Who has been caring for the baby?

Global Financing Facility investments for vulnerable populations: content analysis regarding maternal and newborn health and stillbirths in 11 African countries, 2015 to 2019

BACKGROUND

The Global Financing Facility (GFF) was launched in 2015 to catalyse increased domestic and external financing for reproductive, maternal, newborn, child, adolescent health, and nutrition. Half of the deaths along this continuum are neonatal deaths, stillbirths or maternal deaths; yet these topics receive the least aid financing across the continuum.

OBJECTIVES

To conduct a policy content analysis of maternal and newborn health (MNH), including stillbirths, in GFF country planning documents, and assess the mortality burden related to the investment.

METHODS

Content analysis was conducted on 24 GFF policy documents, investment cases and project appraisal documents (PADs), from 11 African countries. We used a systematic data extraction approach and applied a framework for analysis considering mindset, measures, and money for MNH interventions and mentions of mortality outcomes. We compared PAD investments to MNH-related deaths by country.

RESULTS

For these 11 countries, USD$1,894 million of new funds were allocated through the PADs, including USD$303 million (16%) from GFF. All documents had strong content on MNH, with particular focus on pregnancy and childbirth interventions. The investment cases commonly included comprehensive results frameworks, and PADs generally had less technical content and fewer indicators. Mortality outcomes were mentioned, especially for maternal. Stillbirths were rarely included as targets. Countries had differing approaches to funding descriptions. PAD allocations are commensurate with the burden.

CONCLUSIONS

The GFF country plans present a promising start in addressing MNH. Emphasising links between investments and burden, explicitly including stillbirth, and highlighting high-impact packages, as appropriate, could potentially increase impact.

Overview of the Global and US Burden of Preterm Birth

Preterm birth (PTB) is the leading cause of morbidity and mortality in children globally, yet its prevalence has been difficult to accurately estimate due to unreliable methods of gestational age dating, heterogeneity in counting, and insufficient data. The estimated global PTB rate in 2020 was 9.9% (95% confidence interval: 9.1, 11.2), which reflects no significant change from 2010, and 81% of prematurity-related deaths occurred in Africa and Asia. PTB prevalence in the United States in 2021 was 10.5%, yet with concerning racial disparities. Few effective solutions for prematurity prevention have been identified, highlighting the importance of further research.

Mothers' acceptability of using novel technology with video and audio recording during newborn resuscitation: A cross-sectional survey

OBJECTIVE

This study aims to assess the acceptability of a novel technology, MAchine Learning Application (MALA), among the mothers of newborns who required resuscitation.

SETTING

This study took place at Bharatpur Hospital, which is the second-largest public referral hospital with 13 000 deliveries per year in Nepal.

DESIGN

This is a cross-sectional survey.

DATA COLLECTION AND ANALYSIS

Data collection took place from January 21 to February 13, 2022. Self-administered questionnaires on acceptability (ranged 1-5 scale) were collected from participating mothers. The acceptability of the MALA system, which included video and audio recordings of the newborn resuscitation, was examined among mothers according to their age, parity, education level and technology use status using a stratified analysis.

RESULTS

The median age of 21 mothers who completed the survey was 25 years (range 18-37). Among them, 11 mothers (52.4%) completed their bachelor's or master's level of education, 13 (61.9%) delivered first child, 14 (66.7%) owned a computer and 16 (76.2%) carried a smartphone. Overall acceptability was high that all participating mothers positively perceived the novel technology with video and audio recordings of the infant's care during resuscitation. There was no statistical difference in mothers' acceptability of MALA system, when stratified by mothers' age, parity, or technology usage (p>0.05). When the acceptability of the technology was stratified by mothers' education level (up to higher secondary level vs. bachelor's level or higher), mothers with Bachelor's degree or higher more strongly felt that they were comfortable with the infant's care being video recorded (p = 0.026) and someone using a tablet when observing the infant's care (p = 0.046). Compared with those without a computer (n = 7), mothers who had a computer at home (n = 14) more strongly agreed that they were comfortable with someone observing the resuscitation activity of their newborns (71.4% vs. 14.3%) (p = 0.024).

CONCLUSION

The novel technology using video and audio recordings for newborn resuscitation was accepted by mothers in this study. Its application has the potential to improve resuscitation quality in low-and-middle income settings, given proper informed consent and data protection measures are in place.

Safety of Antenatal Predniso(lo)ne and Dexamethasone on Fetal, Neonatal and Childhood Outcomes: A Systematic Review

CONTEXT

Due to ethical considerations, antenatal dose finding for prednisolone and dexamethasone in pregnant women is limited, leading to a knowledge gap.

OBJECTIVE

In order to guide the clinician in weighing benefits vs risks, the aim is to systematically review the current literature on the side effects of antenatal predniso(lo)ne and dexamethasone use on the fetus, newborn, and (pre)pubertal child.

EVIDENCE ACQUISITION

The search was performed in PubMed/MEDLINE and Embase using prespecified keywords and Medical Subject Headings. This systematic review investigated studies published until August 2022, with the following inclusion criteria: studies were conducted in humans and assessed side effects of long-term antenatal predniso(lo)ne and dexamethasone use during at least one of the trimesters on the child during the fetal period, neonatal phase, and during childhood.

EVIDENCE SYNTHESIS

In total, 328 papers in PubMed and 193 in Embase were identified. Fifteen studies were eligible for inclusion. Seven records were added through references. Antenatal predniso(lo)ne use may be associated with lower gestational age, but was not associated with miscarriages and stillbirths, congenital abnormalities, differences in blood pressure or low blood glucose levels at birth, or with low bone mass, long-term elevated cortisol and cortisone, or high blood pressure at prepubertal age. Increased risks of antenatal dexamethasone use include association with miscarriages and stillbirths, and from age 16 years, associations with disturbed insulin secretion and higher glucose and cholesterol levels.

CONCLUSIONS

Based on the limited evidence found, predniso(lo)ne may have less side effects compared with dexamethasone in short- and long-term outcomes. Current literature shows minimal risk of side effects in the newborn from administration of a prenatal predniso(lo)ne dose of up to 10 mg per day.

Research funding for newborn health and stillbirths, 2011-20: a systematic analysis of levels and trends

BACKGROUND

Worldwide, an estimated 4·4 million newborn deaths and stillbirths occurred in 2020, and 98% of these deaths occurred in low-income and middle-income countries (LMICs). We aimed to analyse new research grants for newborns and stillbirth awarded by major funders in 2019-20, and all research funding allocated to LMIC-based institutions in 2011-20.

METHODS

For this systematic analysis, we searched Dimensions, the world's largest research funding database, for grants relevant to neonatal and stillbirth research. Included grants were categorised by in-depth content analysis, with descriptive quantitative analyses by funder and recipient countries, research pipeline, topic, and year.

FINDINGS

Globally, in 2019-20, major funders awarded a mean annual total of US$577·1 million per year for newborn and stillbirth research (mean total of 550 grants per year). $166·3 million (28·8%) of $577·1 million was directed to small and vulnerable newborn research, but only $8·4 million (1·5%) was directed to stillbirth research. The majority of funding, $537·0 million (93·0%), was allocated to organisations based in high-income countries. Between 2011 and 2020, LMIC-based recipients were named on 1985 grants from all funders worth $486·7 million, of which $73·1 million (15·0%) was allocated to small and vulnerable newborn research and $12·0 million (2·5%) was allocated to stillbirth research. Most LMIC funding supported preclinical or observational studies ($236·8 million [48·7%] of $486·7 million), with implementation research receiving only $13·9 million (2·9%).

INTERPRETATION

Although investment in research related to neonatal health and stillbirths has increased between 2011 and 2020, there are marked disparities in distribution geographically, between major causes of mortality, and among research pipeline types. Stillbirth research received minimal funding in both high-income countries and LMICs, despite a similar number of deaths compared with neonates. Direct investment in LMIC-led research, especially for implementation research, could accelerate the slow global progress on stillbirth prevention and newborn survival.

FUNDING

None.

TRANSLATIONS

For the French, German and Spanish translations of the abstract see Supplementary Materials section.

Donor aid mentioning newborns and stillbirths, 2002-19: an analysis of levels, trends, and equity

BACKGROUND

Global aid for reproductive, maternal, newborn, and child health has stagnated in recent years, and aid mentioning newborns or stillbirths has previously represented a very small proportion of aid for reproductive, maternal, newborn, and child health. Neonatal survival targets have been set by 78 countries, and stillbirth prevention targets have been set by 30 countries, to address the 4·4 million newborn deaths and stillbirths globally. We aimed to generate novel estimates of current levels of, and trends in, aid mentioning newborns and stillbirths over 2002-19, and to assess whether the amount of aid disbursed aligns with the associated mortality burden.

METHODS

For this analysis, we did a manual review and coding of the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System database from 2002 to 2019 using key search terms for aid mentioning newborns and stillbirths. We compared these findings with estimates of aid for reproductive, maternal, newborn, and child health for 2002-19 based on the Muskoka2 method. Findings are presented in 2019 US$ according to the OECD's Development Assistance Committee deflators, which account for variation in exchange rates and inflation in donor countries.

FINDINGS

We identified 21 957 unique records in the 2002-19 period. Aid mentioning newborns and stillbirths comprised approximately 10% ($1·6 billion) of reproductive, maternal, newborn, and child health funding overall in 2019 ($15·9 billion), with a small decrease in value between 2015 and 2019. 1284 (6%) of 21 957 records and 3·4% ($535 million) of their total value mentioned aid focused only on newborn health. Ten donors contributed 87% ($13·7 billion) of the total value of aid mentioning newborns and stillbirths during 2002-19. Aid mentioning newborns and stillbirths was inequitably allocated in the least developed countries (as defined by the UN), ranging from $18 per death in Angola to $1389 per death in Timor-Leste. Stillbirths were not mentioned in any funding in 2002-09, and they were only mentioned in 46 of 21 957 records in 2010-19, comprising $44·4 million of aid disbursed during this period.

INTERPRETATION

Aid mentioning newborns and stillbirths is poorly matched to their corresponding mortality burden (representing 10% of aid for reproductive, maternal, newborn, and child health overall, yet accounting for approximately 50% of mortality in children <5 years) and across recipient countries (with substantial variation in the amount of aid received per newborn death and stillbirth between countries with similar health and economic needs). Our findings indicate that aid needs to be better targeted to populations with the highest mortality burdens, creating greater potential for impact.

FUNDING

John D and Catherine T MacArthur Foundation, Bill & Melinda Gates Foundation, ELMA Philanthropies, Children's Investment Fund Foundation UK, Lemelson Foundation, and Ting Tsung and Wei Fong Chao Foundation.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

The burden of inappropriate birth weight on neonatal survival in term newborns: a population-based study in a middle-income setting

Introduction

Premature birth, perinatal asphyxia, and infections are the main causes of neonatal death. Growth deviations at birth also affect neonatal survival according to week of gestation at birth, particularly in developing countries. The purpose of this study was to verify the association between inappropriate birth weight and neonatal death in term live births.

Methods

This is an observational follow-up study with all term live births from 2004 to 2013 in Sao Paulo State, Brazil. Data were retrieved with the deterministic linkage of death and birth certificates. The definition of very small for gestational age (VSGA) and very large for gestational age (VLGA) used the 10th percentile of 37 weeks and the 90th percentile of 41 weeks + 6 days, respectively, based on the Intergrowth-21st. We measured the outcome in terms of time to death and the status of each subject (death or censorship) in the neonatal period (0-27 days). Survival functions were calculated using the Kaplan-Meier method stratified according to the adequacy of birth weight into three groups (normal, very small, or very large). We used multivariate Cox regression to adjust for proportional hazard ratios (HRs).

Results

The neonatal death rate during the study period was 12.03/10,000 live births. We found 1.8% newborns with VSGA and 2.7% with VLGA. The adjusted analysis showed a significant increase in mortality risk for VSGA infants (HR = 4.25; 95% CI: 3.89-4.65), independent of sex, 1-min Apgar score, and five maternal factors.

Discussion

The risk of neonatal death in full-term live births was approximately four times greater in those with birth weight restriction. The development of strategies to control the factors that determine fetal growth restriction through planned and structured prenatal care can substantially reduce the risk of neonatal death in full-term live births, especially in developing countries such as Brazil.

Separation in Unity: Dialogical Transformation of Maternal Bond

The objective of this paper is to explore mothers' psychological adaptation related to separation from their newborn children immediately after birth. Mother and child separation has traditionally received attention from the child's perspective, but given that the bond is dyadic, the mother's wellbeing should also be considered. This qualitative study is based on interview data with mothers of premature infants. From the analysis, three themes emerged: concerns during pregnancy about premature birth; emotional strain caused by separation; and the need to protect and to be close to the newborn. Drawing on the perspectives of dialogical self theory and semiotic regulation model, the paper will focus on intra-psychological dynamics and will analyze the adaptation process in terms of I-positions. Based on the analysis, the maternal bond represents the integration of the I-position I-as-mother and My child, which is integrated during the pregnancy into the core of the self. It can be assumed that rupture of the self-continuity is activated by the birth of the child, which is then compounded if the child leaves. The maternal superordinate viewpoint (meta-I-position) directs a woman's behavior and allows for a sense of coherence under dynamic organization related to the birth of the child. The potential for psychological adaptation is presented as an ability to establish self-continuity.

Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns

BACKGROUND

Evidence shows that delivery of prompt and appropriate in-patient newborn care (IPNC) through health facility (HF)-based neonatal care and stabilization units (NCU/NSUs) reduce preventable newborn mortalities (NMs). This study investigated the HFs for availability and performance of NCU/NSUs in providing quality IPNC, and explored factors influencing the observed performance outcomes in Mtwara region, Tanzania.

METHODS

A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach. HF-based records and characteristics allowing for delivery of quality IPNC were reviewed first to establish the overall HF performance. The review findings were clarified by healthcare staff and managers through in-depth interviews (IDIs) and focus group discussions (FGDs).

RESULTS

About 70.6% (12/17) of surveyed HFs had at least one NCU/NSU room dedicated for delivery of IPNC but none had a fully established NCUs/NSU, and 74.7% (3,600/4,819) of needy newborns were admitted/transferred in for management. Essential medicines such as tetracycline eye ointment were unavailable in 75% (3/4) of the district hospitals (DHs). A disparity existed between the availability and functioning of equipment including infant radiant warmers (92% vs 73%). Governance, support from implementing patterns (IPs), and access to healthcare commodities were identified from qualitative inquiries as factors influencing the establishment and running of NCUs/NSUs at the HFs in Mtwara region, Tanzania.

CONCLUSION

Despite the positive progress, the establishment and performance of NCUs/NSUs in providing quality IPNC in HFs in Mtwara region is lagging behind the Tanzania neonatal care guideline requirements, particularly after the IPs of newborn health interventions completed their terms in 2016. This study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower avoidable NMs.

Kangaroo Mother Care in Vietnam: A National Survey of a Middle-Income Country

Background: Kangaroo mother care (KMC) is a low-cost intervention that is indicated to be a highly effective practice for which adoption and implementation are lacking. We investigated the current provision of KMC in Vietnam and explored differences among levels of healthcare facility. Methods: A survey form was sent to 187 hospitals in Vietnam, representing the three levels (central, provincial and district) of public hospital-based maternity services. Results: Overall response rate was 74% (138/187 hospitals). Routine KMC implementation was estimated in 49% of the hospitals. Where KMC was implemented or was being introduced, half of the hospitals had a written protocol and a KMC-dedicated room, and held educational courses on KMC. KMC was mainly performed by the mother. Skin-to-skin contact was mostly performed for <12 h/day (55%), exclusive breastfeeding at discharge was very frequent (89%) and early discharge was considered in half of the hospitals (54%), while follow-up was not performed in 29% of the hospitals. Participants considered follow-up after discharge as the main barrier to KMC implementation, and indicated education (of both parents and health caregivers) and environment upgrades (KMC-dedicated room and equipment) as the most important facilitators. Conclusions: Our survey estimated a limited implementation of KMC in Vietnamese maternity hospitals, with marked variations across the different levels of maternity services. Areas of improvements include increasing the duration of skin-to-skin contact, arranging dedicated spaces for KMC, involving the relatives (especially at district level), extending the availability of a written protocol, improving the eligibility process, and implementing early discharge and follow-up monitoring.

A single intravenous injection of cyclosporin A-loaded lipid nanocapsules prevents retinopathy of prematurity

Retinopathy of prematurity (ROP) is a retinal disease that threatens the vision of prematurely born infants. Severe visual impairment up to complete blindness is caused by neovascularization and inflammation, progressively destroying the immature retina. ROP primarily affects newborns in middle- and low-income countries with limited access to current standard treatments such as intraocular drug injections and laser- or cryotherapy. To overcome these limitations, we developed a nanotherapeutic that effectively prevents ROP development with one simple intravenous injection. Its lipid nanocapsules transport the antiangiogenic and anti-inflammatory cyclosporin A efficiently into disease-driving retinal pigment epithelium cells. In a mouse model of ROP, a single intravenous injection of the nanotherapeutic prevented ROP and led to normal retinal development by counteracting neovascularization and inflammation. This nanotherapeutic approach has the potential to bring about a change of paradigm in ROP therapy and prevent millions of preterm born infants from developing ROP.

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Neonatal microbiota-epithelial interactions that impact infection

Despite modern therapeutic developments and prophylactic use of antibiotics during birth or in the first few months of life, enteric infections continue to be a major cause of neonatal mortality and morbidity globally. The neonatal period is characterized by initial intestinal colonization with microbiota and concurrent immune system development. It is also a sensitive window during which perturbations to the environment or host can significantly impact colonization by commensal microbes. Extensive research has demonstrated that these early life alterations to the microbiota can lead to enhanced susceptibility to enteric infections and increased systemic dissemination in newborns. Various contributing factors continue to pose challenges in prevention and control of neonatal enteric infections. These include alterations in the gut microbiota composition, impaired immune response, and effects of maternal factors. In addition, there remains limited understanding for how commensal microbes impact host-pathogen interactions in newborns. In this review, we discuss the recent recognition of initial microbiota-epithelial interactions that occur in neonates and can regulate susceptibility to intestinal infection. These studies suggest the development of neonatal prophylactic or therapeutic regimens that include boosting epithelial defense through microbiota-directed interventions.

Framing and the formation of global health priorities

Health issues vary in the amount of attention and resources they receive from global health organisations and national governments. How issues are framed could shape differences in levels of priority. We reviewed scholarship on global health policy making to examine the role of framing in shaping global health priorities. The review provides evidence of the influence of three framing processes-securitisation, moralisation, and technification. Securitisation refers to an issue's framing as an existential threat, moralisation as an ethical imperative, and technification as a wise investment that science can solve. These framing processes concern more than how issues are portrayed publicly. They are socio-political processes, characterised by contestation among actors in civil society, government, international organisations, foundations, and research institutions. These actors deploy various forms of power to advance particular frames as a means of securing attention and resources for the issues that concern them. The ascription of an issue as a security concern, an ethical imperative, or a wise investment is historically contingent: it is not inevitable that any given issue will be framed in one or more of these ways. A health issue's inherent characteristics-such as the lethality of a pathogen that causes it-also shape these ascriptions, but do not fully determine them. Although commonly facing resistance, global health elites often determine which frames prevail, raising questions about the legitimacy of priority-setting processes. We draw on the review to offer ideas on how to make these processes fairer than they are at present, including a call for democratic representation even as necessary space is preserved for elite expertise.

2.5 Million Annual Deaths-Are Neonates in Low- and Middle-Income Countries Too Small to Be Seen? A Bottom-Up Overview on Neonatal Morbi-Mortality

(1) Background: Every year, 2.5 million neonates die, mostly in low- and middle-income countries (LMIC), in total disregard of their fundamental human rights. Many of these deaths are preventable. For decades, the leading causes of neonatal mortality (prematurity, perinatal hypoxia, and infection) have been known, so why does neonatal mortality fail to diminish effectively? A bottom-up understanding of neonatal morbi-mortality and neonatal rights is essential to achieve adequate progress, and so is increased visibility. (2) Methods: We performed an overview on the leading causes of neonatal morbi-mortality and analyzed the key interventions to reduce it with a bottom-up approach: from the clinician in the field to the policy maker. (3) Results and Conclusions: Overall, more than half of neonatal deaths in LMIC are avoidable through established and well-known cost-effective interventions, good quality antenatal and intrapartum care, neonatal resuscitation, thermal care, nasal CPAP, infection control and prevention, and antibiotic stewardship. Implementing these requires education and training, particularly at the bottom of the healthcare pyramid, and advocacy at the highest levels of government for health policies supporting better newborn care. Moreover, to plan and follow interventions, better-quality data are paramount. For healthcare developments and improvement, neonates must be acknowledged as humans entitled to rights and freedoms, as stipulated by international law. Most importantly, they deserve more respectful care.

Análisis de Costo Efectividad del Contacto Piel a Piel al Nacimiento, Temprano vs Inmediato, en la Morbilidad Neonatal de Recién Nacidos de Bajo Riesgo

OBJECTIVES

This study aimed to evaluate the cost-effectiveness of immediate skin-to-skin contact compared with early skin-to-skin contact in the prevalent neonatal morbidity of the low-risk newborn in Colombia.

METHODS

A cost-effectiveness analysis was conducted. The perspective of the third payer (health system) was used, and the time horizon was the first month of life. Low-risk term infants were included at birth. The cost estimate was obtained from an expert consensus and a retrospective cohort of neonates hospitalized in a neonatal unit. The effectiveness of the interventions was obtained from a clinical trial and was defined as an avoided case of hospitalization. A decision tree was built, and the incremental cost-effectiveness ratio was calculated. Deterministic and probabilistic sensitivity analyses of the effects and costs were performed.

RESULTS

Early skin-to-skin contact was a dominated intervention. In the probabilistic sensitivity analyses, early skin-to-skin contact was not an option to choose in any scenario and it was dominated in 68% of the simulations.

CONCLUSIONS

The findings suggest that early skin-to-skin contact is a dominated intervention. From an economic perspective, immediate skin-to-skin contact is a desired intervention for the prevention of prevalent diseases of the low-risk newborn at birth.

Prioritizing nurturing care at the municipal and district level with the Brazilian Early Childhood Friendly Municipal Index (IMAPI)

The Brazilian Early Childhood Friendly Municipal Index (IMAPI) is a population-based approach to monitor the nurturing care environment for early childhood development (ECD) using routine information system data. It is unknown whether IMAPI can be applied to document metropolitan urban territorial differences in nurturing care environments. We used Brasilia, Brazil's capital with a large metropolitan population of 2,881,854 inhabitants divided into 31 districts, as a case study to examine whether disaggregation of nurturing care data can inform a more equitable prioritization for ECD in metropolitan areas. IMAPI scores were estimated at the municipal level (IMAPI-M, 31 indicators) and at the district level (IMAPI-D, 29 indicators). We developed a quantitative prioritization process for indicators in each IMAPI analysis, and those selected were jointly mapped in the socioecological model for the role of indicators in relation to the enabling environment for nurturing care. Out of 28 common nurturing care indicators across IMAPI analysis, only four were prioritized in both analyses: one from the Adequate nutrition, two from the Opportunities for early learning, and one from the Responsive caregiving domains. These four indicators were mapped as enabling policies, supportive services, and caregivers' capabilities (socioecological model) and Effort, Coverage, and Quality (indicator's role). In conclusion, the different levels of nurturing care data disaggregation in the IMAPI can better inform decision-making than each one individually, especially in metropolitan areas where municipalities and districts within metropolitan areas have relative decision-making autonomy.

Implementing effective community-based surveillance in research studies of maternal, newborn and infant outcomes in low resource settings

Background

Globally adopted health and development milestones have not only encouraged improvements in the health and wellbeing of women and infants worldwide, but also a better understanding of the epidemiology of key outcomes and the development of effective interventions in these vulnerable groups. Monitoring of maternal and child health outcomes for milestone tracking requires the collection of good quality data over the long term, which can be particularly challenging in poorly-resourced settings. Despite the wealth of general advice on conducting field trials, there is a lack of specific guidance on designing and implementing studies on mothers and infants. Additional considerations are required when establishing surveillance systems to capture real-time information at scale on pregnancies, pregnancy outcomes, and maternal and infant health outcomes.

Main body

Based on two decades of collaborative research experience between the Kintampo Health Research Centre in Ghana and the London School of Hygiene and Tropical Medicine, we propose a checklist of key items to consider when designing and implementing systems for pregnancy surveillance and the identification and classification of maternal and infant outcomes in research studies. These are summarised under four key headings: understanding your population; planning data collection cycles; enhancing routine surveillance with additional data collection methods; and designing data collection and management systems that are adaptable in real-time.

Conclusion

High-quality population-based research studies in low resource communities are essential to ensure continued improvement in health metrics and a reduction in inequalities in maternal and infant outcomes. We hope that the lessons learnt described in this paper will help researchers when planning and implementing their studies.

Inadequate Bioavailability of Intramuscular Epinephrine in a Neonatal Asphyxia Model

BACKGROUND

Over half a million newborn deaths are attributed to intrapartum related events annually, the majority of which occur in low resource settings. While progress has been made in reducing the burden of asphyxia, novel approaches may need to be considered to further decrease rates of newborn mortality. Administration of intravenous, intraosseous or endotracheal epinephrine is recommended by the Newborn Resuscitation Program (NRP) with sustained bradycardia at birth. However, delivery by these routes requires both advanced skills and specialized equipment. Intramuscular (IM) epinephrine may represent a simple, low cost and highly accessible alternative for consideration in the care of infants compromised at birth. At present, the bioavailability of IM epinephrine in asphyxia remains unclear.

METHODS

Four term fetal lambs were delivered by cesarean section and asphyxiated by umbilical cord occlusion with resuscitation after 5 min of asystole. IM epinephrine (0.1 mg/kg) was administered intradeltoid after 1 min of positive pressure ventilation with 30 s of chest compressions. Serial blood samples were obtained for determination of plasma epinephrine concentrations by ELISA.

RESULTS

Epinephrine concentrations failed to increase following administration via IM injection. Delayed absorption was observed after return of spontaneous circulation (ROSC) in half of the studies.

CONCLUSIONS

Inadequate absorption of epinephrine occurs with IM administration during asphyxial cardiac arrest, implying this route would be ineffective in infants who are severely compromised at birth. Late absorption following ROSC raises concerns for risks of side effects. However, the bioavailability and efficacy of intramuscular epinephrine in less profound asphyxia may warrant further evaluation.

Preterm neonatal mortality in China during 2009-2018: A retrospective study

In this retrospective analysis, we aimed to analyze the epidemic characteristics of neonatal mortality due to preterm birth at 28-36 weeks gestation in different regions from 2009 to 2018. Data were obtained from China's Under-5 Child Mortality Surveillance System (U5CMSS). The χ2 trend test, Poisson regression and the Cochran-Mantel-Haenszel method were used in this study. We found that 51.3%, 42.0% and 44.5% of neonate deaths were preterm infants, and immaturity was mainly attributed to 60.1%, 64.1% and 69.5% of these deaths, in the eastern, central and western regions, respectively. The preterm neonatal mortality rate due to immaturity dropped from 149.2, 216.5 and 339.5 in 2009 to 47.4, 83.8 and 170.1 per 100 000 live births in 2018, giving an average annual decline rate of 12.1%, 11.6% and 6.3% in the eastern, central and western regions, respectively, during the studying period. The relative risk of preterm neonatal mortality due to immaturity were 1.3 and 2.3 for the central regions and western regions in 2009-2010, ascending to 2.2 and 3.9 in 2017-2018. The proportion of preterm neonatal deaths with a gestational age <32 weeks was highest among the eastern region. There were significantly more preterm neonatal infants who were not delivered at medical institutions in the western region than in the eastern and central regions. The preterm infant, especially with gestational age <32 weeks, should receive the most attention through enhanced policies and programs to improve child survival. Priority interventions should be region-specific, depending on the availability of economic and healthcare resources.

Prevalence and factors associated with skin-to-skin contact (SSC) practice: findings from a population-based cross-sectional survey in 10 selected districts of Bangladesh

BACKGROUND

Skin-to-skin contact (SSC) practice improves newborn survival and child development through preventing hypothermia in newborns, improving early initiation of breastfeeding practice, and strengthening mother-child bonding. Despite having numerous benefits, it is one of the least practiced interventions in low and middle-income countries (1 to 74%). In Bangladesh, the prevalence of SSC was 26% in 2014. In this study, we aimed to estimate the prevalence of SSC in the study districts and identify factors that facilitate or inhibit SSC practice so that context-specific recommendations can be made to advance the use of this intervention.

METHODS

We used baseline household survey data of USAID's MaMoni MNCSP project conducted in 10 districts of Bangladesh in 2019. Our analysis included 13,695 recently delivered women (RDW) with a live birth outcome. Our primary outcome was the mother's reported practice of SSC. We examined various antepartum, intrapartum, newborn, and sociodemographic factors associated with SSC using a multivariable generalized linear model. Our findings were reported using adjusted Prevalence Risk Ratios (aPRRs) and 95% Confidence Intervals (CIs).

RESULTS

Overall, 28% of RDW reported practicing SSC across the 10 surveyed districts. Our multivariable analysis showed that public facility delivery (aPRR 2.01; 95%CI: 1.80, 2.26), private facility delivery (aPRR 1.23; 95%CI: 1.06, 1.42) and ≥ 4 antenatal care (ANC) visits at least one from a medically trained provider (MTP) (aPRR 1.17; 95%CI: 1.03, 1.26) had a significant positive association with SSC practice. Caesarean section (aPRR 0.64; 95%CI: 0.56, 0.73) had a significant negative association with SSC practice compared to vaginal births. We also found a significant positive association of SSC practice with mothers' who perceived the birth size of their baby to be small, mothers with a higher education level (≥10 years), and mothers from households in the highest wealth quintile.

CONCLUSIONS

The prevalence of SSC is very low in the surveyed districts of Bangladesh. Considering the factors associated with SSC, relevant stakeholders need to increase their efforts on improving ANC and facility delivery coverages as well as improving SSC practice in the facilities especially after caesarean deliveries. Countries with a high burden of home deliveries, also need to emphasize community-based interventions and increasing coverage of skilled birth attendance for improving this life-saving intervention.

Saving babies' lives (SBL) - a programme to reduce neonatal mortality in rural Cambodia: study protocol for a stepped-wedge cluster-randomised trial

BACKGROUND

Neonatal mortality remains unacceptably high. Many studies successful at reducing neonatal mortality have failed to realise similar gains at scale. Effective implementation and scale-up of interventions designed to tackle neonatal mortality is a global health priority. Multifaceted programmes targeting the continuum of neonatal care, with sustainability and scalability built into the design, can provide practical insights to solve this challenge. Cambodia has amongst the highest neonatal mortality rates in South-East Asia, with rural areas particularly affected. The primary objective of this study is the design, implementation, and assessment of the Saving Babies' Lives programme, a package of interventions designed to reduce neonatal mortality in rural Cambodia.

METHODS

This study is a five-year stepped-wedge cluster-randomised trial conducted in a rural Cambodian province with an estimated annual delivery rate of 6615. The study is designed to implement and evaluate the Saving Babies' Lives programme, which is the intervention. The Saving Babies' Lives programme is an iterative package of neonatal interventions spanning the continuum of care and integrating into the existing health system. The Saving Babies' Lives programme comprises two major components: participatory learning and action with community health workers, and capacity building of primary care facilities involving facility-based mentorship. Standard government service continues in control arms. Data collection covering the whole study area includes surveillance of all pregnancies, verbal and social autopsies, and quality of care surveys. Mixed methods data collection supports iteration of the complex intervention, and facilitates impact, outcome, process and economic evaluation.

DISCUSSION

Our study uses a robust study design to evaluate and develop a holistic, innovative, contextually relevant and sustainable programme that can be scaled-up to reduce neonatal mortality.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04663620 . Registered on 11th December 2020, retrospectively registered.

Building on momentum from the global campaigns: an exploration of factors that influenced prioritization of stillbirth prevention at the national level in Uganda

BACKGROUND

Of the close to 2.6 million stillbirths that happen annually, most are from low-income countries where until recently policies rarely paid special attention to addressing them. The global campaigns that followed called on countries to implement strategies addressing stillbirths and the adoption of recommendations varied according to contexts. This study explored factors that influenced the prioritization of stillbirth reduction in Uganda.

METHODS

The study employed an exploratory qualitative design adopting Shiffman's framework for political prioritization. Data collection methods included a document review and key informants' interviews with a purposively selected sample of 20 participants from the policy community. Atlas. Ti software was used for data management while thematic analysis was conducted to analyze the findings.

FINDINGS

Political prioritization of stillbirth interventions gained momentum following norm promotion from the global campaigns which peaked during the 2011 Lancet stillbirth series. This was followed by funding and technical support of various projects in Uganda. A combination of domestic advocacy factors such as a cohesive policy community converging around the Maternal and Child Health cluster accelerated the process by vetting the evidence and refining recommendations to support the adoption of the policy. The government's health systems strengthening aspirations and integration of interventions to address stillbirths within the overall Maternal and Child Health programming resonated well.

CONCLUSIONS

The transnational influence played a key role during the initial stages of raising attention to the problem and provision of technical and financial support. The success and subsequent processes, however, relied heavily on domestic advocacy and the national political environment, and the cohesive policy community.

Midwifery students' perceptions and experiences of learning in clinical practice: a qualitative review protocol

OBJECTIVE

This systematic review aims to investigate and synthesize qualitative evidence related to midwifery students' perceptions and experiences of learning in clinical practice.

INTRODUCTION

Midwifery students are required to develop strong competencies during pre-registration education for future practice. Clinical placements provide a good opportunity for students to build essential practice capacities. Understanding the perceptions and experiences of midwifery students in clinical practice helps develop effective midwifery clinical educational strategies. A qualitative systematic review is therefore proposed to improve midwifery clinical education.

INCLUSION CRITERIA

This proposed review will consider qualitative studies that have explored midwifery students' perceptions and experiences of learning in clinical practice in all degrees. The search will be limited to English-language published and unpublished studies to the present.

METHODS

This review will follow the JBI approach for qualitative systematic reviews. A three-stage search will be conducted to include published and unpublished literature. Databases to be searched include PubMed, Science Direct, Web of Science, CINAHL, PsycINFO, American Nurses Association, Google Scholar, ProQuest Dissertation & Theses, and Index to Theses in Great Britain and Ireland. Identified studies will be screened for inclusion in the review by two independent reviewers. Any disagreements will be resolved through discussion. Data will be extracted using a standardized tool. Data synthesis will adhere to the meta-aggregative approach to categorize findings. The categories will be synthesized into a set of findings that can be used to inform midwifery education.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020208189.

Progress towards Every Newborn Action Plan (ENAP) implementation in Iran: obstacles and bottlenecks

Background

Neonatal mortality accounts for more than 47% of deaths among children under five globally but proper care at and around the time of birth could prevent about two-thirds of these deaths. The Every Newborn Action Plan (ENAP) offers a plan and vision to improve and achieve equitable and high-quality care for mothers and newborns. We applied the bottleneck analysis tool offered by ENAP to identify obstacles and bottlenecks hindering the scale-up of newborn care across seven health system building blocks.

Methods

We applied the every newborn bottleneck analysis tool to identify obstacles hindering the scale-up of newborn care across seven health system building blocks. We used qualitative methods to collect data from five medical universities and their corresponding hospitals in three provinces. We also interviewed other national experts, key informants, and stakeholders in neonatal care. In addition, we reviewed and qualitatively analyzed the performance report of neonatal care and services from 16 medical universities around the country.

Results

We identified many challenges and bottlenecks in the scale-up of newborn care in Iran. The major obstacles included but were not limited to the lack of a single leading and governing entity for newborn care, insufficient financial resources for neonatal care services, insufficient number of skilled health professionals, and inadequate patient transfer.

Conclusions

To address identified bottlenecks in neonatal health care in Iran, some of our recommendations were as follows: establishing a single national authorizing and leading entity, allocating specific budget to newborn care, matching high-quality neonatal health care providers to the needs of all urban and rural areas, maintaining clear policies on the distribution of NICUs to minimize the need for patient transfer, and using the available and reliable private sector NICU ambulances for safe patient transfer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03800-x.

Nurturing care indicators for the Brazilian Early Childhood Friendly Municipal Index (IMAPI)

The Nurturing Care Framework (NCF) calls for establishing a global monitoring and accountability systems for early childhood development (ECD). Major gaps to build low-cost and large-scale ECD monitoring systems at the local level remain. In this manuscript, we describe the process of selecting nurturing care indicators at the municipal level from existing routine information systems to develop the Brazilian Early Childhood Friendly Index (IMAPI). Three methodological steps developed through a participatory decision-making process were followed. First, a literature review identified potential indicators to translate the NCF domains. Four technical panels composed of stakeholders from federal, state and municipal levels were consulted to identify data sources, their availability at the municipal level and the strengths and weakness of each potential indicator. Second, national and international ECD experts participated in two surveys to score, following a SMART approach, the expected performance of each nurturing care indicator. This information was used to develop analytical weights for each indicator. Third, informed by strengths and weaknesses pointed out in the previous steps, the IMAPI team reached consensus on 31 nurturing care indicators across the five NCF domains (Good health [n = 14], Adequate nutrition [4], Responsive caregiving [1], Opportunities for early learning [7] and Security and safety [4]). IMAPI represents the first attempt to select nurturing care indicators at the municipal level using data from existing routine information systems.

The rise and fall of global health issues: an arenas model applied to the COVID-19 pandemic shock

Background

The global health agenda is ill-defined as an analytical construct, complicating attempts by scholars and proponents to make claims about the agenda status of issues. We draw on Kingdon’s definition of the agenda and Hilgartner and Bosk’s public arenas model to conceptualize the global health agenda as those subjects or problems to which collectivities of actors operating nationally and globally are paying serious attention at any given time. We propose an arenas model for global health agenda setting and illustrate its potential utility by assessing priority indicators in five arenas, including international aid, pharmaceutical industry, scientific research, news media and civil society. We then apply the model to illustrate how the status of established (HIV/AIDS), emergent (diabetes) and rising (Alzheimer’s disease) issues might be measured, compared and change in light of a pandemic shock (COVID-19).

Results

Coronavirus priority indicators rose precipitously in all five arenas in 2020, reflecting the kind of punctuation often caused by focusing events. The magnitude of change varied somewhat by arena, with the most pronounced shift in the global news media arena. Priority indicators for the other issues showed decreases of up to 21% and increases of up to 41% between 2019 and 2020, with increases suggesting that the agenda for global health issues expanded in some arenas in 2020— COVID-19 did not consistently displace priority for HIV/AIDS, diabetes or Alzheimer’s disease, though it might have for other issues.

Conclusions

We advance an arenas model as a novel means of addressing conceptual and measurement challenges that often undermine the validity of claims concerning the global health agenda status of problems and contributing causal factors. Our presentation of the model and illustrative analysis lays the groundwork for more systematic investigation of trends in global health agenda setting. Further specification of the model is needed to ensure accurate representation of vital national and transnational arenas and their interactions, applicability to a range of disease-specific, health systems, governance and policy issues, and sensitivity to subtler influences on global health agenda setting than pandemic shocks.

Small and sick newborn care during the COVID-19 pandemic: global survey and thematic analysis of healthcare providers' voices and experiences

INTRODUCTION

The COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers' experiences and proposed mitigation strategies.

METHODS

Using a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions.

RESULTS

We analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother-baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families' fear of visiting hospitals (~73%).

CONCLUSION

Newborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better.

Quality improvement strategies to improve inpatient management of small and sick newborns across All Babies Count supported hospitals in rural Rwanda

BACKGROUND

Neonatal mortality contributes to nearly half of child deaths globally and the majority of these deaths are preventable. Poor quality of care is a major driver of neonatal mortality in low- and middle-income countries. The All Babies Count (ABC) intervention was designed to reduce neonatal mortality through provision of equipment and supplies, training, mentorship, and data-driven quality improvement (QI) with peer-to-peer learning through learning collaborative sessions (LCS). We aim to describe the ABC scale-up in seven rural district hospitals from 2017 to 2019 focusing on the QI strategies implemented in hospital neonatal care units (NCUs) and the resultant neonatal care outcomes.

METHODS

A pre-post quasi experimental study was conducted in 7 rural hospitals in Rwanda in two phases. The baseline periods were April-June 2017 for Phase I and July-September 2017 for Phase II; with end-line data collected during the same periods in 2019. Data included facility audits of supplies and staffing, LCS surveys of QI skills, and reports of implemented QI change ideas. Data on NCU admissions and deaths were extracted from Health Management Information System (HMIS). Facility-reported change ideas were coded into common themes. Changes in post-post neonatal mortality were measured using Chi-squared tests.

RESULTS

NCUs were run by a median of 1 nurse [interquartile range (IQR):1-2] at baseline and endline. Median NCU admissions increased from 121 [IQR: 77-155] to 137 [IQR: 79-184]. Availability of advanced equipment improved (syringe pumps: 57-100 %, vital sign monitors: 51-100 % and CPAP machine: 14-100 %). There were significant improvements in QI skills among NCU staff. All 7 NCUs (100 %) addressed non-adherence to protocol as a priority gap, 5 NCUs (86 %) also improved communication with families. NCU case fatality rate declined from 12.4 to 7.8 % (p = 0.001).

CONCLUSIONS

The ABC package of interventions combining the provision of essential equipment to NCU, clinical training and strong mentorship, QI coaching, and the LCS approach for peer-to-peer learning was associated with significant neonatal mortality reduction and services utilization in the intervention hospitals.

Genetic Control of Neonatal Immune Tolerance to an Exogenous Retrovirus

Viruses, including retroviruses, can be passed from mothers to their progeny during birth and breastfeeding. It is assumed that newborns may develop immune tolerance to milk-transmitted pathogens similarly to food antigens. I/LnJ mice are uniquely resistant to retroviruses acquired as newborns or as adults as they produce virus-neutralizing antibodies (Abs). A loss-of-function allele of H2-Ob (Ob), originally mapped within the virus infectivity controller 1 (vic1) locus, is responsible for production of antiretrovirus Abs in I/LnJ mice. Importantly, Ob-deficient and vic1 I/LnJ congenic mice on other genetic backgrounds produce antivirus Abs when infected as adults, but not as newborns. We report here that I/LnJ mice carry an additional genetic locus, virus infectivity controller 2 (vic2), that abrogates neonatal immune tolerance to retroviruses. Further genetic analysis mapped the vic2 locus to the telomeric end of chromosome 15. Identification of the vic2 gene and understanding of the related signaling pathways would make blocking of neonatal immune tolerance to retroviruses an achievable goal.IMPORTANCE This work describes a previously unknown genetic mechanism that allows neonates to respond to infections as efficiently as adults.

Evaluating implementation strategies for essential newborn care interventions in low- and low middle-income countries: a systematic review

Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.

Scaling up Ghana's national newborn care initiative: integrating 'helping babies breathe' (HBB), 'essential care for every baby' (ECEB), and newborn 'infection prevention' (IP) trainings

Background

Responding to stagnating neonatal mortality rates in Ghana, a five-year collaboration called Making Every Baby Count Initiative (MEBCI) was undertaken to improve the quality of newborn care provided around the time of birth. A multi-pronged approach was used to build health worker (HW) capacity in resuscitation, essential newborn care, and infection prevention using a curriculum built on the American Academy of Pediatric’s (AAP) Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) modules with an added section on infection prevention (IP).

Methods

MEBCI used a training of trainer’s approach to train 3688 health workers from district-level facilities in four regions in Ghana between June 2015 and July 2017. Prior to training, HWs familiarized themselves with the learning materials. Concurrently, MEBCI worked to improve enabling environments that would sustain the increased capacity of trained health workers. Knowledge and skills gained were tested using AAP’s Knowledge checklist and validated single-scenario Objective Structured Clinical Examinations (OSCEs) tools.

Findings: Majority of HWs trained were midwives (58.8%) and came from district-level hospitals (88.4%). Most HWs passed the HBB OSCE (99.9%, 3436/3440). Age of doctors was negatively associated with HBB scores (r = − 0.16, p = 0.0312). Similarly, older midwives had lower HBB scores (r = − 0.33, p value < 0.001). Initiating ventilation within the Golden Minute was challenging for HWs (78.5% passed) across all regions. Overall, the pass rate for ECEB OSCEs was 99.9% in all regions. Classify newborn for further care and communicate plan to family were frequent challenges observed in Volta Region (69.5% and 72.0% pass rate respectively). HWs less than 40 years of age performed significantly better than health workers older than 40 years (p = 0.023). Age of only paediatricians was positively associated with ECEB scores (r = 0.77, p < 0.001) while age of midwives was negatively associated with ECEB scores (r = − 0.08, p < 0.001).

Conclusion

MEBCI’s integrated HBB-ECEB-IP training resulted in significant mastery of the clinical knowledge and skills of HWs. Harmonization and standardization of the course delivery by trainers and having a core team to ensure training fidelity are essential to maintaining high quality while scaling a program nationally.

Funding

Children’s Investment Fund Foundation (CIFF).

Humidification Solution as a Source for Spreading Burkholderia cepacia in a Neonatal Intensive Care Unit

Burkholderia cepacia is an important opportunistic organism in hospitalized and immunocompromised patients especially in newborns. The natural ecology of these bacteria associated with plants is also a cause of infectious potential. The disease-causing potential of bacteria as a nosocomial pathogen may be due to its ability to survive in antiseptic solutions, contamination equipment. The patient was hospitalized for prematurity and respiratory distress syndrome. He was treated with surfactant intratracheally for the respiratory distress syndrome. Umbilical catheter was inserted. Ampicillin and gentamicin treatments were initiated. The patient who received respiratory support for a long time was given a steroid protocol because of bronchopulmonary dysplasia. Burkholderia cepacia was detected in the blood and tracheal aspirate cultures of the patient, whose infection markers increased and a new area of infection was detected on the chest radiograph. Colistin and ciprofloxacin treatments were given according to the culture antibiogram. Screening tests revealed B. cepacia colonization in incubator moistening solutions. All incubator humidification solutions in the hospital were changed. Burkholderia cepacia is a rare cause of nosocomial infection in intensive care units but resistant to many treatments. With its capability to colonize water and grow on microbicides, the presence of B. cepacia in a patient's blood warrants further investigation in institutions providing care.

Communication between mothers and health workers is important for quality of newborn care: a qualitative study in neonatal units in district hospitals in South Africa

Background

There is a high global burden of neonatal mortality, with many newborn babies dying of preventable and treatable conditions, particularly in low and middle-income countries. Improving quality of newborn care could save the lives of many thousands of babies. Quality of care (QoC) is a complex and multifaceted construct that is difficult to measure, but patients’ experiences of care are an important component in any measurement of QoC. We report the findings of a qualitative study exploring observations and experiences of health workers (HWs) and mothers of babies in neonatal units in South Africa.

Methods

A qualitative case study approach was adopted to explore care of newborn babies admitted to neonatal units in district hospitals. Observation data were collected by a registered nurse during working hours over a continuous five-day period. Doctors and nurses working in the neonatal unit and mothers of babies admitted during the observation period were interviewed using a semi-structured interview guide. All interviews were audio recorded. Observation data were transcribed from hand written notes. Audiotapes of interviews were transcribed verbatim and, where necessary, translated into English. A thematic content analysis was used to analyse the data.

Results

Observations and interviews were conducted in seven participating hospitals between November 2015 and May 2016. Our findings highlight the importance of information sharing between HWs and mothers of babies, contrasting the positive communication reported by many mothers which led to them feeling empowered and participating actively in the care of their babies, with incidents of poor communication. Poor communication, rudeness and disrespectful behaviour of HWs was frequently described by mothers, and led to mothers feeling anxious, unwilling to ask questions and excluded from their baby’s care. In some cases poor communication and misunderstandings led to serious mismanagement of babies with HWs delaying or withholding care, or to mothers putting their babies at risk by not following instructions.

Conclusion

Good communication between mothers and HWs is critical for building mothers’ confidence, promoting bonding and participation of mothers in the care of their baby and may have long term benefits for the health and well-being of the mother and her baby.

Application of the International Classification of Diseases for Perinatal Mortality (ICD-PM) to vital statistics records for the purpose of classifying perinatal deaths in Antioquia, Colombia

Objective

To describe perinatal mortality in the Department of Antioquia based on the WHO International Classification of Diseases (ICD-PM) and determine the feasibility of applying this classification system to the official records on vital statistics.

Materials and methods

Descriptive study of the causes of perinatal death according to the time of death in relation to the time of delivery and associated maternal conditions. The primary source was the official database of vital statistics for the period between 2013 and 2016. The variables measured were maternal age, gestational age and weight at the time of birth, area of residence, type of delivery, and causes of death, including direct and associated causes, and other pathological conditions. A descriptive analysis is performed, causes are presented in terms of absolute numbers and percentages, and distributed according to the timing of death in relation to childbirth and birthweight.

Results

Of 3901 perinatal deaths occurring in fetuses 22 weeks or more of gestational age or a minimum weight of 500 g, and up to 28 days of life, 1404 (36.0%) occurred before delivery, 378 (9.7%) during the intrapartum period, 1760 (45.1%) during the neonatal period, and 359 (9.2%) cases had no information regarding the time of death in relation to the time of delivery. The main causes of death of the neonates weighing 1000 g or more were congenital malformations, deformities and chromosomal abnormalities (30.2%), antepartum and intrapartum hypoxia (29.3%), and infection (12.3%). In 69.5% of cases, no associated maternal causes were identified and in those in which there were related causes, the most frequent was placenta, cord and membrane complications (16.8%).

Conclusion

The ICD-PM is a system globally applicable to records of vital statistics, enabling the characterization of perinatal mortality in the Department.

Quality of labor and birth care in Sindh Province, Pakistan: Findings from direct observations at health facilities

This study presents data from the first observation of labor, childbirth and immediate newborn care in a clinical setting in Sindh, the second most populous province of Pakistan. Trained midwives observed 310 births at 126 district level referral facilities and primary health care facilities in 10 districts of Sindh where the USAID-funded Maternal Child Health Integrated Program (MCHIP) was implemented. The facility participation rate was 78%. The findings show that monitoring vital signs during the initial examination was conducted for less than one-in-ten women. Infection prevention practices were only observed for one-in-four women. Modesty was preserved for less than half of women. In spite of an absence of monitoring during the first and second stages of labor, providers augmented labor with oxytocin in two-thirds of births. To prevent post-partum hemorrhage, oxytocin was administered within a minute of birth in 51% of cases. Immediate drying of the baby was nearly universal and eight out of ten babies were wrapped in a dry towel. Newborn vital signs and the baby’s weight were taken in one-in-ten cases. Breastfeeding was initiated during the first hour of birth in 18% of cases. A support-person was present during labor and birth for 90% of women. While quality of care is poor across all facilities, the provision of care at district-level referral facilities was even lower quality than at primary health care facilities. This is because dais or assistants without formal training provided labor, birth, and newborn care for 40% of deliveries during night shifts at referral facilities. This study found many examples of suboptimal practice by skilled birth attendants across all levels of health facilities. There remains an urgent need to improve quality of service provision among skilled birth attendants in Pakistan.

Cross-sectional study of the quality of neonatal care services in Armenia

PURPOSE

The purpose of this paper is to report the assessment results of the quality of neonatal care services in Armenia and to describe the identified obstacles to improving the quality of care for newborn infants.

DESIGN/METHODOLOGY/APPROACH

The study carried out a cross-sectional descriptive design. The data were collected in health facilities with different levels of neonatal care that were selected employing a multi-stage, stratified purposeful sampling design. The quality of neonatal services was assessed using the generic WHO tool. Data collection was performed using face-to-face semi-structured interviews, hospital statistics, medical records and direct observations.

FINDINGS

In 31 study hospitals, 31,976 deliveries were performed resulting in 31,701 live births and 734 stillbirths. About 85 percent of all neonatal deaths was attributable to early neonatal deaths with over 48 percent occurring during the first 24 h of life. The proportion of neonatal deaths was highest in infants with low birth weight constituting 92.8 percent of all neonatal deaths. The total neonatal mortality rate was 3.50 per 1,000 live births, whereas stillbirth rate and perinatal mortality rate were 22.60 and 25.26 per 1,000 total births in 2015. Specific indicators with relatively lower mean scores included neonatal resuscitation, early breastfeeding, monitoring of newborn conditions, neonatal sepsis, feeding standards, total parenteral nutrition, and infection treatment.

ORIGINALITY/VALUE

Given the limited scope of research on quality assessment, this paper provides valuable information on the status of quality of neonatal care services in Armenian health facilities. This work also extends the existing studies focused on quality assessment through applying the model of Avedis Donabedian with the structure-process-outcomes approach as a theoretical basis.

Knowledge, skills and competency retention among health workers one year after completing helping babies breathe training in South Sudan

Introduction

This study aimed to evaluate the long-term retention of knowledge, skills, and competency of health workers who completed a Helping Babies Breathe (HBB) training program and its effect on newborn mortality.

Methods

A quasi-experimental pre- and post-intervention study was conducted. Participants were health workers selected based on their previous training on HBB protocols. Participants were assessed for knowledge, skills, and competency in March 2017 (immediately before and after training), June 2017 (three months after training), and September 2018 (one year after training). Assessments were conducted using HBB questionnaires, checklists and practical skill drills. Mean scores were obtained and ANOVA, chi-squared test, and Pearson's test were used for pre intervention, post intervention, and one-year-after comparisons. The effect of training on the management of newborn asphyxia was assessed based on a review of the delivery registry at a maternity and children's ward. The scores were group into percentages and averages means and were computed using chi-squared tests.

Results

Despite improvements in knowledge, skills, and competency three months after training, participants showed a marked decline one year after training. Knowledge increased from 42.5% pretest to 97% posttest but decreased to 84.5% three months' post training and further decreased to 69.4% one year post training. Skills increased from 26.1% pretest to 94.4% posttest, remained at 94.4% at three months, and decreased to 77.0% at one year. Simple resuscitation scores increased from 26.9% to 88.8% pre- and posttest, remained roughly at three months and decreased to 76.4% at one year. For complex resuscitation, scores decreased from 90.9% posttest to 76.9% at one year. The assessments at one year indicated a need for support and practice, especially with bag-mask ventilation.

Conclusion

The immediate evaluation of health workers after HBB training showed significant increases in knowledge, skills and competency in neonatal resuscitation. However, this declined after one year. The training also resulted in decreased neonatal mortality.

Trends, determinants, and newborn mortality related to thermal care and umbilical cord care practices in South Asia

BACKGROUND

Although child mortality has decreased over the last several decades, neonatal mortality has declined less substantially. In South Asia, neonatal deaths account for the majority of all under-five deaths, calling for further study on newborn care practices. We assessed five key practices: immediate drying and wrapping, delayed bathing, immediate skin-to-skin contact after birth, cutting the umbilical cord with a clean instrument, and substances placed on the cord.

METHODS

Using data from Demographic and Health Surveys conducted in Bangladesh, India, and Nepal between 2005 and 2016, we examined trends in coverage of key practices and used multivariable logistic regression to analyze predictors of thermal care and hygienic cord care practices and their associations with neonatal mortality among home births. The analysis excluded deaths on the first day of life to ensure that the exposure to newborn care practices would have preceded the outcome. Given limited neonatal mortality events in Bangladesh and Nepal, we pooled data from these countries.

RESULTS

We found that antenatal care and skilled birth attendance was associated with an increase in the odds of infants' receipt of the recommended practices among home births. Hygienic cord care was significantly associated with newborn survival. After controlling for other known predictors of newborn mortality in Bangladesh and Nepal, antiseptic cord care was associated with an 80% reduction in the odds of dying compared with dry cord care. As expected, skilled care during pregnancy and birth was also associated with newborn survival. Missing responses regarding care practices were common for newborns that died, suggesting that recall or report of details surrounding the traumatic event of a loss of a child may be incomplete.

CONCLUSIONS

This study highlights the importance of maternal and newborn care and services for newborn survival in South Asia, particularly antenatal care, skilled birth attendance, and antiseptic cord care.

Evaluating consistency of recall of maternal and newborn care complications and intervention coverage using PMA panel data in SNNPR, Ethiopia

Background

There is recognition that effective interventions are available to prevent neonatal and maternal deaths but providing reliable and valid coverage estimates remains a challenge. Household surveys rely on recall of self-reported events that may span up to 5 years, raising concerns of recall bias.

Objective

This study assessed the reliability of maternal recall of pregnancy, delivery, and postpartum events over a six-month period and identified relevant individual characteristics associated with inconsistent reporting.

Methodology

A longitudinal household survey was conducted with 321 pregnant women in 44 enumeration areas in Southern Nationals, Nationalities and People’s Region in Ethiopia. Women who were six or more months pregnant were enrolled and interviewed at seven days, six weeks, and six months post-partum using an identical set of questions regarding maternal and neonatal health and receipt of select neonatal care interventions. We compared responses given at 7 days to those reported at 6 weeks and 6 months and conducted sensitivity, specificity, area under receiving operative curve, and Kappa analyses of selected indicators.

Results

We find that reporting complications is higher at the first interview after birth than at either the six-week or six-month interview. The specificity of the majority of complications is high, however sensitivity is generally much lower. The sensitivity of reporting any complication during pregnancy, delivery, or post-partum ranged from 54.5% to 67.6% at the 6-week interview and from 39.2% to 63.2% at the 6-month interview. Though sensitivity of receipt of neonatal interventions was high, specificity and kappa demonstrate low consistency.

Conclusion

As with childbirth, it may be that during the first seven days women note symptoms with higher scrutiny, but if these do not later develop into serious health issues, they may be forgotten over time. Maternal complications and care are likely to be under-reported by women if interviewed for distant events.

"Every Newborn-BIRTH" protocol: observational study validating indicators for coverage and quality of maternal and newborn health care in Bangladesh, Nepal and Tanzania

Background

To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn – Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels.

Methods

EN-BIRTH is an observational study including >20 000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses.

Conclusions

To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.

Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia

Through district system strengthening, integrated services, and community engagement interventions, the Saving Mothers, Giving Life initiative increased emergency obstetric care coverage and access to, and demand for, improved quality of care that led to rapid declines in district maternal and perinatal mortality. Significant reductions in intrapartum stillbirth rate and maternal mortality ratios around the time of birth attest to the success of the initiative.

Background:

Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions.

Methods:

SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities.

Results:

Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country.

Conclusions:

MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths.

Etiology of early onset neonatal sepsis in neonatal intensive care unit - Mansoura, Egypt

INTRODUCTION

This study was conducted to find out the bacterial causes of early onset neonatal sepsis and their susceptibility pattern for different classes of antibiotics in neonates admitted to neonatal intensive care unit (NICU) of Mansoura-Egypt.

METHODS

A descriptive cross-sectional study was conducted. All admitted newborns to our study were infants at <72 hours of age with clinical features of sepsis or product of an in-house delivery at Mansoura University Hospital with risk factors for neonatal sepsis. Identification of Gram-negative isolates was confirmed by API 20E kits (bioMerieux). Antibiotic susceptibility was performed by Kirby-Bauer disc diffusion method. Bacteria resistant to ≥3 antimicrobial classes were counted as multidrug resistant.

RESULTS

One hundred eighty eight babies were admitted to our study. Positive blood culture was reported in 34.6% of newborn infants with prevalence of 4.02/1,000 live births. The most common isolated bacteria in early onset neonatal sepsis were coagulase negative staphylococci followed by Klebsiella pneumoniae and Serratia marcescens. The Gram-positive bacteria showed high resistance to ampicillin 93.9% while all the isolates were susceptible to vancomycin. The isolated Gram-negative bacteria were highly resistant to ampicillin [96.9%], amoxicillin-clavulanic acid [90.6%], cefotaxime [84.4%] and ceftazidime [84.4%]. Best sensitivity among all isolates was observed to imipenem. Multidrug resistance was observed among 45.5% of the Gram-positive and 68.8% of Gram-negative isolates.

CONCLUSION

Appropriate identification of the source of infection and initiation of an effective management can reduce both mortality and morbidity associated with neonatal sepsis. The challenge is to initiate immediate empirical antibiotic therapy according to a strictly implemented updated antibiotic policy based on an individualized community established antimicrobial sensitivity pattern of microorganisms causing early onset neonatal sepsis.

Learning From History About Reducing Infant Mortality: Contrasting the Centrality of Structural Interventions to Early 20th-Century Successes in the United States to Their Neglect in Current Global Initiatives

Policy Points Current efforts to reduce infant mortality and improve infant health in low- and middle-income countries (LMICs) can benefit from awareness of the history of successful early 20th-century initiatives to reduce infant mortality in high-income countries, which occurred before widespread use of vaccination and medical technologies. Improvements in sanitation, civil registration, milk purification, and institutional structures to monitor and reduce infant mortality played a crucial role in the decline in infant mortality seen in the United States in the early 1900s. The commitment to sanitation and civil registration has not been fulfilled in many LMICs. Structural investments in sanitation and water purification as well as in civil registration systems should be central, not peripheral, to the goal of infant mortality reduction in LMICs.

CONTEXT

Between 1915 and 1950, the infant mortality rate (IMR) in the United States declined from 100 to fewer than 30 deaths per 1,000 live births, prior to the widespread use of medical technologies and vaccination. In 2015 the IMR in low- and middle-income countries (LMICs) was 53.2 deaths per 1,000 live births, which is comparable to the United States in 1935 when IMR was 55.7 deaths per 1,000 live births. We contrast the role of public health institutions and interventions for IMR reduction in past versus present efforts to reduce infant mortality in LMICs to critically examine the current evidence base for reducing infant mortality and to propose ways in which lessons from history can inform efforts to address the current burden of infant mortality.

METHODS

We searched the peer-reviewed and gray literature on the causes and explanations behind the decline in infant mortality in the United States between 1850 and 1950 and in LMICs after 2000. We included historical analyses, empirical research, policy documents, and global strategies. For each key source, we assessed the factors considered by their authors to be salient in reducing infant mortality.

FINDINGS

Public health programs that played a central role in the decline in infant mortality in the United States in the early 1900s emphasized large structural interventions like filtering and chlorinating water supplies, building sanitation systems, developing the birth and death registration area, pasteurizing milk, and also educating mothers on infant care and hygiene. The creation of new institutions and policies for infant health additionally provided technical expertise, mobilized resources, and engaged women's groups and public health professionals. In contrast, contemporary literature and global policy documents on reducing infant mortality in LMICs have primarily focused on interventions at the individual, household, and health facility level, and on the widespread adoption of cheap, ostensibly accessible, and simple technologies, often at the cost of leaving the structural conditions that determine child survival largely untouched.

CONCLUSIONS

Current discourses on infant mortality are not informed by lessons from history. Although structural interventions were central to the decline in infant mortality in the United States, current interventions in LMICs that receive the most global endorsement do not address these structural determinants of infant mortality. Using a historical lens to examine the continued problem of infant mortality in LMICs suggests that structural interventions, especially regarding sanitation and civil registration, should again become core to a public health approach to addressing infant mortality.

Factors influencing the implementation of the Becoming Breastfeeding Friendly initiative in Ghana

Becoming Breastfeeding Friendly (BBF) is an initiative designed to help countries assess their readiness to scale-up breastfeeding programs and develop key recommendations to strengthen their breastfeeding environment. In 2016, Ghana was one of two countries to first pilot BBF. In applying BBF, a committee of 15 Ghanaian nutrition, health, and breastfeeding experts implemented the BBF toolbox over 8 months. Following implementation, semistructured interviews were conducted with 12 committee members (CMs) to (a) identify facilitators and barriers to implement BBF and (b) determine factors needed to strengthen the breastfeeding environment in Ghana. Using a grounded theory approach, five domains were identified. First, a dynamic committee of key stakeholders drove the implementation of BBF. Second, CMs faced some logistical and methodological challenges, including difficulty accessing data and the need for strong in-country technical support for adhering to the BBF process. Third, CMs felt well positioned to facilitate and lead the dissemination and implementation of recommendations. Fourth, accountability would be essential to properly translate recommendations. Fifth, to move recommendations to action, advocacy would be a required first step, and BBF was proposed to facilitate this step. BBF provided an in-depth analysis of Ghana's current breastfeeding environment to help Ghana strengthen its breastfeeding governance, policies, and programs while informing CMs' government and non-governmental organizations' breastfeeding efforts.

How does "Becoming Breastfeeding Friendly" work? A Programme Impact Pathways Analysis

Becoming Breastfeeding Friendly (BBF) is an initiative designed to track country readiness and progress to effectively scale up breastfeeding programmes. BBF includes a policy toolbox that has three components: the BBF Index (BBFI), case studies, and a five-meeting process. Mapping pathways of how BBF was implemented and utilized enables contextually grounded interpretation of its impact on breastfeeding outcomes. We conducted a programme impact pathways (PIP) analysis to identify pathways and critical quality control points (CCPs) by which BBF can enable changes in policy, legislation, and implementation of breastfeeding programmes. A BBF PIP diagram was developed, and CCPs were identified through a literature review and an iterative interviewing process with BBF investigators. The PIP was revised after feedback from BBF's Technical Advisory Group. BBF pretesting in Ghana and Mexico informed the formative evaluation of the PIP. PIP analysis identified relevant pathways between BBF activities and outcomes. Eight CCPs that could facilitate or attenuate BBF to fully impact the scaling up of the breastfeeding programmes were identified: (a) committee formed and trained; (b) committee understands BBF and BBFI; (c) committee's ability to acquire data; (d) BBFI scores; (e) criteria used for prioritizing recommendations; (f) dissemination of recommendations; (g) policymaker's reactions and media coverage; (h) committee's motivation and effective teamwork throughout BBF. Ghana and Mexico's pretesting of BBF confirmed the CCPs and provided valuable insights on potential mechanisms of BBF impacts at the country level. To further validate the PIP, a policy analysis framework is being tested in Ghana and Mexico.

A health systems strengthening intervention to improve quality of care for sick and small newborn infants: results from an evaluation in district hospitals in KwaZulu-Natal, South Africa

Background

Many newborn infants die from preventable causes in South Africa, often these deaths occur in district hospitals. A multipronged intervention aiming to improve quality of newborn care in district hospitals was implemented comprising training in clinical care for sick and small newborns, skills development for health managers, on-site mentoring, and hospital accreditation. We present the results of the project evaluation.

Methods

We conducted three sequential cross-sectional surveys in 39 participating district hospitals at baseline, midpoint and endpoint of the three-year intervention period. Data were collected by a trained midwife using a series of checklists including: availability of trained staff, drugs and equipment; newborn care practices; perinatal mortality audits; neonatal unit staff skills; quality of record keeping. A scoring system was developed for three domains: resources; care practices; resuscitation equipment, and a composite score that included all variables measured. Health worker (HW) knowledge was assessed at midpoint and endpoint.

Results

The average score for resources increased from 13.5 at baseline to 22.6 at endpoint (maximum score 34), for care practices from 17.7 to 22.6 (maximum score 29), and for resuscitation equipment from 10.8 to 16.1 (maximum 25). Average composite score improved significantly from 42.0 at baseline to 55.7 at midpoint to 60.7 at endpoint (maximum score 88) (p = 0.0012). Among 39 participating hospitals, 38 achieved higher scores at endpoint compared to baseline. Knowledge was higher among HWs trained during the project at midpoint and endpoint. Gaps that remained included poor infrastructure, lack of resuscitation equipment in some areas, poor postnatal care and lack of a dedicated doctor.

Conclusions

This intervention achieved measurable improvements in many important elements contributing to newborn care. A scoring system was used to track progress, compare facilities’ performance, and identify areas for improvement. Various methods were used to generate the quality of care score, including skills assessment and record reviews. However, measuring quality of clinical care and outcomes was challenging, and we were unable to determine whether the intervention improved clinical care and lead directly to improved outcomes for babies. In developing a future score for quality of care, a stronger focus should be placed on assessing clinical care and outcomes.

Efforts to alter the trajectory of neonatal mortality in Malawi: evaluating relative effects of access to maternal care services and birth history risk factors

BACKGROUND

The neonatal mortality rate (NMR) in Malawi has remained stagnant at around 27 per 1000 live births over the last 15 years, despite an increase in the uptake of targeted health care interventions. We used the nationally representative 2015/16 Demographic Health Survey data set to evaluate the effect of two types of maternal exposures, namely, lack of access to maternal or intra-partum care services and birth history factors, on the risk of neonatal mortality.

METHODS

A causal inference approach was used to estimate a population attributable risk parameter for each exposure, adjusting for co-exposures and household, maternal and child-specific covariates. The maternal exposures evaluated were unmet family planning needs, less than 4+ antenatal care visits, lack of institutional delivery or skilled birth attendance, having prior neonatal mortality, short (8-24 months) birth interval preceding the index birth, first pregnancy, and two or more pregnancy outcomes within the preceding five years of the survey interview.

RESULTS

We included 9553 women and their most recent live birth within 3 years of the survey. The sample's overall neonatal mortality rate was 18.5 per 1000 live births. The adjusted population attributable risk for first pregnancies was 3.9/1000 (P < 0.001), while non-institutional deliveries and the shortest preceding birth interval (8-24 months) each had an attributable risk of 1.3/1000 (Ps = 0.01). Having 2 or more pregnancy outcomes within the last 5 years had an attributable risk of 3/1000 (P = 0.006). Attending less than 4 ANC visits had, a relatively large attributable risk (2.1/1,000), and it was not statistically significant at alpha level 0.05.

CONCLUSIONS

Our analysis addresses the gap in the literature on evaluating the effect of these exposures on neonatal mortality in Malawi. It also helps inform programs and current efforts such as the Every Newborn Action 2020 Plan. Increasing access to maternal care interventions has an important role to play in changing the trajectory of neonatal mortality, and women who are at an increased risk may not be receiving adequate care. Recent studies indicate an urgent need to assess gaps in service readiness and quality of care at the antenatal and obstetric care facilities.