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 to reduce morbidity and mortality in low birthweight infants

BACKGROUND

Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

OBJECTIVES

To determine whether evidence is available to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care, and to assess beneficial and adverse effects.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches in CENTRAL (Cochrane Central Register of Controlled Trials; 2016, Issue 6), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Science Information database), and POPLINE (Population Information Online) databases (all from inception to June 30, 2016), as well as the WHO (World Health Organization) Trial Registration Data Set (up to June 30, 2016). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google Scholar.

SELECTION CRITERIA

Randomized controlled trials comparing KMC versus conventional neonatal care, or early-onset KMC versus late-onset KMC, in LBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

Twenty-one studies, including 3042 infants, fulfilled inclusion criteria. Nineteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early-onset KMC with late-onset KMC in relatively stable LBW infants. Sixteen studies evaluated intermittent KMC, and five evaluated continuous KMC. KMC versus conventional neonatal care: At discharge or 40 to 41 weeks' postmenstrual age, KMC was associated with a statistically significant reduction in the risk of mortality (risk ratio [RR] 0.60, 95% confidence interval [CI] 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to 0.54; five trials, 1239 infants), and hypothermia (RR 0.28, 95% CI 0.16 to 0.49; nine trials, 989 infants; moderate-quality evidence). At latest follow-up, KMC was associated with a significantly decreased risk of mortality (RR 0.67, 95% CI 0.48 to 0.95; 12 trials, 2293 infants; moderate-quality evidence) and severe infection/sepsis (RR 0.50, 95% CI 0.36 to 0.69; eight trials, 1463 infants; moderate-quality evidence). Moreover, KMC was found to increase weight gain (mean difference [MD] 4.1 g/d, 95% CI 2.3 to 5.9; 11 trials, 1198 infants; moderate-quality evidence), length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38; three trials, 377 infants) and head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22; four trials, 495 infants) at latest follow-up, exclusive breastfeeding at discharge or 40 to 41 weeks' postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25; six studies, 1453 mothers) and at one to three months' follow-up (RR 1.20, 95% CI 1.01 to 1.43; five studies, 600 mothers), any (exclusive or partial) breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age (RR 1.20, 95% CI 1.07 to 1.34; 10 studies, 1696 mothers; moderate-quality evidence) and at one to three months' follow-up (RR 1.17, 95% CI 1.05 to 1.31; nine studies, 1394 mothers; low-quality evidence), and some measures of mother-infant attachment and home environment. No statistically significant differences were found between KMC infants and controls in Griffith quotients for psychomotor development at 12 months' corrected age (low-quality evidence). Sensitivity analysis suggested that inclusion of studies with high risk of bias did not affect the general direction of findings nor the size of the treatment effect for main outcomes. Early-onset KMC versus late-onset KMC in relatively stable infants: One trial compared early-onset continuous KMC (within 24 hours post birth) versus late-onset continuous KMC (after 24 hours post birth) in 73 relatively stable LBW infants. Investigators reported no significant differences between the two study groups in mortality, morbidity, severe infection, hypothermia, breastfeeding, and nutritional indicators. Early-onset KMC was associated with a statistically significant reduction in length of hospital stay (MD 0.9 days, 95% CI 0.6 to 1.2).

AUTHORS' CONCLUSIONS

Evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care, mainly in resource-limited settings. Further information is required concerning the effectiveness and safety of early-onset continuous KMC in unstabilized or relatively stabilized LBW infants, as well as long-term neurodevelopmental outcomes and costs of care.

Immediate "Kangaroo Mother Care" and Survival of Infants with Low Birth Weight

BACKGROUND

"Kangaroo mother care," a type of newborn care involving skin-to-skin contact with the mother or other caregiver, reduces mortality in infants with low birth weight (<2.0 kg) when initiated after stabilization, but the majority of deaths occur before stabilization. The safety and efficacy of kangaroo mother care initiated soon after birth among infants with low birth weight are uncertain.

METHODS

We conducted a randomized, controlled trial in five hospitals in Ghana, India, Malawi, Nigeria, and Tanzania involving infants with a birth weight between 1.0 and 1.799 kg who were assigned to receive immediate kangaroo mother care (intervention) or conventional care in an incubator or a radiant warmer until their condition stabilized and kangaroo mother care thereafter (control). The primary outcomes were death in the neonatal period (the first 28 days of life) and in the first 72 hours of life.

RESULTS

A total of 3211 infants and their mothers were randomly assigned to the intervention group (1609 infants with their mothers) or the control group (1602 infants with their mothers). The median daily duration of skin-to-skin contact in the neonatal intensive care unit was 16.9 hours (interquartile range, 13.0 to 19.7) in the intervention group and 1.5 hours (interquartile range, 0.3 to 3.3) in the control group. Neonatal death occurred in the first 28 days in 191 infants in the intervention group (12.0%) and in 249 infants in the control group (15.7%) (relative risk of death, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P = 0.001); neonatal death in the first 72 hours of life occurred in 74 infants in the intervention group (4.6%) and in 92 infants in the control group (5.8%) (relative risk of death, 0.77; 95% CI, 0.58 to 1.04; P = 0.09). The trial was stopped early on the recommendation of the data and safety monitoring board owing to the finding of reduced mortality among infants receiving immediate kangaroo mother care.

CONCLUSIONS

Among infants with a birth weight between 1.0 and 1.799 kg, those who received immediate kangaroo mother care had lower mortality at 28 days than those who received conventional care with kangaroo mother care initiated after stabilization; the between-group difference favoring immediate kangaroo mother care at 72 hours was not significant. (Funded by the Bill and Melinda Gates Foundation; Australian New Zealand Clinical Trials Registry number, ACTRN12618001880235; Clinical Trials Registry-India number, CTRI/2018/08/015369.).

Barriers and enablers of kangaroo mother care practice: a systematic review

Kangaroo mother care (KMC) is an evidence-based approach to reducing mortality and morbidity in preterm infants. Although KMC is a key intervention package in newborn health initiatives, there is limited systematic information available on the barriers to KMC practice that mothers and other stakeholders face while practicing KMC. This systematic review sought to identify the most frequently reported barriers to KMC practice for mothers, fathers, and health practitioners, as well as the most frequently reported enablers to practice for mothers. We searched nine electronic databases and relevant reference lists for publications reporting barriers or enablers to KMC practice. We identified 1,264 unique publications, of which 103 were included based on pre-specified criteria. Publications were scanned for all barriers / enablers. Each publication was also categorized based on its approach to identification of barriers / enablers, and more weight was assigned to publications which had systematically sought to understand factors influencing KMC practice. Four of the top five ranked barriers to KMC practice for mothers were resource-related: "Issues with the facility environment / resources," "negative impressions of staff attitudes or interactions with staff," "lack of help with KMC practice or other obligations," and "low awareness of KMC / infant health." Considering only publications from low- and middle-income countries, "pain / fatigue" was ranked higher than when considering all publications. Top enablers to practice were included "mother-infant attachment" and "support from family, friends, and other mentors." Our findings suggest that mother can understand and enjoy KMC, and it has benefits for mothers, infants, and families. However, continuous KMC may be physically and emotionally difficult, and often requires support from family members, health practitioners, or other mothers. These findings can serve as a starting point for researchers and program implementers looking to improve KMC programs.

Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns

Skin-to-skin care (SSC) and rooming-in have become common practice in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as delineated in the World Health Organization's "Ten Steps to Successful Breastfeeding." SSC and rooming-in are supported by evidence that indicates that the implementation of these practices increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. There have been several recent case reports and case series of severe and sudden unexpected postnatal collapse in the neonatal period among otherwise healthy newborns and near fatal or fatal events related to sleep, suffocation, and falls from adult hospital beds. Although these are largely case reports, there are potential dangers of unobserved SSC immediately after birth and throughout the postpartum hospital period as well as with unobserved rooming-in for at-risk situations. Moreover, behaviors that are modeled in the hospital after birth, such as sleep position, are likely to influence sleeping practices after discharge. Hospitals and birthing centers have found it difficult to develop policies that will allow SSC and rooming-in to continue in a safe manner. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies.

Skin-to-skin contact the first hour after birth, underlying implications and clinical practice

AIM

This paper integrates clinical expertise to earlier research about the behaviours of the healthy, alert, full-term infant placed skin-to-skin with the mother during the first hour after birth following a noninstrumental vaginal birth.

METHOD

This state-of-the-art article forms a link within the knowledge-to-action cycle, integrating clinical observations and practice with evidence-based findings to guide clinicians in their work to implement safe uninterrupted skin-to-skin contact the first hours after birth.

RESULTS

Strong scientific research exists about the importance of skin-to-skin in the first hour after birth. This unique time for both mother and infant, individually and in relation to each other, provides vital advantages to short- and long-term health, regulation and bonding. However, worldwide, clinical practice lags. A deeper understanding of the implications for clinical practice, through review of the scientific research, has been integrated with enhanced understanding of the infant's instinctive behaviour and maternal responses while in skin-to-skin contact.

CONCLUSION

The first hour after birth is a sensitive period for both the infant and the mother. Through an enhanced understanding of the newborn infant's instinctive behaviour, practical, evidence-informed suggestions strive to overcome barriers and facilitate enablers of knowledge translation. This time must be protected by evidence-based routines of staff.

Enhancing sensory experiences for very preterm infants in the NICU: an integrative review

OBJECTIVE

Very preterm infants hospitalized in the neonatal intensive care unit (NICU) experience alterations in sensory experiences. Defining types, timing and frequency of sensory-based interventions that optimize outcomes can inform environmental modifications. The objective of this study was to conduct an integrative review on sensory-based interventions used with very preterm infants in the NICU to improve infant and parent outcomes.

STUDY DESIGN

The data sources include MEDLINE, CINAHL, Cochrane Library and Google Scholar. Studies were identified that used sensory-based interventions in the NICU with preterm infants born ⩽32 weeks gestation, were published in a peer-reviewed journal between 1995 and 2015, and measured outcomes related to infant and parent outcomes. Studies were extracted from electronic databases and hand-searched from identified reference lists.

RESULTS

Eighty-eight articles were identified (31 tactile, 12 auditory, 3 visual, 2 kinesthetic, 2 gustatory/olfactory and 37 multimodal). There was evidence to support the use of kangaroo care, music and language exposure, and multimodal interventions starting at 25 to 28 weeks postmenstrual age. These interventions were related to better infant development and lower maternal stress, but not all findings were consistent. Limitations included lack of consistent outcome measures, study quality and gaps in the literature.

CONCLUSIONS

Most research identified interventions that were done for short periods of time. It is unclear what the potential is for improving outcomes if positive sensory exposures occur consistently throughout NICU hospitalization. Until more research defines appropriate sensory-based interventions to use with infants born very preterm in the NICU, information from this review can be combined with expert opinion and parent/family values to determine best practice.

Effectiveness of early intervention programs for parents of preterm infants: a meta-review of systematic reviews

BACKGROUND

Various intervention programs exist for parents of preterm babies and some systematic reviews (SRs) have synthesised the evidence of their effectiveness. These reviews are, however, limited to specific interventions, components, or outcomes, and a comprehensive evidence base is lacking. The aim of this meta-review was to appraise and meta-synthesise the evidence from existing SRs to provide a comprehensive evidence base on the effectiveness of interventions for parents of preterm infants on parental and infant outcomes.

METHODS

We conducted a comprehensive search of the following databases to identify relevant SRs: Cochrane library, Web of science, EMBASE, CINAHL, British Nursing Index, PsycINFO, Medline, ScienceDirect, Scopus, IBSS, DOAJ, ERIC, EPPI-Centre, PROSPERO, WHO Library. Additional searches were conducted using authors' institutional libraries, Google Scholar, and the reference lists of identified reviews. Identified articles were screened in two stages against an inclusion criteria with titles and abstracts screened first followed by full-text screening. Selected SRs were appraised using the AMSTAR tool. Extracted data using a predesigned tool were synthesised narratively examining the direction of impact on outcomes.

RESULTS

We found 11 SRs eligible for inclusion that synthesised a total of 343 quantitative primary studies. The average quality of the SRs was 'medium'. Thirty four interventions were reported across the SRs with considerable heterogeneity in the structural framework and the targeted outcomes that included maternal-infant dyadic, maternal/parental, and infant outcomes. Among all interventions, Kangaroo Care (KC) showed the most frequent positive impact across outcomes (n = 19) followed by Mother Infant Transaction Program (MITP) (n = 14). Other interventions with most consistent positive impact on infant outcomes were Modified-Mother Infant Transaction Program (M-MITP) (n = 6), Infant Health and Development Program (IHDP) (n = 5) and Creating Opportunities for Parent Empowerment (COPE) (n = 5). Overall, interventions with both home and facility based components showed the most frequent positive impact across outcomes.

CONCLUSIONS

Neonatal care policy and planning for preterm babies should consider the implementation of interventions with most positive impact on outcomes. The heterogeneity in interventions and outcomes calls for the development and implementation of an integrated program for parents of preterm infants with a clearly defined global set of parental and infant outcomes.

Anesthesia and analgesia in the NICU

Painful procedures in the neonatal intensive care unit are common, undertreated, and lead to adverse consequences. A stepwise approach to treatment should include pain recognition, assessment, and treatment, starting with nonpharmacologic and progressing to pharmacologic methods for increasing pain. The most common nonpharmacologic techniques include nonnutritive sucking with and without sucrose, kangaroo care, swaddling, and massage therapy. Drugs used to treat neonatal pain include the opiates, benzodiazepines, barbiturates, ketamine, propofol, acetaminophen, and local and topical anesthetics. The indications, advantages, and disadvantages of the commonly used analgesic drugs are discussed. Guidance and references for drugs and dosing for specific neonatal procedures are provided.

Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions

BACKGROUND

The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick.

METHODS

The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns.

RESULTS

The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems.

CONCLUSIONS

Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.

Implementing facility-based kangaroo mother care services: lessons from a multi-country study in Africa

BACKGROUND

Some countries have undertaken programs that included scaling up kangaroo mother care. The aim of this study was to systematically evaluate the implementation status of facility-based kangaroo mother care services in four African countries: Malawi, Mali, Rwanda and Uganda.

METHODS

A cross-sectional, mixed-method research design was used. Stakeholders provided background information at national meetings and in individual interviews. Facilities were assessed by means of a standardized tool previously applied in other settings, employing semi-structured key-informant interviews and observations in 39 health care facilities in the four countries. Each facility received a score out of a total of 30 according to six stages of implementation progress.

RESULTS

Across the four countries 95 per cent of health facilities assessed demonstrated some evidence of kangaroo mother care practice. Institutions that fared better had a longer history of kangaroo mother care implementation or had been developed as centres of excellence or had strong leaders championing the implementation process. Variation existed in the quality of implementation between facilities and across countries. Important factors identified in implementation are: training and orientation; supportive supervision; integrating kangaroo mother care into quality improvement; continuity of care; high-level buy in and support for kangaroo mother care implementation; and client-oriented care.

CONCLUSION

The integration of kangaroo mother care into routine newborn care services should be part of all maternal and newborn care initiatives and packages. Engaging ministries of health and other implementing partners from the outset may promote buy in and assist with the mobilization of resources for scaling up kangaroo mother care services. Mechanisms for monitoring these services should be integrated into existing health management information systems.

Parent-Infant Skin-to-Skin Contact and Stress Regulation: A Systematic Review of the Literature

Several studies have focused on neonatal maternal separation (MS) to investigate behavioural and neuroendocrine reactions to lack of contact, but only a few have focused on early separation in the first days or weeks after birth. This literature review investigates the vital importance of contact and touch by exploring how skin-to-skin contact (SSC) regulates stress in the mother-infant relationship. Various databases such as PubMed, Scopus, and ScienceDirect were searched for literature published between 2015 and 2020. From 1141 articles, 22 were declared eligible. The reviewed articles showed how SSC regulates child stress by biological indicators such as the autonomic nervous system (ANS), heart rate variability (HRV), cortisol, and oxytocin. This research concludes the importance of SSC for stress regulation, especially during the COVID-19 pandemic. With no research to date indicating a possible risk of neonatal COVID-19 transmission following SSC, SSC should continue to be practiced for all women, as recommended by the WHO.

Neonatal care practices in sub-Saharan Africa: a systematic review of quantitative and qualitative data

BACKGROUND

Recommended immediate newborn care practices include thermal care (immediate drying and wrapping, skin-to-skin contact after delivery, delayed bathing), hygienic cord care and early initiation of breastfeeding. This paper systematically reviews quantitative and qualitative data from sub-Saharan Africa on the prevalence of key immediate newborn care practices and the factors that influence them.

METHODS

Studies were identified by searching relevant databases and websites, contacting national and international academics and implementers and hand-searching reference lists of included articles. English-language published and unpublished literature reporting primary data from sub-Saharan Africa (published between January 2001 and May 2014) were included if it met the quality criteria. Quantitative prevalence data were extracted and summarized. Qualitative data were synthesized through thematic analysis, with deductive coding used to identify emergent themes within each care practice. A framework approach was used to identify prominent and divergent themes.

RESULTS

Forty-two studies were included as well as DHS data - only available for early breastfeeding practices from 33 countries. Results found variation in the prevalence of immediate newborn care practices between countries, with the exception of skin-to-skin contact after delivery which was universally low. The importance of keeping newborn babies warm was well recognized, although thermal care practices were sub-optimal. Similar factors influenced practices across countries, including delayed drying and wrapping because the birth attendant focused on the mother; bathing newborns soon after delivery to remove the dirt and blood; negative beliefs about the vernix; applying substances to the cord to make it drop off quickly; and delayed breastfeeding because of a perception of a lack of milk or because the baby needs to sleep after delivery or does not showing signs of hunger.

CONCLUSION

The majority of studies included in this review came from five countries (Ethiopia, Ghana, Malawi, Tanzania and Uganda). There is a need for more research from a wider geographical area, more research on newborn care practices at health facilities and standardization in measuring newborn care practices. The findings of this study could inform behaviour change interventions to improve the uptake of immediate newborn care practices.

Cerebral motor function in very premature-at-birth adolescents: a brain stimulation exploration of kangaroo mother care effects

AIM

  Given that prematurity has deleterious effects on brain networking development beyond childhood, the study explored whether an early intervention such as Kangaroo Mother Care (KMC) in very preterm preemies could have influenced brain motor function up to adolescence.

METHODS

  Transcranial magnetic stimulation (TMS) was applied over the primary motor cortex (M1) of 39 adolescents born very prematurely (<33 weeks' gestational age, 21 having received KMC after birth, 18 Controls with no KMC) and nine adolescents born at term (>37 weeks' gestational age, >2500 g) to assess the functional integrity of motor circuits in each hemisphere (motor planning) and between hemispheres (callosal function).

RESULTS

  All TMS outcomes were similar between KMC and term adolescents, with typical values as in healthy adults, and better than in Controls. KMC adolescents presented faster conduction times revealing more efficient M1 cell synchronization (p < 0.05) and interhemispheric transfer time (p < 0.0001), more frequent inhibitory processes with a better control between hemispheres (p < 0.0001).

CONCLUSION

  The enhanced synchronization, conduction times and connectivity of cerebral motor pathways in the KMC group suggests that the Kangaroo Mother Care positively influenced the premature brain networks and synaptic efficacy up to adolescence.

Quality improvement initiatives for hospitalised small and sick newborns in low- and middle-income countries: a systematic review

BACKGROUND

An estimated 2.6 million newborns died in 2016; over 98.5% of deaths occurred in low- and middle-income countries (LMICs). Neonates born preterm and small for gestational age are particularly at risk given the high incidence of infectious complications, cardiopulmonary, and neurodevelopmental disorders in this group. Quality improvement (QI) initiatives can reduce the burden of mortality and morbidity for hospitalised newborns in these settings. We undertook a systematic review to synthesise evidence from LMICs on QI approaches used, outcome measures employed to estimate effects, and the nature of implementation challenges.

METHODS

We searched Medline, EMBASE, WHO Global Health Library, Cochrane Library, WHO ICTRP, and ClinicalTrials.gov and scanned the references of identified studies and systematic reviews. Searches covered January 2000 until April 2017. Search terms were "quality improvement", "newborns", "hospitalised", and their derivatives. Studies were excluded if they took place in high-income countries, did not include QI interventions, or did not include small and sick hospitalised newborns. Cochrane Risk of Bias tools were used to quality appraise the studies.

RESULTS

From 8110 results, 28 studies were included, covering 23 LMICs and 65,642 participants. Most interventions were meso level (district and clinic level); fewer were micro (patient-provider level) or macro (above district level). In-service training was the most common intervention subtype; service organisation and distribution of referencing materials were also frequently identified. The most commonly assessed outcome was mortality, followed by length of admission, sepsis rates, and infection rates. Key barriers to implementation of quality improvement initiatives included overburdened staff and lack of sufficient equipment.

CONCLUSIONS

The frequency of meso level, single centre, and educational interventions suggests that these interventions may be easier for programme planners to implement. The success of some interventions in reducing morbidity and mortality rates suggests that QI approaches have a high potential for benefit to newborns. Going forward, there are opportunities to strengthen the focus of QI initiatives and to develop improved, larger-scale, collaborative research into implementation of quality improvement initiatives for this high-risk group.

TRIAL REGISTRATION

PROSPERO CRD42017055459 .

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

INTRODUCTION

The COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers' experiences and proposed mitigation strategies.

METHODS

Using a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions.

RESULTS

We analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother-baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families' fear of visiting hospitals (~73%).

CONCLUSION

Newborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better.

Time of initiation of skin-to-skin contact in extremely preterm infants in Sweden

AIM

To describe the time of first skin-to-skin contact in extremely preterm infants in a national perspective and to investigate possible factors affecting the time of first skin-to-skin contact.

METHODS

A population-based prospective descriptive study of extremely preterm infants (n = 520) in seven regional hospitals in Sweden.

RESULTS

Extremely preterm infants in Sweden experience first skin-to-skin contact with the parent at a median of six postnatal days (range 0-44). Low gestational age, a high score on the clinical risk index for babies, and the number of days on a ventilator tended to delay first skin-to-skin contact. A statistically significant difference was also found between regional hospitals.

CONCLUSION

There is a difference in the time of first skin-to-skin contact based on the infant's medical condition and the tradition in the neonatal intensive care unit at the regional hospital where the infant is born.

Efficacy of early skin-to-skin contact on the rate of exclusive breastfeeding in term neonates: a randomized controlled trial

BACKGROUND

Despite multiple benefits of breast milk, the rates of exclusive breastfeeding in developing countries are low.

OBJECTIVE

To evaluate the efficacy of early skin -to -skin contact (SSC) on the rate of exclusive breastfeeding (EBF) at 6 weeks of age among term neonates born by vaginal delivery.

METHODS

Term neonates born by vaginal delivery and did not require any resuscitation were randomized at birth to SSC (n=100) and control (n=100) group. Immediately after clamping the umbilical cord, SSC group neonates were placed on the bare bosom of mother and control group neonates were placed under a radiant warmer for a period of 45 minutes each while mothers underwent management of the third stage of labor and episiotomy repair. Pain experienced by mother during episiotomy repair was recorded using a numerical pain scale The primary outcome evaluated was the rate of exclusive breastfeeding at 6 weeks of postnatal age.

RESULTS

A significantly higher proportion of neonates were exclusively breastfeed at 6 weeks of age in the SSC group than in the control group (72% vs. 57.6%, p=0.04, relative risk: 1.3, 95% confidence interval: 1.0 -1.6). The pain score during episiotomy repair in mothers of the SSC group was significantly lower than the control group (4.74±0.85 versus 5.34±0.81; P <0.01).

CONCLUSIONS

Early SSC significantly improved the rate of exclusively breastfeeding at 6 weeks of age among healthy term neonates. An important additional effect was a decrease in the amount of pain that mothers in the SSC group experienced during episiotomy repair.

What works to protect, promote and support breastfeeding on a large scale: A review of reviews

Globally women continue to face substantial barriers to breastfeeding. The 2016 Lancet Breastfeeding Series identified key barriers and reviewed effective interventions that address them. The present study updates the evidence base since 2016 using a review of reviews approach. Searches were implemented using the Epistomenikos database. One hundred and fifteen reviews of interventions were identified and assessed for quality and risk of bias. Over half of reviews (53%) were high- or moderate quality, with the remaining low or critically low quality due to weaknesses in assessment of bias. A large portion of studies addressed high-income and upper-middle income settings, (41%), and a majority (63%) addressed health systems, followed by community and family settings (39%). Findings from reviews continue to strengthen the evidence base for effective interventions that improve breastfeeding outcomes across all levels of the social-ecological model, including supportive workplace policies; implementation of the Baby-Friendly Hospital Initiative, skin to skin care, kangaroo mother care, and cup feeding in health settings; and the importance of continuity of care and support in community and family settings, via home visits delivered by CHWs, supported by fathers', grandmothers' and community involvement. Studies disproportionately focus on health systems in high income and upper-middle income settings. There is insufficient attention to policy and structural interventions, the workplace and there is a need for rigorous assessment of multilevel interventions. Evidence from the past 5 years demonstrates the need to build on well-established knowledge to scale up breastfeeding protection, promotion and support programmes.

Kangaroo mother care for preterm or low birth weight infants: a systematic review and meta-analysis

IMPORTANCE

The Cochrane review (2016) on kangaroo mother care (KMC) demonstrated a significant reduction in the risk of mortality in low birth weight infants. New evidence from large multi-centre randomised trials has been available since its publication.

OBJECTIVE

Our systematic review compared the effects of KMC vs conventional care and early (ie, within 24 hours of birth) vs late initiation of KMC on critical outcomes such as neonatal mortality.

METHODS

Eight electronic databases, including PubMed®, Embase, and Cochrane CENTRAL, from inception until March 2022, were searched. All randomised trials comparing KMC vs conventional care or early vs late initiation of KMC in low birth weight or preterm infants were included.

DATA EXTRACTION AND SYNTHESIS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with PROSPERO.

MAIN OUTCOMES AND MEASURES

The primary outcome was mortality during birth hospitalization or 28 days of life. Other outcomes included severe infection, hypothermia, exclusive breastfeeding rates, and neurodevelopmental impairment. Results were pooled using fixed-effect and random-effects meta-analyses in RevMan 5.4 and Stata 15.1 (StataCorp, College Station, TX).

RESULTS

In total, 31 trials with 15 559 infants were included in the review; 27 studies compared KMC with conventional care, while four compared early vs late initiation of KMC. Compared with conventional care, KMC reduces the risks of mortality (relative risk (RR) 0.68; 95% confidence interval (CI) 0.53 to 0.86; 11 trials, 10 505 infants; high certainty evidence) during birth hospitalisation or 28 days of age and probably reduces severe infection until the latest follow-up (RR 0.85, 95% CI 0.79 to 0.92; nine trials; moderate certainty evidence). On subgroup analysis, the reduction in mortality was noted irrespective of gestational age or weight at enrolment, time of initiation, and place of initiation of KMC (hospital or community); the mortality benefits were greater when the daily duration of KMC was at least 8 hours per day than with shorter-duration KMC. Studies comparing early vs late-initiated KMC demonstrated a reduction in neonatal mortality (RR 0.77, 95% CI 0.66 to 0.91; three trials, 3693 infants; high certainty evidence) and a probable decrease in clinical sepsis until 28-days (RR 0.85, 95% CI 0.76 to 0.96; two trials; low certainty evidence) following early initiation of KMC.

CONCLUSIONS AND RELEVANCE

The review provides updated evidence on the effects of KMC on mortality and other critical outcomes in preterm and low birth weight infants. The findings suggest that KMC should preferably be initiated within 24 hours of birth and provided for at least 8 hours daily.

Associations between perceptions of care and women's childbirth experience: a population-based cross-sectional study in Rwanda

BACKGROUND

In recent years Rwanda has achieved remarkable improvement in quality of maternity care services but there is evidence of deficiencies in care quality in terms of disrespectful care. Women's overall childbirth experience is an important outcome of childbirth and a factor in assessing quality of care. The aim of this study was to investigate how women's overall childbirth experience in Rwanda was related to their perceptions of childbirth care.

METHODS

A cross-sectional household study of women who had given birth 1-13 months earlier (n = 921) was performed in the Northern Province and in the capital city. Data was collected via structured interviews following a questionnaire. Significant variables measuring perceptions of care were included in a stepwise forward selection logistic regression model with overall childbirth experience as a dichotomised target variable to find independent predictors of a good childbirth experience.

RESULTS

The majority of women (77.5%) reported a good overall childbirth experience. In a logistic regression model five factors of perceived care were significant independent predictors of a good experience: confidence in staff (Adjusted OR 1.73, 95% CI 1.20-2.49), receiving enough information (AOR 1.44, 95% CI 1.03-2.00), being treated with respect (AOR 1.69, 95% CI 1.18-2.43), getting support from staff (AOR 1.75, 95% CI 1.20-2.56), and having the baby skin-to-skin after birth (AOR 2.21, 95% CI 1.52-3.19).

CONCLUSIONS

To further improve childbirth care in Rwanda and care for women according to their preferences, it is important to make sure that the childbirth care includes the following quality aspects in national and clinical guidelines: build confidence, provide good information, treat women and families with respect, provide good professional support during childbirth and put the newborn baby skin-to-skin with its mother early after birth.

Mothers' experiences of skin-to-skin care of healthy full-term newborns--a phenomenology study

OBJECTIVES

Previous reports have shown that skin-to-skin contact immediately after birth is the optimal form of care for a full-term, healthy infant and its mother. As this is rarely researched the aim of this study was to explore experiences of skin-to-skin care in healthy mothers of healthy, full-term infants in the first days after birth.

STUDY DESIGN

Using a lifeworld phenomenological approach, 20 women who had childbirth in hospital and were practising skin-to-skin care were interviewed 1-2 weeks after birth. Analysis of all interview texts was directed towards discovering qualitative meanings through a process of identifying meaning units. These were then clustered and analysed with the aim of describing themes of meaning and the essence of the phenomenon.

FINDINGS

The mothers wanted to give their newborn child the best possible care and the skin-to-skin care started a positive spiral. A mutual interaction developed which acted as a generator releasing energy to the mother who wanted to continue the practice which in terms increased mother-infant affinity. Happiness, peace and satisfaction were expressed by the newborns; also a child who was crying or troublesome exhibited a positive response to skin-to-skin care.

CONCLUSION

The study provides insight and knowledge which should guide attitudes and promote practices of this simple healthcare intervention; skin-to-skin contact care to healthy infants born at term. Healthcare professionals should support affinity between a mother and her newborn through facilitation and the provision of information about its benefits.

Effects of Kangaroo Mother Care in the NICU on the Physiological Stress Parameters of Premature Infants: A Meta-Analysis of RCTs

OBJECTIVE

The aim of this study was to analyze the randomised controlled trials that explored the effect of kangaroo mother care on physiological stress parameters of premature infants.

METHODS

Two independent researchers performed a systematic review of indexed studies in PubMed, Embase, CINAHL, Cochrane and Scopus. We included data from randomized controlled trials measuring the effects of kangaroo care compared to standard incubator care on physiological stress outcomes, defined as oxygen saturation, body temperature, heart rate and respiratory rate. The PRISMA model was used to conduct data extraction. We performed a narrative synthesis of all studies and a meta-analysis when data were available from multiple studies that compared the same physiological parameters with the kangaroo method as an intervention and controls and used the same outcome measures.

RESULTS

Twelve studies were eligible for inclusion in this meta-analysis. According to statistical analysis, the mean respiratory rate of preterm infants receiving KMC was lower than that of infants receiving standard incubator care (MD, -3.50; 95% CI, -5.17 to -1.83; p < 0.00001). Infants who received kangaroo mother care had a higher mean heart rate, oxygen saturation and temperature, although these results were not statistically significant.

CONCLUSIONS

Current evidence suggests that kangaroo care in the neonatal intensive care unit setting is a safe method that may have a significant effect on some of the physiological parameters of stress in preterm infants. However, due to clinical heterogeneity, further studies are needed to assess the effects of physiological stress in the neonatal intensive care unit on the development of preterm infants.

Skin-to-skin contact diminishes pain from hepatitis B vaccine injection in healthy full-term neonates

PURPOSE

This study was conducted to test the hypothesis that skin-to-skin contact (SSC) would reduce hepatitis B vaccine injection pain in full-term neonates.

DESIGN

Randomized controlled trial (RCT).

SAMPLE

Thirty-six mother-;neonate dyads were randomly assigned to SSC or control groups.

MAIN OUTCOMES

Cry time (CT ), behavioral state (BSt), and heart rate (HR ) were measured throughout the 16-minute protocol. HR and BSt were measured every 30 seconds; CT was recorded continuously.

RESULTS

SSC neonates cried less compared with controls (23 vs 32 seconds during injection; 16 vs 72 seconds during recovery), reached calmer BSts sooner (M = 2.8 vs M = 6.5 time points), and trended toward more rapid HR decrease. SSC as described was safe and effective and merits further testing.