Small Newborns Research Articles

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

IntroductionThe 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...

Quality improvement strategies to improve inpatient management of small and sick newborns across All Babies Count supported hospitals in rural Rwanda

BackgroundNeonatal mortality contributes to nearly half of child deaths globally and the majority of these deaths are preventable. Poor quality of care is a major driver of neonatal mortality in low- and middle-income countries. The All Babies Count (ABC) intervention was designed to reduce neonatal mortality through provision of equipment and supplies, training, mentorship, and data-driven quality improvement (QI) with peer-to-peer learning through learning collaborative sessions (LCS). We aim to describe the ABC scale-up in seven rural district hospitals from 2017 to 2019 focusing on the QI strategies implemented in hospital neonatal care units (NCUs) and the resultant neonatal care outcomes.MethodsA pre-post quasi experimental study was conducted in 7 rural hospitals in Rwanda in two phases. The baseline periods were April-June 2017 for Phase I and July-September 2017 for Phase II; with end-line data collected during the same periods in 2019. Data included facility audits of supplies and staffing, LCS surveys of QI skills, and reports of implemented QI change ideas. Data on NCU admissions and deaths were extracted from Health Management Information System (HMIS). Facility-reported change ideas were coded into common themes. Changes in post-post neonatal mortality were measured using Chi-squared tests.ResultsNCUs were run by a median of 1 nurse [interquartile range (IQR):1–2] at baseline and endline. Median NCU admissions increased from 121 [IQR: 77–155] to 137 [IQR: 79–184]. Availability of advanced equipment improved (syringe pumps: 57–100 %, vital sign monitors: 51–100 % and CPAP machine: 14–100 %). There were significant improvements in QI skills among NCU staff. All 7 NCUs (100 %) addressed non-adherence to protocol as a priority gap, 5 NCUs (86 %) also improved communication with families. NCU case fatality rate declined from 12.4 to 7.8 % (p = 0.001).ConclusionsThe ABC package of interventions combining the provision of essential equipment to NCU, clinical training and strong mentorship, QI coaching, and the LCS approach for peer-to-peer learning was associated with significant neonatal mortality reduction and services utilization in the intervention hospitals.

The comparison of the perinatal outcomes in monochorionic twin pregnancies with and without selective intrauterine growth restriction

Objective Both fetuses may be affected negatively as a result of the non-equal share of the placenta and vascular anastomoses in monochorionic pregnancies with selective intrauterine growth restriction (sIUGR). In our study, we aimed to investigate the perinatal outcomes of both larger and smaller fetuses in monochorionic pregnancies with and without sIUGR (non-sIUGR) separately. Methods A total of 196 monochorionic twin pregnancies were evaluated retrospectively between January 2013 and January 2019. The cases were grouped as sIUGR and non-sIUGR pregnancies. The pregnancies with sIUGR were also separated into sub-groups as the cases with normal umbilical flow pattern and the cases with abnormal umbilical flow pattern. The perinatal outcomes were investigated separately between the groups for larger and smaller fetuses. Results Of 153 monochorionic pregnancies included in the study, 17.6% (n=27) were sIUGR cases and 82.4% (n=126) were non-sIUGR cases. While the umbilical artery flow pattern was normal in 59.3% (n=16) of the pregnancies which developed sIUGR, 40.7% (n=11) of them had abnormal umbilical artery flow pattern. The preeclampsia rate was found significantly higher in sIUGR pregnancies than non-sIUGR pregnancies (25.9% vs. 11.1%, p=0.042). The need for intensive care for both larger and smaller newborns was significantly higher in sIUGR pregnancies compared to non-sIUGR pregnancies (p<0.001). Three (11.1%) of newborns in sIUGR pregnancies passed away during neonatal period. All of the newborns that passed away were the smaller newborns from sIUGR pregnancies with abnormal umbilical artery flow pattern. Conclusion The pregnancies with selective intrauterine growth restriction (sIUGR) are more associated with high risks in terms of perinatal outcomes compared to the pregnancies with non-sIUGR. In pregnancies developing sIUGR, the risk increases for larger fetus as well as smaller fetus. More prospective studies are needed to investigate whether this increased risk in the pregnancies with sIUGR is associated with prematurity which is more common or is a result of sIUGR.

Special Newborn Care Plus Project in India: Preliminary Findings from Community-Based Follow-up of Newborns Discharged from Facilities

An innovation of structured community based followup of SNCU discharged babies by ANM and ASHA was piloted under Norway India Partnership initiative. The current study describes the survival status and other outcomes among newborns discharged from SNCUs and followed at community level in first 42 days of life. It is a retrospective cohort study on newborns discharged from SNCUs from 13 districts across four states of India. Routine health systems data have been utilized to record key parameters like birth weight, sex, weights during follow-ups, any illnesses reported, status of feeding and survival status. These were compared between normal and low birth weight babies. Newborns discharged from special newborn care units (SNCUs) and followed up at community level at 24 hours, 7 days after first visit, and at 6 weeks of life. Follow up of 6319 newborns were conducted by the ANM (25.4%), ASHAs (4.7%) or both (69.8%); 97% of the babies were followed-up at all the visits. The median duration of follow- ups were 1 day post-discharge, 13th day and 45th days of life. Majority (97%) of them were breastfed, and were warm to touch at the time of the visit. More than 11% of the babies needed referral at every visit. Mortality rate in the cohort of babies discharged from SNCUs till 6 weeks of follow up was 1.5%. Among normal birth weight newborns, it was 0.4% while it was 2.02% among LBW babies. The proportion of girls among those who died increased from 20% in the first follow up to 38.1% at second follow up and 41% at 6 weeks. Babies with LBW were at higher risk of death as compared to babies with normal birth weight. Follow-up at critical timepoints can improve survival of small and sick newborns after discharge from SNCUs.

Vaccination timeliness and completeness among preterm and low birthweight infants: a national cohort study

ABSTRACT Vaccinating premature and low birthweight (LBW) infants according to chronological age has been found safe and effective. Although these infants are susceptible to infections, vaccinations are often delayed. We estimated vaccination coverage (VC) in preterm and LBW infants compared to term infants in a cohort study (2016 Israel birth cohort, n = 181,543) using the National Immunization Registry. Vaccinations included Hepatitis B, Diphtheria-Tetanus-acellular Pertussis-IPV-Haemophilus influenzae B, Oral Polio Bivalent, Rotavirus, Pneumococcal Conjugate, Measles-Mumps-Rubella-Varicella and Hepatitis A. Inclusion criteria: (1) born in Israel; (2) having a unique identifier (allowing data matching); and (3) surviving to 24 months. VC at 24 months and timeliness of vaccine doses were evaluated according to infants’ birthweight (BW) and gestational age (GA). Preterm infants (GA < 37 weeks) comprised 7.0% (n = 12,264); LBW infants (BW< 2500 g) were 7.7% (n = 13,950); BW was 1500–2499 g in 6.8%, 1000–1499 g in 0.6% and below 1000 g in 0.3%. Compared to normal birthweight (NBW) infants (BW≥2500 g), LBW infants showed delayed initiation of vaccinations. Odds ratio (OR) for delay: DTaP-IPV-Hib 1 OR = 1.26 [95%CI 1.19–1.33]; Rota 1, OR = 1.22 [95%CI 1.16–1.29]. Vaccination delay rates were higher among smaller new-borns (below 1000 g). At 24 months there was no significant difference regarding vaccination status. This national cohort VC analysis focused on preterm/LBW infants. Vaccinating preterm and LBW infants according to the recommended schedule induces protection against life-threatening infectious diseases. Vaccination initiation among LBW infants showed considerable delay. Health practitioners and parents should cooperate to improve timely vaccination initiation.

Preterm Small Gestational Age Newborns: Impact on Renal Size and Function

OBJECTIVE: The objective of the study was to evaluate the size and function of the kidney in high-risk premature small gestational age (PT/SGA) newborns. Furthermore, estimation of the glomerular filtration rate (GFR) was done by comparing Cystatin C-based method with the creatinine –based method in those preterm newborns.&#x0D; PATIENTS AND METHODS: The study included 20 PT/SGA and controls (20 preterm appropriate for gestational age [PT/AGA] and 20 full-term [FT] newborns). Serum creatinine, blood urea nitrogen, and cystatin C were determined on days 3 and 7 of the study for all newborn infants. GFR was assessed by cystatin C-based method and creatinine-based method. Evaluation of the renal size by ultrasound was done on day 7 of neonatal life.&#x0D; RESULTS: A significant difference was found in the length and transverse diameter of both kidneys, comparing PT/SGA group with PT/AGA and FT group. Cystatin C on day 3 of PT/SGA group had a significant difference than PT/AGA and FT group. Estimation of GFR (eGFR) calculated by filler Zappitelli, Grubb, Larsson, and Dorum formulae of PT/SGA group had a significant difference comparing with PT/AGA and FT group on days 3 and 7.&#x0D; CONCLUSION: PT/SGA newborns have reduced renal size and immature renal function. Cystatin C is a marker for renal function superior to creatinine as it is not affected by body mass index, gestational age, and birth weight. Cystatin C-based eGFR is more accurate and more sensitive to minor changes in GFR than creatinine-based equation.

Birth Anthropometry Predicts Neonatal and Infant Mortality in Rural Bangladesh: A Focus on Circumferential Measurements

Background: Risk of infant death is increased in small newborns. Weight and length are typically measured at birth while circumferences are less often assessed. We investigated abilities of birth length, weight, and mid-upper arm (MUAC), head (HC) and chest (CC) circumferences to predict infant mortality in rural northwest Bangladesh. Methods: Singletons born during an antenatal micronutrient supplementation trial (n=21 174) were measured < 72 hours of birth. Vital status was prospectively recorded throughout infancy, identifying 583 deaths. Optimal cut-offs for predicting neonatal (NMR ≤28 days) and infant (IMR ≤365 days) mortality for each measurement were informed by the Youden Index (sensivity+specificity-1). Relative Risk Ratios (RRRs) and positive predictive values (PPVs) were calculated at cut-offs throughout the range of each measurement, and for indices combining any two. Results: Predictive cutoffs, harmonized to 100 g or 0·5 cm readings, for both NMR and IMR were 44.5 cm for length, 2200 g for weight, 9·0 cm for MUAC, 31·0 cm for HC, and for 28·5 cm CC. A CC <28·5 cm, alone and combined with HC <31·0 cm, versus higher values, yielded highest RRRs [9·68 (95% CI:7·84-11·94) and 15.74 (95% CI:12·54-19·75)] and PPVs (11·3% and 16·3%) for neonatal and infant [RRRs=6.02 (95% CI:5·15-7·02) and 9.19 (95% CI:7·72-10·95) and PPVs (10·7% and 14·6%)] mortality. At harmonized cut-offs, all indices revealed higher RRRs (range:5·34-9·19) and PPVs (range:8·5%-14·5%) than individual measurements (ranges:3·40-6·02 and 6·4%-16·3%, respectively). Conclusions: In rural Bangladesh, chest circumference alone or combined with head circumference was more predictive of neonatal and infant mortality than other measurements. Trial Registration: ClinicalTrials.gov INCT00860470 Funding Statement: Bill & Melinda Gates Foundation (Grants GH614 and OPP1441435, Senior Program Officer: Ellen Piwoz), Seattle, WA, USA and the Sight and Life Global Nutrition Research Institute (Klaus Kraemer), Baltimore MD. Declaration of Interests: None. Ethics Approval Statement: Verbal informed consent was obtained from mothers prior to enrollment in the trial. The study protocol was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, Baltimore, Maryland, and the Bangladesh Medical Research Council, Dhaka, Bangladesh.

World Prematurity Day: improving survival and quality of life for millions of babies born preterm around the world

World Prematurity Day: improving survival and quality of life for millions of babies born preterm around the world

Essential Newborn Care Among Postnatal Mothers at Selected Health Centers in Eastern Province, Rwanda

Background&#x0D; Rwanda's neonatal mortality rate is 20/1000 live births, and the country aims to meet the Sustainable Development Goal of 12 deaths per 1000 live births, or less, by 2030. Countries have decreased newborn deaths, infections, and intensive care unit admissions using the evidenced-based 'Essential Newborn Care' (ENC) guidelines established by the World Health Organization.&#x0D; Objective&#x0D; To assess postnatal mothers’ knowledge and practice of Essential Newborn Care in Kayonza District, Rwanda.&#x0D; Method&#x0D; A descriptive cross-sectional design was used to assess 192 postnatal mothers at the six-week vaccination services at two health facilities. Data collection using a valid questionnaire occurred from February 28 to March 2, 2019. Data analysis included descriptive and binary logistic regression.&#x0D; Results&#x0D; The majority (65.1%) had good ENC knowledge and practice, whereas a third (34.9%) had poor knowledge and practice. Significant gaps in ENC included timing of breastfeeding 33(17.2%), cord care 32(16.7%), and thermoregulation of small birth weight newborns 6(3.1%). Significant associations with ENC included maternal age (p=0.003), and ENC education postpartum (p=0.020).&#x0D; Conclusion&#x0D; The overall knowledge and practice of ENC are encouraging in this population, particularly with ENC education given postpartum, and older mothers. However, major gaps included evidenced-based cord care, thermoregulation, and breastfeeding, particularly among younger mothers.&#x0D; Rwanda J Med Health Sci 2020;3(2):139-151

Placental vascular tree characterization based on ex-vivo MRI with a potential application for placental insufficiency assessment

IntroductionUnderstanding regarding the whole placental vascular network structure is limited. Our aim was to quantitatively characterize the human placental vascular tree ex-vivo using high-resolution MRI. Methods34 normal placentas were rinsed and injected with a solution of gelatin and contrast agent through the umbilical vessels. A sample of six placentas taken from pregnancies with intrauterine-growth-restriction (IUGR) was used to demonstrate the potential application to cases with placental insufficiency. Structural ex-vivo MR scans of the placenta were performed using high resolution T1 weighted images. A semi-automatic method was developed to segment and characterize the placental vascular architecture: placental volume and cord insertion location, number of bifurcations, generations and vessels diameters. ResultsDifferent vascular patterns were found in placentas with central versus marginal cord-insertion. Based on the placental volume and number of bifurcations we were able to predict birth weight. Furthermore, preliminary results on IUGR sample demonstrated the potential of this method to differentiate between small newborns with suspected IUGR from small normal newborns who reached their full growth potential. Results obtained using the automatic method were validated against manual values demonstrating no significant differences or bias. Histopathology supported the imaging findings. DiscussionThis is the first study to quantitatively characterize the human placental vascular architecture using high resolution ex-vivo MRI. Different patterns of vascular architecture may be related to different functioning of the placenta and affect fetal development. This method is simple, relatively fast, provides detailed information of the placental vascular architecture, and may have important clinical applications.

Non-pregnant Women Have a Lower Vitamin D than Pregnant Women After Gastric Bypass.

To compare the nutritional status of vitamin D, calcium, and serum concentrations of parathyroid hormone (PTH) between women undergoing Roux-en-Y gastric bypass (RYGB) who became pregnant and women who did not become pregnant during the same postoperative period, as well as the impact of these changes on maternal and child health. This is a longitudinal and retrospective study of women who previously underwent RYGB, paired by age and preoperative body mass index (BMI), divided into two groups: group 1 (G1), comprising 79 women who did not become pregnant, and group 2 (G2), comprising 40 pregnant women assessed in the overall trimesters. Both groups were analyzed before surgery (T0) and in the same interval after surgery: less than or equal to 1year (T1) or greater than 1year (T2), with a 2-year period at the most. Serum concentrations of vitamin D, calcium, parathyroid hormone (PTH), and gestational and neonatal complications were investigated. Statistical analysis was performed by the Statistical Package for the Social Sciences 21.0 (p < 0.05). Despite the additional nutritional demands at pregnancy, women evaluated after 1year of RYGB had the highest demands of vitamin D when compared with pregnant women in the second trimester(p = 0.04). Women who became pregnant within 1year of bariatric surgery were more likely to develop a urinary tract infection which, in turn, was associated with vitamin D inadequacy (p = 0.02).In the same period, the concentrations of calcium in the second and third trimesters showed a strong correlation with the number of pregnancies (R = 0.8, p = 0.008, R = 0.8, p = 0.003) and deliveries (R = 0.7, p = 0.013, R = 0.8, p = 0.006) and its nutritional status in the first trimester also showed a strong correlation with the occurrence of small newborns for gestational age/large for gestational age (SGA/LGA) (R = 0.8, p = 0.007). Since the highest vitamin D depletions occurred in G1 when compared with G2, the study suggests that a period of time for supplementation and its adjustments in post-bariatric pregnancy may be beneficial. It also encourages further investigation on the number of pregnancies/deliveries during prenatal care, due to vitamin D influence on the nutritional status of calcium, and it points out that changes in concentrations of this vitamin in pregnant women may lead to SGA/LGA newborns' births.

Perceptions and practices related to birthweight in rural Bangladesh: Implications for neonatal health programs in low- and middle-income settings.

BackgroundGlobally, low birthweight (LBW) infants (<2,500 grams) contribute up to 80% of neonatal mortality. In Bangladesh, approximately 62% of all births occur at home and therefore, weighing newborns immediately after birth is not feasible. Thus, estimates of birthweight in Bangladesh are mostly obtained based on maternal perception of the newborn’s birth size. Little is known about how birthweight is perceived in rural communities, and whether families associate birthweight with newborn’s health status. Our objective was to explore families’ perceptions of newborn’s birthweight, preventive practices to LBW, and care practices for a LBW newborn in rural Bangladesh.MethodsWe conducted a qualitative study in two rural settings of Bangladesh, including 32 in-depth interviews (11 with pregnant women, 12 with recently delivered women, 4 with husbands whose wives were pregnant or had a recent birth, 5 with mothers-in-law whose daughters-in-law were pregnant or had a recent birth), 2 focus group discussions with husbands and 4 key-informant interviews with community health workers. We used thematic analysis to analyse the data.ResultsMost participants did not consider birthweight a priority for assessing a newborn’s health status. Recognition of different categories of birthweight was subjective and often included several physical descriptors including birth size of the newborn. LBW was not considered as a criterion of a newborn’s illness unless the newborn appeared unwell. Maternal poor nutrition, inadequate diet in pregnancy, anaemia, illnesses during pregnancy, short stature, twin births and influence of supernatural spirit were identified as the major causes of LBW. Women’s preventive practices to LBW or small newborns were predominantly constrained by a lack of awareness of birthweight and fear of caesarean section. As an effort to avoid caesarean section during birth, several women tended to perform potentially harmful practices in order to give birth to a LBW or small size newborn; such as avoiding nutritious food and decreasing food intake in pregnancy. Common practices to treat a LBW or small newborn who appeared ill included breastfeeding, feeding animal milk, feeding sugary water, feeding formula, oil massage, keeping the small newborn warm and seeking care from formal and informal care providers including a spiritual leader. Maternal lack of decision-making power, financial constraint, home birth and superstition were the major challenges to caring for a LBW newborn.ConclusionBirthweight was not well-understood in the rural community, which highlighted substantial challenges to the prevention and care practices of LBW newborns. Community-level health education is needed to promote awareness related to the recognition of birthweight in rural settings.

Vigilance behaviour in Siberian ibex (Capra sibirica): Effect of group size, group type, sex and age

Gregarious prey species modify their behaviours in response to predation risk in two ways: by increasing vigilance level or enlarging herd size. However, individuals of various sex and age have different responses to the same danger, and even the same individuals react differently depending on their status during biological events or within group types. But how these factors influence the interactions between vigilance level and group size is still poorly understood. Therefore, we studied this phenomenon by observing and analyzing the behaviours of the Siberian ibex (Capra sibirica) in the Eastern Tian-Shan Mountains (China). We found that similar to many other gregarious ungulates, Siberian ibex demonstrated a decrease in vigilance level with an increase in group size, since staying in larger groups increased the probability of predator detection and reduced the possibility of being captured. In general, males were more vigilant than females during the rut due to the sharp increase in their social alertness to achieve greater success in reproduction. In contrast, females were more vigilant than males out of rutting time, particularly significantly following parturition, since mothers spent a lot of their energy in maternal care, which coupled with having small and unexperienced newborns, made them more vulnerable to predation than other conspecifics. Siberian ibex had the same vigilance level in summer and winter, because of seasonally opposite trade-offs between feeding duration and vigilance level based on seasonal changes in food availability. Individuals in mixed-sex and female groups were more often targeted by predators, prompting individuals from these groups to be more vigilant than in male groups. The vigilance level in males decreased with age likely because of their increased body size and enhanced vigilance experience, which reduced their risk of predation. Our study confirmed that the Siberian ibex’ vigilance level inversely correlated with group size, but other various factors, such as forage biomass/quality, sex, biological cycle, group types and age, had significant impacts on their interrelationship.

Genome-Wide DNA Methylation Changes in Placenta Tissues Associated with Small or Gestational age Newborns; Cohort Study In The Chinese Population

Aim: To investigate DNA methylation changes in placenta tissues associated with small for gestational age (SGA). Materials & methods: A prospective cohort study consisting of 1292 pregnant women from China (including 39 SGA with placenta tissues) was performed, microarray and pyrosequencing were conducted. Results:Total 2012 methylation variable positions stood out from all probes (p<0.05; Δβ>0.2). In SGA cases, a CpG site within ANKRD20B showed lower methylation level (p=0.032) than appropriate for gestational age in validation cohort. Five sites within FAM198A (p=0.047, 0.050, 0.039, 0.026 and 0.043, respectively) had a reduced methylation in male newborns whose mother had preconception folic acid supplementation. Conclusion: DNA methylation changes in placenta tissues may be associated with SGA, maternal preconception folic acid supplementation status and also be fetal sex-specific.

Categorising interventions to levels of inpatient care for small and sick newborns: Findings from a global survey.

BackgroundIn 2017, 2.5 million newborns died, mainly from prematurity, infections, and intrapartum events. Preventing these deaths requires health systems to provide routine and emergency care at birth, and quality inpatient care for small and sick newborns. Defined levels of emergency obstetric care (EmOC) and standardised measurement of “signal functions” has improved tracking of maternal care in low- and middle-income countries (LMICs). Levels of newborn care, particularly for small and sick newborns, and associated signal functions are still not consistently defined or tracked.MethodsBetween November 2016-November 2017, we conducted an online survey of professionals working in maternal and newborn health. We asked respondents to categorise 18 clinical care interventions that could act as potential signal functions for small and sick newborns to 3 levels of care they thought were appropriate for health systems in LMICs to provide: “routine care at birth”, “special care” and “intensive care”. We calculated the percentage of respondents that classified each intervention at each level of care and stratified responses to look at variation by respondent characteristics.ResultsSix interventions were classified to specific levels by more than 50% of respondents as “routine care at birth,” three interventions as “special care” and one as “intensive care”. Eight interventions were borderline between these care levels. Responses were more consistent for interventions with relevant WHO clinical care guidelines while more variation in respondents’ classification was observed in complex interventions that lack standards or guidelines. Respondents with experience in lower-income settings were more likely to assign a higher level of care for more complex interventions.ConclusionsResults were consistent with known challenges of scaling up inpatient care in lower-income settings and underline the importance of comprehensive guidelines and standards for inpatient care. Further work is needed to develop a shortlist of newborn signal functions aligned with emergency obstetric care levels to track universal health coverage for mothers and their newborns.

Development and evaluation of a mobile application for case management of small and sick newborns in Bangladesh

BackgroundIn low-income settings, community health workers (CHWs) are frequently the first point of contact for newborns. Mobile technology may aid health workers in classifying illness and providing referral and management guidance for newborn care. This study evaluates the potential for mobile health technology to improve diagnosis and case management of newborns in Bangladesh.MethodsA mobile application based on Bangladesh’s Comprehensive Newborn Care Package national guidelines (mCNCP) was developed to aid CHWs in identifying and managing small and sick infants. After a 2-day training, CHWs assessed newborns at Sylhet Osmani Medical College Hospital and in the Projahnmo research site (Sylhet, Bangladesh) using either mCNCP or a comparable paper form (pCNCP), similar to standard IMCI-formatted paper forms. CHWs were randomized to conduct a block of ~ 6 newborn assessments starting with either mCNCP or pCNCP, then switched to the alternate method. Physicians using mCNCP served as gold standard assessors. CHW performance with mCNCP and pCNCP were compared using chi-squared tests of independence for equality of proportions, and logistic regressions clustered by CHW.ResultsTwo hundred seven total CHW assessments were completed on 101 enrolled infants. mCNCP assessments were more often fully completed and completed faster than pCNCP assessments (100% vs 23.8%, p < 0.001; 17.5 vs 23.6 min; p < 0.001). mCNCP facilitated calculations of respiratory rate, temperature, and gestational age. CHWs using mCNCP were more likely to identify small newborns (Odds Ratio (OR): 20.8, Confidence Interval (CI): (7.1, 60.8), p < 0.001), and to correctly classify 7 out of 16 newborn conditions evaluated, including severe weight loss (OR: 13.1, CI: (4.6, 37.5), p < 0.001), poor movement (OR: 6.6, CI: (2.3, 19.3), p = 0.001), hypothermia (OR: 14.9, CI: (2.7, 82.2), p = 0.002), and feeding intolerance (OR: 2.1, CI: (1.3, 3.3), p = 0.003). CHWs with mCNCP were more likely to provide counseling as needed on 4 out of 7 case management recommendations evaluated, including kangaroo mother care.ConclusionsCHWs in rural Bangladesh with limited experience using tablets successfully used a mobile application for neonatal assessment after a two-day training. mCNCP may aid frontline health workers in Bangladesh to improve completion of neonatal assessment, classification of illnesses, and adherence to neonatal management guidelines.

Facility readiness in low and middle-income countries to address care of high risk/ small and sick newborns

BackgroundThe successful promotion of facility births in low and middle-income countries has not always resulted in improved neonatal outcome. We evaluated key signal functions pertinent to Level II neonatal care to determine facility readiness to care for high risk/ small and sick newborns.MethodFacility readiness for care of high risk/ small and sick babies was determined through self-evaluation using a pre-designed checklist to determine key signal functions pertinent to Level II neonatal care in selected referral hospitals in Uganda (10), Indonesia (4) and India (2) with focus on the Sub-Saharan country with greater challenges.ResultsMost facilities reported having continuous water supply, resources for hand hygiene and waste disposal. Delivery rooms had newborn corners for basic neonatal resuscitation, but few practiced proper reprocessing of resuscitation equipment. Birth weight records were not consistently maintained in the Ugandan hospitals. In facilities with records of birth weights, more than half (51.7%) of newborns admitted to the neonatal units weighed 2500 g or more. Neonatal mortality rates ranged from 1.5 to 22.5%. Evaluation of stillbirths and numbers of babies discharged against medical advice gave a more comprehensive idea of outcome. Kangaroo Mother Care was practiced to varying extents. Incubators were more common in Africa while radiant warmers were preferred in Indian hospitals. Tube feeding was practiced in all and cup feeding in most, with use of human milk at all sites. There were proportionately more certified pediatricians and nurses in Indonesia and India. There was considerable shortage of nursing staff, (worst nurse –bed ratio ranging from 1 to 15 in the day shift, and 1 to 30 at night). There was significant variability in facility readiness, as in data maintenance, availability of commodities such as linen, air -oxygen blenders and infusion pumps and of infection prevention practices.ConclusionsReferral neonatal units in LMIC have challenges in meeting even the basic level II requirements, with significant variability in equipment, staffing and selected care practices. Facility readiness has to improve in concert with increased facility births of high risk newborns in order to have an impact on neonatal outcome, and on achieving Sustainable Development Goals 3.2.2.

Neighbourhood greenness and birth outcomes in a Swedish birth cohort - A short communication.

The present study investigated whether associations between greenness and birth outcomes can be detected in children belonging to a Swedish birth cohort (BAMSE). Normalized difference vegetation index (NDVI) within a 500 m buffer zone around maternal address was used as estimate of greenness. Ordinary least squares and quantile regression models were performed to investigate associations between neighbourhood NDVI and birthweight (n = 2619), birth length (n = 2490) and head circumference (n = 2243). Logistic regression analyses were used to detect the association between NDVI and odds of being born as "small-" or "large-for-gestational-age". There were no clear associations between NDVI and birth weight in the total sample. However, in a suburban sub-sample, increased NDVI levels were significantly associated with elevated birthweight of small new-borns (β2nd percentile = 276 g, 95% CI 61 to 492, p = 0.012), and significantly reduced the odds ratio (OR) for children being born as small-for-gestational-age (OR = 0.31 95% CI 0.1 to 1, p = 0.049). No significant associations were found between NDVI and birth length or head circumference. In conclusion, neighbourhood greenness appears not to be associated with birthweight as such, but rather decrease the odds of being born underweight, in particular in suburban areas.

A health systems strengthening intervention to improve quality of care for sick and small newborn infants: results from an evaluation in district hospitals in KwaZulu-Natal, South Africa

BackgroundMany newborn infants die from preventable causes in South Africa, often these deaths occur in district hospitals. A multipronged intervention aiming to improve quality of newborn care in district hospitals was implemented comprising training in clinical care for sick and small newborns, skills development for health managers, on-site mentoring, and hospital accreditation. We present the results of the project evaluation.MethodsWe conducted three sequential cross-sectional surveys in 39 participating district hospitals at baseline, midpoint and endpoint of the three-year intervention period. Data were collected by a trained midwife using a series of checklists including: availability of trained staff, drugs and equipment; newborn care practices; perinatal mortality audits; neonatal unit staff skills; quality of record keeping. A scoring system was developed for three domains: resources; care practices; resuscitation equipment, and a composite score that included all variables measured. Health worker (HW) knowledge was assessed at midpoint and endpoint.ResultsThe average score for resources increased from 13.5 at baseline to 22.6 at endpoint (maximum score 34), for care practices from 17.7 to 22.6 (maximum score 29), and for resuscitation equipment from 10.8 to 16.1 (maximum 25). Average composite score improved significantly from 42.0 at baseline to 55.7 at midpoint to 60.7 at endpoint (maximum score 88) (p = 0.0012). Among 39 participating hospitals, 38 achieved higher scores at endpoint compared to baseline. Knowledge was higher among HWs trained during the project at midpoint and endpoint. Gaps that remained included poor infrastructure, lack of resuscitation equipment in some areas, poor postnatal care and lack of a dedicated doctor.ConclusionsThis intervention achieved measurable improvements in many important elements contributing to newborn care. A scoring system was used to track progress, compare facilities’ performance, and identify areas for improvement. Various methods were used to generate the quality of care score, including skills assessment and record reviews. However, measuring quality of clinical care and outcomes was challenging, and we were unable to determine whether the intervention improved clinical care and lead directly to improved outcomes for babies. In developing a future score for quality of care, a stronger focus should be placed on assessing clinical care and outcomes.

Geographical Analysis of the Distribution of Publications Describing Spatial Associations among Outdoor Environmental Variables and Really Small Newborns in the USA and Canada

Newborns defined as being of “low birth weight” (LBW) or “small for gestational age” (SGA) are global health issues of concern because they are vulnerable to mortality and morbidity. Prenatal exposures may contribute to LBW/SGA. In this review, we searched peer-reviewed scientific literature to determine what location-based hazards have been linked with LBW/SGA in the industrialized nations of Canada and the USA. After selecting studies based on inclusion/exclusion criteria, we entered relevant details in to an evidence table. We classified and summarized 159 articles based on type of environment (built = 108, natural = 10, and social = 41) and general category of environmental variables studied (e.g., air pollution, chemical, water contamination, waste site, agriculture, vegetation, race, SES, etc.). We linked the geographic study areas by province/state to political boundaries in a GIS to map the distributions and frequencies of the studies. We compared them to maps of LBW percentages and ubiquitous environmental hazards, including land use, industrial activity and air pollution. More studies had been completed in USA states than Canadian provinces, but the number has been increasing in both countries from 1992 to 2018. Our geographic inquiry demonstrated a novel, spatially-focused review framework to promote understanding of the human ‘habitat’ of shared environmental exposures that have been associated with LBW/SGA.