at night and her husband helped her have the child at home. She was just six months into her pregnancy and her newborn was tiny, weighing less than a 1 kg. The young couple had already lost their first child who also had been premature.

Shadiya lives in Iganga district where Nabiwemba has carried out anotherstudy to show why many low birth weight babies do not get to hospital in time. Many times, cultural beliefs held by the babies’ families prevent them from seeking medical care. Many new mothers interviewed for the study said that they had not been aware that their children had low birth weights. Many women fed their newborns porridge instead of breastfeeding them, mistakenly assuming that this would help them grow.

When health workers in Iganga learnt about Shadiya’s second premature child – a baby boy – they visited her armed with Nabiwemba’s foot measuring card. “We used the card to measure the child’s foot length and found that it was smaller than the one drawn in the card,” said Omnlosi Sdhzl, who was part of the team of health workers.

Foot length measuring card used by community healthcare workers in Uganda. (Photo: Priyanka Vora )

Sdhzl and his colleagues have observed that women react better to seeing the difference between the card foot size and their babies’ feet, rather than if they were just told that their babies had low birth weight. “When the mothers see that their baby’s foot is smaller, they realise something is wrong and agree to visit the hospital.”

The health workers referred Shadiya to the hospital where she was admitted for two days.

“We need space for other babies so mothers are discharged quickly,” said Sdhzl. “During these period, we teach the mother about the best feeding practices and how to keep the baby warm and maintain hygiene.”

Shadiya was even taught how to give her baby kangaroo care by holding him against her body to provide skin-to-skin contact for as long as possible. In August, the baby who had been growing weighed 1.3 kilos and Shadiya, seeing the improvement, felt hope at he would survive.