ResearchPad - neonatal-care https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Managing possible serious bacterial infection of young infants where referral is not possible: Lessons from the early implementation experience in Kushtia District learning laboratory, Bangladesh]]> https://www.researchpad.co/article/elastic_article_7649 Serious infections account for 25% of global newborn deaths annually, most in low-resource settings where hospital-based treatment is not accessible or feasible. In Bangladesh, one-third of neonatal deaths are attributable to serious infection; in 2014, the government adopted new policy for outpatient management of danger signs indicating possible serious bacterial infections (PSBI) when referral was not possible. We conducted implementation research to understand what it takes for a district health team to implement quality outpatient PSBI management per national guidelines.MethodsPSBI management was introduced as part of the Comprehensive Newborn Care Package in 2015. The study piloted this package through government health systems with limited partner support to inform scale-up efforts. Data collection included facility register reviews for cases seen at primary level facilities; facility readiness and provider knowledge and skills assessments; household surveys capturing caregiver knowledge of newborn danger signs and care-seeking for newborn illness; and follow-up case tracking, capturing treatment adherence and outcomes. Analysis consisted of descriptive statistics.ResultsOver the 15-month implementation period, 1432 young infants received care, of which 649 (45%) were classified as PSBI. Estimated coverage of care-seeking increased from 22% to 42% during the implementation period. Although facility readiness and providers’ skills increased, providers’ adherence to guidelines was not optimal. Among locally managed PSBI cases, 75% completed the oral antibiotic course and 15% received the fourth day follow-up. Care-seeking remained high among private providers (95%), predominantly village health doctors (over 80%).ConclusionsFacility readiness, including health care provider knowledge and skills were strengthened; future efforts should focus on improving provider adherence to guidelines. Social and behavior change strategies targeting families and communities should explore shifting care-seeking from private, possibly less-qualified providers. Strategies to improve private sector management of PSBI cases and improved linkages between private and public sector providers could be explored. ]]> <![CDATA[Death audits and reviews for reducing maternal, perinatal and child mortality]]> https://www.researchpad.co/article/Nef94be18-f1f5-4323-b046-1cceb61e1f73

Abstract

Background

The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under five years of age, in every country, by 2030. Maternal and perinatal death audit and review is widely recommended as an intervention to reduce maternal and perinatal mortality, and to improve quality of care, and could be key to attaining the SDGs. However, there is uncertainty over the most cost‐effective way of auditing and reviewing deaths: community‐based audit (verbal and social autopsy), facility‐based audits (significant event analysis (SEA)) or a combination of both (confidential enquiry).

Objectives

To assess the impact and cost‐effectiveness of different types of death audits and reviews in reducing maternal, perinatal and child mortality.

Search methods

We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and searched reference lists of included articles.

Selection criteria

Cluster‐randomised trials, cluster non‐randomised trials, controlled before‐and‐after studies and interrupted time series studies of any form of death audit or review that involved reviewing individual cases of maternal, perinatal or child deaths, identifying avoidable factors, and making recommendations. To be included in the review, a study needed to report at least one of the following outcomes: perinatal mortality rate; stillbirth rate; neonatal mortality rate; mortality rate in children under five years of age or maternal mortality rate.

Data collection and analysis

We used standard Cochrane Effective Practice and Organisation of Care (EPOC) group methodological procedures. Two review authors independently extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. We planned to perform a meta‐analysis using a random‐effects model but included studies were not homogeneous enough to make pooling their results meaningful.

Main results

We included two cluster‐randomised trials. Both introduced death review and audit as part of a multicomponent intervention, and compared this to current care. The QUARITE study (QUAlity of care, RIsk management, and TEchnology) concerned maternal death reviews in hospitals in West Africa, which had very high maternal and perinatal mortality rates. In contrast, the OPERA trial studied perinatal morbidity/mortality conferences (MMCs) in maternity units in France, which already had very low perinatal mortality rates at baseline.

The OPERA intervention in France started with an outreach visit to brief obstetricians, midwives and anaesthetists on the national guidelines on morbidity/mortality case management, and was followed by a series of perinatal MMCs. Half of the intervention units were randomised to receive additional support from a clinical psychologist during these meetings. The OPERA intervention may make little or no difference to overall perinatal mortality (low certainty evidence), however we are uncertain about the effect of the intervention on perinatal mortality related to suboptimal care (very low certainty evidence).The intervention probably reduces perinatal morbidity related to suboptimal care (unadjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95; 165,353 births; moderate‐certainty evidence). The effect of the intervention on stillbirth rate, neonatal mortality, mortality rate in children under five years of age, maternal mortality or adverse effects was not reported.

The QUARITE intervention in West Africa focused on training leaders of hospital obstetric teams using the ALARM (Advances in Labour And Risk Management) course, which included one day of training about conducting maternal death reviews. The leaders returned to their hospitals, established a multidisciplinary committee and started auditing maternal deaths, with the support of external facilitators. The intervention probably reduces inpatient maternal deaths (adjusted OR 0.85, 95% CI 0.73 to 0.98; 191,167 deliveries; moderate certainty evidence) and probably also reduces inpatient neonatal mortality within 24 hours following birth (adjusted OR 0.74, 95% CI 0.61 to 0.90; moderate certainty evidence). However, QUARITE probably makes little or no difference to the inpatient stillbirth rate (moderate certainty evidence) and may make little or no difference to the inpatient neonatal mortality rate after 24 hours, although the 95% confidence interval includes both benefit and harm (low certainty evidence). The QUARITE intervention probably increases the percent of women receiving high quality of care (OR 1.87, 95% CI 1.35 ‐ 2.57, moderate‐certainty evidence). The effect of the intervention on perinatal mortality, mortality rate in children under five years of age, or adverse effects was not reported.

We did not find any studies that evaluated child death audit and review or community‐based death reviews or costs.

Authors' conclusions

A complex intervention including maternal death audit and review, as well as development of local leadership and training, probably reduces inpatient maternal mortality in low‐income country district hospitals, and probably slightly improves quality of care. Perinatal death audit and review, as part of a complex intervention with training, probably improves quality of care, as measured by perinatal morbidity related to suboptimal care, in a high‐income setting where mortality was already very low.

The WHO recommends that maternal and perinatal death reviews should be conducted in all hospitals globally. However, conducting death reviews in isolation may not be sufficient to achieve the reductions in mortality observed in the QUARITE trial. This review suggests that maternal death audit and review may need to be implemented as part of an intervention package which also includes elements such as training of a leading doctor and midwife in each hospital, annual recertification, and quarterly outreach visits by external facilitators to provide supervision and mentorship. The same may also apply to perinatal and child death reviews. More operational research is needed on the most cost‐effective ways of implementing maternal, perinatal and paediatric death reviews in low‐ and middle‐income countries.

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<![CDATA[Scoping review to identify and map the health personnel considered skilled birth attendants in low-and-middle income countries from 2000–2015]]> https://www.researchpad.co/article/5c5df337d5eed0c484580f2e

Introduction

The “percentage of births attended by a skilled birth attendant" (SBA) is an indicator that has been adopted by several global monitoring frameworks, including the Sustainable Development Goal (SDG) agenda for regular monitoring as part of target 3.1 for reducing maternal mortality by 2030. However, accurate and consistent measurement is challenged by contextual differences between and within countries on the definition of SBA, including the education, training, competencies, and functions they are qualified to perform. This scoping review identifies and maps the health personnel considered SBA in low-to-middle-income-countries (LMIC).

Methods and analysis

A search was conducted inclusive to the years 2000 to 2015 in PubMed/MEDLINE, EMBASE, CINAHL Complete, Cochrane Database of Systematic Reviews, POPLINE and the World Health Organization Global Index Medicus. Original primary source research conducted in LMIC that evaluated the skilled health personnel providing interventions during labour and childbirth were considered for inclusion. All studies reported disaggregated data of SBA cadres and were disaggregated by country.

Results

The search of electronic databases identified a total of 23,743 articles. Overall, 70 articles were included in the narrative synthesis. A total of 102 unique cadres names were identified from 36 LMIC countries. Of the cadres included, 16% represented doctors, 16% were nurses, and 15% were midwives. We found substantial heterogeneity between and within countries on the reported definition of SBA and the education, training, skills and competencies that they were able to perform.

Conclusion

The uncertainty and diversity of reported qualifications and competency of SBA within and between countries requires attention in order to better ascertain strategic priorities for future health system planning, including training and education. These results can inform recommendations around improved coverage measurement and monitoring of SBA moving forward, allowing for more accurate, consistent, and timely data able to guide decisions and action around planning and implementation of maternal and newborn health programmes.

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<![CDATA[Quality of routine facility data for monitoring priority maternal and newborn indicators in DHIS2: A case study from Gombe State, Nigeria]]> https://www.researchpad.co/article/5c57e705d5eed0c484ef490d

Introduction

Routine health information systems are critical for monitoring service delivery. District Heath Information System, version 2 (DHIS2) is an open source software platform used in more than 60 countries, on which global initiatives increasingly rely for such monitoring. We used facility-reported data in DHIS2 for Gombe State, north-eastern Nigeria, to present a case study of data quality to monitor priority maternal and neonatal health indicators.

Methods

For all health facilities in DHIS2 offering antenatal and postnatal care services (n = 497) and labor and delivery services (n = 486), we assessed the quality of data for July 2016-June 2017 according to the World Health Organization data quality review guidance. Using data from DHIS2 as well as external facility-level and population-level household surveys, we reviewed three data quality dimensions—completeness and timeliness, internal consistency, and external consistency—and considered the opportunities for improvement.

Results

Of 14 priority maternal and neonatal health indicators that could be tracked through facility-based data, 12 were included in Gombe’s DHIS2. During July 2016-June 2017, facility-reported data in DHIS2 were incomplete at least 40% of the time, under-reported 10%-60% of the events documented in facility registers, and showed inconsistencies over time, between related indicators, and with an external data source. The best quality data elements were those that aligned with Gombe’s health program priorities, particularly older health programs, and those that reflected contact indicators rather than indicators related to the provision of commodities or content of care.

Conclusion

This case study from Gombe State, Nigeria, demonstrates the high potential for effective monitoring of maternal and neonatal health using DHIS2. However, coordinated action at multiple levels of the health system is needed to maximize reporting of existing data; rationalize data flow; routinize data quality review, feedback, and supervision; and ensure ongoing maintenance of DHIS2.

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<![CDATA[Peer-assisted learning after onsite, low-dose, high-frequency training and practice on simulators to prevent and treat postpartum hemorrhage and neonatal asphyxia: A pragmatic trial in 12 districts in Uganda]]> https://www.researchpad.co/article/5c21518dd5eed0c4843fabad

An urgent need exists to improve and maintain intrapartum skills of providers in sub-Saharan Africa. Peer-assisted learning may address this need, but few rigorous evaluations have been conducted in real-world settings. A pragmatic, cluster-randomized trial in 12 Ugandan districts provided facility-based, team training for prevention and management of postpartum hemorrhage and birth asphyxia at 125 facilities. Three approaches to facilitating simulation-based, peer assisted learning were compared. The primary outcome was the proportion of births with uterotonic given within one minute of birth. Outcomes were evaluated using observation of birth and supplemented by skills assessments and service delivery data. Individual and composite variables were compared across groups, using generalized linear models. Overall, 107, 195, and 199 providers were observed at three time points during 1,716 births across 44 facilities. Uterotonic coverage within one minute increased from: full group: 8% (CI 4%‒12%) to 50% (CI 42%‒59%); partial group: 19% (CI 9%‒30%) to 42% (CI 31%‒53%); and control group: 11% (5%‒7%) to 51% (40%‒61%). Observed care of mother and newborn improved in all groups. Simulated skills maintenance for postpartum hemorrhage prophylaxis remained high across groups 7 to 8 months after the intervention. Simulated skills for newborn bag-and-mask ventilation remained high only in the full group. For all groups combined, incidence of postpartum hemorrhage and retained placenta declined 17% and 47%, respectively, from during the intervention period compared to the 6‒9 month period after the intervention. Fresh stillbirths and newborn deaths before discharge decreased by 34% and 62%, respectively, from baseline to after completion, and remained reduced 6‒9 months post-implementation. Significant improvements in uterotonic coverage remained across groups 6 months after the intervention. Findings suggest that while short, simulation-based training at the facility improves care and is feasible, more complex clinical skills used infrequently such as newborn resuscitation may require more practice to maintain skills.

Trial Registration: ClinicalTrials.gov NCT03254628.

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<![CDATA[Mothers’ experience of maternity and neonatal care when babies die: A quantitative study]]> https://www.researchpad.co/article/5c117bead5eed0c48469ae49

Background

The death of a newborn baby is devastating. While clinical issues may be a primary concern, interpersonal aspects can impact significantly. Mothers in this situation are not easy to access for research and little quantitative evidence is available. In this study we aimed to describe their experience of care, emphasising associations with infant gestational age.

Methods

Secondary analysis of population-based survey data collected through the Office for National Statistics following neonatal death in England in 2012–13. Women were asked about clinical events and care during pregnancy, labour and birth, when the baby died, postnatally and in the neonatal unit.

Results

249 mothers returned completed questionnaires (30% response rate), 50% of births were at 28 weeks’ gestation or less and 66% had babies admitted for neonatal care. 24% of women were left alone and worried during labour and 18% after birth. Only 49% felt sufficiently involved in decision-making at this time. Postnatally only 53% were cared for away from other mothers and babies, 47% could not have their partner stay with them, and 55% were not located close to their baby. Mothers of term babies were significantly less likely to report confidence in staff, feeling listened to and having concerns taken seriously during labour, and postnatally many felt insufficiently informed about their baby’s condition, and that neonatal staff were not always aware of parental needs. However, most mothers (84%) were satisfied with neonatal care.

Conclusions

There is room for improvement if women whose babies die in the neonatal period are to receive the care and support they need. Women who have a baby admitted to a neonatal unit should be cared for nearby, with room for their partner and with greater involvement in decision-making, particularly where withdrawal of life support is considered.

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<![CDATA[Parental costs for in-patient neonatal services for perinatal asphyxia and low birth weight in Ghana]]> https://www.researchpad.co/article/5bca48f740307c051665641b

The major causes of newborn deaths in sub-Saharan Africa are well-known and countries are gradually implementing evidence-based interventions and strategies to reduce these deaths. Facility-based care provides the best outcome for sick and or small babies; however, little is known about the cost and burden of hospital-based neonatal services on parents in West Africa, the sub-region with the highest global neonatal death burden. To estimate the actual costs borne by parents of newborns hospitalised with birth-associated brain injury (perinatal asphyxia) and preterm/low birth weight, this study examined economic costs using micro-costing bottom-up approach in two referral hospitals operating under the nationwide social health insurance scheme in an urban setting in Ghana. We prospectively assessed the process of care and parental economic costs for 25 out of 159 cases of perinatal asphyxia and 33 out of 337 cases of preterm/low birth weight admitted to hospital on the day of birth over a 3 month period. Results showed that medical-related costs accounted for 66.1% (IQR 49% - 81%) of out-of-pocket payments irrespective of health insurance status. On average, families spent 8.1% and 9.1% of their annual income on acute care for preterm/LBW and perinatal asphyxia respectively. The mean out-of-pocket expenditure for preterm/LBW was $147.6 (median $101.8) and for perinatal asphyxia was $132.3 (median $124). The study revealed important gaps in the financing and organization of health service delivery that may impact the quality of care for hospitalised newborns. It also provides information for reviewing complementary health financing options for newborn services and further economic evaluations.

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<![CDATA[Successful implementation of Helping Babies Survive and Helping Mothers Survive programs—An Utstein formula for newborn and maternal survival]]> https://www.researchpad.co/article/5989db5dab0ee8fa60be0457

Globally, the burden of deaths and illness is still unacceptably high at the day of birth. Annually, approximately 300.000 women die related to childbirth, 2.7 million babies die within their first month of life, and 2.6 million babies are stillborn. Many of these fatalities could be avoided by basic, but prompt care, if birth attendants around the world had the necessary skills and competencies to manage life-threatening complications around the time of birth. Thus, the innovative Helping Babies Survive (HBS) and Helping Mothers Survive (HMS) programs emerged to meet the need for more practical, low-cost, and low-tech simulation-based training. This paper provides users of HBS and HMS programs a 10-point list of key implementation steps to create sustained impact, leading to increased survival of mothers and babies. The list evolved through an Utstein consensus process, involving a broad spectrum of international experts within the field, and can be used as a means to guide processes in low-resourced countries. Successful implementation of HBS and HMS training programs require country-led commitment, readiness, and follow-up to create local accountability and ownership. Each country has to identify its own gaps and define realistic service delivery standards and patient outcome goals depending on available financial resources for dissemination and sustainment.

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<![CDATA[Quality Indicators but Not Admission Volumes of Neonatal Intensive Care Units Are Effective in Reducing Mortality Rates of Preterm Infants]]> https://www.researchpad.co/article/5989db2aab0ee8fa60bd1049

Aim

To investigate how two different strategies to form larger neonatal intensive care units (NICU) impact neonatal mortality rates.

Methods

Cross-sectional study modeling admission volumes and mortality rates of 177,086 VLBW infants aggregated into 862 NICUs. Cumulative 3-year data was abstracted from Vermont Oxford Network. The model simulated a reduction in number of NICUs by stepwise exclusion using either admission volume (VOL) or quality (QUAL) cut-offs. After randomly redirecting infants of excluded to remaining NICUs resulting system mortality rates were calculated with and without adjusting for effects of experience levels (EL) using published data to reflect effects of different team-to-patient exposure.

Results

The quality-based strategy is more effective in reducing mortality; while VOL alone was not able to reduce system mortality, QUAL already achieved a 5% improvement after reducing 8% of NICUs and redirecting 6% of infants. Including “EL”, a 5% improvement of mortality was achieved by reducing 77% (VOL) vs. 7% (QUAL) of NICUs and redirecting 54% (VOL) vs. 5% (QUAL) of VLBW infants, respectively.

Conclusion

While a critical number of admissions is needed to maintain skills this study emphasizes the importance of including quality parameters to restructure neonatal care. The findings can be generalized to other medical fields.

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<![CDATA[Symptoms of an Intrauterine Hematoma Associated with Pregnancy Complications: A Systematic Review]]> https://www.researchpad.co/article/5989db37ab0ee8fa60bd39d9

Objective

To evaluate the predictive value of the symptoms of an intrauterine hematoma (IUH) for adverse pregnancy outcomes.

Methods

A literature review was performed with the search terms, including intrauterine/subchorionic/retroplacental/subplacental hematoma/hemorrhage/bleeding/collection/fluid, covering the period from January, 1981 to January, 2014. We just focused on the pregnancy outcomes associated with different symptoms of an IUH.

Results

It is generally agreed that a retroplacental, posterior or subchorionic in the fundus of uterus, and/or persistent IUH is associated with adverse outcomes in the ongoing pregnancy. However, the prognosis value of both volume and gestational age at diagnosis of IUH still remains controversial. Some researchers argue that a large IUH is associated with an increased risk of adverse events during pregnancy while others refuted. It is believed by some that the earlier an IUH was detected, the higher the risk for adverse outcomes would be, while no or weak association were reported by other studies. The prognostic value of the simultaneous presence of vaginal bleeding on pregnancy outcome is also controversial.

Conclusions

Both the position relative to the placenta or uterus and duration of IUH have strong predictive value on the prognosis in the ongoing pregnancy. However, the prognostic values of the IUH volume, gestational age at diagnosis and the simultaneous presence of vaginal bleeding remain controversial up to now. Moreover, most of previous reports are small, uncontrolled studies with incomplete information. Prospective, large sample, cohorts studies which take all detailed symptoms of an IUH into consideration are needed when we evaluate its clinical significance in the prognosis of pregnancy.

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<![CDATA[Prenatal Care in Combination with Maternal Educational Level Has a Synergetic Effect on the Risk of Neonatal Low Birth Weight: New Findings in a Retrospective Cohort Study in Kunshan City, China]]> https://www.researchpad.co/article/5989da5cab0ee8fa60b901e7

Objectives

To investigate the dose-response relationship and synergetic effect of the maternal educational level and two measures of prenatal care on neonatal low birth weight (LBW) risk.

Methods

Data were derived from the Perinatal Health Care Surveillance System (PHCSS) from January 2001 to September 2009 in Kunshan City, Jiangsu province, eastern China, which included data on 31412 women with a normal birth weight delivery and 640 women with a LBW delivery. Logistic modelling was performed to estimate the association including the joint effects with odds ratio (OR) and 95% confidence interval (CI) between the prenatal care measures and LBW risk after adjusting for the potential confounders. The dose-response relationship between the number of prenatal care visits and the risk of LBW was investigated by modeling the quantitative exposure with restricted cubic splines (RCS).

Results

There was a significant synergetic effect on the LBW risk between maternal educational attainment and the number of prenatal care visits (χ2 = 4.98, P = 0.0257), whereas no significant maternal educational attainment interaction was found with the week of initiation of prenatal care after adjusting for relevant confounding factors (χ2 = 2.04, P = 0.1530), and the LBW risk displayed a ‘U-shape’ curve tendency among the different number of prenatal care visits (P for nonlinearity = 0.0002) using RCS. In particular, the ORs were approaching the curve’s bottom when the women had 9 or 10 prenatal care visits. Comparing with 5 prenatal care visits, the ORs and 95%CI of LBW risk for 7, 9, 11 and ≥13 visits were 0.92 (0.82–1.03), 0.50 (0.38–0.66), 0.62 (0.47–0.82), and 0.99 (0.61–1.60), respectively.

Conclusions

Our findings suggest that appropriate prenatal care, in combination with a higher maternal educational level, can produce a protective interaction effect on LBW risk. Reasonable health resource assignment for different social statuses should be taken into account by policy-makers in developing countries.

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<![CDATA[Poor Quality for Poor Women? Inequities in the Quality of Antenatal and Delivery Care in Kenya]]> https://www.researchpad.co/article/5989db53ab0ee8fa60bdcbda

Background

Quality of healthcare is an important determinant of future progress in global health. However, the distributional aspects of quality of care have received inadequate attention. We assessed whether high quality maternal care is equitably distributed by (1) mapping the quality of maternal care in facilities located in poorer versus wealthier areas of Kenya; and (2) comparing the quality of maternal care available to Kenyans in and not in poverty.

Methods

We assessed three measures of maternal care quality: facility infrastructure and clinical quality of antenatal care and delivery care, using indicators from the 2010 Kenya Service Provision Assessment (SPA), a standardized facility survey with direct observation of maternal care provision. We calculated poverty of the area served by antenatal or delivery care facilities using the Multidimensional Poverty Index. We used regression analyses and non-parametric tests to assess differences in maternal care quality in facilities located in more and less impoverished areas. We estimated effective coverage with a minimum standard of care for the full population and those in poverty.

Results

A total of 564 facilities offering at least one maternal care service were included in this analysis. Quality of maternal care was low, particularly clinical quality of antenatal and delivery care, which averaged 0.52 and 0.58 out of 1 respectively, compared to 0.68 for structural inputs to care. Maternal healthcare quality varied by poverty level: at the facility level, all quality metrics were lowest for the most impoverished areas and increased significantly with greater wealth. Population access to a minimum standard (≥0.75 of 1.00) of quality maternal care was both low and inequitable: only 17% of all women and 8% of impoverished women had access to minimally adequate delivery care.

Conclusion

The quality of maternal care is low in Kenya, and care available to the impoverished is significantly worse than that for the better off. To achieve the national targets of maternal and neonatal mortality reduction, policy initiatives need to tackle low quality of care, starting with high-poverty areas.

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<![CDATA[Pregnant Women’s Intentions and Subsequent Behaviors Regarding Maternal and Neonatal Service Utilization: Results from a Cohort Study in Nyanza Province, Kenya]]> https://www.researchpad.co/article/5989d9edab0ee8fa60b6d05a

Higher use of maternal and neonatal health (MNH) services may reduce maternal and neonatal mortality in Kenya. This study aims to: 1) prospectively explore women’s intentions to use MNH services (antenatal care, delivery in a facility, postnatal care, neonatal care) at <20 and 30–35 weeks’ gestation and their actual use of these services; 2) identify predictors of intention-behavior discordance among women with positive service use intentions; 3) examine associations between place of delivery, women’s reasons for choosing it, and birthing experiences. We used data from a 2012–2013 population-based cohort of pregnant women in the Demographic Surveillance Site in Nyanza province, Kenya. Of 1,056 women completing the study (89.1% response rate), 948 had live-births and 22 stillbirths, and they represent our analytic sample. Logistic regression analysis identified predictors of intention-behavior discordance regarding delivery in a facility and use of postnatal and neonatal care. At <20 and 30–35 weeks’ gestation, most women intended to seek MNH services (≥93.9% and ≥87.5%, respectively, for all services assessed). Actual service use was high for antenatal (98.1%) and neonatal (88.5%) care, but lower for delivery in a facility (76.9%) and postnatal care (51.8%). Woman’s age >35 and high-school education were significant predictors of intention-behavior discordance regarding delivery in a facility; several delivery-related factors were significantly associated with intention-behavior discordance regarding use of postnatal and neonatal care. Delivery facilities were chosen based on proximity to women’s residence, affordability, and service quality; among women who delivered outside a health facility, 16.3% could not afford going to a facility. Good/very good birth experiences were reported by 93.6% of women who delivered in a facility and 32.6% of women who did not. We found higher MNH service utilization than previously documented in Nyanza province. Further increasing the number of facility deliveries and use of postnatal care may improve MNH in Kenya.

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<![CDATA[Treatment of Infections in Young Infants in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis of Frontline Health Worker Diagnosis and Antibiotic Access]]> https://www.researchpad.co/article/5989da18ab0ee8fa60b7c0da

Anne C. C. Lee and colleagues assess the factors affecting access to treatment for neonatal and infant infections in low- and middle-income countries by conducting a systematic review and meta-analysis of frontline health worker diagnosis and access to antibiotics.

Please see later in the article for the Editors' Summary

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<![CDATA[Treatment Trials for Neonatal Seizures: The Effect of Design on Sample Size]]> https://www.researchpad.co/article/5989d9d7ab0ee8fa60b663c5

Neonatal seizures are common in the neonatal intensive care unit. Clinicians treat these seizures with several anti-epileptic drugs (AEDs) to reduce seizures in a neonate. Current AEDs exhibit sub-optimal efficacy and several randomized control trials (RCT) of novel AEDs are planned. The aim of this study was to measure the influence of trial design on the required sample size of a RCT. We used seizure time courses from 41 term neonates with hypoxic ischaemic encephalopathy to build seizure treatment trial simulations. We used five outcome measures, three AED protocols, eight treatment delays from seizure onset (Td) and four levels of trial AED efficacy to simulate different RCTs. We performed power calculations for each RCT design and analysed the resultant sample size. We also assessed the rate of false positives, or placebo effect, in typical uncontrolled studies. We found that the false positive rate ranged from 5 to 85% of patients depending on RCT design. For controlled trials, the choice of outcome measure had the largest effect on sample size with median differences of 30.7 fold (IQR: 13.7–40.0) across a range of AED protocols, Td and trial AED efficacy (p<0.001). RCTs that compared the trial AED with positive controls required sample sizes with a median fold increase of 3.2 (IQR: 1.9–11.9; p<0.001). Delays in AED administration from seizure onset also increased the required sample size 2.1 fold (IQR: 1.7–2.9; p<0.001). Subgroup analysis showed that RCTs in neonates treated with hypothermia required a median fold increase in sample size of 2.6 (IQR: 2.4–3.0) compared to trials in normothermic neonates (p<0.001). These results show that RCT design has a profound influence on the required sample size. Trials that use a control group, appropriate outcome measure, and control for differences in Td between groups in analysis will be valid and minimise sample size.

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<![CDATA[Pelvic Floor Disorders 6 Months after Attempted Operative Vaginal Delivery According to the Fetal Head Station: A Prospective Cohort Study]]> https://www.researchpad.co/article/5989da52ab0ee8fa60b8e24b

Objective

To evaluate the effect of the fetal head station at attempted operative vaginal delivery (aOVD), and specifically midpelvic or low aOVD, on urinary incontinence (UI), anal incontinence (AI), and perineal pain at 6 months.

Design

Prospective cohort study.

Setting

1941 women with singleton term fetuses in vertex presentation with midpelvic or low aOVD between 2008 and 2013 in a tertiary care university hospital.

Methods

Symptoms of urinary incontinence (UI) using the Bristol Female Lower Urinary Tract Symptoms questionnaire, and symptoms of anal incontinence (AI) severity using Fecal Incontinence Severity Index (FISI) were assessed 6 months after aOVD. We measured the association between midpelvic or low aOVD and symptoms of UI, AI, and perineal pain at 6 months using multiple regression and adjusting for demographics, and risk factors of UI and AI, with adjusted odds ratios (aORs) and 95% confidence intervals (95% CI).

Results

The study included 907 women (46.7%) who responded to the questionnaire; 18.4% (167/907) had midpelvic aOVD, and 81.6% (740/907) low; and none of women with symptoms of UI (26.6%, and 22.4%, respectively; p = 0.31), AI (15.9%, and 21.8%; p = 0.09), the FISI score, and perineal pain (17.2%, and 12.7%; p = 0.14) differed significantly between groups. The same was true for stress, urge, and mixed-type UI, severe UI and difficulty voiding. Compared with low pelvic aOVD, the aORs for symptoms of UI in midpelvic aOVD were 0.70 (0.46–1.05) and AI 1.42 (0.85–2.39). Third- and fourth-degree tears were a major risk factor of symptoms of UI (aOR 3.08, 95% CI 1.35–7.00) and AI (aOR 3.47, 95% CI 1.43–8.39).

Conclusion

Neither symptoms of urinary nor anal incontinence differed at 6 months among women who had midpelvic and low pelvic aOVD. These findings are reassuring and need further studies at long-term to confirm these short-term data.

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<![CDATA[Maternal Exposure to Low Levels of Corticosterone during Lactation Protects against Experimental Inflammatory Colitis-Induced Damage in Adult Rat Offspring]]> https://www.researchpad.co/article/5989da40ab0ee8fa60b89906

Opposing emotional events (negative/trauma or positive/maternal care) during the postnatal period may differentially influence vulnerability to the effects of stress later in life. The development and course of intestinal disorders such as inflammatory bowel disease are negatively affected by persistent stress, but to date the role of positive life events on these pathologies has been entirely unknown. In the present study, the effect of early life beneficial experiences in the development of intestinal dysfunctions, where inflammation and stress stimuli play a primary role, was investigated. As a “positive” experimental model we used adult male rat progeny nursed by mothers whose drinking water was supplemented with moderate doses of corticosterone (CORT) (0.2 mg/ml) during the lactation period. Such animals have been generally shown to cope better with different environmental situations during life. The susceptibility to inflammatory experimental colitis induced by intracolonic infusion of TNBS (2,4,6-trinitrobenzenesulphonic acid) was investigated in CORT-nursed rats in comparison with control rats. This mild increase in maternal corticosterone during lactation induced, in CORT-nursed rats, a long lasting protective effect on TNBS-colitis, characterized by improvements in some indices of the disease (increased colonic myeloperoxidase activity, loss of body weight and food intake) and by the involvement of endogenous peripheral pathways known to participate in intestinal disorder development (lower plasma corticosterone levels and colonic mast cell degranulation, alterations in the colonic expression of both corticotrophin releasing factor/CRF and its receptor/CRH-1R). All these findings contribute to suggesting that the reduced vulnerability to TNBS-colitis in CORT-nursed rats is due to recovery from the colonic mucosal barrier dysfunction. Such long lasting changes induced by mild hormonal manipulation during lactation, making the adult also better adapted to colonic inflammatory stress, constitute a useful experimental model to investigate the etiopathogenetic mechanisms and therapeutic treatments of some gastrointestinal diseases.

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<![CDATA[Utilization of Inhaled Corticosteroids for Infants with Bronchopulmonary Dysplasia]]> https://www.researchpad.co/article/5989db08ab0ee8fa60bc92b6

Objective

To determine demographic and clinical variables associated with inhaled corticosteroid administration and to evaluate between-hospital variation in inhaled steroid use for infants with bronchopulmonary dysplasia (BPD).

Design

Retrospective Cohort Study.

Setting

Neonatal units of 35 US children's hospitals; as recorded in the Pediatric Health Information System (PHIS) database.

Patients

1429 infants with evolving BPD at 28 days who were born at <29 weeks gestation with birth weight <1500 grams, admitted within the first 7 postnatal days, and discharged between January 2007–June 2011.

Results

Inhaled steroids were prescribed to 25% (n = 352) of the cohort with use steadily increasing during the first two months of hospitalization. The most frequently prescribed steroid was beclomethasone (n = 194, 14%), followed by budesonide (n = 125, 9%), and then fluticasone (n = 90, 6%). Birth gestation <24 weeks, birth weight 500–999 grams, and prolonged ventilation all increased the adjusted odds of ever receiving inhaled corticosteroids (p<0.05). Wide variations between hospitals in the frequency of infants ever receiving inhaled steroids (range: 0–60%) and the specific drug prescribed were noted. This variation persisted, even after controlling for observed confounders.

Conclusions

Inhaled corticosteroid administration to infants with BPD is common in neonatal units within U.S. Children's hospitals. However, its utilization varies markedly between centers from no treatment at some institutions to the majority of infants with BPD being treated at others. This supports the need for further research to identify the benefits and potential risks of inhaled steroid usage in infants with BPD.

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<![CDATA[Concentrations and Sources of Airborne Particles in a Neonatal Intensive Care Unit]]> https://www.researchpad.co/article/5989db36ab0ee8fa60bd3050

Premature infants in neonatal intensive care units (NICUs) have underdeveloped immune systems, making them susceptible to adverse health consequences from air pollutant exposure. Little is known about the sources of indoor airborne particles that contribute to the exposure of premature infants in the NICU environment. In this study, we monitored the spatial and temporal variations of airborne particulate matter concentrations along with other indoor environmental parameters and human occupancy. The experiments were conducted over one year in a private-style NICU. The NICU was served by a central heating, ventilation and air-conditioning (HVAC) system equipped with an economizer and a high-efficiency particle filtration system. The following parameters were measured continuously during weekdays with 1-min resolution: particles larger than 0.3 μm resolved into 6 size groups, CO2 level, dry-bulb temperature and relative humidity, and presence or absence of occupants. Altogether, over sixteen periods of a few weeks each, measurements were conducted in rooms occupied with premature infants. In parallel, a second monitoring station was operated in a nearby hallway or at the local nurses’ station. The monitoring data suggest a strong link between indoor particle concentrations and human occupancy. Detected particle peaks from occupancy were clearly discernible among larger particles and imperceptible for submicron (0.3–1 μm) particles. The mean indoor particle mass concentrations averaged across the size range 0.3–10 μm during occupied periods was 1.9 μg/m3, approximately 2.5 times the concentration during unoccupied periods (0.8 μg/m3). Contributions of within-room emissions to total PM10 mass in the baby rooms averaged 37–81%. Near-room indoor emissions and outdoor sources contributed 18–59% and 1–5%, respectively. Airborne particle levels in the size range 1–10 μm showed strong dependence on human activities, indicating the importance of indoor-generated particles for infant’s exposure to airborne particulate matter in the NICU.

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<![CDATA[A Five-Year Experience of Carbapenem Resistance in Enterobacteriaceae Causing Neonatal Septicaemia: Predominance of NDM-1]]> https://www.researchpad.co/article/5989db10ab0ee8fa60bcbe0e

Treatment of neonatal sepsis has become a challenge with the emergence of carbapenemase-producing bacteria. This study documents the trend of carbapenem susceptibility in Enterobacteriaceae that caused septicaemia in neonates over a five year period (2007–2011) and the molecular characterisation of Enterobacteriaceae resistant to carbapenems and cephalosporins. Hundred and five Enterobacteriaceae including Escherichia coli (n = 27), Klebsiella pneumoniae (n = 68) and Enterobacter spp. (n = 10) were isolated from blood of septicaemic neonates followed by antibiotic susceptibility tests, determination of MIC values, phenotypic and genotypic detection of β-lactamases. Carbapenem was the most active antimicrobial tested after tigecycline. CTX-M type was the most prevalent ESBL throughout the period (82%). New Delhi Metallo-β-lactamase-1 (NDM-1), which is a recent addition to the carbapenemase list, was the only carbapenemase identified in our setting. Fourteen percent of the isolates possessed blaNDM-1. Carbapenem non-susceptibility was first observed in 2007 and it was due to loss of Omp F/Ompk36 in combination with the presence of ESBLs/AmpCs. NDM-1 first emerged in E. coli during 2008; later in 2010, the resistance was detected in K. pneumoniae and E. cloacae isolates. NDM-1-producing isolates were resistant to other broad-spectrum antibiotics and possessed ESBLs, AmpCs, 16S-rRNA methylases, AAC(6′)-Ib-cr, bleomycin resistant gene and class 1 integron. Pulsed field gel electrophoresis of the NDM-1-producing isolates indicated that the isolates were clonally diverse. The study also showed that there was a significantly higher incidence of sepsis caused by NDM-1-harbouring isolates in the male sex, in neonates with low birth weight and neonates born at an extramural centre. However, sepsis with NDM-1-harbouring isolates did not result in a higher mortality rate. The study is the first to review the carbapenem resistance patterns in neonatal sepsis over an extended period of time. The study highlights the persistence of ESBLs (CTX-Ms) and the emergence of NDM-1 in Enterobacteriaceae in the unit.

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