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

COVID-19 pandemic effects on neonatal inpatient admissions and mortality: interrupted time series analysis of facilities implementing NEST360 in Kenya, Malawi, Nigeria, and Tanzania

BACKGROUND

The emergence of COVID-19 precipitated containment policies (e.g., lockdowns, school closures, etc.). These policies disrupted healthcare, potentially eroding gains for Sustainable Development Goals including for neonatal mortality. Our analysis aimed to evaluate indirect effects of COVID-19 containment policies on neonatal admissions and mortality in 67 neonatal units across Kenya, Malawi, Nigeria, and Tanzania between January 2019 and December 2021.

METHODS

The Oxford Stringency Index was applied to quantify COVID-19 policy stringency over time for Kenya, Malawi, Nigeria, and Tanzania. Stringency increased markedly between March and April 2020 for these four countries (although less so in Tanzania), therefore defining the point of interruption. We used March as the primary interruption month, with April for sensitivity analysis. Additional sensitivity analysis excluded data for March and April 2020, modelled the index as a continuous exposure, and examined models for each country. To evaluate changes in neonatal admissions and mortality based on this interruption period, a mixed effects segmented regression was applied. The unit of analysis was the neonatal unit (n = 67), with a total of 266,741 neonatal admissions (January 2019 to December 2021).

RESULTS

Admission to neonatal units decreased by 15% overall from February to March 2020, with half of the 67 neonatal units showing a decline in admissions. Of the 34 neonatal units with a decline in admissions, 19 (28%) had a significant decrease of ≥ 20%. The month-to-month decrease in admissions was approximately 2% on average from March 2020 to December 2021. Despite the decline in admissions, we found no significant changes in overall inpatient neonatal mortality. The three sensitivity analyses provided consistent findings.

CONCLUSION

COVID-19 containment measures had an impact on neonatal admissions, but no significant change in overall inpatient neonatal mortality was detected. Additional qualitative research in these facilities has explored possible reasons. Strengthening healthcare systems to endure unexpected events, such as pandemics, is critical in continuing progress towards achieving Sustainable Development Goals, including reducing neonatal deaths to less than 12 per 1000 live births by 2030.

Impacts of COVID-19 pandemic on culture-proven sepsis in neonates

Objective

To assess the effects of COVID-19 pandemic on the epidemiology of neonatal sepsis and the antibiotic resistance profiles of pathogens involved.

Methods

This retrospective cohort study analyzed infants diagnosed with culture-proven sepsis at the neonatal department of a tertiary children's hospital in East China from January 2016 to December 2022. We compared the clinical and microbiological characteristics of neonatal sepsis cases between the pre-pandemic Phase I (2016-2019) and during the COVID-19 pandemic Phase II (2020-2022).

Results

A total of 507 infants with 525 sepsis episodes were included, with 343 episodes in Phase I and 182 in Phase II. The incidence of early-onset sepsis (EOS) was significantly lower during Phase II (p < 0.05). Infants in Phase II had lower gestational ages and birth weights compared to Phase I. Clinical signs such as mottled skin, severe anemia, thrombocytopenia were more prevalent in Phase II, alongside a higher incidence of complications. Notably, necrotizing enterocolitis (NEC) (p < 0.05) and meningitis (p < 0.1) occurred more frequently during Phase II. Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae) were the predominant pathogens isolated from infants of death and cases with complications. A significant decrease in the proportion of K. pneumoniae was observed in Phase II, alongside increased antibiotic resistance in both E. coli and K. pneumoniae. The period of the COVID-19 pandemic (Phase II) was identified as an independent risk factor for complications in infants with neonatal sepsis.

Conclusion

COVID-19 pandemic response measures correlated with a decrease in EOS and an increase in neonatal sepsis complications and antibiotic resistance.

Qualitative Insights Into Enhancing Neonatal Resuscitation in Post-Pandemic Vietnam: A Stakeholder Perspective on the Helping Babies Breathe Program

BACKGROUND

The neonatal phase is vital for child survival, with a substantial portion of deaths occurring in the first month. Neonatal mortality rates differ significantly between Vietnam (10.52/1000 live births) and the United States (3.27/1000). In response to these challenges, interventions such as the Helping Babies Breathe (HBB) program have emerged, aiming to enhance the quality of care provided during childbirth, and the postpartum period in low-resource settings.

PURPOSE

The purpose of this study was to explore stakeholder perceptions of the HBB program in Vietnam postpandemic, aiming to identify requisites for resuming training.

METHODS

Utilizing qualitative content analysis, 19 in-person semistructured interviews were conducted with diverse stakeholders in 2 provinces of Central Vietnam.

RESULTS

The content analysis revealed following 5 main themes: (1) the pandemic's impact on HBB training; (2) resource needs for scaling up HBB training as the pandemic abates; (3) participants' perceptions of the pandemic's effect on HBB skills and knowledge; (4) the pandemic's influence on a skilled neonatal resuscitation workforce; and (5) future prospects and challenges for HBB training in a postpandemic era.

IMPLICATIONS FOR PRACTICE AND RESEARCH

This research highlights the importance of sustainable post-HBB training competencies, including skill assessment, innovative knowledge retention strategies, community-based initiatives, and evidence-based interventions for improved healthcare decision-making and patient outcomes. Healthcare institutions should prioritize skill assessments, refresher training, and collaborative efforts among hospitals, authorities, non-government organizations, and community organizations for evidence-based education and HBB implementation.

Community-based postnatal care model: Catalyst for management of mothers and neonates

BACKGROUND

 Early postnatal discharge is perceived as a factor that contributes to the possibilities of the maternal, neonatal complications and deaths. The implementation of the community-based postnatal care model is crucial to mitigate the morbidity and mortality of postnatal women and neonates during the first weeks of delivery. A community-based postnatal care model was developed for the management of neonates during the postnatal care period in the community.

OBJECTIVES

 The study aims to share the developed community-based postnatal care model that could assist postnatal women in the management of neonates.

METHOD

 Empirical findings from the main study formed the basis for model development. The model development in this study was informed by the work of Walker and Avant; Chinn and Kramer Dickoff, James and Wiedenbach; and Chinn and Jacobs.

RESULTS

 The results indicated that there was no community-based postnatal care model developed to manage neonates. The model is described using the practice theory of Dickoff, James and Wiedenbach elements of agents, recipients, context, process, dynamics and outcomes within the community context of the postnatal care period. The model was further described by Chinn and Krammer following the assumptions of the model, concept definition, relation statement and nature of structure.

CONCLUSION

 The utilisation of the model is critical and facilitates the provision of an enabling and supportive community-based context by primary caregivers for the effective management of neonates.Contribution: This study provides a reference guide in the provision of community-based postnatal care by postnatal women after discharge from healthcare facilities.

Comparison and discussion of behavior and pathology of four kinds of cerebral palsy disease models

Explore the differences in behavioral and pathological manifestations of rat models of cerebral palsy made by different methods and discuss what types of studies these models are suitable for. Behavioral evaluation and pathological section observation were used to observe and evaluate the model. Conclusion: except for the absence of data of bilateral common carotid artery ligation rats, the other three methods could all achieve a successful cerebral palsy disease model for both behavioral and pathological. For researchers, the selection of intraperitoneal infection model in pregnant rats or unilateral ischemia and hypoxia model in infant rats is sufficient to meet the experimental needs, whereas the selection of the combined method for modeling does not show enough advantages, which not only causes the waste of financial and human resources but also increases the possibility of experimental error made by intervention factors.

Perspectives and experiences of healthcare providers on the response to the COVID-19 pandemic in three maternal and neonatal referral hospitals in Guinea in 2020: a qualitative study

BACKGROUND

The COVID-19 pandemic has adversely affected access to essential healthcare services. This study aimed to explore healthcare providers' perceptions and experiences of the response to the COVID-19 pandemic in three referral maternal and neonatal hospitals in Guinea.

METHODS

We conducted a longitudinal qualitative study between June and December 2020 in two maternities and one neonatology referral ward in Conakry and Mamou. Participants were purposively recruited to capture diversity of professional cadres, seniority, and gender. Four rounds of in-depth interviews (46 in-depth interviews with 18 respondents) were conducted in each study site, using a semi-structured interview guide that was iteratively adapted. We used both deductive and inductive approaches and an iterative process for content analysis.

RESULTS

We identified four themes and related sub-themes presented according to whether they were common or specific to the study sites, namely: 1) coping strategies & care reorganization, which include reducing staffing levels, maintaining essential healthcare services, suspension of staff daily meetings, insertion of a new information system for providers, and co-management with COVID-19 treatment center for caesarean section cases among women who tested positive for COVID-19; 2) healthcare providers' behavior adaptations during the response, including infection prevention and control measures on the wards and how COVID-19-related information influenced providers' daily work; 3) difficulties encountered by providers, in particular unavailability of personal protective equipment (PPE), lack of financial motivation, and difficulties reducing crowding in the wards; 4) providers perceptions of healthcare service use, for instance their fear during COVID-19 response and perceived increase in severity of complications received and COVID-19 cases among providers and parents of newborns.

CONCLUSION

This study provides insights needed to be considered to improve the preparedness and response of healthcare facilities and care providers to future health emergencies in similar contexts.

Measuring supply-side service disruption: a systematic review of the methods for measuring disruption in the context of maternal and newborn health services in low and middle-income settings

OBJECTIVES

During the COVID-19 pandemic, most essential services experienced some level of disruption. Disruption in LMICs was more severe than in HICs. Early reports suggested that services for maternal and newborn health were disproportionately affected, raising concerns about health equity. Most disruption indicators measure demand-side disruption, or they conflate demand-side and supply-side disruption. There is currently no published guidance on measuring supply-side disruption. The primary objective of this review was to identify methods and approaches used to measure supply-side service disruptions to maternal and newborn health services in the context of COVID-19.

DESIGN

We carried out a systematic review and have created a typology of measurement methods and approaches using narrative synthesis.

DATA SOURCES

We searched MEDLINE, EMBASE and Global Health in January 2023. We also searched the grey literature.

ELIGIBILITY CRITERIA

We included empirical studies describing the measurement of supply-side service disruption of maternal and newborn health services in LMICs in the context of COVID-19.

DATA EXTRACTION AND SYNTHESIS

We extracted the aim, method(s), setting, and study outcome(s) from included studies. We synthesised findings by type of measure (ie, provision or quality of services) and methodological approach (ie, qualitative or quantitative).

RESULTS

We identified 28 studies describing 5 approaches to measuring supply-side disruption: (1) cross-sectional surveys of the nature and experience of supply-side disruption, (2) surveys to measure temporal changes in service provision or quality, (3) surveys to create composite disruption scores, (4) surveys of service users to measure receipt of services, and (5) clinical observation of the provision and quality of services.

CONCLUSION

Our review identified methods and approaches for measuring supply-side service disruption of maternal and newborn health services. These indicators provide important information about the causes and extent of supply-side disruption and provide a useful starting point for developing specific guidance on the measurement of service disruption in LMICs.

Protecting small and sick newborn care in the COVID-19 pandemic: multi-stakeholder qualitative data from four African countries with NEST360

BACKGROUND

Health system shocks are increasing. The COVID-19 pandemic resulted in global disruptions to health systems, including maternal and newborn healthcare seeking and provision. Yet evidence on mitigation strategies to protect newborn service delivery is limited. We sought to understand what mitigation strategies were employed to protect small and sick newborn care (SSNC) across 65 facilities Kenya, Malawi, Nigeria and Tanzania, implementing with the NEST360 Alliance, and if any could be maintained post-pandemic.

METHODS

We used qualitative methods (in-depth interviews n=132, focus group discussions n=15) with purposively sampled neonatal health systems actors in Kenya, Malawi, Nigeria and Tanzania. Data were collected from September 2021 - August 2022. Topic guides were co-developed with key stakeholders and used to gain a detailed understanding of approaches to protect SSNC during the COVID-19 pandemic. Questions explored policy development, collaboration and investments, organisation of care, human resources, and technology and device innovations. Interviews were conducted by experienced qualitative researchers and data were collected until saturation was reached. Interviews were digitally recorded and transcribed verbatim. A common coding framework was developed, and data were coded via NVivo and analysed using a thematic framework approach.

FINDINGS

We identified two pathways via which SSNC was strengthened. The first pathway, COVID-19 specific responses with secondary benefit to SSNC included: rapid policy development and adaptation, new and collaborative funding partnerships, improved oxygen systems, strengthened infection prevention and control practices. The second pathway, health system mitigation strategies during the pandemic, included: enhanced information systems, human resource adaptations, service delivery innovations, e.g., telemedicine, community engagement and more emphasis on planned preventive maintenance of devices. Chronic system weaknesses were also identified that limited the sustainability and institutionalisation of actions to protect SSNC.

CONCLUSION

Innovations to protect SSNC in response to the COVID-19 pandemic should be maintained to support resilience and high-quality routine SSNC delivery. In particular, allocation of resources to sustain high quality and resilient care practices and address remaining gaps for SSNC is critical.

Provision and utilization of maternal health services during the COVID-19 pandemic in 16 hospitals in sub-Saharan Africa

Objective

Maintaining provision and utilization of maternal healthcare services is susceptible to external influences. This study describes how maternity care was provided during the COVID-19 pandemic and assesses patterns of service utilization and perinatal health outcomes in 16 referral hospitals (four each) in Benin, Malawi, Tanzania and Uganda.

Methods

We used an embedded case-study design and two data sources. Responses to open-ended questions in a health-facility assessment survey were analyzed with content analysis. We described categories of adaptations and care provision modalities during the pandemic at the hospital and maternity ward levels. Aggregate monthly service statistics on antenatal care, delivery, caesarean section, maternal deaths, and stillbirths covering 24 months (2019 and 2020; pre-COVID-19 and COVID-19) were examined.

Results

Declines in the number of antenatal care consultations were documented in Tanzania, Malawi, and Uganda in 2020 compared to 2019. Deliveries declined in 2020 compared to 2019 in Tanzania and Uganda. Caesarean section rates decreased in Benin and increased in Tanzania in 2020 compared to 2019. Increases in maternal mortality ratio and stillbirth rate were noted in some months of 2020 in Benin and Uganda, with variability noted between hospitals. At the hospital level, teams were assigned to respond to the COVID-19 pandemic, routine meetings were cancelled, and maternal death reviews and quality improvement initiatives were interrupted. In maternity wards, staff shortages were reported during lockdowns in Uganda. Clinical guidelines and protocols were not updated formally; the number of allowed companions and visitors was reduced.

Conclusion

Varying approaches within and between countries demonstrate the importance of a contextualized response to the COVID-19 pandemic. Maternal care utilization and the ability to provide quality care fluctuated with lockdowns and travel bans. Women's and maternal health workers' needs should be prioritized to avoid interruptions in the continuum of care and prevent the deterioration of perinatal health outcomes.

Perinatal care and breastfeeding education during the COVID-19 pandemic: Perspectives from Kenyan mothers and healthcare workers

The impact of the COVID-19 pandemic on breastfeeding (BF) practices in low- and middle-income countries (LMICs) is not well understood. Modifications in BF guidelines and delivery platforms for breastfeeding education during the COVID-19 pandemic are hypothesised to have affected BF practices. We aimed to understand the experiences with perinatal care, BF education and practice among Kenyan mothers who delivered infants during the COVID-19 pandemic. We conducted in-depth key informant interviews with 45 mothers who delivered infants between March 2020 and December 2021, and 26 health care workers (HCW) from four health facilities in Naivasha, Kenya. While mothers noted that HCWs provided quality care and BF counselling, individual BF counselling was cited to be less frequent than before the pandemic due to altered conditions in health facilities and COVID-19 safety protocols. Mothers stated that some HCW messages emphasised the immunologic importance of BF. However, knowledge among mothers about the safety of BF in the context of COVID-19 was limited, with few participants reporting specific counselling or educational materials on topics such as COVID-19 transmission through human milk and the safety of nursing during a COVID-19 infection. Mothers described COVID-19-related income loss and lack of support from family and friends as the major challenge to practising exclusive breastfeeding (EBF) as they wished or planned. COVID-19 restrictions limited or prevented mothers' access to familial support at facilities and at home, causing them stress and fatigue. In some cases, mothers reported job loss, time spent seeking new means of employment and food insecurity as causes for milk insufficiency, which contributed to mixed feeding before 6 months. The COVID-19 pandemic created changes to the perinatal experience for mothers. While messages about the importance of practising EBF were provided, altered HCW education delivery methods, reduced social support and food insecurity limit EBF practices for mothers in this context.

The COPE Staff study: Study description and initial report regarding job satisfaction, work-life conflicts, stress, and burnout among Swedish maternal and neonatal healthcare workers during the COVID-19 pandemic

OBJECTIVE

To describe the study design of the COPE Staff cohort study on working conditions for maternal and neonatal healthcare workers (MNHCWs), and present baseline data regarding job satisfaction, work-life conflicts, stress, and burnout.

METHODS

Between January and April 2021, 957 MNHCWs (administrative and medical staff) completed a baseline survey. Average levels of job satisfaction, work-life conflicts, stress, and burnout, and associations to perceived workload were assessed.

RESULTS

The average levels of job satisfaction, work-life conflicts, stress, and burnout were 68.6 (95% confidence interval [CI] 64.3-72.8), 42.6 (95% CI 37.3-48.0), 42.0 (95% CI 37.7-46.3), and 1.9 (95% CI 1.6-2.2), respectively. The respondents scoring above critical values indicating clinical burnout ranged between 3% and 18%, respectively, for the four burnout sub-dimensions. Women reported significantly higher levels of stress and burnout. Younger participants had lower job satisfaction and higher levels of work-life conflicts, stress, and burnout. Higher perceived workload was significantly associated with lower job satisfaction levels and higher levels of work-life conflicts, stress, and burnout.

CONCLUSIONS

Our results indicate associations between MNHCWs perceived workload and job satisfaction, work-life conflicts, stress, and burnout during the COVID-19 pandemic. Eighteen percent scored above critical values for exhaustion.

Rescinding evidence-based care and practices during the initial COVID-19 outbreak in the United States: a qualitative study of the experiences of lactation support providers

Background

The COVID-19 pandemic disrupted healthcare systems and services including along the childbearing continuum. The aim of this study was to explore the experiences and perceptions of professional lactation support providers who cared for breastfeeding families during the early months of the pandemic (March 2020 - August 2020) in the United States.

Design/methods

We conducted a qualitative survey among active lactation support providers in the United States. Eligible participants spoke English, were Certified Lactation Counselors who maintained an active certification and who provided lactation care and services prior to and after the onset of the COVID-19 pandemic. Participants were recruited via email from the national database of Certified Lactation Counselors obtained from the national certification body. All ten Health and Human Service regions of the United States were included. Demographic data was collected on each respondent. Qualitative survey responses were analyzed thematically following the framework method.

Findings

Six-hundred and seventy-four (674) Certified Lactation Counselors responded to the survey from June to July of 2022. Their responses fell within the overarching theme of rescinding evidence-based care and practices that had been in place prior to the pandemic. Affected care practices included the insertion of limits on access to care and insinuating stigma and bias based on COVID-19 status. Irregular appointment schedules and staffing shortages also affected care. Participants reported that separation of the mother and their infant became the norm. Decisions made by management seemed to be grounded in fear and uncertainty, rather than on the evidence-based principles that had been in place prior to the pandemic.

Conclusion

A lack of coordination, consistency and support, along with fear of the unknown, troubled lactation support providers and impacted their ability to provide evidence-based care and to maintain access to care for all families. The findings of the survey and analysis underscore the importance of adequately preparing for future public health crises by determining how evidence-based care and practices can be preserved in emergent situations.

Implementing recommended breastfeeding practices in healthcare facilities in India during the COVID-19 pandemic: a scoping review of health system bottlenecks and potential solutions

Background

Breastfeeding practices in institutional settings got disrupted during the COVID-19 pandemic. We reviewed the challenges faced and the "work-around" solutions identified for implementing recommended breastfeeding practices in institutionalized mother-newborn dyads in resource constrained settings during the pandemic with the aim to identify learnings that could be potentially adapted to the Indian and relatable contexts, for building resilient health systems.

Methods

We conducted a scoping review of literature using the PRISMA ScR Extension guidelines. We searched the Medline via PubMed and Web of Science databases for literature published between 1st December 2019 and 15th April 2022. We included original research, reviews, and policy recommendations published in English language and on India while others were excluded. Further, we searched for relevant gray literature on Google (free word search), websites of government and major professional bodies in India. Three reviewers independently conducted screening and data extraction and the results were displayed in tabular form. Challenges and potential solutions for breastfeeding were identified and were categorized under one or more suitable headings based on the WHO building blocks for health systems.

Results

We extracted data from 28 papers that were deemed eligible. Challenges were identified across all the six building blocks. Lack of standard guidelines for crisis management, separation of the newborn from the mother immediately after birth, inadequate logistics and resources for infection prevention and control, limited health workforce, extensive use of formula and alternative foods, inconsistent quality of care and breastfeeding support, poor awareness among beneficiaries about breastfeeding practices (and especially, about its safety during the pandemic) were some of the challenges identified. The solutions primarily focused on the development of standard guidelines and operating procedures, restricted use of formula, use of telemedicine services for counseling and awareness and improving resource availability for risk mitigation through strategic mobilization.

Conclusion

The COVID-19 pandemic has provided rich learning opportunities for health system strengthening in India. Countries must strengthen learning mechanisms to identify and adapt best practices from within their health systems and from other relatable settings.

Changes in moderately low birthweight infant feeding, care, and health outcomes before compared to during the COVID-19 pandemic in Malawi

Background

The coronavirus disease 2019 (COVID-19) and the measures taken to minimise its spread have significantly impacted mother- and infant-related healthcare. We describe the changes in newborn feeding, lactation support, and growth outcomes before compared to during the COVID-19 pandemic among moderately low birthweight infants (LBW) (1.5 to <2.5kg) in Malawi.

Methods

The data presented here are part of the Low Birthweight Infant Feeding Exploration (LIFE) study, a formative, multisite, mixed methods observational cohort study. In this analysis, we included infants born at two public hospitals in Lilongwe, Malawi between 18 October 2019 and 29 July 2020. We categorised births as "pre-COVID-19 period" (before 1 April 2020) and "during COVID-19 period" (on or after 2 April 2020) and used descriptive statistics and mixed effects models to examine differences in birth complications, lactation support, feeding, and growth outcomes between the two time periods.

Results

We included 300 infants and their mothers (n = 273) in the analysis. Most infants (n = 240) were born during the pre-COVID-19 period; 60 were born during the pandemic period. The latter group had a lower prevalence of uncomplicated births (35.8%) compared to pre-pandemic period group (16.7%) (P = 0.004). Fewer mothers reported early initiation of breastfeeding in the pandemic period (27.2%) compared to the pre-pandemic period (14.6%) (P = 0.053), along with significantly less breastfeeding support, particularly in view of discussion of proper latching (44.9% during COVID-19 vs 72.7% pre-COVID-19; P < 0.001) and physical support with positioning (14.3% vs 45.5% pre-COVID-19 P < 0.001). At 10 weeks of age, the prevalence of stunting was 51.0% pre-COVID-19 vs 45.1% during COVID-19 (P = 0.46), the prevalence of underweight was 22.5% pre-COVID-19 vs 30.4% during COVID-19 (P = 0.27), and the prevalence of wasting was 0% pre-COVID-19 vs 2.5% during COVID-19 (P = 0.27).

Conclusions

Our findings highlight the continued need to optimise early initiation of breastfeeding and lactation support for infants during COVID-19 and future pandemics. More studies are needed to evaluate the long-term outcomes of moderately LBW born during the COVID-19 pandemic (including growth outcomes) and determine the impact of restrictive measures on access to lactation support and promotion of early initiation of breastfeeding.

The Effect of Maternal SARS-CoV-2 Infection on Neonatal Outcome

(1) Background: Neonates born to SARS-CoV-2 positive mothers are at risk of infection, as well as adverse outcomes due to the infection. The aim of our study was to analyze the impact of maternal SARS-CoV-2 infection on neonatal outcome. (2) Methods: We conducted a prospective, longitudinal study. We collected data on maternal symptomatology upon admission and their correlation with the development of the infant. Through a questionnaire we analyzed the impact on breastfeeding of the separation of the mother from the newborn, as well as the maternal psycho-emotional effect. (3) Results: Ninety infants were enrolled in the study, from one twin pregnancy and the rest singleton pregnancies. Out of the 89 mothers, 34 showed symptoms. Neonates from mothers with anosmia and ageusia had a higher value of WBC and lymphocytes (p = 0.06 and p = 0.04). Breastfeeding was started in 57.3% of mothers after their discharge from hospital and only 41.6% of the whole study group continued at the follow-up visit. Mothers who described a negative experience during hospitalization associated a 2.42 times higher risk of not continuing breastfeeding. (4) Conclusion: None of the infants enrolled in the study had SARS-CoV-2 infection either at birth or within the first two months of life. Breastfeeding was started with more than half newborns after discharge from hospital. The negative experience generated by the separation from their babies influenced breastfeeding.

How COVID-19 affected food systems, health service delivery and maternal and infant nutrition practices: Implications for moving forward in Kenya

This implementation research study sought to examine the impact of the COVID-19 pandemic on maternal and infant nutrition practices, and related aspects of health and food systems in Nairobi and Uasin Gishu Counties, Kenya. The study triangulated in-depth interviews with 16 pregnant women, 31 lactating women (including COVID-19 positive), 10 facility health workers, 10 community health volunteers, 6 focus group discussions (FGDs) with food vendors, 4 FGDs and 15 stakeholder interviews with government and implementing partners. Trends from Kenyan Health Information System indicators (i.e., exclusive breastfeeding and initiation of breastfeeding, antenatal care) were also examined. During the COVID-19 pandemic, a decline in attendance of antenatal care, and maternity facilities was observed, and corroborated by Kenyan Health Information System data. Lack of clarity among health workers on COVID-19 breastfeeding guidance and fear of COVID-19 infection early in the pandemic were key drivers of early infant formula use, mother-child separation following delivery and delayed initiation of breastfeeding. Most women exclusively breastfed due to Government of Kenya restrictions in movement. Unemployment and job loss was linked to food insecurity and worsened by increased food prices and limited social protection measures. In response, pregnant and lactating women resorted to skipping meals and reducing quantity and variety of foods consumed. Efforts to build forward from COVID-19 in Kenya should include facility and community health education to prevent disruptions in breastfeeding and to support maternal dietary intake, and in the provision of targeted social protection measures alongside other multisectoral interventions (i.e., psychosocial support) for Kenyan pregnant and lactating women.

Real-time COVID-19 Education to Reduce Workplace Risks: Thematic Analysis of a COVID-19 Agricultural Employer Webinar Series

OBJECTIVES

California's agricultural industry, an "essential industry" during the COVID-19 pandemic, required support to understand and implement changing public health knowledge and regulations in the workplace. The Western Center for Agricultural Health and Safety (WCAHS) transitioned from traditional in-person trainings with agricultural stakeholders to remote engagement, such as webinars. We aimed to assess the use of real-time webinar trainings and identify agricultural employer concerns about reducing the risk of COVID-19 in the workplace.

METHODS

We conducted a thematic analysis of webinar chat from WCAHS' "Reduce the Risk of COVID-19 in Your Workplace" monthly webinar series held from December 2020-May 2021. De-identified chat transcripts were analyzed using a deductive approach to assess participant concerns as they related to prevention and response actions, employer responsibilities, and evolving public health knowledge. Codes were identified by an iterative process using semantic interpretation and summarized into four major themes.

RESULTS

Our analysis reveals participants' concerns relating to (1) prevention of COVID-19 in the workplace, (2) response to COVID-19 in the workplace, (3) employer concerns, and (4) evolving, real-time knowledge. Participants shared multiple, overlapping concerns. Many also asked for information tailored to specific scenarios in their workplace.

CONCLUSION

Providing industry-specific guidance and examples in an accessible means is critical for supporting agricultural employers and their highly vulnerable workers. Virtual trainings will likely continue to be an effective means of outreach with the agricultural industry. Future outreach and education efforts should consider virtual engagement and opportunities to document experiences amid changing work environments, social cultures, and learning activities.

Antibiotic dispensing practices during COVID-19 and implications for antimicrobial resistance (AMR): parallel mystery client studies in Uganda and Tanzania

BACKGROUND

Over-the-counter antibiotic access is common in low-and-middle-income countries and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller-client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in Tanzania and Uganda, countries with different government responses to the pandemic.

METHODS

Research assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms =  415, nADDOs = 116) and Mbarara, Uganda (nPharms = 440, nDSs  = 67), from June 10 to July 30, 2021. The mystery clients held no prescription and sought advice for simulated COVID-19 symptoms from the drug sellers. They documented the quality of their interaction with sellers and the type of drugs dispensed.

RESULTS

Adherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms = 36%, DSs = 35%, P-value = 0.947) compared to Mwanza (Pharms = 9%, ADDOs = 4%, P-value = 0.112) identified the client's symptoms as possibly COVID-19. More than three-quarters of drug sellers that sold prescription-only medicines in both Mbarara (Pharms = 86%, DSs = 89%) and Mwanza (Pharms = 93%, ADDOs = 97%) did not ask the MCs for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms = 51%, ADDOs = 67%) compared to Mbarara (Pharms = 31%, DSs = 42%) sold a partial course without any hesitation. Of those who sold antibiotics, a higher proportion of drug sellers in Mbarara (Pharms = 73%, DSs = 78%, P-value = 0.580) compared to Mwanza (Pharms = 40% ADDOs = 46%, P-value = 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients.

CONCLUSION

Our study highlights low vigilance towards COVID-19 symptoms, widespread propensity to dispense prescription-only antibiotics without a prescription, and to dispense partial doses of antibiotics. This implies that drug dispensing related to COVID-19 may further drive AMR. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to COVID-19 and to prepare them for future health emergencies.

Sequential interventions to maintain the safety and service provisions of human milk banking in India: keeping up with the call to action in response to the COVID-19 pandemic

BACKGROUND

WHO recommends donor milk as the next best choice if Mothers' own milk (MOM) is unavailable. At our milk bank, during the COVID 19 pandemic, we observed a steep decline in the collection of donor milk, while Pasteurised Donor human milk (PDHM) demand increased. This called for active intervention.

METHODS

We employed the quasi-experimental quality improvement initiative. During September 2020 (baseline period) the team members identified modifiable bottlenecks and suggested interventions (using WhatsApp to increase follow up, telehealth and digital tools) which were implemented in October 2020 and the impact was evaluated till March 2021. The SMART aim was "to meet the demand (estimated as 15,000 ml/month) of donor milk for adjoining 80-bedded NICU". Process measures were; daily amount of donor milk collected, pasteurized donor milk disbursed to NICU, number of donors and frequency of donations. The balancing measure was that the collection of donor milk should not undermine the provision of freshly expressed MOM for babies.

RESULTS

Collection of donor milk increased by 180% from baseline during the Intervention phase. This was sustained throughout the sustenance phase (November 2020 and March 2021) with an average monthly collection of 16,500 ml. Strikingly, the increased follow-up of mothers with emphasis on MOM decreased the NICU's donor milk requirement from 13,300 ml (baseline) to 12,500 ml (intervention) to 8,300 ml (sustenance). Monitoring of daily MOM used in the NICU revealed a 32% surge from 20,000 ml (baseline) to 27,000 ml (intervention) sustained at 25,000 ml per month.

CONCLUSION

By improving the provisions of human milk banks, near-exclusive human milk feeding can be ensured even during the pandemic time.

Learning from the Implementation of the Child Nutrition Program: A Mixed Methods Evaluation of Process

Nutrition and feeding interventions are important for children’s growth and development. Holt International’s Child Nutrition Program (CNP) is a child nutrition and feeding intervention. This study aims to describe and explore the implementation of CNP in Mongolia and the Philippines using mixed methods including qualitative and quantitative data analysis. The analysis framework was guided by the WHO’s Monitoring the Building Blocks of Health Systems. Key informant interviews (KIIs) were conducted, transcribed, translated and coded. Knowledge, Attitude and Practice Surveys (KAPS) and pre-/post-tests from routine program audit data were analyzed. Analysis of nutrition (Mongolia: 95% CI: 7.5-16.6 (p = < 0.0001), Philippines: 95% CI: 7.6-15.7 (p= < 0.0001)) and feeding (Mongolia: 95% CI: 11.7-23.9 (p = < 0.0001), Philippines: 95% CI: 6.6-16.9 (p = < 0.0001)) tests indicate improvement post-training in both countries. KAPS indicate changes in desired practices from pre-training to post-training. Thematic analysis of KIIs highlight essential components for program implementation and effectiveness, including strong leadership, buy-in, secure funding, reliable supply chains, training and adequate staffing. This evaluation of program implementation highlights successful strategies and challenges in implementing CNP to improve the health of children in Mongolia and the Philippines. Lessons learned from the implementation of CNP can inform growth of the program, scaling strategies and provide insights for similar interventions.

Barriers and enablers of breastfeeding in mother-newborn dyads in institutional settings during the COVID-19 pandemic: A qualitative study across seven government hospitals of Delhi, India

Introduction

The COVID-19 pandemic disrupted newborn care and breastfeeding practices across most healthcare facilities. We undertook this study to explore the barriers and enablers for newborn care and breastfeeding practices in hospitals in Delhi, India for recently delivered mother (RDM)-newborn dyads during the first wave of the COVID-19 pandemic (2020) and inductively design a "pathway of impaction" for informing mitigatory initiatives during the current and future pandemics, at least in the initial months.

Materials and methods

We used an exploratory descriptive design (qualitative research method) and collected information from seven leading public health facilities in Delhi, India. We conducted separate interviews with the head and senior faculty from the Departments of Pediatrics/Neonatology (n = 12) and Obstetrics (n = 7), resident doctors (n = 14), nurses (labor room/maternity ward; n = 13), and RDMs (n = 45) across three profiles: (a) COVID-19-negative RDM with healthy newborn (n = 18), (b) COVID-19-positive RDM with healthy newborn (n = 19), and (c) COVID-19 positive RDM with sick newborn needing intensive care (n = 8) along with their care-giving family members (n = 39). We analyzed the data using grounded theory as the method and phenomenology as the philosophy of our research.

Results

Anxiety among clients and providers, evolving evidence and advisories, separation of the COVID-positive RDM from her newborn at birth, providers' tendency to minimize contact duration and frequency with COVID-positive mothers, compromised counseling on breastfeeding, logistic difficulties in expression and transportation of COVID-positive mother's milk to her baby in the nursery, COVID restrictions, staff shortage and unavailable family support in wards and nursery, and inadequate infrastructure were identified as major barriers. Keeping the RDM-newborn together, harmonization of standard operating procedures between professional associations and within and between departments, strategic mobilization of resources, optimization of human resources, strengthening client-provider interaction, risk triaging, leveraging technology, and leadership-in-crisis-situations were notable enablers.

Conclusion

The separation of the RDM and newborn led to a cascade of disruptions to newborn care and breastfeeding practices in the study institutions. Separating the newborn from the mother should be avoided during public health emergencies unless there is robust evidence favoring the same; routine institutional practices should be family centered.

IMAgiNE EURO: Data for action on quality of maternal and newborn care in 20 European countries during the COVID-19 pandemic

A summary of the findings in the Supplement, highlighting the heterogeneity in reported quality of maternity care and inequalities within and between countries in the European region.

Implementing quality improvement intervention to improve intrapartum fetal heart rate monitoring during COVID-19 pandemic- observational study

Introduction

Adherence to intrapartum fetal heart rate monitoring (FHRM) for early decision making in high-risk pregnancies remains a global health challenge. COVID-19 has led to disruption of routine intrapartum care in all income settings. This study aims to evaluate the implementation of quality improvement (QI) intervention to improve intrapartum FHRM and birth outcome before and during pandemic.

Method and materials

We conducted an observational study among 10,715 pregnant women in a hospital of Nepal, over 25 months. The hospital implemented QI intervention i.e facilitated plan-do-study-act (PDSA) meetings before and during pandemic. We assessed the change in intrapartum FHRM, timely action in high-risk deliveries and fetal outcomes before and during pandemic.

Results

The number of facilitated PDSA meetings increased from an average of one PDSA meeting every 2 months before pandemic to an average of one PDSA meeting per month during the pandemic. Monitoring and documentation of intrapartum FHRM at an interval of less than 30 minutes increased from 47% during pre-pandemic to 73.3% during the pandemic (p<0.0001). The median time interval from admission to abnormal heart rate detection decreased from 160 minutes to 70 minutes during the pandemic (p = 0.020). The median time interval from abnormal FHR detection to the time of delivery increased from 122 minutes to 177 minutes during the pandemic (p = 0.019). There was a rise in abnormal FHR detection during the time of admission (1.8% vs 4.7%; p<0.001) and NICU admissions (2.9% vs 6.5%; p<0.0001) during the pandemic.

Conclusion

Despite implementation of QI intervention during the pandemic, the constrains in human resource to manage high risk women has led to poorer neonatal outcome. Increasing human resources to manage high risk women will be key to timely action among high-risk women and prevent stillbirth.

Barriers to optimal care and strategies to promote safe and optimal management of sick young infants during the COVID-19 pandemic: A multi-country formative research study

Background

Essential health and nutrition services for pregnant women, newborns, and children, particularly in low- and middle-income countries (LMICs), are disrupted by the COVID-19 pandemic. This formative research was conducted at five LMICs to understand the pandemic's impact on barriers to and mitigation for strategies of care-seeking and managing possible serious bacterial infection (PSBI) in young infants.

Methods

We used a convergent parallel mixed-method design to explore the possible factors influencing PSBI management, barriers, and facilitators at three levels: 1) national and local policy, 2) the health systems, public and private facilities, and 3) community and caregivers. We ascertained trends in service provision and utilisation across pre-lockdown, lockdown, and post-lockdown periods by examining facility records and community health worker registers.

Results

The pandemic aggravated pre-existing challenges in the identification of young infants with PSBI; care-seeking, referral, and treatment due to several factors at the policy level (limited staff and resource reallocation), health facility level (staff quarantine, sub-optimal treatment in facilities, limited duration of service availability, lack of clear guidelines on the management of sick young infants, and inadequate supplies of protective kits and essential medicines) and at the community level (travel restrictions, lack of transportation, and fear of contracting the infection in hospitals). Care-seeking shifted to faith healers, traditional and informal private sources, or home remedies. However, caregivers were willing to admit their sick young infants to the hospital if advised by doctors. A review of facility records showed low attendance (<50%) of sick young infants in the OPD/emergencies during lockdowns in Bangladesh, India (both sites) and Pakistan, but it gradually increased as lockdowns eased. Stakeholders suggested aspirational and pragmatic mitigation strategies.

Conclusions

We obtained useful insights on health system preparedness during catastrophes and strategies to strengthen services and improve utilisation regarding PSBI management. The current pandemic provides an opportunity for implementing various mitigation strategies at the policy, health system, and community levels to improve preparedness.

The impact of the COVID-19 pandemic on nursing care and nurses' work in a neonatal intensive care unit

PURPOSE

This study was conducted to determine the effects of the COVID-19 pandemic process on nursing care and nurses' work in neonatal intensive care units.

DESIGN AND METHODS

The study was conducted using a qualitative method. The data were collected by voice recording with a one-on-one in-depth interview technique, and a semi-structured question form was used in the interviews. The data obtained from voice recordings were evaluated using the qualitative content analysis method.

RESULTS

The main themes and subthemes of the study were as follows: (1) decrease in physical contact with newborns due to fear of transmitting Covid-19 (decrease in physical contact between neonatal nurses and newborns, decrease in physical contact between mothers and newborns, decrease in physical contact between fathers and newborns), (2) communication problems between healthcare professionals and parents (3) changes in the working conditions for neonatal nurses (increase in the frequency and duration of work intense working speed, exhaustion and decreased motivation due to use of protective equipment).

CONCLUSION

The COVID-19 pandemic process led to a decrease in nurses' and parents' touching newborns, nurses' experiencing problems with parents due to measures taken, heavier working conditions and a decrease in motivation for nurses.

PRACTICE IMPLICATIONS

This study will inform future research to be directed to nursing care and the work of nursing who work on the front line in the COVID-19 pandemic process.

Can machine learning models predict maternal and newborn healthcare providers' perception of safety during the COVID-19 pandemic? A cross-sectional study of a global online survey

BACKGROUND

Maternal and newborn healthcare providers are essential professional groups vulnerable to physical and psychological risks associated with the COVID-19 pandemic. This study uses machine learning algorithms to create a predictive tool for maternal and newborn healthcare providers' perception of being safe in the workplace globally during the pandemic.

METHODS

We used data collected between 24 March and 5 July 2020 through a global online survey of maternal and newborn healthcare providers. The questionnaire was available in 12 languages. To predict healthcare providers' perception of safety in the workplace, we used features collected in the questionnaire, in addition to publicly available national economic and COVID-19-related factors. We built, trained and tested five machine learning models: Support Vector Machine (SVM), Random Forest (RF), XGBoost, CatBoost and Artificial Neural Network (ANN) for classification and regression. We extracted from RF models the relative contribution of features in output prediction.

RESULTS

Models included data from 941 maternal and newborn healthcare providers from 89 countries. ML models performed well in classification and regression tasks, whereby RF had 82% cross-validated accuracy for classification, and CatBoost with 0.46 cross-validated root mean square error for regression. In both classification and regression, the most important features contributing to output prediction were classified as three themes: (1) information accessibility, clarity and quality; (2) availability of support and means of protection; and (3) COVID-19 epidemiology.

CONCLUSION

This study identified salient features contributing to maternal and newborn healthcare providers perception of safety in the workplace. The developed tool can be used by health systems globally to allow real-time learning from data collected during a health system shock. By responding in real-time to the needs of healthcare providers, health systems could prevent potential negative consequences on the quality of care offered to women and newborns.

The Lived Experiences of Women without COVID-19 in Breastfeeding Their Infants during the Pandemic: A Descriptive Phenomenological Study

The coronavirus disease 2019 (COVID-19) outbreak in 2020 has led to several changes and disturbances in the daily lives of the general public. Particularly for new (first-time) mothers, there has been a significant impact on the practices of raising and feeding their babies. Social distancing measures everywhere have made mothers hesitant to breastfeed their babies anywhere else but at home. Combined with the fear of being infected with COVID-19, the present situation has created unprecedented barriers for breastfeeding mothers to accessing various types of support: emotional, instrumental, informational, and appraisal. There has been no research on the influence of the pandemic on social support regarding breastfeeding in Hong Kong. This study aimed to explore the social support and impact of COVID-19 on mothers breastfeeding their babies. Semi-structured interviews were conducted with 20 currently breastfeeding women in Hong Kong. Colaizzi’s seven-step method was used for data analysis. Two key themes emerged from the interview data: (1) positive influences on breastfeeding support during COVID-19 and (2) negative influences on breastfeeding support during COVID-19. Our findings may help mothers prepare to breastfeed their babies in places other than their homes.

Parents' experiences regarding neonatal care during the COVID-19 pandemic: country-specific findings of a multinational survey

OBJECTIVES

The COVID-19 pandemic has disrupted healthcare systems, challenging neonatal care provision globally. Curtailed visitation policies are known to negatively affect the medical and emotional care of sick, preterm and low birth weight infants, compromising the achievement of the 2030 Development Agenda. Focusing on infant and family-centred developmental care (IFCDC), we explored parents' experiences of the disruptions affecting newborns in need of special or intensive care during the first year of the pandemic.

DESIGN

Cross-sectional study using an electronic, web-based questionnaire.

SETTING

Multicountry online-survey.

METHODS

Data were collected between August and November 2020 using a pretested online, multilingual questionnaire. The target group consisted of parents of preterm, sick or low birth weight infants born during the first year of the COVID-19 pandemic and who received special/intensive care. The analysis followed a descriptive quantitative approach.

RESULTS

In total, 1148 participants from 12 countries (Australia, Brazil, Canada, China, France, Italy, Mexico, New Zealand, Poland, Sweden, Turkey and Ukraine) were eligible for analysis. We identified significant country-specific differences, showing that the application of IFCDC is less prone to disruptions in some countries than in others. For example, parental presence was affected: 27% of the total respondents indicated that no one was allowed to be present with the infant receiving special/intensive care. In Australia, Canada, France, New Zealand and Sweden, both the mother and the father (in more than 90% of cases) were allowed access to the newborn, whereas participants indicated that no one was allowed to be present in China (52%), Poland (39%), Turkey (49%) and Ukraine (32%).

CONCLUSIONS

The application of IFCDC during the COVID-19 pandemic differs between countries. There is an urgent need to reconsider separation policies and to strengthen the IFCDC approach worldwide to ensure that the 2030 Development Agenda is achieved.

Effect of the COVID-19 Pandemic on Well-Baby Nursery

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic is associated with fewer deliveries and premature births; however, the impact of this pandemic on the well-baby nursery (WBN) is unknown.

OBJECTIVE

The aim of the study is to evaluate the impact of the COVID-19 pandemic on infants admitted to the WBN by comparing pandemic and pre-pandemic cohorts.

STUDY DESIGN

We performed a retrospective study of infants admitted to a WBN during the pandemic period (March 18, 2020 to March 17, 2021) and compared them to those during the pre-pandemic period (March 18, 2019 to March 17, 2020). Maternal (age, parity, gestation, method of delivery, and COVID-19 status) and neonatal (sex, weight, Apgar score, feeding pattern, urine toxicology, and neonatal intensive care unit [NICU] admission) data were collected and compared between the two periods. The results were statistically analyzed, and significance was set at p <0.05.

RESULTS

There were 824 and 859 WBN admissions during the pandemic and pre-pandemic periods, respectively, a 4% decrease in WBN admissions during the pandemic period. During the pandemic period, the number of deliveries among nulliparous women increased (From 40.3% to 45.1% p = 0.01), and deliveries among multiparous women decreased (From 59.2% to 53.1% p = 0.01). The number of infants exposed to marijuana in utero increased (From 8.2% to 16.1% p = 0.035), and transfers from WBN to NICU decreased (From 9% to 6.3% p = 0.044) during the pandemic period.

CONCLUSION

Compared with the pre-pandemic period, the number of WBN admissions, multiparous deliveries, and NICU admissions decreased, while the number of nulliparous deliveries and infants exposed to marijuana in-utero increased during the pandemic period.

KEY POINTS

· COVID-19 Pandemic is associated with decreased number of deliveries, preterm births, and NICU admissions.. · We observed decreased admissions to WBN, deliveries by multiparous women, and transfers from WBN.. · More nulliparous women delivered, and more infants were exposed to marijuana in-utero during the Pandemic..

'We are not going to shut down, because we cannot postpone pregnancy': a mixed-methods study of the provision of maternal healthcare in six referral maternity wards in four sub-Saharan African countries during the COVID-19 pandemic

INTRODUCTION

Referral hospitals in sub-Saharan Africa are located in crowded urban areas, which were often epicentres of the COVID-19 pandemic. This paper prospectively assesses how maternal healthcare was provided in six referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the COVID-19 pandemic.

METHODS

Mixed-methods design using three data sources: (1) qualitative data from repeated rounds of semi-structured interviews conducted between July 2020 and February 2021 with 22 maternity skilled heath personnel (SHP) on perceptions of care provision; (2) quantitative monthly routine data on caesarean section and labour induction from March 2019 to February 2021; and (3) timeline data of COVID-19 epidemiology, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on timeline analysis, and triangulated during reporting.

RESULTS

We identified three periods: first wave, slow period and second wave. The first wave was challenging for SHP given little knowledge about COVID-19, lack of infection prevention and control training, and difficulties reaching workplace. Challenges that persisted beyond the first wave were shortage of personal protective equipment and no rapid testing for women suspected with COVID-19. We noted no change in the proportion of caesarean sections during the pandemic, and a small increase in the proportion of labour inductions. All hospitals arranged isolation areas for women suspected/confirmed with COVID-19 and three hospitals provided care to women with suspected/confirmed COVID-19. Breastfeeding was not discouraged and newborns were not separated from mothers confirmed with COVID-19. Care provision was maintained through dedication of SHP, support from hospital management and remote communication between SHP.

CONCLUSION

Routine maternal care provision was maintained in referral hospitals, despite first wave challenges. Referral hospitals and SHP contributed to guideline development for pregnant women suspected/confirmed with COVID-19. Maternity SHP, women and pregnancy must always be included in priority setting when responding to health system shocks, including outbreaks.

COVID-19 pandemic in the neonatal intensive care unit: any effect on late-onset sepsis and necrotizing enterocolitis?

The study was aimed at describing potential indirect effects of pandemic-related measures on very-low-birthweight infants in four Italian NICUs. No overall change in late-onset sepsis (LOS) and necrotizing enterocolitis was documented. However, in the NICU where baseline LOS rate was high, a significant reduction in LOS incidence was recorded. Conclusion: COVID-19-related implementation of NICU hygiene policies is likely to reduce the occurrence of LOS in high-risk settings. What is Known: • COVID-19 pandemic has disrupted routine care in Neonatal Intensive Care Units (NICUs), mostly by tightening infection control measures and restricting parental presence in the NICU. • Beyond the described psychological impact of COVID-19 related measures on healthcare workers and NICU families, their consequences in terms of preterm infants' clinical outcomes have not been described in detail yet. What is New: • Strengthened infection-control measures do not seem to have an overall influence on the incidence of necrotising enterocolitis and late-onset sepsis in very-low-birth-weight infants. • However, the implementation of these measures appears to reduce the occurrence of late-onset sepsis in settings where the baseline incidence of the disease is high.

The Implications of COVID-19 on Family-Centered Care in the NICU

During the recent COVID-19 pandemic, neonatal intensive care units (NICUs) issued strict visiting policies that limited parent visitation and impacted how family-centered care was practiced. This article describes how these visiting policies impacted parents and neonates. Implications for clinical practice and future research will also be discussed.

"Separated during the first hours"-Postnatal care for women and newborns during the COVID-19 pandemic: A mixed-methods cross-sectional study from a global online survey of maternal and newborn healthcare providers

Routine postnatal care (PNC) allows monitoring, early detection and management of complications, and counselling to ensure immediate and long-term wellbeing of mothers and newborns; yet effective coverage is sub-optimal globally. The COVID-19 pandemic disrupted availability and quality of maternal and newborn care despite established guidelines promoting continuity of essential services. We conducted a cross-sectional global online survey of 424 maternal and newborn healthcare providers from 61 countries, to explore PNC provision, availability, content and quality following the early phase of the COVID-19 pandemic. The questionnaire (11 languages), included four multiple-choice and four open-text questions on changes to PNC during the pandemic. Quantitative and qualitative responses received between July and December 2020 were analysed separately and integrated during reporting. Tightened rules for visiting postpartum women were reported in health facilities, ranging from shorter visiting hours to banning supportive companions and visitors. A quarter (26%) of respondents reported that mothers suspected/confirmed with COVID-19 were routinely separated from their newborns. Early initiation of breastfeeding was delayed due to waiting for maternal SARS-CoV-2 test results. Reduced provision of breastfeeding support was reported by 40% of respondents in high-income countries and 7% in low-income countries. Almost 60% reported that women were discharged earlier than usual and 27% perceived a reduction in attendance to outpatient PNC. Telemedicine and home visits were mostly reported in high-income countries to ensure safe care provision. Beyond the early phase of the COVID-19 pandemic, severe disruptions to content and quality of PNC continued to exist, whereas disruptions in availability and use were less commonly reported. Depriving women of support, reducing availability of PNC services, and mother-newborn separation could lead to negative long-term outcomes for women, newborns and families, and deny their rights to respectful care. Protecting these essential services is imperative to promoting quality woman-centred PNC during and beyond the pandemic.

Impact of the early COVID-19 pandemic on outcomes in a rural Ugandan neonatal unit: A retrospective cohort study

BACKGROUND

During the early COVID-19 pandemic travel in Uganda was tightly restricted which affected demand for and access to care for pregnant women and small and sick newborns. In this study we describe changes to neonatal outcomes in one rural central Ugandan newborn unit before and during the early phase of the COVID-19 pandemic.

METHODS

We report outcomes from admissions captured in an electronic dataset of a well-established newborn unit before (September 2019 to March 2020) and during the early COVID-19 period (April-September 2020) as well as two seasonally matched periods one year prior. We report excess mortality as the percent change in mortality over what was expected based on seasonal trends.

FINDINGS

The study included 2,494 patients, 567 of whom were admitted during the early COVID-19 period. During the pandemic admissions decreased by 14%. Patients born outside the facility were older on admission than previously (median 1 day of age vs. admission on the day of birth). There was an increase in admissions with birth asphyxia (22% vs. 15% of patients). Mortality was higher during COVID-19 than previously [16% vs. 11%, p = 0.017]. Patients born outside the facility had a relative increase of 55% above seasonal expected mortality (21% vs. 14%, p = 0.028). During this period patients had decreased antenatal care, restricted transport and difficulty with expenses and support. The hospital had difficulty with maternity staffing and supplies. There was significant community and staff fear of COVID-19.

INTERPRETATION

Increased newborn mortality during the early COVID-19 pandemic at this facility was likely attributed to disruptions affecting maternal and newborn demand for, access to and quality of perinatal healthcare. Lockdown conditions and restrictions to public transit were significant barriers to maternal and newborn wellbeing, and require further focus by national and regional health officials.

Parents' pandemic NICU experience in the United States: a qualitative study

Background

Prior to the COVID-19 pandemic, parents of infants in the Neonatal Intensive Care Unit (NICU) frequently reported high levels of stress, uncertainty, and decreased parenting confidence. Early research has demonstrated that parents have had less access to their infants in the hospital due to restrictions on parental presence secondary to the pandemic. It is unknown how parents have perceived their experiences in the NICU since the beginning of the COVID-19 pandemic. The purpose of this study was to describe the lived experience of parents who had an infant in the NICU in the context of the COVID-19 pandemic to inform healthcare providers and policy makers for future development of policies and care planning.

Methods

The study design was a qualitative description of the impact of the COVID-19 pandemic on parents’ experiences of having an infant in the NICU. Free-text responses to open-ended questions were collected as part of a multi-method study of parents’ experiences of the NICU during the first six months of the pandemic. Participants from the United States were recruited using social media platforms between the months of May and July of 2020. Data were analyzed using a reflexive thematic approach.

Findings

Free-text responses came from 169 parents from 38 different states in the United States. Three broad themes emerged from the analysis: (1) parents’ NICU experiences during the COVID-19 pandemic were emotionally isolating and overwhelming, (2) policy changes restricting parental presence created disruptions to the family unit and limited family-centered care, and (3) interactions with NICU providers intensified or alleviated emotional distress felt by parents. A unifying theme of experiences of emotional distress attributed to COVID-19 circumstances ran through all three themes.

Conclusions

Parents of infants in the NICU during the first six months of the COVID-19 pandemic experienced emotional struggles, feelings of isolation, lack of family-centered care, and deep disappointment with system-level decisions. Moving forward, parents need to be considered essential partners in the development of policies concerning care of and access to their infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-03028-w.

Starting parenting in isolation a qualitative user-initiated study of parents' experiences with hospitalization in Neonatal Intensive Care units during the COVID-19 pandemic

BACKGROUND

Worldwide, strict infection control measures including visitation regulations were implemented due to the COVID-19 pandemic at Neonatal Intensive Care Units (NICUs). These regulations gave restricted access for parents to their hospitalized infants. The consequence was limited ability to involve in the care of their infants. At Oslo University Hospital entry to NICU was denied to all except healthy mothers in March 2020. The absolute access ban for fathers lasted for 10 weeks. The aim of this study was to explore parental experiences with an infant hospitalized in the NICU during this absolute visitation ban period.

METHODS

We invited post discharge all parents of surviving infants that had been hospitalized for at least 14 days to participate. They were interviewed during autumn 2020 using an explorative semi-structured interview approach. Data were analyzed via inductive thematic analysis.

RESULTS

Nine mothers and four fathers participated. The COVID-19 regulations strongly impacted the parent's experiences of their stay. The fathers' limited access felt life-impacting. Parents struggled to become a family and raised their voices to be heard. Not being able to experience parenthood together led to emotional loneliness. The fathers struggled to learn how to care for their infant. The regulations might lead to a postponed attachment. On the other hand, of positive aspect the parents got some quietness. Being hospitalized during this first wave was experienced as exceptional and made parents seeking alliances by other parents. Social media was used to keep in contact with the outside world.

CONCLUSIONS

The regulations had strong negative impact on parental experiences during the NICU hospitalization. The restriction to fathers' access to the NICU acted as a significant obstacle to early infant-father bonding and led to loneliness and isolation by the mothers. Thus, these COVID-19 measures might have had adverse consequences for families.

The impact of COVID-19 on the provision of respectful maternity care: Findings from a global survey of health workers

Background

Significant adjustments to maternity care in response to the COVID-19 pandemic and the direct impacts of COVID-19 can compromise the quality of maternal and newborn care.

Aim

To explore how the COVID-19 pandemic negatively affected frontline health workers’ ability to provide respectful maternity care globally.

Methods

We conducted a global online survey of health workers to assess the provision of maternal and newborn healthcare during the COVID-19 pandemic. We collected qualitative data between July and December 2020 among a subset of respondents and conducted a qualitative content analysis to explore open-ended responses.

Findings

Health workers (n = 1127) from 71 countries participated; and 120 participants from 33 countries provided qualitative data. The COVID-19 pandemic negatively affected the provision of respectful maternity care in multiple ways. Six central themes were identified: less family involvement, reduced emotional and physical support for women, compromised standards of care, increased exposure to medically unjustified caesarean section, and staff overwhelmed by rapidly changing guidelines and enhanced infection prevention measures. Further, respectful care provided to women and newborns with suspected or confirmed COVID-19 infection was severely affected due to health workers’ fear of getting infected and measures taken to minimise COVID-19 transmission.

Discussion

Multidimensional and contextually-adapted actions are urgently needed to mitigate the impacts of the COVID-19 pandemic on the provision and continued promotion of respectful maternity care globally in the long-term.

Conclusions

The measures taken during the COVID-19 pandemic had the capacity to disrupt the provision of respectful maternity care and therefore the quality of maternity care.

Neonatal care during the COVID-19 pandemic - a global survey of parents' experiences regarding infant and family-centred developmental care

BACKGROUND

The COVID-19 pandemic restrictions affect provision and quality of neonatal care. This global study explores parents' experiences regarding the impact of the restrictions on key characteristics of infant and family-centred developmental care (IFCDC) during the first year of the pandemic.

METHODS

For this cross-sectional study, a pre-tested online survey with 52 questions and translated into 23 languages was used to collect data between August and November 2020. Parents of sick or preterm infants born during the pandemic and receiving special/intensive care were eligible for participation. Data analysis included descriptive statistics and statistical testing based on different levels of restrictive measures.

FINDINGS

In total, 2103 participants from 56 countries provided interpretable data. Fifty-two percent of respondents were not allowed to have another person present during birth. Percentages increased with the extent of restrictions in the respondents' country of residence (p = 0·002). Twenty-one percent of total respondents indicated that no-one was allowed to be present with the infant receiving special/intensive care. The frequency (p < 0·001) and duration (p = 0·001) of permitted presence largely depended on the extent of restrictions. The more restrictive the policy measures were, the more the respondents worried about the pandemic situation during pregnancy and after birth.

INTERPRETATION

COVID-19 related restrictions severely challenged evidence-based cornerstones of IFCDC, such as separating parents/ legal guardians and their newborns. Our findings must therefore be considered by public health experts and policy makers alike to reduce unnecessary suffering, calling for a zero separation policy.

FUNDING

EFCNI received an earmarked donation by Novartis Pharma AG in support of this study.

Estimating the Impact of the COVID-19 Pandemic on Maternal and Perinatal Health Care Services in Italy: Results of a Self-Administered Survey

The coronavirus disease 2019 (COVID-19) pandemic is strongly changing the way most people live their lives, and disrupting specialist healthcare systems. Such public health disruptions have resulted in significant collateral damage with particular implications for vulnerable populations, including the perinatal population. This Study aims to estimate the impact of the COVID-19 pandemic on Italian maternal and perinatal health care services. A questionnaire was designed to evaluate the COVID-19 impact on Italian maternal and perinatal healthcare facilities and their activities and provision of services from March to May 2020. The survey was completed by hospital-based and community-based Italian maternal and perinatal healthcare facilities. Most of these were located in Lombardy or Veneto (the most affected Italian regions). 70% of all facilities reported that the first wave of the COVID-19 pandemic negatively influenced the functioning of one or more aspects of the perinatal service; only 28.4% of facilities all over the country continued to provide outpatient routine visits and examinations as usual; 23.4% of facilities became understaffed during the index period due to various reasons such as ward transfer and sick leave. This is the first Italian study, and among very few international studies that describe the effects of the COVID-19 pandemic on antenatal and postnatal healthcare facilities and their provision of activities and services. Our findings confirm that healthcare systems even in high-income countries were not entirely prepared to handle such a global health emergency; indeed, specialized maternal and perinatal healthcare services have been disrupted by this global health emergency.

Preterm care during the COVID-19 pandemic: A comparative risk analysis of neonatal deaths averted by kangaroo mother care versus mortality due to SARS-CoV-2 infection

BACKGROUND

COVID-19 is disrupting health services for mothers and newborns, particularly in low- and middle-income countries (LMIC). Preterm newborns are particularly vulnerable. We undertook analyses of the benefits of kangaroo mother care (KMC) on survival among neonates weighing ≤2000 g compared with the risk of SARS-CoV-2 acquired from infected mothers/caregivers.

METHODS

We modelled two scenarios over 12 months. Scenario 1 compared the survival benefits of KMC with universal coverage (99%) and mortality risk due to COVID-19. Scenario 2 estimated incremental deaths from reduced coverage and complete disruption of KMC. Projections were based on the most recent data for 127 LMICs (~90% of global births), with results aggregated into five regions.

FINDINGS

Our worst-case scenario (100% transmission) could result in 1,950 neonatal deaths from COVID-19. Conversely, 125,680 neonatal lives could be saved with universal KMC coverage. Hence, the benefit of KMC is 65-fold higher than the mortality risk of COVID-19. If recent evidence of 10% transmission was applied, the ratio would be 630-fold. We estimated a 50% reduction in KMC coverage could result in 12,570 incremental deaths and full disruption could result in 25,140 incremental deaths, representing a 2·3-4·6% increase in neonatal mortality across the 127 countries.

INTERPRETATION

The survival benefit of KMC far outweighs the small risk of death due to COVID-19. Preterm newborns are at risk, especially in LMICs where the consequences of disruptions are substantial. Policymakers and healthcare professionals need to protect services and ensure clearer messaging to keep mothers and newborns together, even if the mother is SARS-CoV-2-positive.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health & Human Development; Bill & Melinda Gates Foundation; Elma Philanthropies; Wellcome Trust; and Joint Global Health Trials scheme of Department of Health and Social Care, Department for International Development, Medical Research Council, and Wellcome Trust.