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Tumukunde V, Medvedev MM, Tann CJ, Mambule I, Pitt C, Opondo C, Kakande A, Canter R, Haroon Y, Kirabo-Nagemi C, Abaasa A, Okot W, Katongole F, Ssenyonga R, Niombi N, Nanyunja C, Elbourne D, Greco G, Ekirapa-Kiracho E, Nyirenda M, Allen E, Waiswa P, Lawn JE. Effectiveness of kangaroo mother care before clinical stabilisation versus standard care among neonates at five hospitals in Uganda (OMWaNA): a parallel-group, individually randomised controlled trial and economic evaluation. Lancet 2024; 403:2520-2532. [PMID: 38754454 DOI: 10.1016/s0140-6736(24)00064-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/05/2023] [Accepted: 01/11/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Preterm birth is the leading cause of death in children younger than 5 years worldwide. WHO recommends kangaroo mother care (KMC); however, its effects on mortality in sub-Saharan Africa and its relative costs remain unclear. We aimed to compare the effectiveness, safety, costs, and cost-effectiveness of KMC initiated before clinical stabilisation versus standard care in neonates weighing up to 2000 g. METHODS We conducted a parallel-group, individually randomised controlled trial in five hospitals across Uganda. Singleton or twin neonates aged younger than 48 h weighing 700-2000 g without life-threatening clinical instability were eligible for inclusion. We randomly assigned (1:1) neonates to either KMC initiated before stabilisation (intervention group) or standard care (control group) via a computer-generated random allocation sequence with permuted blocks of varying sizes, stratified by birthweight and recruitment site. Parents, caregivers, and health-care workers were unmasked to treatment allocation; however, the independent statistician who conducted the analyses was masked. After randomisation, neonates in the intervention group were placed prone and skin-to-skin on the caregiver's chest, secured with a KMC wrap. Neonates in the control group were cared for in an incubator or radiant heater, as per hospital practice; KMC was not initiated until stability criteria were met. The primary outcome was all-cause neonatal mortality at 7 days, analysed by intention to treat. The economic evaluation assessed incremental costs and cost-effectiveness from a disaggregated societal perspective. This trial is registered with ClinicalTrials.gov, NCT02811432. FINDINGS Between Oct 9, 2019, and July 31, 2022, 2221 neonates were randomly assigned: 1110 (50·0%) neonates to the intervention group and 1111 (50·0%) neonates to the control group. From randomisation to age 7 days, 81 (7·5%) of 1083 neonates in the intervention group and 83 (7·5%) of 1102 neonates in the control group died (adjusted relative risk [RR] 0·97 [95% CI 0·74-1·28]; p=0·85). From randomisation to 28 days, 119 (11·3%) of 1051 neonates in the intervention group and 134 (12·8%) of 1049 neonates in the control group died (RR 0·88 [0·71-1·09]; p=0·23). Even if policy makers place no value on averting neonatal deaths, the intervention would have 97% probability from the provider perspective and 84% probability from the societal perspective of being more cost-effective than standard care. INTERPRETATION KMC initiated before stabilisation did not reduce early neonatal mortality; however, it was cost-effective from the societal and provider perspectives compared with standard care. Additional investment in neonatal care is needed for increased impact, particularly in sub-Saharan Africa. FUNDING Joint Global Health Trials scheme of the Department of Health and Social Care, Foreign, Commonwealth and Development Office, UKRI Medical Research Council, and Wellcome Trust; Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- Victor Tumukunde
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK; Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Melissa M Medvedev
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Cally J Tann
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK; Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda; Department of Neonatal Medicine, University College London Hospitals NHS Trust, London, UK
| | - Ivan Mambule
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Catherine Pitt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Ayoub Kakande
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Ruth Canter
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Yiga Haroon
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Charity Kirabo-Nagemi
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Andrew Abaasa
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Wilson Okot
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Fredrick Katongole
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Raymond Ssenyonga
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Natalia Niombi
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Carol Nanyunja
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Giulia Greco
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK; Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Moffat Nyirenda
- Non-Communicable Disease Programme, Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Waiswa
- Department of Health Policy, Planning, and Management, Makerere University, Kampala, Uganda; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Joy E Lawn
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK.
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Sturrock S, Sadoo S, Nanyunja C, Le Doare K. Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations. Res Rep Trop Med 2023; 14:121-134. [PMID: 38116466 PMCID: PMC10728307 DOI: 10.2147/rrtm.s410785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Neonatal sepsis causes significant global morbidity and mortality, with the highest burden in resource-limited settings where 99% of neonatal deaths occur. There are multiple challenges to achieving successful treatment of neonates in this setting. Firstly, reliable and low-cost strategies for risk identification are urgently needed to facilitate treatment as early as possible. Improved laboratory capacity to allow identification of causative organisms would support antimicrobial stewardship. Antibiotic treatment is still hampered by availability, but also increasingly by antimicrobial resistance - making surveillance of organisms and judicious antibiotic use a priority. Finally, supportive care is key in the management of the neonate with sepsis and has been underrecognized as a priority in resource-limited settings. This includes fluid balance and nutritional support in the acute phase, and follow-up care in order to mitigate complications and optimise long-term outcomes. There is much more work to be done in identifying the holistic needs of neonates and their families to provide effective family-integrated interventions and complete the package of neonatal sepsis management in resource-limited settings.
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Affiliation(s)
- Sarah Sturrock
- Centre for Neonatal and Paediatric Infection, St George’s, University of London, London, UK
| | - Samantha Sadoo
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Carol Nanyunja
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Kirsty Le Doare
- Centre for Neonatal and Paediatric Infection, St George’s, University of London, London, UK
- UK Health Security Agency, Salisbury, UK
- Makerere University, Johns Hopkins University, Kampala, Uganda
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Cross JH, Bohne C, Ngwala SK, Shabani J, Wainaina J, Dosunmu O, Kassim I, Penzias RE, Tillya R, Gathara D, Zimba E, Ezeaka VC, Odedere O, Chiume M, Salim N, Kawaza K, Lufesi N, Irimu G, Tongo OO, Malla L, Paton C, Day LT, Oden M, Richards-Kortum R, Molyneux EM, Ohuma EO, Lawn JE. Neonatal inpatient dataset for small and sick newborn care in low- and middle-income countries: systematic development and multi-country operationalisation with NEST360. BMC Pediatr 2023; 23:567. [PMID: 37968588 PMCID: PMC10652643 DOI: 10.1186/s12887-023-04341-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 10/02/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Every Newborn Action Plan (ENAP) coverage target 4 necessitates national scale-up of Level-2 Small and Sick Newborn Care (SSNC) (with Continuous Positive Airway Pressure (CPAP)) in 80% of districts by 2025. Routine neonatal inpatient data is important for improving quality of care, targeting equity gaps, and enabling data-driven decision-making at individual, district, and national-levels. Existing neonatal inpatient datasets vary in purpose, size, definitions, and collection processes. We describe the co-design and operationalisation of a core inpatient dataset for use to track outcomes and improve quality of care for small and sick newborns in high-mortality settings. METHODS A three-step systematic framework was used to review, co-design, and operationalise this novel neonatal inpatient dataset in four countries (Malawi, Kenya, Tanzania, and Nigeria) implementing with the Newborn Essential Solutions and Technologies (NEST360) Alliance. Existing global and national datasets were identified, and variables were mapped according to categories. A priori considerations for variable inclusion were determined by clinicians and policymakers from the four African governments by facilitated group discussions. These included prioritising clinical care and newborn outcomes data, a parsimonious variable list, and electronic data entry. The tool was designed and refined by > 40 implementers and policymakers during a multi-stakeholder workshop and online interactions. RESULTS Identified national and international datasets (n = 6) contained a median of 89 (IQR:61-154) variables, with many relating to research-specific initiatives. Maternal antenatal/intrapartum history was the largest variable category (21, 23.3%). The Neonatal Inpatient Dataset (NID) includes 60 core variables organised in six categories: (1) birth details/maternal history; (2) admission details/identifiers; (3) clinical complications/observations; (4) interventions/investigations; (5) discharge outcomes; and (6) diagnosis/cause-of-death. Categories were informed through the mapping process. The NID has been implemented at 69 neonatal units in four African countries and links to a facility-level quality improvement (QI) dashboard used in real-time by facility staff. CONCLUSION The NEST360 NID is a novel, parsimonious tool for use in routine information systems to inform inpatient SSNC quality. Available on the NEST360/United Nations Children's Fund (UNICEF) Implementation Toolkit for SSNC, this adaptable tool enables facility and country-level comparisons to accelerate progress toward ENAP targets. Additional linked modules could include neonatal at-risk follow-up, retinopathy of prematurity, and Level-3 intensive care.
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Affiliation(s)
- James H Cross
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK.
| | - Christine Bohne
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
- Ifakara Health Institute, Ifakara, Tanzania
| | - Samuel K Ngwala
- Research Support Center, School of Public Health and Family Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - John Wainaina
- Kenya Medical Research Institute, Wellcome Trust Research Program, Nairobi, Kenya
| | | | | | - Rebecca E Penzias
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - David Gathara
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
- Kenya Medical Research Institute, Wellcome Trust Research Program, Nairobi, Kenya
| | - Evelyn Zimba
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
| | | | - Opeyemi Odedere
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
- APIN Public Health Initiatives, Abuja, Nigeria
| | - Msandeni Chiume
- Department of Paediatrics, Kamuzu University of Health Sciences (Formerly College of Medicine, University of Malawi), Blantyre, Malawi
- Kamuzu Central Hospital, Lilongwe, Malawi
| | - Nahya Salim
- Ifakara Health Institute, Ifakara, Tanzania
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Kondwani Kawaza
- Department of Paediatrics, Kamuzu University of Health Sciences (Formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - Norman Lufesi
- Department of Curative and Medical Rehabilitation, Ministry of Health, Lilongwe, Malawi
| | - Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Olukemi O Tongo
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Lucas Malla
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Chris Paton
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Louise T Day
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
- Maternal and Newborn Health Group, Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Maria Oden
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
| | | | - Elizabeth M Molyneux
- Department of Paediatrics, Kamuzu University of Health Sciences (Formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - Eric O Ohuma
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
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Spurlock EJ, Pickler RH, Terry RE, Drake E, Roux G, Amankwaa L. Narrative Review of Use and Continued Relevance of the Maternal Infant Responsiveness Instrument. J Perinat Neonatal Nurs 2023; 37:205-213. [PMID: 37494689 PMCID: PMC10372724 DOI: 10.1097/jpn.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND The Maternal Infant Responsiveness Instrument (MIRI) was developed in 2002 to measure a critical aspect of maternal-infant health. The objective of this analysis was to examine use, results, and continued relevance of the MIRI 20 years after its creation. METHODS For the completion of this narrative review, 5 electronic databases were accessed using key search terms. Inclusion criteria were English-language, peer-reviewed research using the MIRI. Hand searches of reference lists were conducted. Five authors performed screening, data extraction, appraisal, and summarized findings. RESULTS Fifteen studies were included. All studies reported an internal consistency of α > 0.70 for the MIRI. Positive correlations were reported with self-efficacy, infant temperament, and life satisfaction. Inverse relationships were reported with stress, depression, and experiential avoidance. Depressive symptomatology, life satisfaction, self-esteem, self-efficacy, and previous childcare experience were predictors of maternal responsiveness. DISCUSSION Maternal well-being (postpartum depression and stress) can affect maternal responsiveness. Given the pervasive disparities in maternal health and well-being, it is important to have reliable measures of the effects of those disparities. The MIRI, a valid and reliable measure, may be useful for assessing the effectiveness of interventions designed to improve infant and maternal well-being.
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Affiliation(s)
- Elizabeth J. Spurlock
- College of Nursing, The Ohio State University, 1585 Neil Avenue, Newton Hall 324, Columbus, OH 43210
| | - Rita H. Pickler
- College of Nursing, The Ohio State University, 200V Heminger Hall, 1577 Neil Avenue, Columbus, OH 43210
| | - Rollins E. Terry
- Children’s Hospital of Philadelphia, University of Virginia, School of Nursing, Charlottesville, VA
| | - Emily Drake
- University of Virginia, School of Nursing, CMNEB 3007, Charlottesville, VA
| | - Gayle Roux
- University of North Dakota, College of Nursing & Professional Disciplines, 430 Oxford St, Stop 9025, Grand Forks ND 58202-9025
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Medvedev MM, Tumukunde V, Kirabo-Nagemi C, Greco G, Mambule I, Katumba K, Waiswa P, Tann CJ, Elbourne D, Allen E, Ekirapa-Kiracho E, Pitt C, Lawn JE. Process and costs for readiness to safely implement immediate kangaroo mother care: a mixed methods evaluation from the OMWaNA trial at five hospitals in Uganda. BMC Health Serv Res 2023; 23:613. [PMID: 37301974 PMCID: PMC10257176 DOI: 10.1186/s12913-023-09624-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Preterm birth complications result in > 1 million child deaths annually, mostly in low- and middle-income countries. A World Health Organisation (WHO)-led trial in hospitals with intensive care reported reduced mortality within 28 days among newborns weighing 1000-1799 g who received immediate kangaroo mother care (iKMC) compared to those who received standard care. Evidence is needed regarding the process and costs of implementing iKMC, particularly in non-intensive care settings. METHODS We describe actions undertaken to implement iKMC, estimate financial and economic costs of essential resources and infrastructure improvements, and assess readiness for newborn care after these improvements at five Ugandan hospitals participating in the OMWaNA trial. We estimated costs from a health service provider perspective and explored cost drivers and cost variation across hospitals. We assessed readiness to deliver small and sick newborn care (WHO level-2) using a tool developed by Newborn Essential Solutions and Technologies and the United Nations Children's Fund. RESULTS Following the addition of space to accommodate beds for iKMC, floor space in the neonatal units ranged from 58 m2 to 212 m2. Costs of improvements were lowest at the national referral hospital (financial: $31,354; economic: $45,051; 2020 USD) and varied across the four smaller hospitals (financial: $68,330-$95,796; economic: $99,430-$113,881). In a standardised 20-bed neonatal unit offering a level of care comparable to the four smaller hospitals, the total financial cost could be in the range of $70,000 to $80,000 if an existing space could be repurposed or remodelled, or $95,000 if a new unit needed to be constructed. Even after improvements, the facility assessments demonstrated broad variability in laboratory and pharmacy capacity as well as the availability of essential equipment and supplies. CONCLUSIONS These five Ugandan hospitals required substantial resource inputs to allow safe implementation of iKMC. Before widespread scale-up of iKMC, the affordability and efficiency of this investment must be assessed, considering variation in costs across hospitals and levels of care. These findings should help inform planning and budgeting as well as decisions about if, where, and how to implement iKMC, particularly in settings where space, devices, and specialised staff for newborn care are unavailable. TRIAL REGISTRATION ClinicalTrials.gov, NCT02811432 . Registered: 23 June 2016.
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Affiliation(s)
- Melissa M Medvedev
- Department of Pediatrics, University of California San Francisco, 550 16th St., Box 1224, San Francisco, CA, 94158, USA.
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK.
| | - Victor Tumukunde
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Charity Kirabo-Nagemi
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Giulia Greco
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl., London, WC1H 9SH, UK
| | - Ivan Mambule
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Kenneth Katumba
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl., London, WC1H 9SH, UK
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, New Mulago Hill Rd., Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Cally J Tann
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
- Department of Neonatal Medicine, University College London Hospital, 235 Euston Rd, London, NW1 2BU, UK
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
| | - Elizabeth Ekirapa-Kiracho
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, New Mulago Hill Rd., Kampala, Uganda
| | - Catherine Pitt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl., London, WC1H 9SH, UK
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
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Joshi A, Londhe A, Joshi T, Deshmukh L. Quality improvement in Kangaroo Mother Care: learning from a teaching hospital. BMJ Open Qual 2022; 11:bmjoq-2021-001459. [PMID: 35545277 PMCID: PMC9092177 DOI: 10.1136/bmjoq-2021-001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 11/09/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Kangaroo Mother Care (KMC) is a low-resource, evidence-based, high-impact intervention for low-birth weight (LBW) care. Quality improvement in KMC requires meso-level, macro-level and micro-level interventions. Our institution, a public teaching hospital, hosts a level-II/III neonatal intensive care unit (NICU). The average demand for beds typically exceeds available capacity, with 60% occupancy attributed to LBW patients. There was low uptake of KMC practice at our unit. AIM STATEMENT In the initial phase, we aimed to improve the coverage of KMC in admitted eligible neonates from a baseline of 20%-80% within 15 days. After a period of complacency, we revised the aim statement with a target of improving the percentage of babies receiving 6-hour KMC from 30% to 80% in 12 weeks. METHODS We report this quasi-experimental time-series study. With the Point of Care Quality Improvement methodology, we performed Plan-Do-Study-Act (PDSA) cycles to improve KMC practice. We involved all the healthcare workers, mothers and caregivers to customise various KMC tools (KMC book format, KMC bag, mother's gown) and minimise interruptions. Feedback from all levels guided our PDSA cycles. RESULTS The percentage of babies receiving at least 1-hour KMC increased from 20% to 100% within 15 days of August 2017. In the improvement phase, baseline 6-hour KMC coverage of 30% increased to 80% within 12 weeks (October-December 2017). It sustained for more than 2 years (January 2018 till February-2020) at 76.5%±2.49%. CONCLUSIONS Quality improvement methods helped increase the coverage and percentage of babies receiving 6-hour KMC per day in our NICU. The duration specified KMC coverage should be adopted as the quality indicator of KMC. The training of healthcare workers and KMC provider should include hands-on sessions involving the mother and the baby. Maintaining data and providing suitable KMC tools are necessary elements for improving KMC. Minimising interruption is possible with family support and appropriate scheduling of activities. Having a designated KMC block helps in peer motivation.
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Affiliation(s)
- Amol Joshi
- Neonatology, Government Medical College and Hospital Aurangabad, Aurangabad, Maharashtra, India
| | - Atul Londhe
- Neonatology, Government Medical College and Hospital Aurangabad, Aurangabad, Maharashtra, India
| | - Trupti Joshi
- Pediatrics, Government Medical College and Hospital Aurangabad, Aurangabad, Maharashtra, India
| | - Laxmikant Deshmukh
- Neonatology, Government Medical College and Hospital Aurangabad, Aurangabad, Maharashtra, India
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Cho YC, Gai A, Diallo BA, Samateh AL, Lawn JE, Martinez-Alvarez M, Brotherton H. Barriers and enablers to kangaroo mother care prior to stability from perspectives of Gambian health workers: A qualitative study. Front Pediatr 2022; 10:966904. [PMID: 36090565 PMCID: PMC9459153 DOI: 10.3389/fped.2022.966904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/28/2022] [Indexed: 12/02/2022] Open
Abstract
AIMS Kangaroo mother care (KMC) is an evidence-based intervention recommended for stable newborns <2,000 g. Recent trials have investigated survival benefits of earlier initiation of KMC, including prior to stability, with WHO's iKMC trial showing 25% relative risk reduction for mortality of neonates 1-1.8 kg at tertiary Indian and African neonatal units (NNU). However, evidence is lacking about how to safely deliver this intervention to the most vulnerable neonates in resource limited settings (RLS). Our study aimed to understand barriers and enablers for early KMC prior to stability from perspectives of neonatal health care workers (HCW) in a high neonatal mortality RLS. METHODS This qualitative study was conducted at Edward Francis Small Teaching Hospital (EFSTH), the main neonatal referral unit in The Gambia. It was ancillary study to the eKMC clinical trial. Ten semi-structured interviews were conducted with all neonatal HCW cadres (4 nurses; 1 nurse attendant; 5 doctors; all Gambian). Study participants were purposively selected, and saturation was reached. Thematic analysis was conducted using Atun's conceptual framework for evaluation of new health interventions with methods to ensure data reliability and trustworthiness. RESULTS HCW's perceptions of early KMC prior to stability included recognition of potential benefits as well as uncertainty about effectiveness and safety. Barriers included: Unavailability of mothers during early neonatal unit admission; safety concerns with concomitant intravenous fluids and impact on infection prevention control; insufficient beds, space, WASH facilities and staffing; and lack of privacy and respectful care. Enablers included: Education of HCW with knowledge transfer to KMC providers; paternal and community sensitization and peer-to-peer support. CONCLUSIONS Addressing health systems limitations for delivery of KMC prior to stability is foundational with linkage to comprehensive HCW and KMC provider education about effectiveness, safe delivery and monitoring. Further context specific research into safe and respectful implementation is required from varied settings and should include perceptions of all stakeholders, especially if there is a shift in global policy toward KMC for all small vulnerable newborns.
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Affiliation(s)
- Ying Chun Cho
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Abdou Gai
- MRC Unit the Gambia at LSHTM, Fajara, Gambia.,Pediatric Department, Edward Francis Small Teaching Hospital, Banjul, Gambia
| | | | | | - Joy E Lawn
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Melisa Martinez-Alvarez
- MRC Unit the Gambia at LSHTM, Fajara, Gambia.,Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Helen Brotherton
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom.,MRC Unit the Gambia at LSHTM, Fajara, Gambia
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8
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Liu X, Chen XH, Li ZK, Cao B, Yue SJ, Liu QY, Yang CZ, Yang CY, Zhao YX, Zhao GL, Feng Q. Implementation experience of a 12-month intervention to introduce intermittent kangaroo mother care to eight Chinese neonatal intensive care units. World J Pediatr 2022; 18:849-853. [PMID: 36006551 PMCID: PMC9617830 DOI: 10.1007/s12519-022-00607-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 08/07/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Xin Liu
- Neonatal Intensive Care Unit, Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Xiao-Hui Chen
- Department of Neonatology, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Zhan-Kui Li
- Department of Neonatology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Bei Cao
- Department of Neonatology, The Maternal and Child Health Care Hospital of Hunan Province, Changsha, China
| | - Shao-Jie Yue
- Department of Neonatology, Xiangya Hospital Central South University, Changsha, China
| | - Qiong-Yu Liu
- Department of Neonatology, Women & Children's Health Care Hospital of Linyi, Linyi, China
| | - Chuan-Zhong Yang
- Department of Neonatology, Shenzhen Maternity & Child Healthcare Hospital, Shenzhen, China
| | - Chang-Yi Yang
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Fuzhou, China
| | - Ying-Xi Zhao
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Geng-Li Zhao
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Qi Feng
- Neonatal Intensive Care Unit, Department of Pediatrics, Peking University First Hospital, Beijing 100034, China.
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9
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Brotherton H, Gai A, Kebbeh B, Njie Y, Walker G, Muhammad AK, Darboe S, Jallow M, Ceesay B, Samateh AL, Tann CJ, Cousens S, Roca A, Lawn JE. Impact of early kangaroo mother care versus standard care on survival of mild-moderately unstable neonates <2000 grams: A randomised controlled trial. EClinicalMedicine 2021; 39:101050. [PMID: 34401686 PMCID: PMC8358420 DOI: 10.1016/j.eclinm.2021.101050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Understanding the effect of early kangaroo mother care on survival of mild-moderately unstable neonates <2000 g is a high-priority evidence gap for small and sick newborn care. METHODS This non-blinded pragmatic randomised clinical trial was conducted at the only teaching hospital in The Gambia. Eligibility criteria included weight <2000g and age 1-24 h with exclusion if stable or severely unstable. Neonates were randomly assigned to receive either standard care, including KMC once stable at >24 h after admission (control) versus KMC initiated <24 h after admission (intervention). Randomisation was stratified by weight with twins in the same arm. The primary outcome was all-cause mortality at 28 postnatal days, assessed by intention to treat analysis. Secondary outcomes included: time to death; hypothermia and stability at 24 h; breastfeeding at discharge; infections; weight gain at 28d and admission duration. The trial was prospectively registered at www.clinicaltrials.gov (NCT03555981). FINDINGS Recruitment occurred from 23rd May 2018 to 19th March 2020. Among 1,107 neonates screened for participation 279 were randomly assigned, 139 (42% male [n = 59]) to standard care and 138 (43% male [n = 59]) to the intervention with two participants lost to follow up and no withdrawals. The proportion dying within 28d was 24% (34/139, control) vs. 21% (29/138, intervention) (risk ratio 0·84, 95% CI 0·55 - 1·29, p = 0·423). There were no between-arm differences for secondary outcomes or serious adverse events (28/139 (20%) for control and 30/139 (22%) for intervention, none related). One-third of intervention neonates reverted to standard care for clinical reasons. INTERPRETATION The trial had low power due to halving of baseline neonatal mortality, highlighting the importance of implementing existing small and sick newborn care interventions. Further mortality effect and safety data are needed from varying low and middle-income neonatal unit contexts before changing global guidelines.
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Key Words
- CFR, (Case-fatality rate)
- CI, (confidence interval)
- CLSI, (Clinical & Laboratory Standards Institute)
- CONSORT, (Consolidated Standards of Reporting Trials)
- CSF, (Cerebral-Spinal Fluid)
- DSMB, (Data Safety Monitoring Board)
- EFSTH, (Edward Francis Small Teaching Hospital)
- GEE, (Generalized Estimating Equation)
- HR, (Hazard Ratio)
- ICH-GCP, (International Conference on Harmonisation – Good Clinical Practice)
- IQR, (Inter Quartile Range)
- ISO, (International organisation for standardisation)
- IV, (intravenous)
- KMC, (Kangaroo mother care)
- Kangaroo Mother Care
- Kangaroo method
- LMIC, (Low and middle-income countries)
- LSHTM, (London School of Hygiene & Tropical Medicine)
- MDR, (Multi-drug resistant)
- MRCG, (Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine)
- Mortality
- NA, (not applicable)
- NNU, (Neonatal Unit)
- Neonate
- Newborn
- Premature
- RCT, (Randomised controlled trial)
- RD, (Risk difference)
- RDS, (Respiratory Distress Syndrome)
- RR, (Risk Ratio)
- SAE, (Serious Adverse Event)
- SD, (Standard Deviation)
- SDG, (Sustainable Development Goal)
- SSA, (Sub-Saharan Africa)
- Skin-to-skin contact
- Survival
- WHO, (World Health Organisation)
- aPSBI, (adapted Possible Severe Bacterial Infection)
- aSCRIP, (adapted Stability of Cardio-respiratory in Preterm infants)
- bCPAP, (bubble Continuous Positive Airway Pressure)
- eKMC trial, (early Kangaroo Mother Care before Stabilisation trial)
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Affiliation(s)
- Helen Brotherton
- Department of Infectious Disease Epidemiology and MARCH Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, UK
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, Gambia
| | - Abdou Gai
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, Gambia
| | - Bunja Kebbeh
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, Gambia
| | - Yusupha Njie
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, Gambia
| | - Georgia Walker
- Department of Infectious Disease Epidemiology and MARCH Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, UK
| | | | | | - Mamadou Jallow
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, Gambia
| | - Buntung Ceesay
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, Gambia
| | | | - Cally J Tann
- Department of Infectious Disease Epidemiology and MARCH Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, UK
- MRC/UVRI and LSHTM Uganda Research Unit, Nakiwogo Road, Entebbe, Uganda
- Neonatal Medicine, University College London Hospitals NHS Trust, Euston Rd, London, UK
| | - Simon Cousens
- Department of Infectious Disease Epidemiology and MARCH Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, UK
| | - Anna Roca
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, Gambia
| | - Joy E Lawn
- Department of Infectious Disease Epidemiology and MARCH Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, UK
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10
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Waiswa P, Wanduru P, Okuga M, Kajjo D, Kwesiga D, Kalungi J, Nambuya H, Mulowooza J, Tagoola A, Peterson S. Institutionalizing a Regional Model for Improving Quality of Newborn Care at Birth Across Hospitals in Eastern Uganda: A 4-Year Story. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:365-378. [PMID: 33956641 PMCID: PMC8324186 DOI: 10.9745/ghsp-d-20-00156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 03/02/2021] [Indexed: 12/03/2022]
Abstract
A locally developed, low-cost package of interventions implemented in a regional network of hospitals resulted in significant reductions in mortality for mothers and newborns as well as the institutionalization of the quality improvement initiative. This work demonstrates that it is possible to achieve the World Health Organization/United Nations Children's Fund Quality of Care targets in hospitals. Introduction: Despite the rapid increase in facility deliveries in Uganda, the number of adverse birth outcomes (e.g., neonatal and maternal deaths) has remained high. We aimed to codesign and co-implement a locally designed package of interventions to improve the quality of care in hospitals in the Busoga region. Design and Implementation: This project was designed and implemented in 3 phases in the 6 main hospitals in east-central Uganda from 2013 to 2016. First, the inception phase engaged health system managers to codesign the intervention. Second, the implementation phase involved training health providers, strengthening the data information system, and providing catalytic equipment and medicines to establish newborn care units (NCUs) within the existing infrastructure. Third, the hospital collaborative phase focused on clinical mentorship, maternal and perinatal death reviews (MPDRs), and collaborative learning sessions. Achievements: In all 6 participating hospitals, we achieved institutionalization of NCUs in maternity units by establishing kangaroo mother care areas, resuscitation corners, and routine MPDRs. These improvements were associated with reduced maternal and neonatal deaths. Facilitators of success included a simple, low-cost, and integrated package designed with local health managers; the emergence of local neonatal care champions; implementation and support over a reasonably long period; decentralization of newborn care services; and use of mainly existing local resources (e.g., physical space, human resources, and commodities). Barriers to success related to limited hospital resources, unstable electricity, and limited participation from doctors. More advanced NCUs have been established in 3 of the 6 hospitals, and 7 high-volume comprehensive health centers have been established with functional NCUs. Conclusion: The involvement of local health workers and leaders was the foundation for designing, sustaining, and scaling up feasible interventions by harnessing available resources. These findings are relevant for the quality of care improvement efforts in Uganda and other resource-restrained settings.
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Affiliation(s)
- Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda. .,Global Public Health, Karolinska Institute, Stockholm, Sweden.,Busoga Health Forum, Jinja, Uganda
| | - Phillip Wanduru
- Makerere University School of Public Health, Kampala, Uganda.,Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Monica Okuga
- Makerere University School of Public Health, Kampala, Uganda
| | - Darius Kajjo
- Makerere University School of Public Health, Kampala, Uganda
| | - Doris Kwesiga
- Makerere University School of Public Health, Kampala, Uganda.,Uppsala University, Uppsala, Sweden
| | - James Kalungi
- Makerere University School of Public Health, Kampala, Uganda
| | | | | | | | - Stefan Peterson
- Makerere University School of Public Health, Kampala, Uganda.,Global Public Health, Karolinska Institute, Stockholm, Sweden.,Uppsala University, Uppsala, Sweden
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11
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Minckas N, Gram L, Smith C, Mannell J. Disrespect and abuse as a predictor of postnatal care utilisation and maternal-newborn well-being: a mixed-methods systematic review. BMJ Glob Health 2021; 6:bmjgh-2020-004698. [PMID: 33883187 PMCID: PMC8061800 DOI: 10.1136/bmjgh-2020-004698] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Globally, a substantial number of women experience abusive and disrespectful care from health providers during childbirth. As evidence mounts on the nature and frequency of disrespect and abuse (D&A), little is known about the consequences of a negative experience of care on health and well-being of women and newborns. This review summarises available evidence on the associations of D&A of mother and newborns during childbirth and the immediate postnatal period (understood as the first 24 hours from birth) with maternal and neonatal postnatal care (PNC) utilisation, newborn feeding practices, newborn weight gain and maternal mental health. Methods We conducted a systematic review of all published qualitative, quantitative and mixed-methods studies on D&A and its postnatal consequences across all countries. Pubmed, Embase, Web of Science, LILACS and Scopus were searched using predetermined search terms. Quantitative and qualitative data were analysed and presented separately. Thematic analysis was used to synthesise the qualitative evidence. Results A total of 4 quantitative, 1 mixed-methods and 16 qualitative studies were included. Quantitative studies suggested associations between several domains of D&A and use of PNC as well as maternal mental health. Different definitions of exposure meant formal meta-analysis was not possible. Three main themes emerged from the qualitative findings associated with PNC utilisation: (1) women’s direct experiences; (2) women’s expectations and (3) women’s agency. Conclusion This review is the first to examine the postnatal effect of D&A of women and newborns during childbirth. We highlight gaps in research that could help improve health outcomes and protect women and newborns during childbirth. Understanding the health and access consequences of a negative birth experience can help progress the respectful care agenda.
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Affiliation(s)
- Nicole Minckas
- Institute for Global Health, University College London, London, UK
| | - Lu Gram
- Institute for Global Health, University College London, London, UK
| | - Colette Smith
- Institute for Global Health, University College London, London, UK
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12
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de Oliveira AG, Macedo H, Santos EFDS, Leone C, Leitão FNC, Pimentel RMM, de Abreu LC, Wajnsztejn R. Early neonatal mortality trend in adolescent pregnant women in the State of São Paulo, Brazil, from 1996 to 2017. Transl Pediatr 2021; 10:1573-1585. [PMID: 34295772 PMCID: PMC8261576 DOI: 10.21037/tp-20-438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/05/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The Infant mortality rate indicates the quality of life of a population. Infant mortality has two important components: neonatal mortality, divided into early and late and post-neonatal mortality. The more developed a country is and the greater its population's well-being, the greater the weight of the neonatal component on infant mortality. In addition several factors may determine or be associated with the occurrence of infant deaths including maternal age. The teenage pregnancy rates in Latin America and the Caribbean remain the second highest in the world, In Brazil, between 2010 and 2015, for every thousand adolescents between 15 and 19 years old, about 69 became pregnant and gave birth to their babies. Thus, the objective of this study is to evaluate the trend of Early Neonatal Mortality Rates in children of pregnant adolescents, which occurred in the period 1996-2017, in the state of São Paulo, Brazil, according to the maternal age group. METHODS This is an ecological study of time series using official mortality data obtained from the Mortality Information System and live birth data obtained from the Live Birth Information System. Deaths of newborns aged between zero and six complete days were collected by place of residence. The trends in rates per 1,000 live births were calculated by Prais-Winsten regression, obtaining their annual percentage change (VPA) and the respective 95% confidence intervals, analyzed by age group. All analyzes were processed using the STATA 15.1 software. RESULTS In the state of São Paulo, between 1996 and 2017, 16,161 deaths were reported in children from zero to six days old and 2,320,584 live births in mothers aged 10-19 years, living in the state of São Paulo, Brazil. Of this total, it was observed that the early neonatal mortality rate decreased until the year 2005-2006, remained stationary after, and was higher in newborns of mothers aged 10-14 years (13.18 per 1,000) compared to mothers between 15-19 years (6.75 per 1,000). CONCLUSIONS In conclusion, although the early neonatal mortality rate showed a significant decreasing trend until approximately 2005, it remained stables after that.
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Affiliation(s)
- Adriana Gonçalves de Oliveira
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário Saúde ABC, Santo André, SP, Brasil
- Serviço de Neonatologia, Hospital Municipal de Diadema, SP, Brasil
- Programa de Pós-graduação em Ciências da Saúde, Centro Universitário Saúde ABC, Santo André, SP, Brasil
| | - Hugo Macedo
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário Saúde ABC, Santo André, SP, Brasil
| | - Edigê Felipe de Sousa Santos
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário Saúde ABC, Santo André, SP, Brasil
- Departamento de Epidemiologia, Faculdade de Saúde Pública da Universidade de São Paulo, Brazil
| | - Claudio Leone
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário Saúde ABC, Santo André, SP, Brasil
| | | | - Renata M. M. Pimentel
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário Saúde ABC, Santo André, SP, Brasil
| | - Luiz Carlos de Abreu
- Adjunct Professor, School of Medicine, University of Limerick, Limerick, Ireland
- Professor Titular, Departamento de Educação Integrada em Saúde e Programa de Pós-Graduação em Saúde Coletiva, Universidade Federal do Espírito Santo, ES, Brasil
- Orientador Pleno, Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rubens Wajnsztejn
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário Saúde ABC, Santo André, SP, Brasil
- Programa de Pós-graduação em Ciências da Saúde, Centro Universitário Saúde ABC, Santo André, SP, Brasil
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13
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Salim N, Shabani J, Peven K, Rahman QSU, Kc A, Shamba D, Ruysen H, Rahman AE, Kc N, Mkopi N, Zaman SB, Shirima K, Ameen S, Kong S, Basnet O, Manji K, Kabuteni TJ, Brotherton H, Moxon SG, Amouzou A, Hailegebriel TD, Day LT, Lawn JE. Kangaroo mother care: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth 2021; 21:231. [PMID: 33765950 PMCID: PMC7995571 DOI: 10.1186/s12884-020-03423-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Kangaroo mother care (KMC) reduces mortality among stable neonates ≤2000 g. Lack of data tracking coverage and quality of KMC in both surveys and routine information systems impedes scale-up. This paper evaluates KMC measurement as part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. METHODS The EN-BIRTH observational mixed-methods study was conducted in five hospitals in Bangladesh, Nepal and Tanzania from 2017 to 2018. Clinical observers collected time-stamped data as gold standard for mother-baby pairs in KMC wards/corners. To assess accuracy, we compared routine register-recorded and women's exit survey-reported coverage to observed data, using different recommended denominator options (≤2000 g and ≤ 2499 g). We analysed gaps in quality of provision and experience of KMC. In the Tanzanian hospitals, we assessed daily skin-to-skin duration/dose and feeding frequency. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine register design, filling and use. RESULTS Among 840 mother-baby pairs, compared to observed 100% coverage, both exit-survey reported (99.9%) and register-recorded coverage (92.9%) were highly valid measures with high sensitivity. KMC specific registers outperformed general registers. Enablers to register recording included perceptions of data usefulness, while barriers included duplication of data elements and overburdened health workers. Gaps in KMC quality were identified for position components including wearing a hat. In Temeke Tanzania, 10.6% of babies received daily KMC skin-to-skin duration/dose of ≥20 h and a further 75.3% received 12-19 h. Regular feeding ≥8 times/day was observed for 36.5% babies in Temeke Tanzania and 14.6% in Muhimbili Tanzania. Cup-feeding was the predominant assisted feeding method. Family support during admission was variable, grandmothers co-provided KMC more often in Bangladesh. No facility arrangements for other family members were reported by 45% of women at exit survey. CONCLUSIONS Routine hospital KMC register data have potential to track coverage from hospital KMC wards/corners. Women accurately reported KMC at exit survey and evaluation for population-based surveys could be considered. Measurement of content, quality and experience of KMC need consensus on definitions. Prioritising further KMC measurement research is important so that high quality data can be used to accelerate scale-up of high impact care for the most vulnerable.
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Affiliation(s)
- Nahya Salim
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania.
| | - Josephine Shabani
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - Kimberly Peven
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Kings College London, London, UK
| | - Qazi Sadeq-Ur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh
| | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Donat Shamba
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - Harriet Ruysen
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Ahmed Ehsanur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh
| | - Naresh Kc
- Ministry of Health, Department of Health Services, Kathmandu, Nepal
| | - Namala Mkopi
- Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Sojib Bin Zaman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh
| | - Kizito Shirima
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - Shafiqul Ameen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh
| | - Stefanie Kong
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | | | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Theopista John Kabuteni
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization (WHO), Dar Es Salaam, Tanzania
| | - Helen Brotherton
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah G Moxon
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Agbessi Amouzou
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Louise T Day
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Joy E Lawn
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
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14
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Minckas N, Medvedev MM, Adejuyigbe EA, Brotherton H, Chellani H, Estifanos AS, Ezeaka C, Gobezayehu AG, Irimu G, Kawaza K, Kumar V, Massawe A, Mazumder S, Mambule I, Medhanyie AA, Molyneux EM, Newton S, Salim N, Tadele H, Tann CJ, Yoshida S, Bahl R, Rao SP, Lawn JE. 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. EClinicalMedicine 2021; 33:100733. [PMID: 33748724 PMCID: PMC7955179 DOI: 10.1016/j.eclinm.2021.100733] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/29/2020] [Accepted: 01/13/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Nicole Minckas
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organisation, Avenue Appia 20, CH-1211 Geneva 27, Switzerland
| | - Melissa M. Medvedev
- Department of Pediatrics, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA 94158, United States
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London WC1E 7HT, United Kingdom
- Corresponding author at: Department of Pediatrics, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA 94158, USA.
| | - Ebunoluwa A. Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife 220005, Nigeria
| | - Helen Brotherton
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London WC1E 7HT, United Kingdom
- Medical Research Council Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Harish Chellani
- Department of Paediatrics, Vardhaman Mahavir Medical College and Safdarjung Hospital, Ansari Nagar, New Delhi 110029, India
| | - Abiy Seifu Estifanos
- Department of Reproductive, Family and Population Health, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Chinyere Ezeaka
- Department of Paediatrics, University of Lagos College of Medicine and Lagos University Teaching Hospital, P.M.B. 12003, Lagos, Nigeria
| | - Abebe G. Gobezayehu
- Maternal and Newborn Health in Ethiopia Partnership, Emory Ethiopia, P.O. Box 793, Addis Ababa, Ethiopia
| | - Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi and Kenyatta National Hospital, P.O. Box 19676-00202, Nairobi, Kenya
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Kondwani Kawaza
- Department of Paediatrics and Child Health, University of Malawi College of Medicine and Queen Elizabeth Central Hospital, P.B. 360, Chichiri, Blantyre 3, Malawi
| | - Vishwajeet Kumar
- Community Empowerment Lab, 26/11 Wazir Hasan Road, Lucknow 226001, India
| | - Augustine Massawe
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Sarmila Mazumder
- Centre for Health Research and Development, Society for Applied Studies, 45 Kalu Sarai, New Delhi 110016, India
| | - Ivan Mambule
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | | | - Elizabeth M. Molyneux
- Department of Paediatrics and Child Health, University of Malawi College of Medicine and Queen Elizabeth Central Hospital, P.B. 360, Chichiri, Blantyre 3, Malawi
| | - Sam Newton
- School of Public Health, Kwame Nkrumah University of Science and Technology, P.M.B. SPH-KNUST, Kumasi 00233, Ghana
| | - Nahya Salim
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Henok Tadele
- Department of Pediatrics and Child Health, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Cally J. Tann
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London WC1E 7HT, United Kingdom
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
- Department of Neonatal Medicine, University College London Hospital, 235 Euston Road, London NW1 2BU, United Kingdom
| | - Sachiyo Yoshida
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organisation, Avenue Appia 20, CH-1211 Geneva 27, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organisation, Avenue Appia 20, CH-1211 Geneva 27, Switzerland
| | - Suman P.N. Rao
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organisation, Avenue Appia 20, CH-1211 Geneva 27, Switzerland
- Department of Neonatology, St John's Medical College Hospital, Sarjapur Road, Bangalore 560034, India
| | - Joy E. Lawn
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London WC1E 7HT, United Kingdom
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15
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Kinshella MLW, Salimu S, Chiwaya B, Chikoti F, Chirambo L, Mwaungulu E, Banda M, Newberry L, Njirammadzi J, Hiwa T, Vidler M, Molyneux EM, Dube Q, Mfutso-Bengo J, Goldfarb DM, Kawaza K, Nyondo-Mipando AL. "So sometimes, it looks like it's a neglected ward": Health worker perspectives on implementing kangaroo mother care in southern Malawi. PLoS One 2020; 15:e0243770. [PMID: 33332395 PMCID: PMC7746165 DOI: 10.1371/journal.pone.0243770] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/27/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction Kangaroo mother care (KMC) involves continuous skin-to-skin contact of baby on mother’s chest to provide warmth, frequent breastfeeding, recognizing danger signs of illness, and early discharge. Though KMC is safe, effective and recommended by the World Health Organization, implementation remains limited in practice. The objective of this study is to understand barriers and facilitators to KMC practice at tertiary and secondary health facilities in southern Malawi from the perspective of health workers. Methods This study is part of the “Integrating a neonatal healthcare package for Malawi” project in the Innovating for Maternal and Child Health in Africa initiative. In-depth interviews were conducted between May-Aug 2019 with a purposively drawn sample of service providers and supervisors working in newborn health at a large tertiary hospital and three district-level hospitals in southern Malawi. Data were analyzed using a thematic approach using NVivo 12 software (QSR International, Melbourne, Australia). Findings A total of 27 nurses, clinical officers, paediatricians and district health management officials were interviewed. Staff attitudes, inadequate resources and reliance on families emerged as key themes. Health workers from Malawi described KMC practice positively as a low-cost, low-technology solution appropriate for resource-constrained health settings. However, staff perceptions that KMC babies were clinically stable was associated with lower prioritization in care and poor monitoring practices. Neglect of the KMC ward by medical staff, inadequate staffing and reliance on caregivers for supplies were associated with women self-discharging early. Conclusion Though routine uptake of KMC was policy for stable low birthweight and preterm infants in the four hospitals, there were gaps in monitoring and maintenance of practice. While conceptualized as a low-cost intervention, sustainable implementation requires investments in technologies, staffing and hospital provisioning of basic supplies such as food, bedding, and KMC wraps. Strengthening hospital capacities to support KMC is needed as part of a continuum of care for premature infants.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
- * E-mail:
| | - Sangwani Salimu
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Brandina Chiwaya
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Felix Chikoti
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lusungu Chirambo
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Ephrida Mwaungulu
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mwai Banda
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Laura Newberry
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jenala Njirammadzi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Tamanda Hiwa
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Elizabeth M. Molyneux
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Joseph Mfutso-Bengo
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- Center of Bioethics for Eastern & Southern Africa (CEBESA), Blantyre, Malawi
| | - David M. Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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16
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Brotherton H, Gai A, Tann CJ, Samateh AL, Seale AC, Zaman SMA, Cousens S, Roca A, Lawn JE. Protocol for a randomised trial of early kangaroo mother care compared to standard care on survival of pre-stabilised preterm neonates in The Gambia (eKMC). Trials 2020; 21:247. [PMID: 32143737 PMCID: PMC7059319 DOI: 10.1186/s13063-020-4149-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/06/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Complications of preterm birth cause more than 1 million deaths each year, mostly within the first day after birth (47%) and before full post-natal stabilisation. Kangaroo mother care (KMC), provided as continuous skin-to-skin contact for 18 h per day to fully stabilised neonates ≤ 2000 g, reduces mortality by 36-51% at discharge or term-corrected age compared with incubator care. The mortality effect of starting continuous KMC before stabilisation is a priority evidence gap, which we aim to investigate in the eKMC trial, with a secondary aim of understanding mechanisms, particularly for infection prevention. METHODS We will conduct a single-site, non-blinded, individually randomised, controlled trial comparing two parallel groups to either early (within 24 h of admission) continuous KMC or standard care on incubator or radiant heater with KMC when clinically stable at > 24 h of admission. Eligible neonates (n = 392) are hospitalised singletons or twins < 2000 g and 1-24 h old at screening who are mild to moderately unstable as per a trial definition using cardio-respiratory parameters. Randomisation is stratified by weight category (< 1200 g; ≥ 1200 g) and in random permuted blocks of varying sizes with allocation of twins to the same arm. Participants are followed up to 28 ± 5 days of age with regular inpatient assessments plus criteria-led review in the event of clinical deterioration. The primary outcome is all-cause neonatal mortality by age 28 days. Secondary outcomes include the time to death, cardio-respiratory stability, hypothermia, exclusive breastfeeding at discharge, weight gain at age 28 days, clinically suspected infection (age 3 to 28 days), intestinal carriage of extended-spectrum beta-lactamase producing (ESBL) Klebsiella pneumoniae (age 28 days), and duration of the hospital stay. Intention-to-treat analysis will be applied for all outcomes, adjusting for twin gestation. DISCUSSION This is one of the first clinical trials to examine the KMC mortality effect in a pre-stabilised preterm population. Our findings will contribute to the global evidence base in addition to providing insights into the infection prevention mechanisms and safety of using this established intervention for the most vulnerable neonatal population. TRIAL REGISTRATION ClinicalTrials.gov NCT03555981. Submitted 8 May 2018 and registered 14 June 2018. Prospectively registered.
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Affiliation(s)
- Helen Brotherton
- Faculty of Epidemiology and Population Health, and MARCH Centre, London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, UK.
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia.
- Department of Medical Paediatrics, Royal Hospital for Sick Children, Edinburgh, UK.
| | - Abdou Gai
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Cally J Tann
- Faculty of Epidemiology and Population Health, and MARCH Centre, London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, UK
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Entebbe, Uganda
- Neonatal Medicine, University College London Hospitals NHS Trust, 235 Euston Rd, London, UK
| | | | - Anna C Seale
- Faculty of Epidemiology and Population Health, and MARCH Centre, London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, UK
| | - Syed M A Zaman
- Education Department, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Simon Cousens
- Faculty of Epidemiology and Population Health, and MARCH Centre, London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, UK
| | - Anna Roca
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Joy E Lawn
- Faculty of Epidemiology and Population Health, and MARCH Centre, London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, UK
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