The experience of mothers whose very low-birth-weight infant requires the delivery of supplemental oxygen in the neonatal intensive care unit

'Let him die in peace': understanding caregiver's refusal of medical oxygen treatment for children in Nigeria

INTRODUCTION

Efforts to improve oxygen access have focused mainly on the supply side, but it is important to understand demand barriers, such as oxygen refusal among caregivers. We therefore aimed to understand caregiver, community and healthcare provider (HCP) perspectives and experiences of medical oxygen treatments and how these shape oxygen acceptance among caregivers of sick children in Lagos and Jigawa states, which are two contrasting settings in Nigeria.

METHODS

Between April 2022 and January 2023, we conducted an exploratory qualitative study using reflexive thematic analysis, involving semistructured interviews with caregivers (Jigawa=18 and Lagos=7), HCPs (Jigawa=7 and Lagos=6) and community group discussions (Jigawa=4 and Lagos=5). We used an inductive-deductive approach to identify codes and themes through an iterative process using the theoretical framework of acceptability and the normalisation process theory as the analytic lens.

RESULTS

Medical oxygen prescription was associated with tension, characterised by fear of death, hopelessness about a child's survival and financial distress. These were driven by community narratives around oxygen, past negative experiences and contextual differences between both settings. Caregiver acceptance of medical oxygen was a sense-making process from apprehension and scepticism about their child's survival chances to positioning prescribed oxygen as an 'appropriate' or 'needed' intervention. Achieving this transition occurred through various means, such as trust in HCPs, a perceived sense of urgency for care, previous positive experience of oxygen use and a symbolic perception of oxygen as a technology. Misconceptions and pervasive negative narratives were acknowledged in Jigawa, while in Lagos, the cost was a major reason for oxygen refusal.

CONCLUSION

Non-acceptance of medical oxygen treatment for sick children is modifiable in the Nigerian context, with the root causes of refusal being contextually specific. Therefore, a one-size-fits-all policy is unlikely to work. Financial constraints and community attitudes should be addressed in addition to improving client-provider interactions.

Ethical Consequences of Technological Mediation on Parental Decision-Making Experiences in the Neonatal Intensive Care Unit

The neonatal intensive care unit (NICU) is a morally charged space in which parents may be confronted with difficult decisions about the treatment of their newborns, decisions often complicated and created by the increasing use of technologies. This paper adopts a postphenomenological approach to explore the ethical consequences of technological mediation on parental treatment decision-making in the NICU. Semi-structured interviews were conducted with parents of children who received invasive technological support in the NICU to better understand how they made treatment decisions or decisions about specific interventions during their child's hospitalization. The findings suggest that technological mediation-or the various ways in which humans can interact with their world via technologies-contributes to experiences of ambiguity, ambivalence, and alienation in parental decision-making. The ambiguity of invasive NICU technologies can create uncertainty in a decision, which can then lead to internal ambivalence about which decision to make. Ultimately, this ambiguity and ambivalence may lead to alienation from one's child, as parents are disconnected physically and emotionally from the decision and thus their child. Articulating the effects of technological mediation on parental decision-making is a key step in addressing decisional conflict in neonatal intensive care settings and better supporting parents in their decision-making roles.

Perception and experience of clinicians and caregivers in treating childhood severe pneumonia and hypoxemia using bubble continuous positive airway pressure in Ethiopian tertiary and general hospitals

BACKGROUND

In low and middle-income countries (LMICs), severe pneumonia with hypoxemia is the leading cause of child deaths, even with the provision of WHO-recommended antibiotic therapy, oxygen therapy and other supportive care. Previous studies found positive outcomes from the use of bubble continuous positive airway pressure (bCPAP) for treating these children compared to the standard oxygen therapy. Due to lack of data on the perceptions and experiences of hospital health care workers and caregivers of children on the feasibility and acceptability of bCPAP in treating children with severe pneumonia and hypoxemia in real-life settings, we examined these issues in tertiary and general hospitals in Ethiopia.

METHODS

As part of a three-stages clinical trial, this qualitative study was conducted in two tertiary (stage I) and two general (stage II) hospitals from September 2019 to July 2020. During stages I and II, we have consecutively enrolled children with severe pneumonia and hypoxemia and put them on bCPAP to examine its feasibility and acceptability by clinicians and parents. A total of 89 children were enrolled (49 from two tertiary and 40 from two general hospitals). Then qualitative data were collected through 75 repeated in-depth interviews by social-science experts with purposively selected 30 hospital health workers and 15 parents of 12 children who received bCPAP oxygen therapy in the hospitals. Interview data were supplemented by 6 observations in the hospitals. Data were analyzed using a thematic approach.

RESULTS

Identified structural and functional challenges for the introduction of bCPAP in treating childhood severe pneumonia and hypoxemia in the study hospitals include: inadequate number of pulse oximeters; unavailability of nasal prongs with age-specific size; inadequate and non-functioning oxygen flow meters, concentrator, and cylinders; disruption in power-supply; and inadequate number of staff. The opportunities in introducing bCPAP oxygen therapy included the availability of a dedicated corner for the study patients situated in front of nurse's station, required medicines and satisfactory level of clinicians' knowledge and skills for treating severe pneumonia patients. Additionally, the identified operational challenges were occasional lack of bubbling in the water-filled plastic bottle, lack of stand for holding the water-filled plastic bottle, and delayed shifting of oxygen source from an oxygen concentrator to a cylinder, particularly during electricity disruption. Participants (clinicians and parents) expressed their satisfaction as bCPAP oxygen therapy was found to be simple to handle, children had ease of breathing and recovered fast without major ill effects.

CONCLUSION

Our study identified some important structural, functional, and operational challenges that need to be addressed before implementation of bCPAP oxygen therapy especially in frontline general hospitals with limited resources. In spite of these observed challenges, the clinicians and caregivers were highly satisfied with the overall performance of bCPAP oxygen therapy.

Parents' Experience of Having an Infant in the Neonatal Intensive Care Unit: A Qualitative Study

INTRODUCTION

Admission to the neonatal intensive care unit (NICU) is usually unexpected and can be stressful to the parents causing strenuous psychosocial effects. Parents of these infants are subject to suffering stress, depression, and feelings of powerlessness. This study aimed at describing parents' experience of having their infant in the neonatal intensive care unit.

METHOD

 A qualitative descriptive design was used. Parents (six couples and four mothers) of infants hospitalized for at least ten days regardless of gestational age, gender, or medical diagnosis were selected from a teaching hospital in Amman, Jordan. Semi-structured interviews were conducted between June 2019 and November 2019.

RESULTS

 Thematic analysis of the data revealed four emerging themes: (1) Living the ambiguities of the admission to the NICU, (2) Living the burdens of their infants' hospitalization, (3) Coping with the stresses of a hospitalized infant, and (4) Reflecting on interactions with healthcare staff and the environment.

DISCUSSION AND CONCLUSION

 The study findings demonstrated parents' worries and needs and highlighted the use of spirituality/religiosity as a coping mechanism. The findings will guide healthcare providers and policymakers to develop caring strategies that enhance care delivered to parents of infants in intensive care units.

Focus group discussions on low-flow oxygen and bubble CPAP treatments among mothers of young children in Malawi: a CPAP IMPACT substudy

OBJECTIVE

To determine the acceptability of bubble continuous positive airway pressure (bCPAP) and low-flow oxygen among mothers of children who had received either therapy.

SETTING

A district hospital in Salima, Malawi.

PARTICIPANTS

We conducted eight focus group discussions (FGDs) with a total of 54 participants. Eligible participants were mothers of children 1 to 59 months of age with severe pneumonia and a comorbidity (HIV-infection, HIV-exposure, malnutrition or hypoxaemia) who, with informed consent, had been enrolled in a randomised clinical trial, CPAP IMPACT (Improving Mortality for Pneumonia in African Children Trial), comparing low-flow oxygen and bCPAP treatments (ClinicalTrials.gov, NCT02484183).

PRIMARY AND SECONDARY OUTCOME MEASURES

FGDs assessed mothers' attitudes and feelings towards oxygen and bCPAP before and after therapy along with general community perceptions of respiratory therapies. Data was analysed using inductive thematic analysis to assess themes and subthemes of the transcripts.

RESULTS

Community perceptions of oxygen and bCPAP were widely negative. Mothers recounted that they are told that 'oxygen kills babies'. They are often fearful of allowing their child to receive oxygen therapy and will delay treatment or seek alternative therapies. Mothers report limiting oxygen and bCPAP by intermittently removing the nasal cannulas or mask. After oxygen or bCPAP treatment, regardless of patient outcome, mothers were supportive of the treatment their child received and would recommend it to other mothers.

CONCLUSION

There are significant community misconceptions around oxygen and bCPAP causing mothers to be fearful of either treatment. In order for low-flow oxygen treatment and bCPAP implementation to be effective, widespread community education is necessary.

Health workers' views on factors affecting caregiver engagement with bubble CPAP

Background

Severe respiratory distress is a leading cause of mortality among neonates in Malawi. Despite evidence on the safety, cost effectiveness and efficacy of bubble continuous positive airway pressure (CPAP) in managing the condition, its use in Malawian health facilities is limited and little is known about caregivers’ engagement with perspectives of bubble CPAP. The purpose of this study was to explore caregiver perspectives for bubble CPAP at both central and district hospitals and key factors that enable effective caregiver engagement in Malawi.

Methods

This was a descriptive qualitative study employing secondary analysis of 46 health care worker in-depth interviews. We interviewed the health workers about their thoughts on caregiver perspectives regarding use of bubble CPAP. We implemented the study at a tertiary facility and three district hospitals in southern Malawi. This was a part of a larger study to understand barriers and facilitators to implementing neonatal innovations in resource-constrained hospitals. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia). Health workers were purposively selected to include nurses, clinicians and district health management involved in the use of bubble CPAP.

Results

Emerging issues included caregiver fears around bubble CPAP equipment as potentially harmful to their new-borns and how inadequate information provided to caregivers exacerbated knowledge gaps and was associated with refusal of care. However, good communication between health care providers and caregivers was associated with acceptance of care. Caregivers’ decision-making was influenced by relatives and peer advocates were helpful in supporting caregivers and alleviating fears or misconceptions about bubble CPAP.

Conclusions

Since caregivers turn to relatives and peers for support, there is need to ensure that both relatives and peers are counselled on bubble CPAP for improved understanding and uptake. Health workers need to provide simplified, accurate, up-to-date information on the intervention as per caregivers’ level of understanding. Notably, contextualised comprehensible information will help alleviate caregivers’ fear and anxieties about bubble CPAP.

Experiences of mothers with preterm babies at a Mother and Baby Unit of a tertiary hospital: A descriptive phenomenological study

Aim

To describe the lived experiences of mothers with preterm babies at a Mother and Baby Unit (MBU) of a tertiary hospital.

Design

A descriptive phenomenological approach.

Method

Ten mothers were purposively sampled during the month of May, 2017 to describe their experiences of having preterm babies. Recorded in-depth individual interviews were transcribed verbatim; codes were generated and inductively organised into themes.

Results

Four themes were actively generated: 'Emotional experiences of mothers', 'Mother-baby interaction', 'Perception on care and support' and 'Challenges within Mother and Baby Unit environment'. Mothers were anxious about the premature delivery and were afraid of possible infant's death. They cherished interactions with their babies during kangaroo mother care and breastfeeding. Mothers applauded the nurses for their professional competence. They expressed concerns about inadequate accommodation, high cost of care, the frequency and duration of mother-baby interactions.

Posttraumatic Stress in Mothers While Their Preterm Infants Are in the Newborn Intensive Care Unit: A Mixed Research Synthesis

In this mixed research synthesis on posttraumatic stress in mothers related to their preterm infants' stay in the newborn intensive care unit (NICU), we synthesized and integrated a total of 37 studies, 25 of which were quantitative and 12 were qualitative studies. The prevalence rates of NICU mothers with elevated posttraumatic stress symptoms ranged from 18% in the United States to 81% in Turkey. Nine of the 12 studies testing interventions to decrease mothers' stress related to their NICU experiences reported significant results. Content analysis of the qualitative studies' findings revealed 5 themes: stark contrast to images of joyous motherhood, cultural overlay, issues of ownership and control, support, and learning to be a NICU mother.

Parents' experiences of neonatal transfer. A meta-study of qualitative research 2000-2017

Transfers of critically ill neonates are frequent phenomena. Even though parents' participation is regarded as crucial in neonatal care, a transfer often means that parents and neonates are separated. A systematic review of the parents' experiences of neonatal transfer is lacking. This paper describes a meta-study addressing qualitative research about parents' experiences of neonatal transfer. Through deconstruction and reflections of theories, methods, and empirical data, the aim was to achieve a deeper understanding of theoretical, empirical, contextual, historical, and methodological issues of qualitative studies concerning parents' experiences of neonatal transfer over the course of this meta-study (2000-2017). Meta-theory and meta-method analyses showed that caring, transition, and family-centered care were main theoretical frames applied and that interviewing with a small number of participants was the preferred data collection method. The meta-data-analysis showed that transfer was a scary, unfamiliar, and threatening experience for the parents; they were losing familiar context, were separated from their neonate, and could feel their parenthood disrupted. We identified 'wavering and wandering' as a metaphoric representation of the parents' experiences. The findings add knowledge about meta-study as an approach for comprehensive qualitative research and point at the value of meta-theory and meta-method analyses.

Parents' Perspectives of Closeness and Separation With Their Preterm Infants in the NICU

OBJECTIVE

To discover parents' perceptions of closeness to and separation from their preterm infants in the NICU.

DESIGN

Qualitative descriptive.

SETTING

Urban Level III NICU.

PARTICIPANTS

Twenty parents of preterm infants in the NICU.

METHODS

After ethics approval, data were collected with a smartphone application created for this study. Parents recorded their descriptions of moments of closeness and separation over a 24-hour period in the NICU. Data were transcribed verbatim and content was analyzed.

RESULTS

Five themes related to parents' perceptions of closeness and separation were identified: Having a role as a parent: Feeling autonomous and making decisions; Providing for and getting to know the infant: Feeding, holding, and interacting; Support from staff; Reluctantly leaving the infant's bedside; and NICU environment.

CONCLUSION

Autonomy is a key element of a parent's perception of closeness. Staff in the NICU can facilitate autonomy by involving parents in the care of their preterm infants as much as possible to reinforce the parental role. Parents described leaving their infants' bedsides as very difficult.

Lived experiences of parents of premature babies in the intensive care unit in a private hospital in Johannesburg, South Africa

Background

Many of the 15 million premature babies born worldwide every year survive because of advanced medical interventions. Their parents have intense experiences when their babies are in the intensive care unit (ICU), and these have an impact on their thoughts, feelings and relationships, including their relationships with their premature babies.

Objectives

The aim of the study was to explore and describe the lived experiences of parents of premature babies in an ICU.

Method

Research design was qualitative, exploratory, descriptive and contextual. A purposive sample of parents with premature babies in an ICU in a private hospital in Johannesburg Gauteng in South Africa was used. Eight parents, four mothers and four fathers, married and either Afrikaans or English-speaking, were included in the study. Data were collected by conducting in-depth phenomenological interviews with them and making use of field notes. Trustworthiness was ensured by implementing the strategies of credibility, transferability, dependability and confirmability. Ethical principles such as autonomy, beneficence, non-maleficence and justice were adhered to throughout the research process.

Results

Thematic analyses were utilised to analyse the data. Two themes in the experiences of parents with premature babies in ICU became apparent. Parents experienced thoughts, emotions and hope while their premature babies were in the ICU as well as challenges in their relationships and these challenges influenced their experiences.

Recommendations

Mindfulness of intensive care nurses should be facilitated so that intensive care nurses can promote the mental health of parents with premature babies in the ICU.

Conclusion

Parents with premature babies in the ICU have thoughts and emotional experiences which include hope and they affect parents’ relationships.

Parental interaction with infants treated with medical technology

BACKGROUND

It is well established that parents must interact with their new-born babies to facilitate attachment. However, very little is known about how parents perceive different types of medical technology products commonly used in the neonatal intensive care unit (NICU) as barriers to their wish to interact with their infants.

AIM

This study aims to examine to what extent the different medical technology products commonly used in the NICU are perceived by parents to be obstacles in their wish to interact with their babies.

DESIGN AND METHODS

In 2010, a cross-sectional survey, using a questionnaire specifically developed for this study, was conducted among the parents of children who were discharged from any of the five NICUs of the Västra Götaland region in Sweden. A consecutive sample of 248 parents participated, and multiple regressions and t-tests were used to analyse the data.

RESULTS

The parents generally perceived the various medical technology products differently, according to the perceived level of obstruction. The variables of gender, age, educational level, origin, gestational age, previous experience of being a parent, and the offer of accommodation at the NICU were significantly associated with the perceived level of obstruction in the parents' wish to interact with their baby while the baby was being treated with different medical technology products.

CONCLUSION

The primary implication for practice is that to facilitate attachment, nurses should involve different categories of parents in different ways in the care of their children, depending on the equipment being used in the treatment of the children. Thus, the individual care plan should explicitly include the details of the specific medical equipment, because although its use is medically beneficial for the child, it is associated with potential liabilities regarding parent-child interaction and, consequently, regarding parent-child attachment.