Carriage of antimicrobial-resistant Enterobacterales among pregnant women and newborns in Amhara, Ethiopia

OBJECTIVES

Infections are one of the most common causes of neonatal mortality, and maternal colonization has been associated with neonatal infection. In this study, we sought to quantify carriage prevalence of extended-spectrum-beta-lactamase (ESBL) -producing and carbapenem-resistant Enterobacterales (CRE) among pregnant women and their neonates and to characterize risk factors for carriage in rural Amhara, Ethiopia.

METHODS

We conducted a prospective cohort study nested in the Birhan field site. We collected rectal and vaginal samples from 211 pregnant women in their third trimester and/or during labor/delivery and perirectal or stool samples from 159 of their neonates in the first week of life.

RESULTS

We found that carriage of ESBL-producing organisms was fairly common (women: 22.3%, 95% CI: 16.8-28.5; neonates: 24.5%, 95% CI: 18.1-32.0), while carriage of CRE (women: 0.9%, 95% CI: 0.1-3.4; neonates: 2.5%, 95% CI: 0.7-6.3) was rare. Neonates whose mothers tested positive for ESBL-producing organisms were nearly twice as likely to also test positive for ESBL-producing organisms (38.7% vs 21.1%, P-value = 0.06). Carriage of ESBL-producing organisms was also associated with Woreda (district) of sample collection and recent antibiotic use.

CONCLUSION

Understanding carriage patterns of potential pathogens and antibiotic susceptibility among pregnant women and newborns will inform local, data-driven recommendations to prevent and treat neonatal infections.

Prevalence, Incidence, and Reversal Pattern of Childhood Stunting From Birth to Age 2 Years in Ethiopia

Importance

Although there has been a reduction in stunting (low-height-for-age and low-length-for-age), a proxy of malnutrition, the prevalence of malnutrition in Ethiopia is still high. Child growth patterns and estimates of stunting are needed to increase awareness and resources to improve the potential for recovery.

Objective

To estimate the prevalence, incidence, and reversal of stunting among children aged 0 to 24 months.

Design, Setting, and Participants

This population-based cohort study of the Birhan Maternal and Child Health cohort in North Shewa Zone, Amhara, Ethiopia, was conducted between December 2018 and November 2020. Eligible participants included children aged 0 to 24 months who were enrolled during the study period and had their length measured at least once. Data analysis occurred from Month Year to Month Year.

Main Outcomes and Measures

The primary outcome of this study was stunting, defined as length-for-age z score (LAZ) at least 2 SDs below the mean. Z scores were also used to determine the prevalence, incidence, and reversal of stunting at each key time point. Growth velocity was determined in centimeters per month between key time points and compared with global World Health Organization (WHO) standards for the same time periods. Heterogeneity was addressed by excluding outliers in sensitivity analyses using modeled growth trajectories for each child.

Results

A total of 4354 children were enrolled, out of which 3674 (84.4%; 1786 [48.7%] female) had their length measured at least once and were included in this study. The median population-level length was consistently below WHO growth standards from birth to 2 years of age. The observed prevalence of stunting was highest by 2 years of age at 57.4% (95% CI, 54.8%-9 60.0%). Incidence of stunting increased over time and reached 51.0% (95% CI, 45.3%-56.6%) between ages 12 and 24 months. Reversal was 63.5% (95% CI, 54.8%-71.4%) by age 6 months and 45.2% (95% CI, 36.0%-54.8%) by age 2 years. Growth velocity point estimate differences were slowest compared with WHO standards during the neonatal period (-1.4 cm/month for girls and -1.6 cm/month for boys). There was substantial heterogeneity in anthropometric measurements.

Conclusions and Relevance

The evidence from this cohort study highlights a chronically malnourished population with much of the burden associated with growth faltering during the neonatal periods as well as after 6 months of age. To end all forms of malnutrition, growth faltering in populations such as that in young children in Amhara, Ethiopia, needs to be addressed.

Antenatal care coverage in a low-resource setting: Estimations from the Birhan Cohort

Antenatal care (ANC) coverage estimates commonly rely on self-reported data, which may carry biases. Leveraging prospectively collected longitudinal data from the Birhan field site and its pregnancy and birth cohort, the Birhan Cohort, this study aimed to estimate the coverage of ANC, minimizing assumptions and biases due to self-reported information and describing retention patterns in ANC in rural Amhara, Ethiopia. The study population were women enrolled and followed during pregnancy between December 2018 and April 2020. ANC visits were measured by prospective facility chart abstraction and self-report at enrollment. The primary study outcomes were the total number of ANC visits attended during pregnancy and the coverage of at least one, four, or eight ANC visits. Additionally, we estimated ANC retention patterns. We included 2069 women, of which 150 (7.2%) women enrolled <13 weeks of gestation with complete prospective facility reporting. Among these 150 women, ANC coverage of at least one visit was 97.3%, whereas coverage of four visits or more was 34.0%. Among all women, coverage of one ANC visit was 92.3%, while coverage of four or more visits was 28.8%. No women were found to have attended eight or more ANC visits. On retention in care, 70.3% of participants who had an ANC visit between weeks 28 and <36 of gestation did not return for a subsequent visit. Despite the high proportion of pregnant women who accessed ANC at least once in our study area, the coverage of four visits remains low. Further efforts are needed to enhance access to more ANC visits, retain women in care, and adhere to the most recent Ethiopian National ANC guideline of at least eight ANC visits. It is essential to identify the factors that lead a large proportion of women to discontinue ANC follow-up.

Implementation science to design, test and scale up effective Kangaroo Mother Care in Oromia region, Ethiopia

AIM

To develop a locally tested and optimised Kangaroo Mother Care (KMC) scale-up model to achieve high population-based effective coverage of KMC in Oromia region.

METHOD

We conducted an implementation research study to design and test KMC scale-up models from March 2017 to March 2019 in five hospitals and 39 health centres covering a population of 1.1 million in Oromia region, Ethiopia. We evaluated the models by measuring effective KMC coverage (at least 8 hours of skin-to-skin care plus exclusive breastfeeding) for newborns weighing <2000 g in the 24 hours before discharge from the KMC facility and on the 7th-day post-discharge.

RESULTS

After three cycles of iterative model implementation, we developed a KMC scale-up model that resulted in increased population-based effective KMC coverage. We enhanced the existing health system by strengthening the health system, reinforcing the linkages between the health system and communities and improving community engagement. Our final model achieved effective KMC coverage of 54%: 95% CI [49, 60] in the 24 hours before discharge from the facility and 38%: 95% CI [32, 43] on the 7th-day post-discharge.

CONCLUSION

Through iterative testing and adaptations, a model to scale up KMC that achieves 54% population-based effective coverage of KMC can be developed.

Health care seeking behaviors of pregnant women in rural Amhara, Ethiopia: a qualitative study of perceptions of pregnant women, community members, and health care providers

Introduction

in Ethiopia, increasing access to basic antenatal and neonatal health services may improve maternal and newborn survival. This study examined perceptions regarding antenatal health seeking behaviors from pregnant women, their families, community members, and health care providers in rural Amhara, Ethiopia.

Methods

the study was conducted in four rural districts of the Amhara region of Ethiopia. A total of forty participants who were living and working within the catchment areas of the selected health centres were interviewed from October 3rd through October 14th, 2018. A phenomenological qualitative study design was used to understand participants' perceptions and experiences about pregnant women's health care seeking behaviors.

Results

early disclosure of pregnancy status was not common in the study area. However, the data from the present study further provided new information, suggesting that some women did disclose their pregnancy status early but preferentially only to their partners and close relatives. Most women did not seek care unless sick or experienced new discomfort or pain. Some reasons for the low utilization of available antenatal services include long distance to health facilities, lack of transportation, difficult topography, and discomfort with male providers.

Conclusion

despite the rapid expansion of health posts and deployment of health extension workers since 2003, there are still critical barriers to accessing facility-based care that limit women's health care seeking practices.

Development of risk prediction models for preterm delivery in a rural setting in Ethiopia

Background

Preterm birth complications are the leading causes of death among children under five years. However, the inability to accurately identify pregnancies at high risk of preterm delivery is a key practical challenge, especially in resource-constrained settings with limited availability of biomarkers assessment.

Methods

We evaluated whether risk of preterm delivery can be predicted using available data from a pregnancy and birth cohort in Amhara region, Ethiopia. All participants were enrolled in the cohort between December 2018 and March 2020. The study outcome was preterm delivery, defined as any delivery occurring before week 37 of gestation regardless of vital status of the foetus or neonate. A range of sociodemographic, clinical, environmental, and pregnancy-related factors were considered as potential inputs. We used Cox and accelerated failure time models, alongside decision tree ensembles to predict risk of preterm delivery. We estimated model discrimination using the area-under-the-curve (AUC) and simulated the conditional distributions of cervical length (CL) and foetal fibronectin (FFN) to ascertain whether they could improve model performance.

Results

We included 2493 pregnancies; among them, 138 women were censored due to loss-to-follow-up before delivery. Overall, predictive performance of models was poor. The AUC was highest for the tree ensemble classifier (0.60, 95% confidence interval = 0.57-0.63). When models were calibrated so that 90% of women who experienced a preterm delivery were classified as high risk, at least 75% of those classified as high risk did not experience the outcome. The simulation of CL and FFN distributions did not significantly improve models' performance.

Conclusions

Prediction of preterm delivery remains a major challenge. In resource-limited settings, predicting high-risk deliveries would not only save lives, but also inform resource allocation. It may not be possible to accurately predict risk of preterm delivery without investing in novel technologies to identify genetic factors, immunological biomarkers, or the expression of specific proteins.

Development of Prediction Models for Antenatal Care Attendance in Amhara Region, Ethiopia

Importance

Antenatal care prevents maternal and neonatal deaths and improves birth outcomes. There is a lack of predictive models to identify pregnant women who are at high risk of failing to attend antenatal care in low-resource settings.

Objective

To develop a series of predictive models to identify women who are at high risk of failing to attend antenatal care in a rural setting in Ethiopia.

Design, Setting, and Participants

This prognostic study used data from the Birhan Health and Demographic Surveillance System and its associated pregnancy and child cohort. The study was conducted at the Birhan field site, North Shewa zone, Ethiopia, a platform for community- and facility-based research and training, with a focus on maternal and child health. Participants included women enrolled during pregnancy in the pregnancy and child cohort between December 2018 and March 2020, who were followed-up in home and facility visits. Data were analyzed from April to December 2022.

Exposures

A wide range of sociodemographic, economic, medical, environmental, and pregnancy-related factors were considered as potential predictors. The selection of potential predictors was guided by literature review and expert knowledge.

Main Outcomes and Measures

The outcome of interest was failing to attend at least 1 antenatal care visit during pregnancy. Prediction models were developed using logistic regression with regularization via the least absolute shrinkage and selection operator and ensemble decision trees and assessed using the area under the receiving operator characteristic curve (AUC).

Results

The study sample included 2195 participants (mean [SD] age, 26.8 [6.1] years; mean [SD] gestational age at enrolment, 25.5 [8.8] weeks). A total of 582 women (26.5%) failed to attend antenatal care during cohort follow-up. The AUC was 0.61 (95% CI, 0.58-0.64) for the regularized logistic regression model at conception, with higher values for models predicting at weeks 13 (AUC, 0.68; 95% CI, 0.66-0.71) and 24 (AUC, 0.66; 95% CI, 0.64-0.69). AUC values were similar with slightly higher performance for the ensembles of decision trees (conception: AUC, 0.62; 95% CI, 0.59-0.65; 13 weeks: AUC, 0.70; 95% CI, 0.67-0.72; 24 weeks: AUC, 0.67; 95% CI, 0.64-0.69).

Conclusions and Relevance

This prognostic study presents a series of prediction models for antenatal care attendance with modest performance. The developed models may be useful to identify women at high risk of missing their antenatal care visits to target interventions to improve attendance rates. This study opens the possibility to develop and validate easy-to-use tools to project health-related behaviors in settings with scarce resources.

Setting a research agenda to advance maternal, newborn, and child health in Ethiopia: An adapted CHNRI prioritization exercise

Background

Critical to the improvement of maternal, newborn, and child health (MNCH) in Ethiopia - where 14 000 mothers die from pregnancy-, childbirth-, or postpartum-related complications each year - is high-quality research and its effective translation into policy and practice. While Ethiopia has rapidly expanded the number of institutions that train and conduct MNCH research, the absence of a shared research agenda inhibits a coordinated approach to inform critical MNCH policy needs. The HaSET Maternal and Child Health Research Program (MCHRP) conducted a mixed methods formative assessment and prioritization exercise to guide investments in future MNCH research in Ethiopia.

Methods

We adapted the Child Health and Nutrition Research Initiative (CHNRI) method, soliciting 56 priority research questions via key informant interviews. Through an online survey, experts scored these on their ability to generate new, actionable evidence that could inform more effective and equitable MNCH programs in Ethiopia. At a workshop in Addis Ababa, experts scored the questions by answerability and ethics, usefulness, disease burden reduction, and impact on equity. Research priority scores were calculated for both the online survey and workshop scoring and averaged to attain a ranked priority list. We validated and contextualized the results by conducting consensus-building discussions with MNCH experts and two community workshops. In total, approximately 100 participants were involved.

Results

Average research priority scores ranged from 58.4 to 83.7 out of 100.0. The top identified research priorities speak to critical needs in the Ethiopian context: to improve population coverage of proven interventions like integrated community case management (ICCM), family integrated newborn care, and kangaroo mother care (KMC); to better understand the determinants of outcomes like home deliveries, immunization drop-out, and antenatal and postpartum care-seeking; and to strengthen health system and workforce capabilities.

Conclusions

This exercise expanded on the CHNRI methodology by comparing prioritization across different audiences, formats, and criteria. Agreement between both scoring rounds and consensus-building discussions was strong, demonstrating the reliability of the CHNRI method. By sharing this research priority list broadly among researchers, practitioners, and donors, we aim to improve coordinated MNCH evidence generation and translation into policy in Ethiopia.

Factors associated with small-for-gestational-age births among preterm babies born <2000 g: a multifacility cross-sectional study in Ethiopia

OBJECTIVES

This study aimed to determine the prevalence of small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA); compare variations in multiple risk factors, and identify factors associated with SGA births among preterm babies born <2000 g.

DESIGN

Cross-sectional study.

SETTING

The study was conducted at five public hospitals in Oromia Regional State and Addis Ababa City Administration, Ethiopia.

PARTICIPANTS

531 singleton preterm babies born <2000 g from March 2017 to February 2019.

OUTCOME MEASURES

Birth size-for-gestational-age was an outcome variable. Birth size-for-gestational-age centiles were produced using Intergrowth-21st data. Newborn birth size-for-gestational-age below the 10th percentile were classified as SGA; those>10th to 90th percentiles were classified as AGA; those >90th percentiles, as large-for-gestational-age, according to sex. SGA and AGA prevalence were determined. Babies were compared for variations in multiple risk factors.

RESULTS

Among 531 babies included, the sex distribution was: 55.44% males and 44.56% females. The prevalences of SGA and AGA were 46.14% and 53.86%, respectively. The percentage of SGA was slightly greater among males (47.62%) than females (44.30%), but not statistically significant The prevalence of SGA was significantly varied between pre-eclamptic mothers (32.42%, 95% CI 22.36% to 43.22%) and non-pre-eclamptic mothers (57.94%, 95% CI 53.21% to 62.54%). Mothers who had a history of stillbirth (adjusted OR (AOR) 2.96 95% CI 1.04 to 8.54), pre-eclamptic mothers (AOR 3.36, 95% CI 1.95 to 5.79) and being born extremely low birth weight (AOR 10.48, 95% CI 2.24 to 49.02) were risk factors significantly associated with SGA in this population.

CONCLUSION

Prevalence of SGA was very high in these population in the study area. Maternal pre-eclampsia substantially increases the risk of SGA. Hence, given the negative consequences of SGA, maternal and newborn health frameworks must look for and use evidence on gestational age and birth weight to assess the newborn's risks and direct care.

Characterisation of Staphylococci species from neonatal blood cultures in low- and middle-income countries

Background

In low- and middle-income countries (LMIC) Staphylococcus aureus is regarded as one of the leading bacterial causes of neonatal sepsis, however there is limited knowledge on the species diversity and antimicrobial resistance caused by Gram-positive bacteria (GPB).

Methods

We characterised GPB isolates from neonatal blood cultures from LMICs in Africa (Ethiopia, Nigeria, Rwanda, and South Africa) and South-Asia (Bangladesh and Pakistan) between 2015–2017. We determined minimum inhibitory concentrations and performed whole genome sequencing (WGS) on Staphylococci isolates recovered and clinical data collected related to the onset of sepsis and the outcome of the neonate up to 60 days of age.

Results

From the isolates recovered from blood cultures, Staphylococci species were most frequently identified. Out of 100 S. aureus isolates sequenced, 18 different sequence types (ST) were found which unveiled two small epidemiological clusters caused by methicillin resistant S. aureus (MRSA) in Pakistan (ST8) and South Africa (ST5), both with high mortality (n = 6/17). One-third of S. aureus was MRSA, with methicillin resistance also detected in Staphylococcus epidermidis, Staphylococcus haemolyticus and Mammaliicoccus sciuri. Through additional WGS analysis we report a cluster of M. sciuri in Pakistan identified between July-November 2017.

Conclusions

In total we identified 14 different GPB bacterial species, however Staphylococci was dominant. These findings highlight the need of a prospective genomic epidemiology study to comprehensively assess the true burden of GPB neonatal sepsis focusing specifically on mechanisms of resistance and virulence across species and in relation to neonatal outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07541-w.

Impact of the COVID-19 pandemic on utilisation of facility-based essential maternal and child health services from March to August 2020 compared with pre-pandemic March-August 2019: a mixed-methods study in North Shewa Zone, Ethiopia

INTRODUCTION

Health systems are often weakened by public health emergencies that make it harder to access health services. We aimed to assess maternal, newborn and child health (MNCH) service utilisation during the first 6 months of the COVID-19 pandemic compared with prior to the pandemic.

METHODS

We conducted a mixed study design in eight health facilities that are part of the Birhan field site in Amhara, Ethiopia and compared the trend of service utilisation in the first 6 months of COVID-19 with the corresponding time and data points of the preceding year.

RESULT

New family planning visits (43.2 to 28.5/month, p=0.014) and sick under 5 child visits (225.0 to 139.8/month, p=0.007) declined over the first 6 months of the pandemic compared with the same period in the preceding year. Antenatal (208.9 to 181.7/month, p=0.433) and postnatal care (26.6 to 19.8/month, p=0.155) visits, facility delivery rates (90.7 to 84.2/month, p=0.776), and family planning visits (313.3 to 273.4/month, p=0.415) declined, although this did not reach statistical significance. Routine immunisation visits (37.0 to 36.8/month, p=0.982) for children were maintained. Interviews with healthcare providers and clients highlighted several barriers to service utilisation during COVID-19, including fear of disease transmission, economic hardship, and transport service disruptions and restrictions. Enablers of service utilisation included communities' decreased fear of COVID-19 and awareness-raising activities.

CONCLUSION

We observed a decline in essential MNCH services particularly in sick children and new family planning visits. To improve the resiliency of fragile health systems, resources are needed to continuously monitor service utilisation and clients' evolving concerns during public health emergencies.

Estimates of Stillbirths, Neonatal Mortality, and Medically Vulnerable Live Births in Amhara, Ethiopia

IMPORTANCE

Data on birth outcomes and early mortality are scarce, especially in settings with limited resources. Total births, both stillbirths and live births, are often not counted, yet such data are critical to allocate resources and target interventions to improve survival.

OBJECTIVE

To estimate the prevalence of stillbirths, neonatal deaths, and medically vulnerable phenotypes, such as preterm births, small-for-gestational-age (SGA), large-for-gestational-age (LGA), and low-birth-weight (LBW) births, in a setting where these key indicators remain largely unknown.

DESIGN, SETTING, AND PARTICIPANTS

This prospective pregnancy cohort study of women and their newborns was conducted between December 12, 2018, and November 5, 2020. The study was conducted in North Shewa Zone, Amhara, Ethiopia. Data were analyzed from July 2021 to May 2022.

MAIN OUTCOMES AND MEASURES

Pregnancy status, gestational age, birth weight, and vital status were measured to estimate the prevalence of stillbirths, live births, and medically vulnerable live births (ie, preterm, SGA, LGA, and LBW births). For mortality outcomes, the prevalence of neonatal (overall, early, and late) and perinatal mortality were estimated.

RESULTS

Among the 2801 enrolled women, the median (IQR) age at conception was 26.5 (22.2-31.0) years, and the median (IQR) gestational age at enrollment was 24 (17-31) weeks. Of the 2628 women (93.8%) with outcome data, 101 pregnancies (3.8%) resulted in an early loss (<28 gestational weeks). Among the 2527 remaining pregnant women, there were 2518 births between 28 and less than 46 weeks' gestation; 2459 (97.7%; 95% CI, 97.0%-98.2%) were live births and 59 (2.3%; 95% CI, 1.8%-3.0%) were stillbirths. Many newborns (41.7%) were born preterm, SGA, LGA, or LBW. The estimated prevalence was 15.1% (95% CI, 13.7%-16.6%) for preterm births, 23.1% (95% CI, 21.3%-25.1%) for SGA births, 10.6% (95% CI, 9.3%-12.1%) for LGA births, and 9.4% (95% CI, 8.2%-10.8%) for LBW births. Among live births, the overall prevalence of neonatal mortality was 3.1% (95% CI, 2.5%-3.9%); mortality was higher among preterm births (7.2%; 95% CI, 4.9%-10.4%), LBW births (12.2%; 95% CI, 8.2%-17.7%), and SGA births (4.1%; 95% CI, 2.6%-6.5%). The prevalence of early neonatal mortality was almost twice as high as the prevalence of late neonatal mortality. The perinatal mortality prevalence was 4.3% (95% CI, 3.6%-5.2%), with a 1.2:1 ratio of stillbirths to first-week deaths.

CONCLUSIONS AND RELEVANCE

These findings have important implications for newborn health and survival. For policy makers and programmers, accurate data on key indicators of neonatal health provide information for resource allocation and to evaluate progress. For researchers, the findings underlie the importance for further research to develop and deliver interventions that improve health outcomes.

Neonatal sepsis and mortality in low-income and middle-income countries from a facility-based birth cohort: an international multisite prospective observational study

Background

Neonatal sepsis is a primary cause of neonatal mortality and is an urgent global health concern, especially within low-income and middle-income countries (LMICs), where 99% of global neonatal mortality occurs. The aims of this study were to determine the incidence and associations with neonatal sepsis and all-cause mortality in facility-born neonates in LMICs.

Methods

The Burden of Antibiotic Resistance in Neonates from Developing Societies (BARNARDS) study recruited mothers and their neonates into a prospective observational cohort study across 12 clinical sites from Bangladesh, Ethiopia, India, Pakistan, Nigeria, Rwanda, and South Africa. Data for sepsis-associated factors in the four domains of health care, maternal, birth and neonatal, and living environment were collected for all mothers and neonates enrolled. Primary outcomes were clinically suspected sepsis, laboratory-confirmed sepsis, and all-cause mortality in neonates during the first 60 days of life. Incidence proportion of livebirths for clinically suspected sepsis and laboratory-confirmed sepsis and incidence rate per 1000 neonate-days for all-cause mortality were calculated. Modified Poisson regression was used to investigate factors associated with neonatal sepsis and parametric survival models for factors associated with all-cause mortality.

Findings

Between Nov 12, 2015 and Feb 1, 2018, 29 483 mothers and 30 557 neonates were enrolled. The incidence of clinically suspected sepsis was 166·0 (95% CI 97·69–234·24) per 1000 livebirths, laboratory-confirmed sepsis was 46·9 (19·04–74·79) per 1000 livebirths, and all-cause mortality was 0·83 (0·37–2·00) per 1000 neonate-days. Maternal hypertension, previous maternal hospitalisation within 12 months, average or higher monthly household income, ward size (>11 beds), ward type (neonatal), living in a rural environment, preterm birth, perinatal asphyxia, and multiple births were associated with an increased risk of clinically suspected sepsis, laboratory-confirmed sepsis, and all-cause mortality. The majority (881 [72·5%] of 1215) of laboratory-confirmed sepsis cases occurred within the first 3 days of life.

Interpretation

Findings from this study highlight the substantial proportion of neonates who develop neonatal sepsis, and the high mortality rates among neonates with sepsis in LMICs. More efficient and effective identification of neonatal sepsis is needed to target interventions to reduce its incidence and subsequent mortality in LMICs.

Funding

Bill & Melinda Gates Foundation.

Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study: protocol of a pragmatic clinical effectiveness study to improve birth outcomes in Ethiopia

INTRODUCTION

The WHO Nutrition Target aims to reduce the global prevalence of low birth weight by 30% by the year 2025. The Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study will test the impact of packages of pregnancy interventions to enhance maternal nutrition and infection management on birth outcomes in rural Ethiopia.

METHODS AND ANALYSIS

ENAT is a pragmatic, open-label, 2×2 factorial, randomised clinical effectiveness study implemented in 12 rural health centres in Amhara, Ethiopia. Eligible pregnant women presenting at antenatal care (ANC) visits at <24 weeks gestation are enrolled (n=2400). ANC quality is strengthened across all centres. Health centres are randomised to receive an enhanced nutrition package (ENP) or standard nutrition care, and within each health centre, individual women are randomised to receive an enhanced infection management package (EIMP) or standard infection care. At ENP centres, women receive a regular supply of adequately iodised salt and iron-folate (IFA), enhanced nutrition counselling and those with mid-upper arm circumference of <23 cm receive a micronutrient fortified balanced energy protein supplement (corn soya blend) until delivery. In standard nutrition centres, women receive routine counselling and IFA. EIMP women have additional screening/treatment for urinary and sexual/reproductive tract infections and intensive deworming. Non-EIMP women are managed syndromically per Ministry of Health Guidelines. Participants are followed until 1-month post partum, and a subset until 6 months. The primary study outcomes are newborn weight and length measured at <72 hours of age. Secondary outcomes include preterm birth, low birth weight and stillbirth rates; newborn head circumference; infant weight and length for age z-scores at birth; maternal anaemia; and weight gain during pregnancy.

ETHICS AND DISSEMINATION

ENAT is approved by the Institutional Review Boards of Addis Continental Institute of Public Health (001-A1-2019) and Mass General Brigham (2018P002479). Results will be disseminated to local and international stakeholders.

REGISTRATION NUMBER

ISRCTN15116516.

Effects of antibiotic resistance, drug target attainment, bacterial pathogenicity and virulence, and antibiotic access and affordability on outcomes in neonatal sepsis: an international microbiology and drug evaluation prospective substudy (BARNARDS)

BACKGROUND

Sepsis is a major contributor to neonatal mortality, particularly in low-income and middle-income countries (LMICs). WHO advocates ampicillin-gentamicin as first-line therapy for the management of neonatal sepsis. In the BARNARDS observational cohort study of neonatal sepsis and antimicrobial resistance in LMICs, common sepsis pathogens were characterised via whole genome sequencing (WGS) and antimicrobial resistance profiles. In this substudy of BARNARDS, we aimed to assess the use and efficacy of empirical antibiotic therapies commonly used in LMICs for neonatal sepsis.

METHODS

In BARNARDS, consenting mother-neonates aged 0-60 days dyads were enrolled on delivery or neonatal presentation with suspected sepsis at 12 BARNARDS clinical sites in Bangladesh, Ethiopia, India, Pakistan, Nigeria, Rwanda, and South Africa. Stillborn babies were excluded from the study. Blood samples were collected from neonates presenting with clinical signs of sepsis, and WGS and minimum inhibitory concentrations for antibiotic treatment were determined for bacterial isolates from culture-confirmed sepsis. Neonatal outcome data were collected following enrolment until 60 days of life. Antibiotic usage and neonatal outcome data were assessed. Survival analyses were adjusted to take into account potential clinical confounding variables related to the birth and pathogen. Additionally, resistance profiles, pharmacokinetic-pharmacodynamic probability of target attainment, and frequency of resistance (ie, resistance defined by in-vitro growth of isolates when challenged by antibiotics) were assessed. Questionnaires on health structures and antibiotic costs evaluated accessibility and affordability.

FINDINGS

Between Nov 12, 2015, and Feb 1, 2018, 36 285 neonates were enrolled into the main BARNARDS study, of whom 9874 had clinically diagnosed sepsis and 5749 had available antibiotic data. The four most commonly prescribed antibiotic combinations given to 4451 neonates (77·42%) of 5749 were ampicillin-gentamicin, ceftazidime-amikacin, piperacillin-tazobactam-amikacin, and amoxicillin clavulanate-amikacin. This dataset assessed 476 prescriptions for 442 neonates treated with one of these antibiotic combinations with WGS data (all BARNARDS countries were represented in this subset except India). Multiple pathogens were isolated, totalling 457 isolates. Reported mortality was lower for neonates treated with ceftazidime-amikacin than for neonates treated with ampicillin-gentamicin (hazard ratio [adjusted for clinical variables considered potential confounders to outcomes] 0·32, 95% CI 0·14-0·72; p=0·0060). Of 390 Gram-negative isolates, 379 (97·2%) were resistant to ampicillin and 274 (70·3%) were resistant to gentamicin. Susceptibility of Gram-negative isolates to at least one antibiotic in a treatment combination was noted in 111 (28·5%) to ampicillin-gentamicin; 286 (73·3%) to amoxicillin clavulanate-amikacin; 301 (77·2%) to ceftazidime-amikacin; and 312 (80·0%) to piperacillin-tazobactam-amikacin. A probability of target attainment of 80% or more was noted in 26 neonates (33·7% [SD 0·59]) of 78 with ampicillin-gentamicin; 15 (68·0% [3·84]) of 27 with amoxicillin clavulanate-amikacin; 93 (92·7% [0·24]) of 109 with ceftazidime-amikacin; and 70 (85·3% [0·47]) of 76 with piperacillin-tazobactam-amikacin. However, antibiotic and country effects could not be distinguished. Frequency of resistance was recorded most frequently with fosfomycin (in 78 isolates [68·4%] of 114), followed by colistin (55 isolates [57·3%] of 96), and gentamicin (62 isolates [53·0%] of 117). Sites in six of the seven countries (excluding South Africa) stated that the cost of antibiotics would influence treatment of neonatal sepsis.

INTERPRETATION

Our data raise questions about the empirical use of combined ampicillin-gentamicin for neonatal sepsis in LMICs because of its high resistance and high rates of frequency of resistance and low probability of target attainment. Accessibility and affordability need to be considered when advocating antibiotic treatments with variance in economic health structures across LMICs.

FUNDING

The Bill & Melinda Gates Foundation.

Birhan maternal and child health cohort: a study protocol

INTRODUCTION

Reliable estimates on maternal and child morbidity and mortality are essential for health programmes and policies. Data are needed in populations, which have the highest burden of disease but also have the least evidence and research, to design and evaluate health interventions to prevent illnesses and deaths that occur worldwide each year.

METHODS AND ANALYSIS

The Birhan Maternal and Child Health cohort is an open prospective pregnancy and birth cohort nested within the Birhan Health and Demographic Surveillance System. An estimated 2500 pregnant women are enrolled each year and followed through pregnancy, birth and the postpartum period. Newborns are followed through 2 years of life to assess growth and development. Baseline medical data, signs and symptoms, laboratory test results, anthropometrics and pregnancy and birth outcomes (stillbirth, preterm birth, low birth weight) are collected from both home and health facility visits. We will calculate the period prevalence and incidence of primary morbidity and mortality outcomes.

ETHICS AND DISSEMINATION

The cohort has received ethical approval. Findings will be disseminated at scientific conferences, peer-reviewed journals and to relevant stakeholders including the Ministry of Health.

Effect of birthweight measurement quality improvement on low birthweight prevalence in rural Ethiopia

BACKGROUND

Low birthweight (LBW) (< 2500 g) is a significant determinant of infant morbidity and mortality worldwide. In low-income settings, the quality of birthweight data suffers from measurement and recording errors, inconsistent data reporting systems, and missing data from non-facility births. This paper describes birthweight data quality and the prevalence of LBW before and after implementation of a birthweight quality improvement (QI) initiative in Amhara region, Ethiopia.

METHODS

A comparative pre-post study was performed in selected rural health facilities located in West Gojjam and South Gondar zones. At baseline, a retrospective review of delivery records from February to May 2018 was performed in 14 health centers to collect birthweight data. A birthweight QI initiative was introduced in August 2019, which included provision of high-quality digital infant weight scales (precision 5 g), routine calibration, training in birth weighing and data recording, and routine field supervision. After the QI implementation, birthweight data were prospectively collected from late August to early September 2019, and December 2019 to June 2020. Data quality, as measured by heaping (weights at exact multiples of 500 g) and rounding to the nearest 100 g, and the prevalence of LBW were calculated before and after QI implementation.

RESULTS

We retrospectively reviewed 1383 delivery records before the QI implementation and prospectively measured 1371 newborn weights after QI implementation. Heaping was most frequently observed at 3000 g and declined from 26% pre-initiative to 6.7% post-initiative. Heaping at 2500 g decreased from 5.4% pre-QI to 2.2% post-QI. The percentage of rounding to the nearest 100 g was reduced from 100% pre-initiative to 36.5% post-initiative. Before the QI initiative, the prevalence of recognized LBW was 2.2% (95% confidence interval [CI]: 1.5-3.1) and after the QI initiative increased to 11.7% (95% CI: 10.1-13.5).

CONCLUSIONS

A QI intervention can improve the quality of birthweight measurements, and data measurement quality may substantially affect estimates of LBW prevalence.

Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study

Objectives

Kangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage.

Design

This study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge.

Participants

3804 infants of birth weight under 2000 g who survived the first 3 days, were available in the study area and whose mother resided in the study area.

Main outcome measures

The primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7 days postdischarge.

Results

Key barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%–86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7 days postdischarge, KMC was provided to 53%–65% of infants in all sites, except Oromia (38%) and Karnataka (36%).

Conclusions

This study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers’ conviction that KMC is the standard of care, women’s and families’ acceptance of KMC, and changes in infrastructure, policy, skills and practice.

Trial registration numbers

ISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

Prevalence and risk factors for antimicrobial resistance among newborns with gram-negative sepsis

INTRODUCTION

Newborn sepsis accounts for more than a third of neonatal deaths globally and one in five neonatal deaths in Ethiopia. The first-line treatment recommended by WHO is the combination of gentamicin with ampicillin or benzylpenicillin. Gram-negative bacteria (GNB) are increasingly resistant to previously effective antibiotics.

OBJECTIVES

Our goal was to estimate the prevalence of antibiotic-resistant gram-negative bacteremia and identify risk factors for antibiotic resistance, among newborns with GNB sepsis.

METHODS

At a tertiary hospital in Ethiopia, we enrolled a cohort pregnant women and their newborns, between March and December 2017. Newborns who were followed up until 60 days of life for clinical signs of sepsis. Among the newborns with clinical signs of sepsis, blood samples were cultured; bacterial species were identified and tested for antibiotic susceptibility. We described the prevalence of antibiotic resistance, identified newborn, maternal, and environmental factors associated with multidrug resistance (MDR), and combined resistance to ampicillin and gentamicin (AmpGen), using multivariable regression.

RESULTS

Of the 119 newborns with gram-negative bacteremia, 80 (67%) were born preterm and 82 (70%) had early-onset sepsis. The most prevalent gram-negative species were Klebsiella pneumoniae 94 (79%) followed by Escherichia coli 10 (8%). Ampicillin resistance was found in 113 cases (95%), cefotaxime 104 (87%), gentamicin 101 (85%), AmpGen 101 (85%), piperacillin-tazobactam 47 (39%), amikacin 10 (8.4%), and Imipenem 1 (0.8%). Prevalence of MDR was 88% (n = 105). Low birthweight and late-onset sepsis (LOS) were associated with higher risks of AmpGen-resistant infections. All-cause mortality was higher among newborns treated with ineffective antibiotics.

CONCLUSION

There was significant resistance to current first-line antibiotics and cephalosporins. Additional data are needed from primary care and community settings. Amikacin and piperacillin-tazobactam had lower rates of resistance; however, context-specific assessments of their potential adverse effects, their local availability, and cost-effectiveness would be necessary before selecting a new first-line regimen to help guide clinical decision-making.

Gaps in maternal, newborn, and child health research: a scoping review of 72 years in Ethiopia

Background

Despite significant reductions in maternal and child mortality over the past few decades, a disproportionate number of global deaths occur in low and middle-income country settings, such as Ethiopia. To prioritize research questions that would generate policy recommendations for better outcomes, we conducted a scoping review that gathers the current knowledge of maternal, newborn, and child health (MNCH) and illustrates remaining gaps in Ethiopia.

Methods

We conducted a search strategy from 1946-2018 in PubMed/MEDLINE, EMBASE, and the WHO African Index Medicus. The study team of reviewers independently screened titles, abstracts, and full-texts; abstracted data; and reconciled differences in pairs. Descriptive analyses were conducted.

Results

We identified 7,829 unique articles of which 2,170 were included. Most MNCH publications in Ethiopia (70.0%) were published in the last decade, 2010-2018. Most studies included children aged one to less than 10 years old (30.5%), women of reproductive age (22.0%), and pregnant women (21.9%); fewer studies included newborns (7.0%), infants (6.6%), and postpartum women (2.9%). Research topics included demographics and social determinants of health (43.4%), nutrition (15.3%), and infectious diseases (13.0%). There were limited studies on violence (1.4%), preterm birth (0.8%), antenatal/postpartum depression (0.7%), stillbirths (0.1%), and accidents (0.1%). Most study designs were cross-sectional (53.6%). A few study designs included prospective cohort studies (5.5%) and randomized control trials (2.3%).

Conclusions

This is the first scoping review to describe the landscape of MNCH research in Ethiopia. Understanding the depth of existing knowledge will support the prioritization and development of future research questions. Additional studies are needed to focus on the neonatal, infant, and postpartum populations as well as preterm and stillbirth outcomes.

Characterization of antimicrobial-resistant Gram-negative bacteria that cause neonatal sepsis in seven low- and middle-income countries

Antimicrobial resistance in neonatal sepsis is rising, yet mechanisms of resistance that often spread between species via mobile genetic elements, ultimately limiting treatments in low- and middle-income countries (LMICs), are poorly characterized. The Burden of Antibiotic Resistance in Neonates from Developing Societies (BARNARDS) network was initiated to characterize the cause and burden of antimicrobial resistance in neonatal sepsis for seven LMICs in Africa and South Asia. A total of 36,285 neonates were enrolled in the BARNARDS study between November 2015 and December 2017, of whom 2,483 were diagnosed with culture-confirmed sepsis. Klebsiella pneumoniae (n = 258) was the main cause of neonatal sepsis, with Serratia marcescens (n = 151), Klebsiella michiganensis (n = 117), Escherichia coli (n = 75) and Enterobacter cloacae complex (n = 57) also detected. We present whole-genome sequencing, antimicrobial susceptibility and clinical data for 916 out of 1,038 neonatal sepsis isolates (97 isolates were not recovered from initial isolation at local sites). Enterobacterales (K. pneumoniae, E. coli and E. cloacae) harboured multiple cephalosporin and carbapenem resistance genes. All isolated pathogens were resistant to multiple antibiotic classes, including those used to treat neonatal sepsis. Intraspecies diversity of K. pneumoniae and E. coli indicated that multiple antibiotic-resistant lineages cause neonatal sepsis. Our results will underpin research towards better treatments for neonatal sepsis in LMICs.

Scoping review protocol on maternal, newborn and child health research in Ethiopia

INTRODUCTION

There has been a tremendous reduction in maternal and child mortality in the last decade. However, a significant number of deaths still occur disproportionately in low-income country settings. Ethiopia is the second-most populous nation in sub-Saharan Africa with a high maternal mortality rate of 412 deaths per 100 000 live births and an under-five mortality rate of 55 per 1000 live births. This study presents a scoping review protocol to describe the current knowledge of maternal and child health in Ethiopia to identify gaps for prioritisation of future maternal, newborn and child health research.

METHODS AND ANALYSES

A search strategy will be conducted in PubMed/MEDLINE, EMBASE and the WHO African Index Medicus. Researchers will independently screen title and abstracts followed by full texts for inclusion. Study characteristics, research topics, exposures and outcomes will be abstracted from articles meeting inclusion criteria using standardised forms. Descriptive analysis of abstracted data will be conducted.

ETHICS AND DISSEMINATION

Data will be abstracted from published manuscripts and no additional ethical approval is required. The results of the review will be shared with maternal and child health experts in Ethiopia through stakeholder meetings to prioritise research questions. Findings will be submitted to a peer-reviewed journal for publication, in addition to national-level and global-level disseminations.

Distribution and determinants of pneumonia diagnosis using Integrated Management of Childhood Illness guidelines: a nationally representative study in Malawi

Background

Pneumonia remains the leading cause of child mortality in sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) strategy was developed to standardise care in low-income and middle-income countries for major childhood illnesses and can effectively improve healthcare worker performance. Suboptimal clinical evaluation can result in missed diagnoses and excess morbidity and mortality. We estimate the sensitivity of pneumonia diagnosis and investigate its determinants among children in Malawi.

Methods

Data were obtained from the 2013-2014 Service Provision Assessment survey, a census of health facilities in Malawi that included direct observation of care and re-examination of children by trained observers. We calculated sensitivity of pneumonia diagnosis and used multilevel log-binomial regression to assess factors associated with diagnostic sensitivity.

Results

3136 clinical visits for children 2-59 months old were observed at 742 health facilities. Healthcare workers completed an average of 30% (SD 13%) of IMCI guidelines in each encounter. 573 children met the IMCI criteria for pneumonia; 118 (21%) were correctly diagnosed. Advanced practice clinicians were more likely than other providers to diagnose pneumonia correctly (adjusted relative risk 2.00, 95% CI 1.21 to 3.29). Clinical quality was strongly associated with correct diagnosis: sensitivity was 23% in providers at the 75th percentile for guideline adherence compared with 14% for those at the 25th percentile. Contextual factors, facility structural readiness, and training or supervision were not associated with sensitivity.

Conclusions

Care quality for Malawian children is poor, with low guideline adherence and missed diagnosis for four of five children with pneumonia. Better sensitivity is associated with provider type and higher adherence to IMCI. Existing interventions such as training and supportive supervision are associated with higher guideline adherence, but are insufficient to meaningfully improve sensitivity. Innovative and scalable quality improvement interventions are needed to strengthen health systems and reduce avoidable child mortality.

What is kangaroo mother care? Systematic review of the literature

BACKGROUND

Kangaroo mother care (KMC), often defined as skin-to-skin contact between a mother and her newborn, frequent or exclusive breastfeeding, and early discharge from the hospital has been effective in reducing the risk of mortality among preterm and low birth weight infants. Research studies and program implementation of KMC have used various definitions.

OBJECTIVES

To describe the current definitions of KMC in various settings, analyze the presence or absence of KMC components in each definition, and present a core definition of KMC based on common components that are present in KMC literature.

METHODS

We conducted a systematic review and searched PubMed, Embase, Scopus, Web of Science, and the World Health Organization Regional Databases for studies with key words "kangaroo mother care", "kangaroo care" or "skin to skin care" from 1 January 1960 to 24 April 2014. Two independent reviewers screened articles and abstracted data.

FINDINGS

We screened 1035 articles and reports; 299 contained data on KMC and neonatal outcomes or qualitative information on KMC implementation. Eighty-eight of the studies (29%) did not define KMC. Two hundred and eleven studies (71%) included skin-to-skin contact (SSC) in their KMC definition, 49 (16%) included exclusive or nearly exclusive breastfeeding, 22 (7%) included early discharge criteria, and 36 (12%) included follow-up after discharge. One hundred and sixty-seven studies (56%) described the duration of SSC.

CONCLUSIONS

There exists significant heterogeneity in the definition of KMC. A large number of studies did not report definitions of KMC. Skin-to-skin contact is the core component of KMC, whereas components such as breastfeeding, early discharge, and follow-up care are context specific. To implement KMC effectively development of a global standardized definition of KMC is needed.

Barriers and enablers of health system adoption of kangaroo mother care: a systematic review of caregiver perspectives

Background

Despite improvements in child survival in the past four decades, an estimated 6.3 million children under the age of five die each year, and more than 40% of these deaths occur in the neonatal period. Interventions to reduce neonatal mortality are needed. Kangaroo mother care (KMC) is one such life-saving intervention; however it has not yet been fully integrated into health systems around the world. Utilizing a conceptual framework for integration of targeted health interventions into health systems, we hypothesize that caregivers play a critical role in the adoption, diffusion, and assimilation of KMC. The objective of this research was to identify barriers and enablers of implementation and scale up of KMC from caregivers’ perspective.

Methods

We searched Pubmed, Embase, Web of Science, Scopus, and WHO regional databases using search terms ‘kangaroo mother care’ or ‘kangaroo care’ or ‘skin to skin care’. Studies published between January 1, 1960 and August 19, 2015 were included. To be eligible, published work had to be based on primary data collection regarding barriers or enablers of KMC implementation from the family perspective. Abstracted data were linked to the conceptual framework using a deductive approach, and themes were identified within each of the five framework areas using Nvivo software.

Results

We identified a total of 2875 abstracts. After removing duplicates and ineligible studies, 98 were included in the analysis. The majority of publications were published within the past 5 years, had a sample size less than 50, and recruited participants from health facilities. Approximately one-third of the studies were conducted in the Americas, and 26.5% were conducted in Africa.

We identified four themes surrounding the interaction between families and the KMC intervention: buy in and bonding (i.e. benefits of KMC to mothers and infants and perceptions of bonding between mother and infant), social support (i.e. assistance from other people to perform KMC), sufficient time to perform KMC, and medical concerns about mother or newborn health. Furthermore, we identified barriers and enablers of KMC adoption by caregivers within the context of the health system regarding financing and service delivery. Embedded within the broad social context, barriers to KMC adoption by caregivers included adherence to traditional newborn practices, stigma surrounding having a preterm infant, and gender roles regarding childcare.

Conclusion

Efforts to scale up and integrate KMC into health systems must reduce barriers in order to promote the uptake of the intervention by caregivers.

Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis

CONTEXT

Kangaroo mother care (KMC) is an intervention aimed at improving outcomes among preterm and low birth weight newborns.

OBJECTIVE

Conduct a systematic review and meta-analysis estimating the association between KMC and neonatal outcomes.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Latin American and Caribbean Health Sciences Information System (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR), and Western Pacific Region Index Medicus (WPRIM).

STUDY SELECTION

We included randomized trials and observational studies through April 2014 examining the relationship between KMC and neonatal outcomes among infants of any birth weight or gestational age. Studies with <10 participants, lack of a comparison group without KMC, and those not reporting a quantitative association were excluded.

DATA EXTRACTION

Two reviewers extracted data on study design, risk of bias, KMC intervention, neonatal outcomes, relative risk (RR) or mean difference measures.

RESULTS

1035 studies were screened; 124 met inclusion criteria. Among LBW newborns, KMC compared to conventional care was associated with 36% lower mortality(RR 0.64; 95% [CI] 0.46, 0.89). KMC decreased risk of neonatal sepsis (RR 0.53, 95% CI 0.34, 0.83), hypothermia (RR 0.22; 95% CI 0.12, 0.41), hypoglycemia (RR 0.12; 95% CI 0.05, 0.32), and hospital readmission (RR 0.42; 95% CI 0.23, 0.76) and increased exclusive breastfeeding (RR 1.50; 95% CI 1.26, 1.78). Newborns receiving KMC had lower mean respiratory rate and pain measures, and higher oxygen saturation, temperature, and head circumference growth.

LIMITATIONS

Lack of data on KMC limited the ability to assess dose-response.

CONCLUSIONS

Interventions to scale up KMC implementation are warranted.

Kangaroo mother care: a systematic review of barriers and enablers

OBJECTIVE

To investigate factors influencing the adoption of kangaroo mother care in different contexts.

METHODS

We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization's regional databases, for studies on "kangaroo mother care" or "kangaroo care" or "skin-to-skin care" from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems.

FINDINGS

We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption.

CONCLUSION

Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake.

Validation of a novel tool for assessing newborn resuscitation skills among birth attendants trained by the Helping Babies Breathe program

OBJECTIVE

To validate a simplified objective structured clinical examination (OSCE) tool for evaluating the competency of birth attendants in low-resource countries who have been trained in neonatal resuscitation by the Helping Babies Breathe (HBB) program.

METHODS

A prospective cross-sectional study of the OSCE tool was conducted among trained birth attendants working at dispensaries, health centers, or hospitals in five regions of Tanzania between October 1, 2013, and May 1, 2014. A 13-item checklist was used to assess clinical competency in a simulated newborn resuscitation scenario. The OSCE tool was simultaneously administered by HBB trainers and experienced external evaluators. Paired results were compared using the Cohen κ value to measure inter-rater reliability. Participant performance was rated by health cadre, region, and facility type.

RESULTS

Inter-rater reliability was moderate (κ = 0.41-0.60) or substantial (κ = 0.61-0.80) for eight of the OSCE items; agreement was fair (κ = 0.21-0.41) for the remaining five items. The best OSCE performances were recorded among nurses and providers from facilities with high annual birth volumes.

CONCLUSION

The simplified OSCE tool could facilitate efficient implementation of national-level HBB programs. Limitations in inter-rater reliability might be improved through additional training.

The effect of abnormal birth history on ambulatory blood pressure and disease progression in children with chronic kidney disease

OBJECTIVE

To examine the associations between abnormal birth history (birth weight <2500 g, gestational age <36 weeks, or small for gestational age), blood pressure (BP), and renal function among 332 participants (97 with abnormal and 235 with normal birth history) in the Chronic Kidney Disease in Children Study, a cohort of children with chronic kidney disease (CKD).

STUDY DESIGN

Casual and 24-hour ambulatory BP were obtained. Glomerular filtration rate (GFR) was determined by iohexol disappearance. Confounders (birth and maternal characteristics, socioeconomic status) were used to generate predicted probabilities of abnormal birth history for propensity score matching. Weighted linear and logistic regression models with adjustment for quintiles of propensity scores and CKD diagnosis were used to assess the impact of birth history on BP and GFR.

RESULTS

Age at enrollment, percent with glomerular disease, and baseline GFR were similar between the groups. Those with abnormal birth history were more likely to be female, of Black race or Hispanic ethnicity, to have low household income, or part of a multiple birth. Unadjusted BP measurements, baseline GFR, and change in GFR did not differ significantly between the groups; no differences were seen after adjusting for confounders by propensity score matching.

CONCLUSIONS

Abnormal birth history does not appear to have exerted a significant influence on BP or GFR in this cohort of children with CKD. The absence of an observed association is likely secondary to the dominant effects of underlying CKD and its treatment.

The effect of intrapartum antibiotics on early-onset neonatal sepsis in Dhaka, Bangladesh: a propensity score matched analysis

BACKGROUND

We estimate the effect of antibiotics given in the intrapartum period on early-onset neonatal sepsis in Dhaka, Bangladesh using propensity score techniques.

METHODS

We followed 600 mother-newborn pairs as part of a cohort study at a maternity center in Dhaka. Some pregnant women received one dose of intravenous antibiotics during labor based on clinician discretion. Newborns were followed over the first seven days of life for early-onset neonatal sepsis defined by a modified version of the World Health Organization Young Infants Integrated Management of Childhood Illnesses criteria.Using propensity scores we matched women who received antibiotics with similar women who did not. A final logistic regression model predicting sepsis was run in the matched sample controlling for additional potential confounders.

RESULTS

Of the 600 mother-newborn pairs, 48 mothers (8.0%) received antibiotics during the intrapartum period. Seventy-seven newborns (12.8%) were classified with early-onset neonatal sepsis. Antibiotics appeared to be protective (odds ratio 0.381, 95% confidence interval 0.115-1.258), however this was not statistically significant. The results were similar after adjusting for prematurity, wealth status, and maternal colonization status (odds ratio 0.361, 95% confidence interval 0.106-1.225).

CONCLUSIONS

Antibiotics administered during the intrapartum period may reduce the risk of early-onset neonatal sepsis in high neonatal mortality settings like Dhaka.

Risk of early-onset neonatal infection with maternal infection or colonization: a global systematic review and meta-analysis

BACKGROUND

Neonatal infections cause a significant proportion of deaths in the first week of life, yet little is known about risk factors and pathways of transmission for early-onset neonatal sepsis globally. We aimed to estimate the risk of neonatal infection (excluding sexually transmitted diseases [STDs] or congenital infections) in the first seven days of life among newborns of mothers with bacterial infection or colonization during the intrapartum period.

METHODS AND FINDINGS

We searched PubMed, Embase, Scopus, Web of Science, Cochrane Library, and the World Health Organization Regional Databases for studies of maternal infection, vertical transmission, and neonatal infection published from January 1, 1960 to March 30, 2013. Studies were included that reported effect measures on the risk of neonatal infection among newborns exposed to maternal infection. Random effects meta-analyses were used to pool data and calculate the odds ratio estimates of risk of infection. Eighty-three studies met the inclusion criteria. Seven studies (8.4%) were from high neonatal mortality settings. Considerable heterogeneity existed between studies given the various definitions of laboratory-confirmed and clinical signs of infection, as well as for colonization and risk factors. The odds ratio for neonatal lab-confirmed infection among newborns of mothers with lab-confirmed infection was 6.6 (95% CI 3.9-11.2). Newborns of mothers with colonization had a 9.4 (95% CI 3.1-28.5) times higher odds of lab-confirmed infection than newborns of non-colonized mothers. Newborns of mothers with risk factors for infection (defined as prelabour rupture of membranes [PROM], preterm <37 weeks PROM, and prolonged ROM) had a 2.3 (95% CI 1.0-5.4) times higher odds of infection than newborns of mothers without risk factors.

CONCLUSIONS

Neonatal infection in the first week of life is associated with maternal infection and colonization. High-quality studies, particularly from settings with high neonatal mortality, are needed to determine whether targeting treatment of maternal infections or colonization, and/or prophylactic antibiotic treatment of newborns of high risk mothers, may prevent a significant proportion of early-onset neonatal sepsis. Please see later in the article for the Editors' Summary.

Improving health services to displaced persons in Aceh, Indonesia: a balanced scorecard

PROBLEM

After the Indian Ocean tsunami in December 2004, the International Organization for Migration constructed temporary health clinics to provide medical services to survivors living in temporary accommodation centres throughout Aceh, Indonesia. Limited resources, inadequate supervision, staff turnover and lack of a health information system made it challenging to provide quality primary health services.

APPROACH

A balanced scorecard was developed and implemented in collaboration with local health clinic staff and district health officials. Performance targets were identified. Staff collected data from clinics and accommodation centres to develop 30 simple performance measures. These measures were monitored periodically and discussed at meetings with stakeholders to guide the development of health interventions.

LOCAL SETTING

Two years after the tsunami, 34 000 displaced persons continued to receive services from temporary health clinics in two districts of Aceh province. From March to December 2007, the scorecard was implemented in seven temporary health clinics.

RELEVANT CHANGES

Interventions stimulated and tracked by the scorecard showed measurable improvements in preventive medicine, child health, capacity building of clinic staff and availability of essential drugs. By enhancing communication, the scorecard also led to qualitative benefits.

LESSONS LEARNT

The balanced scorecard is a practical tool to focus attention and resources to facilitate improvement in disaster rehabilitation settings where health information infrastructure is poor. Introducing a mechanism for rapid improvement fostered communication between nongovernmental organizations, district health officials, clinic health workers and displaced persons.

Non-specific effects of diphtheria tetanus pertussis vaccination on child mortality in Cebu, The Philippines

BACKGROUND

To determine the non-specific effects of diphtheria, tetanus and pertussis (DTP) vaccination and sex on mortality before 30 months of age among those who received Bacille Calmette Guerin (BCG) vaccine in a high mortality area.

METHODS

This analysis used a longitudinal study of child survival monitoring the use of primary care services, morbidity and mortality in Metro Cebu, The Philippines. Participants included 14 537 children under 30 months of age who received a BCG vaccination from July 1988 to January 1991. The main outcome measure was all-cause mortality.

RESULTS

Mortality before 30 months of age was 57% lower among BCG-vaccinated children who received DTP vaccination than BCG-vaccinated children who did not receive DTP vaccination {hazard ratio (HR) for vaccinated vs unvaccinated 0.43 [95% confidence interval (CI) 0.21-0.88]}. Females had lower mortality rates [HR = 0.19 (0.04-0.86), P = 0.03] than males among DTP-unvaccinated children. The protective effect of DTP vaccination was more pronounced in males [HR 0.32 (0.14-0.73)] than in females [HR 0.86 (0.18-4.23)]. DTP vaccination increased (interaction term P = 0.08) the female-to-male mortality ratio to 0.76 (0.52-1.12).

CONCLUSIONS

Among BCG-vaccinated children under 30 months of age, DTP vaccination is associated with improved survival. The increased female-male mortality ratio is associated with reduced mortality among males following DTP vaccination rather than increased mortality among female children.