Impact of simple interventions on neonatal mortality in a low-resource teaching hospital in India

Feasibility, Sustainability, and Effectiveness of the Implementation of "Facility-Team-Driven" Approach for Improving the Quality of Newborn Care in South India

OBJECTIVES

The primary objective of the study was to assess the feasibility and sustainability of the implementation of the point of care quality improvement (POCQI) methodology for improving the quality of neonatal care at the level 2 special newborn care unit (SNCU). Additional objective was to evaluate the effectiveness of the quality improvement (QI) and preterm baby package training model.

METHODS

This study was conducted in a level-II SNCU. The study period was divided into baseline; intervention and sustenance phases. The primary outcome i.e., feasibility was defined as completion of training for 80% or more health care professionals (HCPs) through workshops, their attendance in subsequent review meetings and, successful accomplishment of at least two plan-do-study-act (PDSA) cycles in each project.

RESULTS

Of the total, 1217 neonates were enrolled during the 14 mo study period; 80 neonates in the baseline, 1019 in intervention and 118 in sustenance phases. Feasibility of training was achieved within a month of initiation of intervention phase; 22/24 (92%) nurses and 14/15 (93%) doctors attended the meetings. The outcomes of individual projects suggested an improvement in proportion of neonates being given exclusive breast milk on day 5 (22.8% to 78%); mean difference (95% CI) [55.2 (46.5 to 63.9)]. Neonates on any antibiotics declined, proportion of any enteral feeds on day one and duration of kangaroo mother care (KMC) increased. Proportion of neonates receiving intravenous fluids during phototherapy decreased.

CONCLUSIONS

The present study demonstrates the feasibility, sustainability, and effectiveness of a facility-team-driven QI approach augmented with capacity building and post-training supportive supervision.

Infection prevention and care bundles addressing health care-associated infections in neonatal care in low-middle income countries: a scoping review

BACKGROUND

Health care-associated infections (HCAI) in neonatal units in low- and middle-income countries (LMIC) are a major cause of mortality. This scoping review aimed to synthesise published literature on infection prevention and care bundles addressing neonatal HCAI in LMICs and to construct a Classification Framework for their components (elements).

METHODS

Five electronic databases were searched between January 2001 and July 2020. A mixed-methods approach was applied: qualitative content analysis was used to build a classification framework to categorise bundle elements and the contents of the classification groups were then described quantitatively.

FINDINGS

3619 records were screened, with 44 eligible studies identified. The bundle element Classification Framework created involved: (1) Primary prevention, (2) Detection, (3) Case management, and Implementation (3 + I). The 44 studies included 56 care bundles with 295 elements that were then classified. Primary prevention elements (128, 43%) predominated of which 71 (55%) focused on central line catheters and mechanical ventilators. Only 12 elements (4%) were related to detection. A further 75 (25%) elements addressed case management and 66 (88%) of these aimed at outbreak control.

INTERPRETATION

The 3 + I Classification Framework was a feasible approach to reporting and synthesising research for infection-relevant bundled interventions in neonatal units. A shift towards the use in infection prevention and care bundles of primary prevention elements focused on the neonate and on commonly used hospital devices in LMIC (e.g., self-inflating bags, suctioning equipment) would be valuable to reduce HCAI transmission. Detection elements were a major gap.

FUNDING

This work was made possible in part by the John D. and Catherine T. MacArthur Foundation, the Bill & Melinda Gates Foundation, ELMA Philanthropies, The Children's Investment Fund Foundation UK, The Lemelson Foundation, and the Ting Tsung and Wei Fong Chao Foundation under agreements to William Marsh Rice University. The project leading to these results has also received the support of a fellowship from the "la Caixa" Foundation (ID 100010434). The fellowship code is LCF/BQ/EU19/11710040. EJAF is an Academic Clinical Fellow whose salary is funded by the UK National Institute for Health Research (NIHR). NES receives a Research Training Program Scholarship (Australian Commonwealth Government).

Impact of a Multifactorial Educational Training on the Management of Preterm Infants in the Central-Eastern European Region

Background: Differences in management and outcomes of extremely preterm infants have been reported across European countries. Implementation of standardized guidelines and interventions within existing neonatal care facilities can improve outcomes of extremely preterm infants. This study evaluated whether a multifactorial educational training (MET) course in Vienna focusing on the management of extremely preterm infants had an impact on the management of extremely preterm infants in Central-Eastern European (CEE) countries. Methods: Physicians and nurses from different hospitals in CEE countries participated in a two-day MET in Vienna, Austria with theoretical lectures, bedside teaching, and simulation trainings. In order to evaluate the benefit of the workshops, participants had to complete pre- and post-workshop questionnaires, as well as follow-up questionnaires three and twelve months after the MET. Results: 162 participants from 15 CEE countries completed the two-day MET at our department. Less invasive surfactant administration (LISA) was only used by 39% (63/162) of the participants. After the MET, 80% (122/152) were planning to introduce LISA, and 66% (101/152) were planning to introduce regular simulation training, which was statistically significantly increased three and twelve months after the MET. Thirty-six percent and 57% of the participants self-reported improved outcomes three and twelve months after the MET, respectively. Conclusion: Our standardized training in Vienna promoted the implementation of different perinatal concepts including postnatal respiratory management using LISA as well as regular simulation trainings at the participants' home departments. Moreover, our MET contributed to dissemination of guidelines, promoted best-practice, and improved self-reported outcomes.

Clinical profile and predictors of mortality among the referred neonates at a tertiary care centre in north India: a prospective observational study

The National Family Health Survey (NFHS-4) shows encouraging improvement in infant and under-five mortality rates in India. However, the neonatal mortality rate (NMR) still remains high as India contributes to about one-fifth of global deaths. This prospective study was conducted from 15 January to 30 April 2016 to examine the clinical profile and predictors of mortality among referred neonates at our centre. Among 301 neonates, prematurity (40%) was the most common indication for referral followed by need for ventilation (38%) and birth asphyxia (28%). Approximately 73% neonates were referred within 24 h of birth. Ninety (29.9%) neonates died; of these, 63% died within 24 h of presentation. Prematurity, birth asphyxia, hypothermia, shock at presentation and extreme low birth weight were the most significant predictors of mortality. Adequate training of peripheral health personnel, dedicated teams for neonatal referral and strengthening of peripheral sick newborn care units (SNCUs) seem to be promising interventions for favourable outcome.

Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols.  Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.

Causes of death in preterm neonates (<33 weeks) born in tertiary care hospitals in India: analysis of three large prospective multicentric cohorts

OBJECTIVE

To estimate the direct causes of mortality among preterm neonates <33 weeks' gestation by examining three large multisite, hospital-based datasets in India.

METHOD

Three prospective hospital-based datasets: the National Neonatal Perinatal Database (NNPD) of India, the Delhi Neonatal Infection Study (DeNIS) cohort, and the Goat Lung Surfactant Extract (GLSE)-Plus cohort were analyzed to study the causes of death among preterm neonates of less than 33 weeks' gestation admitted to the participating tertiary care hospitals in India.

RESULTS

A total of 8024 preterm neonates were admitted in the three cohorts with 2691 deaths. Prematurity-related complications and sepsis contributed to 53.5% and 19.8% of deaths in the NNPD cohort, 51.0% and 25.0% in the DeNIS cohort, and 39.7% and 40.9% in GLSE-Plus cohort, respectively.

CONCLUSIONS

Nearly a quarter (20-40%) of preterm neonates less than 33 weeks' gestation admitted to Indian NICUs died of sepsis. The study results have implications for health policies targeted to reduce the neonatal mortality rate in India.

Care of infants with gastroschisis in low-resource settings

There is great global disparity in the outcome of infants born with gastroschisis. Mortality approaches 100% in many low income countries. Barriers to better outcomes include lack of antenatal diagnosis, deficient pre-hospital care, ineffective neonatal resuscitation and venous access, limited intensive care facilities, poor access to the operating theatre and safe neonatal anesthesia, and lack of neonatal parenteral nutrition. However, lessons can be learned from the evolution in management of gastroschisis in high-income countries, generic efforts to improve neonatal survival in low- and middle-income countries as well as specific gastroschisis management initiatives in low-resource settings. Micro and meso-level interventions include educational outreach programs, and pre and in hospital management protocols that focus on resuscitation and include the delay or avoidance of early neonatal anesthesia by using a preformed silo or equivalent. Furthermore, multidisciplinary team training, nurse empowerment, and the intentional involvement of mothers in monitoring and care provision may contribute to improving survival. Macro level interventions include the incorporation of ultrasound into World Health Organisation antenatal care guidelines to improve antenatal detection and the establishment of the infrastructure to enable parenteral nutrition provision for neonates in low- and middle-income countries. On a global level, gastroschisis has been suggested as a bellwether condition for evaluating access to and outcomes of neonatal surgical care provision.

Assessment of the quality of neonatal care in the Solomon Islands

AIM

To identify strengths and obstacles for improving the quality of newborn care in the Solomon Islands. Improving the quality of newborn care is a priority in the Sustainable Development Goals and the Action Plan for Healthy Newborns in the Western Pacific. The neonatal mortality rate in the Solomon Islands, a lower-middle-income country, has improved slower than overall child mortality. In 2013, neonatal mortality (13.2/1000) constituted 44% of under-5 deaths (30.1/1000).

METHODS

A cross-sectional study of newborn care in five provincial hospitals using a World Health Organization assessment tool for hospital quality of care. Twelve months of neonatal records of the National Referral Hospital (NRH) labour ward and nursery were audited.

RESULTS

Essential medications and basic equipment were generally available. Challenges included workforce shortages and lack of expertise, high costs, organisation and maintenance of equipment, infection control and high rates of stillbirth. Over 12 months at the NRH labour ward, there were 5412 live births, 65 (1.2%) 'fresh' stillbirths and 96 (1.8%) 'macerated' stillbirths. Over the same period, there were an associated 779 nursery admissions, and the main causes of mortality were complications of prematurity, birth asphyxia, congenital abnormalities and sepsis. Total neonatal mortality at NRH was 16 per 1000 live births, and 77% of deaths occurred in the first 3 days of life.

CONCLUSIONS

Infrastructure limitations, technical maintenance and equipment organisation were obstacles to newborn care. Greater health-care worker knowledge and skills for early essential newborn care, infection control and management of newborn complications is needed.

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 .

Improved referral and survival of newborns after scaling up of intensive care in Suriname

BACKGROUND

Scaling up neonatal care facilities in developing countries can improve survival of newborns. Recently, the only tertiary neonatal care facility in Suriname transitioned to a modern environment in which interventions to improve intensive care were performed. This study evaluates impact of this transition on referral pattern and outcomes of newborns.

METHODS

A retrospective chart study amongst newborns admitted to the facility was performed and outcomes of newborns between two 9-month periods before and after the transition in March 2015 were compared.

RESULTS

After the transition more intensive care was delivered (RR 1.23; 95% CI 1.07-1.42) and more outborn newborns were treated (RR 2.02; 95% CI 1.39-2.95) with similar birth weight in both periods (P=0.16). Mortality of inborn and outborn newborns was reduced (RR 0.62; 95% CI 0.41-0.94), along with mortality of sepsis (RR 0.37; 95% CI 0.17-0.81) and asphyxia (RR 0.21; 95% CI 0.51-0.87). Mortality of newborns with a birth weight <1000 grams (34.8%; RR 0.90; 95% CI 0.43-1.90) and incidence of sepsis (38.8%, 95% CI 33.3-44.6) and necrotizing enterocolitis (NEC) (12.5%, 95% CI 6.2-23.6) remained high after the transition.

CONCLUSIONS

After scaling up intensive care at our neonatal care facility more outborn newborns were admitted and survival improved for both in- and outborn newborns. Challenges ahead are sustainability, further improvement of tertiary function, and prevention of NEC and sepsis.

Using routine health data and intermittent community surveys to assess the impact of maternal and neonatal health interventions in low-income countries: A systematic review

BACKGROUND

There is a need to provide increased evidence on effective interventions to reduce maternal and neonatal mortality in low- and middle-income countries (LMICs).

OBJECTIVES

To summarize the breadth of knowledge on using routine data (Routine Health Information Systems [RHIS] and Intermittent Community Surveys [ICS]) for well-designed maternal and neonatal health evaluations in LMICs.

SEARCH STRATEGY

We searched reports and articles published in Embase, Medline, and Google scholar. Selection criteria Studies were considered for inclusion if they were carried out in LMICs, using RHIS or ICS data with experimental or quasi-experimental design.

DATA COLLECTION AND ANALYSIS

A form was used to collect information on indicators used for interventions' impact assessment. Descriptive statistics and multiple correspondence analyses were then performed.

MAIN RESULTS

Of the 1201 publications identified, 46 studies met the inclusion criteria. Most of these were using RHIS data (n=40), mainly extracted from health facility registers (n=34), and non-controlled before and after design (n=30). The indicators, which were mostly reported, were related to the use of healthcare services (n=36) and maternal/neonatal health outcomes (n=31). Few studies used ICS data (n=6) or indicators of severity (n=2).

CONCLUSION

RHIS and ICS data should be increasingly used for impact studies on maternal and neonatal health in LMICs.

[Trends in neonatal mortality of very-low-birth-weight infants between 1998 and 2013 in Essos Hospital, Yaoundé, Cameroon]

OBJECTIVE

To measure the mortality rate and the survival of very-low-birth-weight (VLBW) infants at two given periods.

METHOD

Descriptive retrospective study. Data were extracted from activity reports and pediatric registries during the years 1998, 1999, and 2004 for the first period and from 2010 to 2013 from the second period. This population study comprised all VLBW infants admitted to the unit weighing <1500g irrespective of gestational age. The main outcome measurement was the percentage of VLBW infants discharged alive during each period.

RESULTS

During the cumulated period, we included a total of 5250 newborn babies, of whom 315 were VLBW, giving a prevalence of 6% (7.1% in period 1 vs 5.5% in period 2, P≤0.05). The overall survival rate of VLNW infants was 52%, corresponding to a mortality rate of 48%. The death rate was 53% during the first period vs 46% in period 2 (P=0.9). In infants weighing between 1000 and 1500g, the mortality rate ranged from 47% in period 1 to 37% in period 2 (P≤0.05). Below 1000g, the rate of survival was consistently below 5%, significantly lower than for infants born above 1000g (P<0.001). In period 2, the caesarian section rate was 7% (20/217), 11% between 1000 and 1500g, 0% below 1000g. The mortality rate was higher with vaginal delivery (47%; 93/196) versus 20% caesarian section (4/20) (OR 3, 61 [1.17-11], P≤0.02).

CONCLUSION

In this center, the hospital mortality rate of VLBW infants seems to have improved, notably in those weighing more than 1000g. Significant efforts are needed to prevent VLBW births and improve management of both delivery and newborn care.

[Immediate neonatal outcome of extreme prematurity: retrospective data of a neonatal unit in Yaounde, Cameroon from 2009 to 2013]

L'objectif est de notre étude de décrire la typologie de la prématurité et mesurer la survie hospitalière à court terme des grands et extrêmes prématurés dans un pays à ressources limitées (PRL). C'est une étude descriptive rétrospective. Données extraites du registre des admissions du service. Inclusions de tous les nouveau-nés admis dans le service durant la période, ayant un âge gestationnel annoncé ≤ 36 semaines et 6 jours et plus de 26SA, avec au moins deux paramètres présents: âge gestationnel et poids de naissance. Principaux paramètres mesurés: pourcentage de nouveau-nés sortants vivants selon le type de prématurité: tardive, grande ou extrême. Nous avons recensé 1015 prématurés dont 314 grands prématurés (GP) et 61 extrêmes prématurés (EP). Le taux de nouveau-nés sortant vivants était de 95% chez les prématurés tardifs, de 71% chez les grands prématurés et de moins de 23% chez les extrêmes prématurés. Avant 28 semaines, le taux de mortalité était de prés de 100% chez les grands ou extrêmes prématurés de moins de 1000g contre 64% chez les plus de 1000g. Chez les GP le taux de décès était de 13% chez les nés par césarienne vs 21% chez ceux nés par voie basse (p ≤ 0,01). Le taux de prématurité médicalement induite était faible dans l'ensemble et de 3% chez les prématurés extrêmes. En conclusion le taux de mortalité hospitalière des EP est préoccupant, le faible taux de prématurité médicalement induite urge au renforcement de la prévention et à la mise en place de collaboration obstétrico-pédiatrique.

Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review

INTRODUCTION

Forty per cent of global child deaths occur in the neonatal period. Low and middle income countries need effective and simple methods to improve hospital-based neonatal care. Bubble continuous positive airway pressure (CPAP) may have a role in improving the quality of respiratory support in hospitals in low and middle income countries.

AIM

To examine the evidence for the efficacy and safety of bubble CPAP in neonates with respiratory distress in low and middle income settings.

METHOD

A systematic search (1946-March 2014) was performed of Pubmed, Ovid MEDLINE, Web of Science, Google Scholar and the references of relevant articles. Articles meeting inclusion criteria (CPAP for respiratory distress in infants <28 days of age in hospitals in low and middle income countries) were assessed using Grading of Recommendations, Assessment, Development and Evaluation and Newcastle-Ottawa Quality Assessment Scale methodology. Outcomes included need for mechanical ventilation, complications and mortality.

RESULTS

In three studies, the initial use of bubble CPAP compared with oxygen therapy, followed by mechanical ventilation if required, reduced the need for mechanical ventilation by 30%-50%. In another three trials comparing bubble CPAP with ventilator CPAP, mortality and complication rates were similar, while meta-analysis of CPAP failure in these same trials showed a lower failure rate in the bubble CPAP groups (p <0.003).

CONCLUSIONS

There is evidence that bubble CPAP is safe and reduces the need for mechanical ventilation. Further research into the efficacy of bubble CPAP in low-income and middle-income countries is needed.

Educational barriers of nurses caring for sick and at-risk infants in India

AIM

To gain ideas and information from healthcare providers to optimize the education and clinical practices of nurses caring for sick or at-risk newborns in India.

BACKGROUND

Improving infant survival has been identified as a Millennium Development Goals; however, India still faces many challenges with 3.1 million neonatal deaths and 2.6 million stillbirths annually. Skilled nursing care has been associated with decreased morbidity and mortality in newborns. However, core competencies in newborn care education and training are lacking for nurses.

METHODS

Qualitative data were collected from 12 focus groups with 101 newborn care providers from three areas of India as well as from a 2-day stakeholders' meeting. Data analysis was undertaken using descriptive and thematic content analysis.

RESULTS

Perceived challenges included limited manpower and high nurse turnover, lack of access to evidence-based orientation to newborn care and problems with access to appropriate learner-based, neonatal training. Relevant, ongoing education opportunities, led by nursing leaders were identified to be important solutions.

CONCLUSION

Findings provide insight into the current healthcare system in India with specific reference to the nursing care of at-risk newborns. There is a lack of existing resources to provide standardized and specific orientation curricula for nurses.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Policy makers in health and education need to: support and enact learner-based orientation and continuing educational opportunities as well as ongoing competency-based education programmes; encourage nurse leader involvement and support; and provide sustainable system-related supports. Nurses and other health providers need to work together to influence government policy.

Educational innovation for infection control in Tanzania: bridging the policy to practice gap

The incidence of hospital acquired infection in developing countries is between two to 20 times higher than in developed countries and is attributable to multiple causes. Evidence-based international policies and guidelines developed to improve infection prevention and control are often not used in practice in these countries. To combat this challenge, this article presents an innovative educational framework used to bridge the gap between policy written by global health agencies and the realities of practice in Tanzania.

Educating neonatal nurses in Brazil: a before-and-after study with interrupted time series analysis

BACKGROUND

Preterm birth contributes significantly to infant mortality and morbidity, including blindness from retinopathy of prematurity (ROP). Access to intensive neonatal care is expanding in many countries, but care is not always optimal, one factor being that nursing is often by inadequately trained nurse assistants.

OBJECTIVE

The aim of this study was to evaluate whether an educational package for nurses improves a range of outcomes including survival rates and severe ROP in 5 neonatal units in Rio de Janeiro, Brazil.

METHODS

The study design included an uncontrolled before-and-after study in 5 units, with interrupted time series analysis. Participatory approaches were used to develop a self-administered educational package for control of pain, oxygenation, infection, nutrition, and temperature and to improve supportive care ('POINTS of Care'). Educational materials and DVD clips were developed and training skills of nurse tutors were enhanced. There were two 1-year periods of data collection before and after a 3-month period of self-administration of the education package.

RESULTS

Overall, 74% of 401 nurses and nurse assistants were trained. A total of 679 and 563 infants were included in the pre- and post-training periods, respectively. Despite improvement in knowledge and nursing practices, such as the delivery and monitoring of oxygen, there was no change in survival (pre-training 80%, post-training 78.2%), severe ROP (1.6 vs. 2.8%), sepsis (11.3 vs. 12.3 cases per 1,000 infant days) or other outcomes. Outcomes worsened over the pre-intervention period but the change to an improvement after the intervention was not statistically significant. During the study period many trained staff left the units, but few were replaced.

CONCLUSIONS

Future studies need to focus on barriers to implementation, team building, leadership and governance, as well as the acquisition of knowledge and skills.

Family-centred care for hospitalised children aged 0-12 years

BACKGROUND

This is an update of the Cochrane systematic review of family-centred care published in 2007 (Shields 2007). Family-centred care (FCC) is a widely used model in paediatrics, is thought to be the best way to provide care to children in hospital and is ubiquitous as a way of delivering care. When a child is admitted, the whole family is affected. In giving care, nurses, doctors and others must consider the impact of the child's admission on all family members. However, the effectiveness of family-centred care as a model of care has not been measured systematically.

OBJECTIVES

To assess the effects of family-centred models of care for hospitalised children aged from birth (unlike the previous version of the review, this update excludes premature neonates) to 12 years, when compared to standard models of care, on child, family and health service outcomes.

SEARCH METHODS

In the original review, we searched up until 2004. For this update, we searched: the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 12 2011); MEDLINE (Ovid SP); EMBASE (Ovid SP); PsycINFO (Ovid SP); CINAHL (EBSCO Host); and Sociological Abstracts (CSA). We did not search three that were included in the original review: Social Work Abstracts, the Australian Medical Index and ERIC. We searched EMBASE in this update only and searched from 2004 onwards. There was no limitation by language. We performed literature searches in May and June 2009 and updated them again in December 2011.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) including cluster randomised trials in which family-centred care models are compared with standard models of care for hospitalised children (0 to 12 years, but excluding premature neonates). Studies had to meet criteria for family-centredness. In order to assess the degree of family-centredness, we used a modified rating scale based on a validated instrument, (same instrument used in the initial review), however, we decreased the family-centredness score for inclusion from 80% to 50% in this update. We also changed several other selection criteria in this update: eligible study designs are now limited to randomised controlled trials (RCTs) only; single interventions not reflecting a FCC model of care have been excluded; and the selection criterion whereby studies with inadequate or unclear blinding of outcome assessment were excluded from the review has been removed.

DATA COLLECTION AND ANALYSIS

Two review authors undertook searches, and four authors independently assessed studies against the review criteria, while two were assigned to extract data. We contacted study authors for additional information.

MAIN RESULTS

Six studies found since 2004 were originally viewed as possible inclusions, but when the family-centred score assessment was tested, only one met the minimum score of family-centredness and was included in this review. This was an unpublished RCT involving 288 children post-tonsillectomy in a care-by-parent unit (CBPU) compared with standard inpatient care.The study used a range of behavioural, economic and physical measures. It showed that children in the CBPU were significantly less likely to receive inadequate care compared with standard inpatient admission, and there were no significant differences for their behavioural outcomes or other physical outcomes. Parents were significantly more satisfied with CBPU care than standard care, assessed both before discharge and at 7 days after discharge. Costs were lower for CPBU care compared with standard inpatient care. No other outcomes were reported. The study was rated as being at low to unclear risk of bias.

AUTHORS' CONCLUSIONS

This update of a review has found limited, moderate-quality evidence that suggests some benefit of a family-centred care intervention for children's clinical care, parental satisfaction, and costs, but this is based on a small dataset and needs confirmation in larger RCTs. There is no evidence of harms. Overall, there continues to be little high-quality quantitative research available about the effects of family-centred care. Further rigorous research on the use of family-centred care as a model for care delivery to children and families in hospitals is needed. This research should implement well-developed family-centred care interventions, ideally in randomised trials. It should investigate diverse participant groups and clinical settings, and should assess a wide range of outcomes for children, parents, staff and health services.

Capacity building of nurses providing neonatal care in Rio de Janeiro, Brazil: methods for the POINTS of care project to enhance nursing education and reduce adverse neonatal outcomes

Background

Increased survival of preterm infants in developing countries has often been accompanied by increased morbidity. A previous study found rates of severe retinopathy of prematurity varied widely between different neonatal units in Rio de Janeiro. Nurses have a key role in the care of high-risk infants but often do not have access to ongoing education programmes. We set out to design a quality improvement project that would provide nurses with the training and tools to decrease neonatal mortality and morbidity. The purpose of this report is to describe the methods and make the teaching package (POINTS of care--six modules addressing Pain control; optimal Oxygenation; Infection control; Nutrition interventions; Temperature control; Supportive care) available to others.

Methods/Design

Six neonatal units, caring for 40% of preterm infants in Rio de Janeiro were invited to participate. In Phase 1 of the study multidisciplinary workshops were held in each neonatal unit to identify the neonatal morbidities of interest and to plan for data collection. In Phase 2 the teaching package was developed and tested. Phase 3 consisted of 12 months data collection utilizing a simple tick-sheet for recording. In Phase 4 (the Intervention) all nurses were asked to complete all six modules of the POINTS of care package, which was supplemented by practical demonstrations. Phase 5 consisted of a further 12 months data collection. In Phase 1 it was agreed to include inborn infants with birthweight ≤ 1500 g or gestational age of ≤ 34 weeks. The primary outcome was death before discharge and secondary outcomes included retinopathy of prematurity and bronchopulmonary dysplasia. Assuming 400-450 infants in both pre- and post-intervention periods the study had 80% power at p = < 0.05 to detect an increase in survival from 68% to 80%; a reduction in need for supplementary oxygen at 36 weeks post menstrual age from 11% to 5.5% and a reduction in retinopathy of prematurity requiring treatment from 7% to 2.5%.

Discussion

The results of the POINTS of Care intervention will be presented in a separate publication.

Trial registration

Current Controlled Trials: ISRCTN83110114

Antenatal education for expectant mothers results in sustained improvement in knowledge of newborn care

OBJECTIVE

Basic perinatal education to increase parental knowledge of neonatal illnesses (such as respiratory distress, sepsis, complications of prematurity) could be a feasible way to reduce high neonatal mortality rates in limited-resource nurseries. To assess the efficacy of antenatal education in increasing mothers' knowledge of basic newborn care in a limited-resource nursery, and to determine whether the knowledge is retained postpartum.

STUDY DESIGN

In March to April 2008, we implemented a 10-min educational program on basic neonatal care for women receiving prenatal care in a maternal child hospital in Vientiane, Laos. The educational intervention was a structured, face-to-face interactive module taught by Lao providers using pictographic and written materials about temperature control, umbilical cord care and signs of neonatal illness. We assessed knowledge before and immediately after the module using a standardized interview tool. When possible, we reassessed knowledge postpartum to determine whether they retained information after the training.

RESULT

We recruited 101 women (average age=26.3 years), and the majority (53%) were primigravidas. Participants were well educated by local standards; 57% of women had >8 years and 28% had >12 years of education. Women's knowledge of neonatal care increased by 10% on immediate posttest (P<0.0001), especially regarding knowledge of umbilical cord care and temperature control (normal temperature ranges, thermometer use). Maternal education (P=0.025) and previous births (P=0.037) correlated positively with higher pretest scores. Higher maternal education correlated with higher posttest scores (P=0.01); however, less-educated women increased their scores as much as did women with more education. Nulliparous women also increased their posttest scores to comparable levels in women with previous deliveries. Women retested after delivery retained the educational message, achieving similar posttest and postdelivery scores (P=0.08).

CONCLUSION

Brief antenatal education increases mothers' understanding of basic newborn care. Mothers retain this knowledge into the early postpartum period and during early infancy when it might help reduce morbidity and mortality. The education was efficacious for women with little education. Brief antenatal educational modules seem a feasible, sustainable means of improving mothers' knowledge of newborn care. We speculate that similar programs could improve neonatal morbidity and mortality in developing countries.

Impact of a district level sick newborn care unit on neonatal mortality rate: 2-year follow-up

OBJECTIVE

To evaluate the impact of creating a sick newborn care unit (SNCU) in a district hospital on neonatal mortality rate (NMR).

STUDY DESIGN

This study was conducted in a district hospital with 6500 deliveries a year. A 14 bed SNCU that included controlled environment, individual warming and monitoring devices, infusion pump, central oxygen and oxygen concentrators, resuscitation and exchange transfusion, portable X-ray and in-house laboratory was created. Doctors and nursing personnel were trained. Baseline data for 10 months were compared with 2 years data of SNCU operation.

RESULTS

Compared with the baseline neonatal mortality in the district hospital, neonatal mortality was reduced by 14% in the first year and by 21% in the second year after SNCU became functional. Estimated neonatal deaths averted were 329, which would reduce NMR of the district from 55 to 47 in 2 years.

CONCLUSION

A modern sick newborn care facility created in a district hospital can substantially reduce hospital neonatal deaths and NMR of the district. This model may be an effective tool to reduce NMR of the country.

Comparison of neonates born outside and inside hospitals in a children emergency unit, southwest of Nigeria

OBJECTIVE

To describe the effects of out-of-hospital birth on early neonatal morbidity and outcome among referred newborns.

METHODS

Using a structured case record form, we prospectively collected data on place of birth, morbidity, and outcome of all neonates admitted to the Emergency Ward, University College Hospital, Ibadan, in the first week of life.

RESULTS

Of the 541 admitted in the early neonatal period, 61.8% and 38.2% were delivered outside and inside the hospital setting, respectively. Babies were delivered at religious or "mission" house (46.7%), house of residence (38.0%), traditional birth attendants' homes (8.4%), and on the way to the hospital (6.9%). Births outside the hospital significantly increased as the birth order increased (chi = 34.04; P = 0.000). Over half of the out-of-hospital deliveries took place under personnel whose primary responsibilities did not include labor care. Women who had less than secondary level of education and those from the lower social class were more likely to deliver outside the hospital (P < 0.05). Out-of-hospital births were significantly associated with many complications, namely, hypothermia (53.6%), perinatal asphyxia (48.5%), hemorrhage (26.5%), cephalhematoma (12.9%), prematurity (9.9%), and neonatal tetanus (4.2%). Neonatal mortality rate of 12.6% in the out-of-hospital group was significantly higher than 6.3% obtained in the hospital birth group (P = 0.019).

CONCLUSIONS

Out-of-hospital births had greater risk of morbidity than hospital births. There is need to retrain and monitor the activities of birth attendants and midwives involved in births outside the hospitals closer than it is presently done.