Reducing newborn mortality in the Asia-Pacific region: Quality hospital services and community-based care

A lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical needs-a qualitative study among multiparous women in Somaliland

Background

Around 20% of births in Somaliland take place at health facilities staffed by trained healthcare professionals; 80% take place at home assisted by Traditional Birth Attendants (TBAs) with no formal training. There has been no research into women’s choice of place of birth.

Objective

In this study, we explore multipara women’s needs and preferences when choosing the place of birth.

Method

An explorative qualitative study using individual in-depth interviews analysed inductively using content analysis. The interviews were conducted in Somaliland with 25 multiparous women who had experience of giving birth both at home and at a health facility within the past three years.

Results

The results provide a description of how, for women in Somaliland, a lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need. The women in this study desired intentionality in their role as mothers and sought some measure of control over the environment where they planned to give birth, depending on the circumstances of that particular birth. The results describe what quality care means for multipara women in Somaliland and how women choose birthplace based on previous experiences of care. The expectation of respectful care was a vital part for women when choosing a place of birth.

Conclusion

To meet women’s needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.

Home based postpartum care and determinants in Ethiopia: A multilevel analysis

Introduction

Neonatal mortality remains a persisting public health challenge in Ethiopia. Timely intervention to neonatal morbidity and early neonatal care visit could reduce the burden of mortality. Studies related to home based postnatal care is limited in Ethiopia. Therefore, this study aimed to assess home based postnatal care visits and determinants in Ethiopia.

Methods

A secondary data analysis using 2016 EDHS data was conducted among 7590 women who had live births two years preceding the survey. A multilevel mixed-effect logistic regression analysis model was used and those variables with a P-value ≤ of 0.05 in multivariable analysis were considered as predictors. Results: Home based postpartum care by health care providers was 6.3% and 67.9% of women gave birth at home. Women perceived that distance is not big problem [AOR = 1.37; 95% CI: 1.06, 1.68], richer wealth index [AOR = 1.69; 95% CI: 1.15, 2.48], attending antenatal care visit [AOR = 2.17; 95% CI:1.57, 2.99], giving birth in health institution [AOR = 2.07; 95% CI:1.53, 2.80], giving birth by cesarean section [AOR = 3.41; 95% CI: 2.33, 4.99], and having awareness about neonatal danger sign [AOR = 3.68; 95% CI: 2.90,4.70] were factors associated with home based postpartum care.

Conclusion

Home based care by health care providers was low. Therefore, measures should be taken in increasing the number of nearby health care facility, strengthen the continuum of care on antenatal care follow-up, institutional delivery and improve mother’s knowledge about neonatal danger sign.

Why health policies should be transnational: A case for East Asia Pacific countries

This paper argues that health policies should transcend national boundaries yet should not reach the supranational level. Along with multinational global health efforts, such cross-national health policies are essential to leverage joint efforts by countries learning from their peers that experience similar health system challenges. In our analysis, we used World Bank Health, Nutrition, and Population (HNP) data from 1995 to 2014 for East Asia Pacific (EAP) countries to explore health system comparability across member nations. We applied a hierarchical cluster analysis using Ward's method and a squared Euclidean distance approach to classify 24 EAP countries into four relatively stable clusters based on their (dis)similarities over nine selected health expenditure and health system performance related indicators. One-way analysis of variance (ANOVA) was used to assess the discreteness of the formed clusters. Each cluster had unique characteristics based on the included indicators and health system performance of the member countries. We present transnational health policy recommendations for the EAP region based on both our use of robust methodology and the resulting comparative clusters.

Cross-sectional observational assessment of quality of newborn care immediately after birth in health facilities across six sub-Saharan African countries

OBJECTIVE

To present information on the quality of newborn care services and health facility readiness to provide newborn care in 6 African countries, and to advocate for the improvement of providers' essential newborn care knowledge and skills.

DESIGN

Cross-sectional observational health facility assessment.

SETTING

Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and Tanzania.

PARTICIPANTS

Health workers in 643 facilities. 1016 health workers were interviewed, and 2377 babies were observed in the facilities surveyed.

MAIN OUTCOME MEASURES

Indicators of quality of newborn care included (1) provision of immediate essential newborn care: thermal care, hygienic cord care, and early and exclusive initiation of breast feeding; (2) actual and simulated resuscitation of asphyxiated newborn infants; and (3) knowledge of health workers on essential newborn care, including resuscitation.

RESULTS

Sterile or clean cord cutting instruments, suction devices, and tables or firm surfaces for resuscitation were commonly available. 80% of newborns were immediately dried after birth and received clean cord care in most of the studied facilities. In all countries assessed, major deficiencies exist for essential newborn care supplies and equipment, as well as for health worker knowledge and performance of key routine newborn care practices, particularly for immediate skin-to-skin contact and breastfeeding initiation. Of newborns who did not cry at birth, 89% either recovered on their own or through active steps taken by the provider through resuscitation with initial stimulation and/or ventilation. 11% of newborns died. Assessment of simulated resuscitation using a NeoNatalie anatomic model showed that less than a third of providers were able to demonstrate ventilation skills correctly.

CONCLUSIONS

The findings shared in this paper call attention to the critical need to improve health facility readiness to provide quality newborn care services and to ensure that service providers have the necessary equipment, supplies, knowledge and skills that are critical to save newborn lives.

Non-invasive respiratory support for infants in low- and middle-income countries

The overwhelming majority of neonatal deaths worldwide occur in low- and middle-income countries. Most of these deaths are attributable to respiratory illnesses and complications of preterm birth. The available data suggest that non-invasive continuous positive airway pressure (CPAP) is a safe and cost-effective therapy to reduce neonatal morbidity and mortality in these settings. Bubble CPAP compared to mechanical ventilator-generated CPAP reduces the need for subsequent invasive ventilation in newborn infants. There are limited data on the safety and efficacy of high-flow nasal cannulae in low- and middle-income countries, requiring further study prior to widespread implementation.

Efficacy and acceptability of an "App on sick newborn care" in physicians from newborn units

BACKGROUND

There has been an increased emphasis on institutional births, and thus an increasing clinical work load for health care professionals in the recent past. Hence, continuing education, training, ongoing supervision, and mentorship of health care professionals working in these health facilities with easy access to guidelines in a cost effective manner has become a challenging task. With the increased emphasis on institutional births, and an increasing clinical work load, continuing education and training of health care professional managing these health facilities, their ongoing supervision, mentorship, with ready availability of guidelines in a cost effective manner becomes imperative and is a challenging task. Training opportunities can be linked to mobile electronic devices and 'Apps' to improve the care of seriously ill newborn. The aim of this study was to evaluate the efficacy of an innovative point of care tool- Android based App- 'AIIMS-WHO CC STPs' on the knowledge, skill scores, and satisfaction among Special Newborn Care Unit (SNCU) physicians managing sick neonates.

METHODS

The baseline knowledge and skill scores of pediatricians working in SNCUs in the state of Tamil Nadu, India (n = 32) were assessed by 25 multiple choice questions (MCQs) and by five Objective Structured Clinical Examination (OSCE) skill stations. The training was conducted in a single-day workshop using the app on four modules followed by post-training assessment of knowledge and skill scores after 3 weeks using the same. The satisfaction was assessed by mixed method approach using Likert's scale and focus group discussion (FGD) after 3 weeks.

RESULTS

The mean knowledge scores [19.4 (2.6) vs. 10.7 (3.2); maximum marks (MM) 25, mean difference 8.7 (95 % CI 7.6 to 9.9)], and the composite mean skill scores [55.2 (5.8) and 42 (6.2), MM 75, mean difference 13.2 (95 % CI 10.4 to 15.9)] improved after training. The median (IQR) satisfaction score with the course was 4 (4 to 5) (Likert's scale). Focus group discussion revealed that the physicians were overall satisfied using the device. They expressed overall satisfaction on the teaching methodology using wall charts, simulators, and device.

CONCLUSION

Training SNCU physicians on Android based App- 'AIIMS-WHO CC STPs' improved their knowledge and skills. This app may have a potential role as a supplement to other modalities in training doctors for improving newborn care.

Closing the gaps in child health in the Pacific: an achievable goal in the next 20 years

It is not inconceivable that by 2035 the substantial gaps in child health across the Pacific can close significantly. Currently, Australia and New Zealand have child mortality rates of 5 and 6 per 1000 live births, respectively, while Pacific island developing nations have under 5 mortality rates ranging from 13 to 16 (Vanuatu, Fiji and Tonga) to 47 and 58 per 1000 live births (Kiribati and Papua New Guinea, respectively). However, these Pacific child mortality rates are falling, by an average of 1.4% per year since 1990, and more rapidly (1.9% per year) since 2000. Based on progress elsewhere, there is a need to (i) define the specific things needed to close the gaps in child health; (ii) be far more ambitious and hopeful than ever before; and (iii) form a new regional compact based on solidarity and interdependence.

Assessment of neonatal care in clinical training facilities in Kenya

OBJECTIVE

An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya.

DESIGN

Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data.

SETTING

Neonatal units of 22 public hospitals.

PATIENTS

Neonates aged <7 days.

MAIN OUTCOME MEASURES

Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission.

RESULTS

All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing—for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0-3) and a median score of 6 out of 8 for signs of severe illness (IQR 4-7) were documented. Maternal HIV status was documented in 674/1249 (54%, 95% CI 41.9% to 66.1%) cases. Drug doses exceeded recommendations by >20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively.

CONCLUSIONS

Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training.

Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review

INTRODUCTION

Forty per cent of global child deaths occur in the neonatal period. Low and middle income countries need effective and simple methods to improve hospital-based neonatal care. Bubble continuous positive airway pressure (CPAP) may have a role in improving the quality of respiratory support in hospitals in low and middle income countries.

AIM

To examine the evidence for the efficacy and safety of bubble CPAP in neonates with respiratory distress in low and middle income settings.

METHOD

A systematic search (1946-March 2014) was performed of Pubmed, Ovid MEDLINE, Web of Science, Google Scholar and the references of relevant articles. Articles meeting inclusion criteria (CPAP for respiratory distress in infants <28 days of age in hospitals in low and middle income countries) were assessed using Grading of Recommendations, Assessment, Development and Evaluation and Newcastle-Ottawa Quality Assessment Scale methodology. Outcomes included need for mechanical ventilation, complications and mortality.

RESULTS

In three studies, the initial use of bubble CPAP compared with oxygen therapy, followed by mechanical ventilation if required, reduced the need for mechanical ventilation by 30%-50%. In another three trials comparing bubble CPAP with ventilator CPAP, mortality and complication rates were similar, while meta-analysis of CPAP failure in these same trials showed a lower failure rate in the bubble CPAP groups (p <0.003).

CONCLUSIONS

There is evidence that bubble CPAP is safe and reduces the need for mechanical ventilation. Further research into the efficacy of bubble CPAP in low-income and middle-income countries is needed.