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Kirabira VN, Nakaggwa F, Nazziwa R, Nalunga S, Nasiima R, Nyagabyaki C, Sebunya R, Latigi G, Pirio P, Ahmadzai M, Ojom L, Nabwami I, Burgoine K, Blencowe H. Impact of secondary and tertiary neonatal interventions on neonatal mortality in a low- resource limited setting hospital in Uganda: a retrospective study. BMJ Open 2022; 12:e055698. [PMID: 35953254 PMCID: PMC9379481 DOI: 10.1136/bmjopen-2021-055698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess the impact of secondary and tertiary level neonatal interventions on neonatal mortality over a period of 11 years. DESIGN Interrupted time series analysis. SETTING Nsambya Hospital, Uganda. INTERVENTIONS Neonatal secondary interventions (phase I, 2007-2014) and tertiary level interventions (phase II, 2015-2020). PARTICIPANTS Neonates. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome: neonatal mortality. SECONDARY OUTCOME case fatality rate (CFR) for prematurity, neonatal sepsis and asphyxia. RESULTS During the study period, a total of 25 316 neonates were admitted, of which 1853 (7.3%) died. The average inpatient mortality reduced from 8.2% during phase I to 5.7% during phase II (p=0.001). The CFR for prematurity reduced from 16.2% to 9.2% (p=0.001). There was a trend in reduction for the CFR of perinatal asphyxia from 14.9% to 13.0% (p=0.34). The CFR for sepsis had a more than a twofold increase (3%-6.8% p=0.001) between phase I and phase II. CONCLUSION Implementation of secondary and tertiary neonatal care in resource-limited settings is feasible. This study shows that these interventions can significantly reduce the neonatal mortality, with the largest impact seen in the reduction of deaths from perinatal asphyxia and prematurity. An increase in sepsis related deaths was observed, suggesting emphasis on infection control is key.
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Affiliation(s)
- Victoria Nakibuuka Kirabira
- Paediatrics, Nsambya Hospital, Kampala, Uganda
- Medicine Post Graduate School, Nkozi University, Kampala, Uganda
| | - Florence Nakaggwa
- School of Nursing and Midwifery, Clarke International University, Kampala, Uganda
| | - Ritah Nazziwa
- Medicine Post Graduate School, Nkozi University, Kampala, Uganda
| | | | | | | | | | | | | | - Malalay Ahmadzai
- UNICEF Eastern and Southern Africa Regional Office, Kampala, Uganda
| | | | | | - Kathy Burgoine
- Neonatal Unit, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Hannah Blencowe
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, UK
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Carns J, Liaghati-Mobarhan S, Asibon A, Chalira A, Lufesi N, Molyneux E, Oden MZ, Richards-Kortum R, Kawaza K. National scale of neonatal CPAP to district hospitals in Malawi improves survival for neonates weighing between 1.0 and 1.3 kg. Arch Dis Child 2022; 107:553-557. [PMID: 34725045 PMCID: PMC9125365 DOI: 10.1136/archdischild-2021-322964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/19/2021] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To determine whether a national quality improvement programme implementing continuous positive airway pressure (CPAP) at government hospitals in Malawi improved outcomes for neonates prioritised by an algorithm recommending early CPAP for infants weighing 1.0-1.3 kg (the 50th percentile weight at 30 weeks' gestation). DESIGN The analysis includes neonates admitted with respiratory illness for 5.5 months before CPAP was introduced (baseline period) and for 15 months immediately after CPAP was implemented (implementation period). A follow-up data analysis was completed for neonates treated with CPAP for a further 11 months. SETTING AND PATIENTS Neonates with admission weights of 1.0-1.3 kg before (106 neonates treated with nasal oxygen) and after implementation of CPAP (153 neonates treated with nasal oxygen, 103 neonates treated with CPAP) in the newborn wards at Malawi government district hospitals. Follow-up analysis included 87 neonates treated with CPAP. INTERVENTION Neonatal CPAP. MAIN OUTCOME MEASURE We assessed survival to discharge at 23 government district hospitals with no significant differences in transfer rates before and after implementation of CPAP. RESULTS Survival improved for neonates with admission weights from 1.0 to 1.3 kg treated with CPAP (30.1%) as compared with neonates of the same weight band treated with oxygen during the baseline (17.9%) and implementation (18.3%) periods. There was no significant difference in survival for neonates treated with CPAP during the implementation and follow-up periods (30.1% vs 28.7%). CONCLUSIONS Survival for neonates weighing 1.0-1.3 kg significantly increased with a nurse-led CPAP service in a low-resource setting and improvements were sustained during follow-up.
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Affiliation(s)
- Jennifer Carns
- Rice360 Institute for Global Health, Rice University, Houston, Texas, USA,Department of Bioengineering, Rice University, Houston, Texas, USA
| | | | - Aba Asibon
- Rice360 Institute for Global Health, Rice University, Houston, Texas, USA
| | - Alfred Chalira
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
| | - Norman Lufesi
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
| | - Elizabeth Molyneux
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Maria Z Oden
- Rice360 Institute for Global Health, Rice University, Houston, Texas, USA,Department of Bioengineering, Rice University, Houston, Texas, USA
| | - Rebecca Richards-Kortum
- Rice360 Institute for Global Health, Rice University, Houston, Texas, USA .,Department of Bioengineering, Rice University, Houston, Texas, USA
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
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Feleke ED, Gebremaryam EG, Regassa FT, Kuma HR, Sabir HS, Abagaro AM, Dese K. A novel low-cost bubble continuous positive airway pressure device with pressure monitoring and controlling system for low resource settings. Digit Health 2022. [DOI: 10.1177/20552076221109060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Currently bubble continuous positive airway pressure (bCPAP) is commonly used in low resource settings to treat respiratory distress. However, the accumulation of condensate in the patient's exhalation limb during operation could significantly increase pressure delivered to the body, which can lead to severe respiratory failure in the infant. The objective of this research was to develop a novel low-cost bCPAP device that can monitor and control the pressure delivered to infants. Methods When the neonate expires, the pressure sensor inside the expiratory limb measures the instant positive end-expiratory pressure. The microcontroller decides whether to turn the relay to switch the path of expiration between the two expiratory tubes connected to the valve outlets. This depends on the pressure reading and the cutoff pressure value inserted by the physician. Results The system was tested for accuracy, safety, cost, ease of use, and durability. The prototype was accurate in eight iterations at eight different depths of water that were made to monitor and control the pressure. It was safe and provided suitable pressure for the neonate, and the prototype was built in less than 193 USD. Conclusions The performance testing of the device demonstrated accurate and safe control and monitoring of continuous positive air pressure (CPAP) and oxygen levels with humidity levels safe for infants. The device provides humidified, blended, and pressurized gas for the patient. It allows physicians to easily monitor and control the accumulation of condensate in the exhalation limb of the CPAP machine accurately and safely.
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Affiliation(s)
| | | | - Feven Tadele Regassa
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
- Gilando Biomedical Solution Plc, Addis Ababa, Ethiopia
*These authors have equal first authorship
| | - Hawi Rorissa Kuma
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Hayat Solomon Sabir
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Ahmed Mohammed Abagaro
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Kokeb Dese
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
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Wastnedge E, Waters D, Murray SR, McGowan B, Chipeta E, Nyondo-Mipando AL, Gadama L, Gadama G, Masamba M, Malata M, Taulo F, Dube Q, Kawaza K, Khomani PM, Whyte S, Crampin M, Freyne B, Norman JE, Reynolds RM. Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review. J Glob Health 2021; 11:04050. [PMID: 35003711 PMCID: PMC8709903 DOI: 10.7189/jogh.11.04050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required. METHODS A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted. RESULTS 179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions. CONCLUSIONS Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.
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Affiliation(s)
- Elizabeth Wastnedge
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Donald Waters
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Sarah R Murray
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Brian McGowan
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Effie Chipeta
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Health Systems & Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luis Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gladys Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Martha Masamba
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Monica Malata
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Frank Taulo
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Sonia Whyte
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Mia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust Research Program, Blantyre, Malawi
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
| | - Jane E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Rebecca M Reynolds
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
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Dada S, Ashworth H, Sobitschka A, Raguveer V, Sharma R, Hamilton RL, Burke T. Experiences with implementation of continuous positive airway pressure for neonates and infants in low-resource settings: A scoping review. PLoS One 2021; 16:e0252718. [PMID: 34115776 PMCID: PMC8195417 DOI: 10.1371/journal.pone.0252718] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 05/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background Continuous positive airway pressure (CPAP) is the gold standard of care in providing non-invasive positive pressure support to neonates in respiratory distress in high-resource settings. While safety has been demonstrated in low-resource settings, there is a lack of knowledge on the barriers and facilitators to proper implementation. Objective To identify and describe the barriers, facilitators, and priorities for future implementation of CPAP for neonates and infants in low-resource settings. Methods A systematic search (database inception to March 6, 2020) was performed on MEDLINE, Embase, Web of Science, CINAHL, Global Health, and the WHO Global Index Medicus using PRISMA-ScR guidelines. Original research articles pertaining to implementation of CPAP devices in low-resource settings, provider or parent perspectives and experiences with CPAP, cost-benefit analyses, and cost-effectiveness studies were included. Inductive content analysis was conducted. Findings 1385 article were screened and 54 studies across 19 countries met inclusion criteria. Six major themes emerged: device attributes, patient experiences, parent experiences, provider experiences, barriers, and facilitators. Nasal trauma was the most commonly reported complication. Barriers included unreliable electricity and lack of bioengineering support. Facilitators included training, mentorship and empowerment of healthcare providers. Device design, supply chain infrastructure, and training models were imperative to the adoption and sustainability of CPAP. Conclusion Sustainable implementation of CPAP in low resource settings requires easy-to-use devices, ready access to consumables, and holistic, user-driven training. Further research is necessary on standardizing metrics, interventions that support optimal provider performance, and conditions needed for successful long-term health system integration.
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Affiliation(s)
- Sara Dada
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- * E-mail:
| | - Henry Ashworth
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alina Sobitschka
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of Göttingen, Göttingen, Germany
| | - Vanitha Raguveer
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of Illinois College of Medicine, Chicago, Illinois, United States of America
| | - Rupam Sharma
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of California Los Angeles Kern Medical Center, Bakersfield, California, United States of America
| | - Rebecca L. Hamilton
- Massachusetts General Hospital, Department of Anesthesiology, Boston, Massachusetts, United States of America
- Karolinska Institute, Department of Cell and Molecular Biology, Solna, Sweden
| | - Thomas Burke
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Global Health Innovation Lab, Department of Emergency Medicine, Boston, Massachusetts, United States of America
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Mwita S, Jande M, Katabalo D, Kamala B, Dewey D. Reducing neonatal mortality and respiratory distress syndrome associated with preterm birth: a scoping review on the impact of antenatal corticosteroids in low- and middle-income countries. World J Pediatr 2021; 17:131-140. [PMID: 33389692 DOI: 10.1007/s12519-020-00398-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The most common cause of death among preterm infants in low- and middle-income countries is respiratory distress syndrome. The purpose of this review was to assess whether antenatal corticosteroids given to women at risk of preterm birth at ≤ 34 weeks of gestation reduce rates of neonatal mortality and respiratory distress syndrome in low- and middle-income countries. METHODS Two reviewers independently searched four databases including MEDLINE (through PubMed), CINAHL, Embase, and Cochrane Libraries. We did not apply any language or date restrictions. All publications up to April 2020 were included in this search. RESULTS The search yielded 71 articles, 10 of which were included in this review (3 randomized controlled trials, 7 observational studies, 36,773 neonates). The majority of studies reported associations between exposure to antenatal corticosteroids and lower rates of neonatal mortality and respiratory distress syndrome. However, a few studies reported that antenatal corticosteroids were not associated with improved preterm birth outcomes. CONCLUSIONS Most of the studies in low- and middle-income countries showed that use of antenatal corticosteroids in hospitals with high levels of neonatal care was associated with lower rates of neonatal mortality and respiratory distress syndrome. However, the findings are inconclusive because some studies in low-resource settings reported that antenatal corticosteroids had no benefit in reducing rates of neonatal mortality or respiratory distress syndrome. Further research on the impact of antenatal corticosteroids in resource-limited settings in low-income countries is a priority.
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Affiliation(s)
- Stanley Mwita
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania.
| | - Mary Jande
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Deogratias Katabalo
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Benjamin Kamala
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Deborah Dewey
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
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Kinshella MLW, Salimu S, Hiwa T, Banda M, Vidler M, Newberry L, Dube Q, Molyneux EM, Goldfarb DM, Kawaza K, Nyondo-Mipando AL. Scaling up newborn care technologies from tertiary- to secondary-level hospitals in Malawi: an implementation case study of health professional perspectives on bubble CPAP. Implement Sci Commun 2020; 1:100. [PMID: 33292844 PMCID: PMC7640662 DOI: 10.1186/s43058-020-00092-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/25/2020] [Indexed: 11/10/2022] Open
Abstract
Background While Malawi has achieved success in reducing overall under-five mortality, reduction of neonatal mortality remains a persistent challenge. There has, therefore, been a push to strengthen the capacity for quality newborn care at district hospitals through the implementation of innovative neonatal technologies such as bubble continuous positive airway pressure (CPAP). This study investigates tertiary- versus secondary-level hospital differences in capacities for bubble CPAP use and implications for implementation policies. Methods A secondary analysis of interviews was conducted with 46 health workers at one tertiary hospital and three secondary hospitals in rural Southern Malawi. Grounded theory was utilized to explore the emerging themes according to health worker cadres (nurse, clinician, district health management) and facility level (tertiary- and secondary-level facilities), which were managed using NVivo 12 (QSR International, Melbourne, Australia). Results We identified frequent CPAP use and the availability of neonatal nurses, physicians, and reliable electricity as facilitators for CPAP use at the tertiary hospital. Barriers at the tertiary hospital included initiation eligibility disagreements between clinicians and nurses and insufficient availability of the CPAP machines. At secondary-level hospitals, the use was supported by decision-making and initiation by nurses, involving caretakers to assist in monitoring and reliable availability of CPAP machines. Bubble CPAP was hindered by unreliable electricity, staffing shortages and rotation policies, and poor systems of accountability. Conclusion While this study looked at the implementation of bubble CPAP in Malawi, the findings may be applicable for scaling up other novel neonatal technologies in low-resource settings. Implementation policies must consider staffing and management structures at different health services levels for effective scale-up.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Sangwani Salimu
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Tamanda Hiwa
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mwai Banda
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Laura Newberry
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Elizabeth M Molyneux
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- School of Public Health and Family Medicine, Department of Health Systems and Policy, College of Medicine, University of Malawi, Blantyre, Malawi.
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Switchenko N, Kibaru E, Tsimbiri P, Grubb P, Anderson Berry A, Fassl B. Implementation of a Bubble CPAP Treatment Program for Sick Newborns in Nakuru, Kenya: A Quality Improvement Initiative. Glob Pediatr Health 2020; 7:2333794X20939756. [PMID: 32821774 PMCID: PMC7412892 DOI: 10.1177/2333794x20939756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/11/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction. Respiratory distress (RD) contributes to common causes of neonatal mortality. Bubble continuous positive airway pressure (bCPAP) is a safe, low-cost therapy for RD; however, adoption of bCPAP programs remains challenging. Aim. To increase the percentage of neonates with RD treated with bCPAP from 2% to 25% by January 2019. Methods. In the newborn unit (NBU) at the Nakuru County and Referral Hospital in Kenya, a pre-initiative (pre) period (March 2016 to December 2017) and a post-initiative (post) period (January 2018 to December 2018) were defined. Tests of change included organization of infrastructure, staff trainings, development of a nurse educator role, and treatment protocols. Clinical and outcome data were abstracted from all available medical records. Results. A total of 405 infants were included in the pre group, with 2% bCPAP use. A total of 1157 infants were included in the post group, with 100 (17.6%) treated with bCPAP. bCPAP use increased during the post period. Rates of RD (49.9% pre, 49.0% post, P = .64) and mortality (30.9% pre, 29.1% post, P = .35) were similar. Neonates treated with bCPAP had lower mean birth weight and a higher risk of death (relative risk = 1.41, 95% confidence interval = 1.21-1.65) compared with those not treated with bCPAP. Conclusion. It was possible to build capacity for the use of bCPAP to treat neonates in this low-resource setting. Gaps in the delivery bCPAP remain, and the current capacity in the PGH NBU allows for application of bCPAP to smaller, likely, sicker neonates.
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Nabwera HM, Wright JL, Patil M, Dickinson F, Godia P, Maua J, Sammy MK, Naimoi BC, Warfa OH, Dewez JE, Murila F, Manu A, Smith H, Mathai M. 'Sometimes you are forced to play God…': a qualitative study of healthcare worker experiences of using continuous positive airway pressure in newborn care in Kenya. BMJ Open 2020; 10:e034668. [PMID: 32792424 PMCID: PMC7430418 DOI: 10.1136/bmjopen-2019-034668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE: To explore the experiences of using continuous positive airway pressure (CPAP) in newborn care among healthcare workers in Kenya, and to identify factors that would promote successful scale-up. DESIGN AND SETTING: A qualitative study using key informant interviews and focus group discussions, based at secondary and tertiary level hospitals in Kenya. PARTICIPANTS: Healthcare workers in the newborn units providing CPAP. PRIMARY AND SECONDARY OUTCOME MEASURE: Facilitators and barriers of CPAP use in newborn care in Kenya. RESULTS: 16 key informant interviews and 15 focus group discussions were conducted across 19 hospitals from September 2017 to February 2018. Main barriers reported were: (1) inadequate infrastructure to support the effective delivery of CPAP, (2) shortage of skilled staff rendering it difficult for the available staff to initiate or monitor infants on CPAP and (3) inadequate knowledge and training of staff that inhibited the safe care of infants on CPAP. Key facilitators reported were positive patient outcomes after CPAP use that increased staff confidence and partnership with caregivers in the management of newborns on CPAP. Healthcare workers in private/mission hospitals had more positive experiences of using CPAP in newborn care as the relevant support and infrastructure were available. CONCLUSION: CPAP use in newborn care is valued by healthcare workers in Kenya. However, we identified key challenges that threaten its safe use and sustainability. Further scale-up of CPAP in newborn care should ensure that staff members have ready access to optimal training on CPAP and that there are enough resources and infrastructure to support its use. ETHICS: This study was approved through the appropriate ethics committees in Kenya and the UK (see in text) with written informed consent for each participant.
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Affiliation(s)
- Helen M Nabwera
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jemma L Wright
- Paediatrics Department, Betsi Cadwaladr CHC, Wrexham, UK
| | - Manasi Patil
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Fiona Dickinson
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Pamela Godia
- International Public Health, Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Judith Maua
- International Public Health, Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Mercy K Sammy
- General Paediatrics, Gertrude's Garden Children's Hospital, Nairobi, Kenya
| | | | - Osman H Warfa
- Neonatal, Child and Adolescent Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Juan Emmanuel Dewez
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Florence Murila
- Paediatrics and Child Health, University of Nairobi School of Medicine, Nairobi, Kenya
| | - Alexander Manu
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Smith
- Maternal and Newborn Health, International Health Consulting Services Ltd, Liverpool, UK
| | - Matthews Mathai
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Mwatha AB, Mahande M, Olomi R, John B, Philemon R. Treatment outcomes of Pumani bubble-CPAP versus oxygen therapy among preterm babies presenting with respiratory distress at a tertiary hospital in Tanzania-Randomised trial. PLoS One 2020; 15:e0235031. [PMID: 32603380 PMCID: PMC7326169 DOI: 10.1371/journal.pone.0235031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 06/05/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Respiratory distress syndrome (RDS) is the most common respiratory disease in premature babies and the major cause of morbidity and mortality among preterm babies. Effective treatment of these babies requires exogenous surfactant and/or mechanical ventilation but these are of limited availability in low and middle income countries. A cheaper, simpler and more accessible treatment for preterms with RDS called bubble-continuous positive airway pressure (bCPAP) has been reported to be effective in treating RDS in preterm babies with varying levels of effectiveness ranging from 42% to 85%. We aimed to implement and determine the efficacy of bCPAP and its immediate outcomes as compared to oxygen therapy in preterm babies presenting with respiratory distress at a tertiary hospital in Tanzania. METHOD A randomized control trial, conducted from December 2016 to May 2017, included all preterm babies admitted at the neonatal care unit presenting with signs of respiratory distress and meeting the inclusion criteria. The primary outcome was survival while the secondary outcomes were treatment duration, duration of hospital stay and treatment complications. RESULTS A total of 824 babies were admitted in the neonatal care unit during the study period. Of these, 187 babies were preterm and 48 babies were recruited and randomized (25 bCPAP vs 23 oxygen). The overall survival to discharge for all eligible participants (n = 48) was 58.2% compared to those who adhered to treatment protocol (n = 45, 62.2%). Babies in the bCPAP group had higher survival (17/22; 77.3%) as compared to their counterparts in the oxygen therapy group (11/23; 47.8%). Babies treated with bCPAP had 52% lower risk of death (crude HR 0.48, 95% CI = 0.16-1.43) compared to babies receiving oxygen therapy. The median duration of treatment for babies in the oxygen therapy group was 2 (Range 0-16) days compared to 2 (Range 0-5) days in the bCPAP group. The median duration of hospital stay for babies receiving bCPAP was 14 (range 7-43) days. Nasal bleeding was commonly observed among babies in the bCPAP group as compared to those in the oxygen therapy group. CONCLUSION This study revealed that treatment with bCPAP had a 30% clinical improvement in survival to discharge. Our findings highlight the role of bCPAP in reducing neonatal mortality in resource limited settings but further adequately powered studies in this or similar settings are required.
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Affiliation(s)
- Annette Baine Mwatha
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Center (KCMC), Moshi, Tanzania
- Gertrude`s Children`s Hospital, Nairobi, Kenya
| | - Michael Mahande
- Institute of Public Health, Department of Epidemiology & Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
| | - Raimos Olomi
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Center (KCMC), Moshi, Tanzania
| | - Beatrice John
- Institute of Public Health, Department of Epidemiology & Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
| | - Rune Philemon
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Center (KCMC), Moshi, Tanzania
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11
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Nørgaard M, Stagstrup C, Lund S, Poulsen A. To Bubble or Not? A Systematic Review of Bubble Continuous Positive Airway Pressure in Children in Low- and Middle-Income Countries. J Trop Pediatr 2020; 66:339-353. [PMID: 31599959 DOI: 10.1093/tropej/fmz069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Bubble-continuous positive airway pressure (bCPAP) is a simple, low-cost ventilation therapy with the potential to lower morbidity and mortality in children in low- and middle-income countries (LMICs). AIM To examine (i) whether bCPAP is a safe and effective treatment for children in all age-groups presenting with respiratory distress from any cause, (ii) LMIC-implemented bCPAP devices including their technical specifications and costs and (iii) the setting and level of health care bCPAP has been implemented in. METHOD A systematic search was performed of Embase, PubMed and Web of Science. Inclusion criteria: bCPAP for children with respiratory distress in all age groups in LMICs. Database searches were performed up to 1 November 2018. RESULTS A total of 24 publications were eligible for the review. For neonates bCPAP was superior in improving survival and clinical progression compared with oxygen therapy and mechanical ventilation (MV). In two studies bCPAP was superior to low flow oxygen in reducing mortality in children 29 days to 13 months. Respiratory rate reductions were significant across all ages. Only three of six studies in children of all ages evaluated serious adverse events. In 12 studies comprising 1338 neonates treated with bCPAP, pneumothorax was reported 27 times. The majority of studies were carried out at tertiary hospitals in middle-income countries and 50% implemented the most expensive bCPAP-device. CONCLUSION In neonates and children below 13 months bCPAP is a safe treatment improving clinical outcomes and reducing the need for MV, without an increase in mortality. High-quality studies from non-tertiary settings in low-income countries are needed.
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Affiliation(s)
- Mathilde Nørgaard
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Cecilie Stagstrup
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Stine Lund
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anja Poulsen
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Kinshella MLW, Walker CR, Hiwa T, Vidler M, Nyondo-Mipando AL, Dube Q, Goldfarb DM, Kawaza K. Barriers and facilitators to implementing bubble CPAP to improve neonatal health in sub-Saharan Africa: a systematic review. Public Health Rev 2020; 41:6. [PMID: 32368359 PMCID: PMC7189679 DOI: 10.1186/s40985-020-00124-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 04/07/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Bubble continuous positive airway pressure (CPAP) has been shown to be effective in supporting breathing in newborns with respiratory distress. The factors that influence implementation in resource-constrained settings remain unclear. The objective of this review is to evaluate the barriers and facilitators of CPAP implementation for newborn care at sub-Saharan African health facilities and how different facility levels and types of bubble CPAP systems may impact utilization. METHODS A systematic search (database inception to July 2019) was performed on MEDLINE Ovid, EMBASE, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), the WHO Regional Database for Africa, African Index Medicus (AIM), African Journals Online, grey literature and the references of relevant articles. Studies that met the inclusion criteria (primary research, bubble CPAP implementation with neonates ≤ 28 days old at a health facility in sub-Saharan Africa) were included in the review and assessed with National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) quality assessment tools. The review protocol was published to PROSPERO (CRD42018116082). RESULTS Seventeen studies were included in the review. Reliable availability of equipment, effectively informing and engaging caregivers and staffing shortages were frequently mentioned barriers to the implementation of bubble CPAP. Understaffed neonatal units and high turnover of nurses and doctors compromised effective training. Provider-to-provider clinical mentorship models as well as affordability and cost-effectiveness of innovative bubble CPAP systems were identified as frequently mentioned facilitators of implementation. CONCLUSIONS With a strong recommendation by the World Health Organization for its use with premature infants with respiratory distress, it is important to understand the barriers and facilitators that can inform the implementation of bubble CPAP. More research is needed into health system factors that can support or impede the use of this potentially promising intervention.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Celia R. Walker
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Tamanda Hiwa
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Alinane Linda Nyondo-Mipando
- School of Public Health and Family Medicine, Department of Health Systems and Policy, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - David M. Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
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13
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Asibon A, Lufesi N, Choudhury A, Olvera S, Molyneux E, Oden M, Richards‐Kortum R, Kawaza K. Using a peer mentorship approach improved the use of neonatal continuous positive airway pressure and related outcomes in Malawi. Acta Paediatr 2020; 109:705-710. [PMID: 31535392 DOI: 10.1111/apa.15025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 07/09/2019] [Accepted: 09/16/2019] [Indexed: 11/27/2022]
Abstract
AIM This study evaluated whether peer mentorship was an effective and sustainable way of improving and maintaining knowledge and skills on neonatal continuous positive airway pressure (CPAP) in a low-resource setting with a high turnover of healthcare providers. METHODS The Malawi Ministry of Health recruited five nurses with considerable CPAP experience and provided them with mentorship training from July to August 2014. The mentors then provided 1-week on-site mentorship for 113 colleagues at 10 secondary and one tertiary hospital where gaps in neonatal CPAP use had been identified. CPAP competencies and outcomes were compared 3 months before and after each mentorship. RESULTS In the 3 months before and after mentorship, the average CPAP competency score increased from 32 ± 4% to 97 ± 2%, while CPAP usage increased from 7% to 23% among eligible neonates. Survival following CPAP mentorship increased from 23% to 35%, but this was not significant due to the small sample size. Both mentees and mentors reported useful transfers of knowledge and skills when using CPAP. CONCLUSION Mentorship effectively bridged the knowledge and skills gaps among health workers and increased CPAP use, competency scores and survival rates.
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Affiliation(s)
- Aba Asibon
- Rice 360 Institute for Global Health Houston Texas
| | | | | | | | - Elizabeth Molyneux
- Department of Pediatrics College of Medicine Queen Elizabeth Central Hospital Blantyre Malawi
| | - Maria Oden
- Rice 360 Institute for Global Health Houston Texas
- Department of Bioengineering Rice University Houston Texas
| | - Rebecca Richards‐Kortum
- Rice 360 Institute for Global Health Houston Texas
- Department of Bioengineering Rice University Houston Texas
| | - Kondwani Kawaza
- Department of Pediatrics College of Medicine Queen Elizabeth Central Hospital Blantyre Malawi
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14
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Dewez JE, Nangia S, Chellani H, White S, Mathai M, van den Broek N. Availability and use of continuous positive airway pressure (CPAP) for neonatal care in public health facilities in India: a cross-sectional cluster survey. BMJ Open 2020; 10:e031128. [PMID: 32114460 PMCID: PMC7053015 DOI: 10.1136/bmjopen-2019-031128] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the availability of continuous positive airway pressure (CPAP) and to provide an overview of its use in neonatal units in government hospitals across India. SETTING Cross-sectional cluster survey of a nationally representative sample of government hospitals from across India. PRIMARY OUTCOMES Availability of CPAP in neonatal units. SECONDARY OUTCOMES Proportion of hospitals where infrastructure and processes to provide CPAP are available. Case fatality rates and complication rates of neonates treated with CPAP. RESULTS Among 661 of 694 government hospitals with neonatal units that provided information on availability of CPAP for neonatal care, 68.3% of medical college hospitals (MCH) and 36.6% of district hospitals (DH) used CPAP in neonates. Assessment of a representative sample of 142 hospitals (79 MCH and 63 DH) showed that air-oxygen blenders were available in 50.7% (95% CI 41.4% to 60.9%) and staff trained in the use of CPAP were present in 56.0% (45.8% to 65.8%) of hospitals. The nurse to patient ratio was 7.3 (6.4 to 8.5) in MCH and 6.6 (5.5 to 8.3) in DH. Clinical guidelines were available in 31.0% of hospitals (22.2% to 41.4%). Upper oxygen saturation limits of above 94% were used in 72% (59.8% to 81.6%) of MCH and 59.3% (44.6% to 72.5%) of DH. Respiratory circuits were reused in 53.8% (42.3% to 63.9%) of hospitals. Case fatality rate for neonates treated with CPAP was 21.4% (16.6% to 26.2%); complication rates were 0.7% (0.2% to 1.2%) for pneumothorax, 7.4% (0.9% to 13.9%) for retinopathy and 1.4% (0.7% to 2.1%) for bronchopulmonary dysplasia. CONCLUSIONS CPAP is used in neonatal units across government hospitals in India. Neonates may be overexposed to oxygen as the means to detect and treat consequences of oxygen toxicity are insufficient. Neonates may also be exposed to nosocomial infections by reuse of disposables. Case fatality rates for neonates receiving CPAP are high. Complications might be under-reported. Support to infrastructure, training, guidelines implementation and staffing are needed to improve CPAP use.
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Affiliation(s)
- Juan Emmanuel Dewez
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Hospital, New Delhi, Delhi, India
| | - Harish Chellani
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Sarah White
- Department of International Public Health, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Matthews Mathai
- Department of International Public Health, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nynke van den Broek
- Department of International Public Health, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
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15
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Nyondo-Mipando AL, Woo Kinshella ML, Bohne C, Suwedi-Kapesa LC, Salimu S, Banda M, Newberry L, Njirammadzi J, Hiwa T, Chiwaya B, Chikoti F, Vidler M, Dube Q, Molyneux E, Mfutso-Bengo J, Goldfarb DM, Kawaza K, Mijovic H. Barriers and enablers of implementing bubble Continuous Positive Airway Pressure (CPAP): Perspectives of health professionals in Malawi. PLoS One 2020; 15:e0228915. [PMID: 32053649 PMCID: PMC7018070 DOI: 10.1371/journal.pone.0228915] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/27/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Preterm birth complications are the leading cause of neonatal deaths. Malawi has high rates of preterm birth, with 18.1 preterm births per 100 live births. More than 50% of preterm neonates develop respiratory distress which if left untreated, can lead to respiratory failure and death. Term and preterm neonates with respiratory distress can often be effectively managed with Continuous Positive Airway Pressure (CPAP) and this is considered an essential intervention for the management of preterm neonates by the World Health Organization. Bubble CPAP may represent a safe and cost-effective method for delivering CPAP in low-income settings. OBJECTIVE The study explored the factors that influence the implementation of bubble CPAP among health care professionals in secondary and tertiary hospitals in Malawi. METHODS This was a qualitative study conducted in three district hospitals and a tertiary hospital in southern Malawi. We conducted 46 in-depth interviews with nurses, clinicians and clinical supervisors, from June to August 2018. All data were digitally recorded, transcribed verbatim and thematically analyzed. RESULTS Factors that influenced implementation of bubble CPAP occurred in an interconnected manner and included: inadequate healthcare provider training in preparation for use, rigid division of roles and responsibilities among providers, lack of effective communication among providers and between providers and newborn's caregivers, human resource constraints, and inadequate equipment and infrastructure. CONCLUSION There are provider, caregiver and health system level factors that influence the implementation of bubble CPAP among neonates in Malawian health facilities. Ensuring adequate staffing in the nurseries, combined with ongoing training for providers, team cohesion, improved communication with caregivers, and improved hospital infrastructure would ensure optimal utilization of bubble CPAP and avoid inadvertent harm from inappropriate use.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Christine Bohne
- Institute for Global Health, NEST 360°, Rice University, Houston, Texas, United States of America
| | | | | | - Mwai Banda
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Laura Newberry
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jenala Njirammadzi
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Tamanda Hiwa
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Felix Chikoti
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Queen Dube
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Elizabeth Molyneux
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Joseph Mfutso-Bengo
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Center of Bioethics for Eastern & Southern Africa (CEBESA), Blantyre, Malawi
| | - David M. Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Hana Mijovic
- Department of Pediatrics, BC Children’s Hospital and University of British Columbia, Vancouver, Canada
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16
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Okello F, Egiru E, Ikiror J, Acom L, Loe K, Olupot-Olupot P, Burgoine K. Reducing preterm mortality in eastern Uganda: the impact of introducing low-cost bubble CPAP on neonates <1500 g. BMC Pediatr 2019; 19:311. [PMID: 31484567 PMCID: PMC6724283 DOI: 10.1186/s12887-019-1698-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/27/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Complications of prematurity are the leading cause of deaths in children under the age of five. The predominant reason for these preterm deaths is respiratory distress syndrome (RDS). In low-income countries (LICs) there are limited treatment options for RDS. Due to their simplicity and affordability, low-cost bubble continuous positive airway pressure (bCPAP) devices have been introduced in neonatal units in LICs to treat RDS. This study is the first observational study from a LIC to compare outcomes of very-low-birth-weight (VLBW) neonates in pre- and post-CPAP periods. METHODS This was a retrospective study of VLBW neonates (weight < 1500 g) in Mbale Regional Referral Hospital Neonatal Unit (MRRH-NNU), a government hospital in eastern Uganda. It aimed to measure the outcome of VLBW neonates in two distinct study periods: A 14-month period beginning at the opening of MRRH-NNU and covering the period until bCPAP was introduced (pre-bCPAP) and an 18-month period following the introduction of bCPAP (post-bCPAP). After the introduction of bCPAP, it was applied to preterm neonates with RDS when clinically indicated and if a device was available. Clinical features and outcomes of all neonates < 1500 g were compared before and after the introduction of bCPAP. RESULTS The admission records of 377 VLBW neonates < 1500 g were obtained. One hundred fifty-eight were admitted in the pre-bCPAP period and 219 in the post-bCPAP period. The mortality rate in the pre- bCPAP period was 39.2% (62/158) compared with 26.5% (58/219, P = 0.012) in the post-bCPAP period. Overall, there was a 44% reduction in mortality (OR 0.56, 95%CI 0.36-0.86, P = 0.01). There were no differences in birthweight, sex, presence of signs of respiratory distress or apnoea between the two groups. CONCLUSION Specialized and resource-appropriate neonatal care, that appropriately addresses the challenges of healthcare provision in LICs, has the potential to reduce neonatal deaths. The use of a low-cost bCPAP to treat RDS in VLBW neonates resulted in a significant improvement in their survival in a neonatal unit in eastern Uganda. Since RDS is one of the leading causes of neonatal mortality, it is possible that this relatively simple and affordable intervention could have a huge impact on global neonatal mortality.
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Affiliation(s)
- F Okello
- Mbale Campus, Busitema University, P.O.Box 1460, Mbale, Uganda
- Varimetrics Group Limited, P. O Box 2190, Mbale, Uganda
| | - E Egiru
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - J Ikiror
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - L Acom
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - Ksm Loe
- Diamedica UK Ltd, Grange Hill Industrial Estate, Bratton Fleming, UK
| | - P Olupot-Olupot
- Mbale Campus, Busitema University, P.O.Box 1460, Mbale, Uganda
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - K Burgoine
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda.
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda.
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17
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Gupta N, Hirschhorn LR, Rwabukwisi FC, Drobac P, Sayinzoga F, Mugeni C, Nkikabahizi F, Bucyana T, Magge H, Kagabo DM, Nahimana E, Rouleau D, VanderZanden A, Murray M, Amoroso C. Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy. BMC Public Health 2018; 18:1378. [PMID: 30558586 PMCID: PMC6296058 DOI: 10.1186/s12889-018-6282-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 11/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood. Methods We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death. Results We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4–2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3–3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5–15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6–1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1–2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2–1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7–4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2–2.3), household size (aOR: 1.2; 95% CI: 1.0–1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2–3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4–1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0–1.8). Conclusion In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.
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Affiliation(s)
- Neil Gupta
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA. .,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
| | | | | | - Peter Drobac
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA.,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | | | | | | | - Hema Magge
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA.,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | | | - Megan Murray
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
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18
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Nyishime M, Borg R, Ingabire W, Hedt-Gauthier B, Nahimana E, Gupta N, Hansen A, Labrecque M, Nkikabahizi F, Mutaganzwa C, Biziyaremye F, Mukayiranga C, Mwamini F, Magge H. A retrospective study of neonatal case management and outcomes in rural Rwanda post implementation of a national neonatal care package for sick and small infants. BMC Pediatr 2018; 18:353. [PMID: 30419867 PMCID: PMC6233583 DOI: 10.1186/s12887-018-1334-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 10/31/2018] [Indexed: 11/23/2022] Open
Abstract
Background Despite worldwide efforts to reduce neonatal mortality, 44% of under-five deaths occur in the first 28 days of life. The primary causes of neonatal death are preventable or treatable. This study describes the presentation, management and outcomes of hospitalized newborns admitted to the neonatal units of two rural district hospitals in Rwanda after the 2012 launch of a national neonatal protocol and standards. Methods We retrospectively reviewed routinely collected data for all neonates (0 to 28 days) admitted to the neonatal units at Rwinkwavu and Kirehe District Hospitals from January 1, 2013 to December 31, 2014. Data on demographic and clinical characteristics, clinical management, and outcomes were analyzed using median and interquartile ranges for continuous data and frequencies and proportions for categorical data. Clinical management and outcome variables were stratified by birth weight and differences between low birth weight (LBW) and normal birth weight (NBW) neonates were assessed using Fisher’s exact or Wilcoxon rank-sum tests at the α = 0.05 significance level. Results A total of 1723 neonates were hospitalized over the two-year study period; 88.7% were admitted within the first 48 h of life, 58.4% were male, 53.8% had normal birth weight and 36.4% were born premature. Prematurity (27.8%), neonatal infection (23.6%) and asphyxia (20.2%) were the top three primary diagnoses. Per national protocol, vital signs were assessed every 3 h within the first 48 h for 82.6% of neonates (n = 965/1168) and 93.4% (n = 312/334) of neonates with infection received antibiotics. The overall mortality rate was 13.3% (n = 185/1386) and preterm/LBW infants had similar mortality rate to NBW infants (14.7 and 12.2% respectively, p = 0.131). The average length of stay in the neonatal unit was 5 days. Conclusions Our results suggest that it is possible to provide specialized neonatal care for both LBW and NBW high-risk neonates in resource-limited settings. Despite implementation challenges, with the introduction of the neonatal care package and defined clinical standards these most vulnerable patients showed survival rates comparable to or higher than neighboring countries.
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Affiliation(s)
- Merab Nyishime
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda.
| | - Ryan Borg
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda
| | - Willy Ingabire
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda
| | - Bethany Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Evrard Nahimana
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda
| | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda.,Brigham and Women's Hospital, Boston, USA
| | | | | | | | | | | | | | | | - Hema Magge
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda.,Brigham and Women's Hospital, Boston, USA.,Boston Children's Hospital, Boston, USA.,Institute for Healthcare Improvement, Addis Ababa, Ethiopia
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19
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Dewez JE, Chellani H, Nangia S, Metsis K, Smith H, Mathai M, van den Broek N. Healthcare workers' views on the use of continuous positive airway pressure (CPAP) in neonates: a qualitative study in Andhra Pradesh, India. BMC Pediatr 2018; 18:347. [PMID: 30400844 PMCID: PMC6220518 DOI: 10.1186/s12887-018-1311-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/16/2018] [Indexed: 01/25/2023] Open
Abstract
Background Continuous Positive Airway Pressure (CPAP) is a form of non-invasive ventilatory support which is increasingly used in low- and middle-income countries to treat neonates with acute respiratory distress. However, it may be harmful if used incorrectly. We aimed to explore the experiences of doctors and nurses using CPAP in neonatal units in India and their views on enablers and barriers to implementation of CPAP. Methods Participants from 15 neonatal units across Andhra Pradesh were identified through purposive sampling. Eighteen in-depth interviews (IDI) with doctors and eight focus group discussions (FGD) with 51 nurses were conducted. Data were analysed thematically using the framework approach. Results Common structural factors that limit the use of CPAP include shortages of staff, consumables and equipment, and problems with regard to the organisation of neonatal units in both district hospitals and medical colleges. This meant that CPAP was often not available for babies who were identified to need CPAP, or that CPAP use was not perceived to be of the highest quality. Providing care under constrained circumstances left staff feeling powerless to provide good quality care for neonates with acute respiratory distress. Despite this, staff were enthusiastic about the use of CPAP and its potential to save lives. CPAP use was mostly perceived as technically easier to provide than ventilation and allowed nurses to provide advanced neonatal care, independently of doctors. Conclusions Doctors and nurses embraced CPAP use but identified barriers to implementation which will need to be addressed in order not to impact on safety and quality of care. Ensuring a supportive and enabling environment is in place will be crucial if CPAP is to be scaled-up more widely. Electronic supplementary material The online version of this article (10.1186/s12887-018-1311-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juan Emmanuel Dewez
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Harish Chellani
- Department of Paediatrics, Vardhman Mahavir Medical College & Safdarjung Hospital, Ring Road, Safdarjung West, Safdarjung Campus, Ansari Nagar East, New Delhi, Delhi, 110029, India
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College & Kalawati Saran Children's Hospital, C-604, Shaheed Bhagat Singh Road, Diz Area, Connaught Place, New Delhi, Delhi, 110001, India
| | - Katrin Metsis
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Helen Smith
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Matthews Mathai
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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20
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Odhiambo J, Amoroso CL, Barebwanuwe P, Warugaba C, Hedt-Gauthier BL. Adapting operational research training to the Rwandan context: the Intermediate Operational Research Training programme. Glob Health Action 2018; 10:1386930. [PMID: 29119872 PMCID: PMC5700541 DOI: 10.1080/16549716.2017.1386930] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Promoting national health research agendas in low- and middle-income countries (LMICs) requires adequate numbers of individuals with skills to initiate and conduct research. Recently, non-governmental organizations (NGOs) have joined research capacity building efforts to increase research leadership by LMIC nationals. Partners In Health, an international NGO operating in Rwanda, implemented its first Intermediate Operational Research Training (IORT) course to cultivate Rwandan research talent and generate evidence to improve health care delivery. Objective: This paper describes the implementation of IORT to share experiences with other organizations interested in developing similar training programmes. Methods: The Intermediate Operational Research Training utilized a deliverable-driven training model, using learning-by-doing pedagogy with intensive hands-on mentorship to build research skills from protocol development to scientific publication. The course had short (two-day) but frequent training sessions (seven sessions over eight months). Trainees were clinical and programme staff working at the district level who were paired to jointly lead a research project. Results: Of 10 trainees admitted to the course from a pool of 24 applicants, nine trainees completed the course with five research projects published in peer-reviewed journals. Strengths of the course included supportive national and institutional research capacity guidelines, building from a successful training model, and trainee commitment. Challenges included delays in ethical review, high mentorship workload of up to 250 hours of practicum mentorship, lack of access to literature in subscription journals and high costs of open access publication. Conclusions: The IORT course was an effective way to support the district-based government and NGO staff in gaining research skills, as well as answering research questions relevant to health service delivery at district hospitals. Other NGOs should build on successful programmes while adapting course elements to address context-specific challenges. Mentorship for LMIC trainees is critical for effectiveness of research capacity building initiatives.
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Affiliation(s)
- Jackline Odhiambo
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda
| | - Cheryl L Amoroso
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda
| | - Peter Barebwanuwe
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda
| | - Christine Warugaba
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda
| | - Bethany L Hedt-Gauthier
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda.,b Department of Global Health and Social Medicine , Harvard Medical School , Boston , MA , USA
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21
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Kirk CM, Uwamungu JC, Wilson K, Hedt-Gauthier BL, Tapela N, Niyigena P, Rusangwa C, Nyishime M, Nahimana E, Nkikabahizi F, Mutaganzwa C, Ngabireyimana E, Mutabazi F, Magge H. Health, nutrition, and development of children born preterm and low birth weight in rural Rwanda: a cross-sectional study. BMC Pediatr 2017; 17:191. [PMID: 29141590 PMCID: PMC5688768 DOI: 10.1186/s12887-017-0946-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/09/2017] [Indexed: 12/11/2022] Open
Abstract
Background As care for preterm and low birth weight (LBW) infants improves in resource-limited settings, more infants are surviving the neonatal period. Preterm and (LBW) infants are at high-risk of nutritional and medical comorbidities, yet little is known about their developmental outcomes in low-income countries. This study evaluated the health, nutritional, and developmental status of preterm/LBW children at ages 1–3 years in Rwanda. Methods Cross-sectional study of preterm/LBW infants discharged between October 2011 and October 2013 from a hospital neonatal unit in rural Rwanda. Gestational age and birth weight were gathered from hospital records to classify small for gestational age (SGA) at birth and prematurity. Children were located in the community for household assessments in November–December 2014. Caregivers reported demographics, health status, and child development using locally-adapted Ages and Stages Questionnaires (ASQ-3). Anthropometrics were measured. Bivariate associations with continuous ASQ-3 scores were conducted using Wilcoxon Rank Sum and Kruskal Wallis tests. Results Of 158 eligible preterm/LBW children discharged from the neonatal unit, 86 (54.4%) were alive and located for follow-up. Median birth weight was 1650 grams, median gestational age was 33 weeks, and 50.5% were SGA at birth. At the time of household interviews, median age was 22.5 months, 46.5% of children had feeding difficulties and 39.5% reported signs of anemia. 78.3% of children were stunted and 8.8% wasted. 67.4% had abnormal developmental screening. Feeding difficulties (p = 0.008), anemia symptoms (p = 0.040), microcephaly (p = 0.004), stunting (p = 0.034), SGA (p = 0.023), very LBW (p = 0.043), lower caregiver education (p = 0.001), and more children in the household (p = 0.016) were associated with lower ASQ-3 scores. Conclusions High levels of health, growth, and developmental abnormalities were seen in preterm/LBW children at age 1–3 years. As we achieve necessary gains in newborn survival in resource-limited settings, follow-up and early intervention services are critical for ensuring high-risk children reach their developmental potential. Electronic supplementary material The online version of this article doi: (10.1186/s12887-017-0946-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Kim Wilson
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Neo Tapela
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | | | | | | | - Francis Mutabazi
- Rwinkwavu District Hospital, Ministry of Health, Rwinkwavu, Rwanda
| | - Hema Magge
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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22
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Arnim AOVSAV, Jamal SM, John-Stewart GC, Musa NL, Roberts J, Stanberry LI, Howard CRA. Pediatric Respiratory Support Technology and Practices: A Global Survey. Healthcare (Basel) 2017; 5:healthcare5030034. [PMID: 28754002 PMCID: PMC5618162 DOI: 10.3390/healthcare5030034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/07/2017] [Accepted: 07/13/2017] [Indexed: 11/16/2022] Open
Abstract
Objective: This global survey aimed to assess the current respiratory support capabilities for children with hypoxemia and respiratory failure in different economic settings. Methods: An online, anonymous survey of medical providers with experience in managing pediatric acute respiratory illness was distributed electronically to members of the World Federation of Pediatric Intensive and Critical Care Society, and other critical care websites for 3 months. Results: The survey was completed by 295 participants from 64 countries, including 28 High-Income (HIC) and 36 Low- and Middle-Income Countries (LMIC). Most respondents (≥84%) worked in urban tertiary care centers. For managing acute respiratory failure, endotracheal intubation with mechanical ventilation was the most commonly reported form of respiratory support (≥94% in LMIC and HIC). Continuous Positive Airway Pressure (CPAP) was the most commonly reported form of non-invasive positive pressure support (≥86% in LMIC and HIC). Bubble-CPAP was used by 36% HIC and 39% LMIC participants. ECMO for acute respiratory failure was reported by 45% of HIC participants, compared to 34% of LMIC. Oxygen, air, gas humidifiers, breathing circuits, patient interfaces, and oxygen saturation monitoring appear widely available. Reported ICU patient to health care provider ratios were higher in LMIC compared to HIC. The frequency of respiratory assessments was hourly in HIC, compared to every 2–4 h in LMIC. Conclusions: This survey indicates many apparent similarities in the presence of respiratory support systems in urban care centers globally, but system quality, quantity, and functionality were not established by this survey. LMIC ICUs appear to have higher patient to medical staff ratios, with decreased patient monitoring frequencies, suggesting patient safety should be a focus during the introduction of new respiratory support devices and practices.
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Affiliation(s)
- Amélie O von Saint André-von Arnim
- Department of Pediatrics, University of Washington and Seattle Children's, 4800 Sand Point Way NE, M/S FA.2.112 P.O. Box 5371, Seattle, WA 98105, USA.
| | - Shelina M Jamal
- Department of Pediatrics, University of Washington and Seattle Children's, 4800 Sand Point Way NE, M/S FA.2.112 P.O. Box 5371, Seattle, WA 98105, USA.
| | - Grace C John-Stewart
- Departments of Global Health, Medicine, Epidemiology, and Pediatrics, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA 98104, USA.
| | - Ndidiamaka L Musa
- Department of Pediatrics, University of Washington and Seattle Children's, 4800 Sand Point Way NE, M/S FA.2.112 P.O. Box 5371, Seattle, WA 98105, USA.
| | - Joan Roberts
- Department of Pediatrics, University of Washington and Seattle Children's, 4800 Sand Point Way NE, M/S FA.2.112 P.O. Box 5371, Seattle, WA 98105, USA.
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23
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Jensen EA, Chaudhary A, Bhutta ZA, Kirpalani H. Non-invasive respiratory support for infants in low- and middle-income countries. Semin Fetal Neonatal Med 2016; 21:181-8. [PMID: 26915655 DOI: 10.1016/j.siny.2016.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The overwhelming majority of neonatal deaths worldwide occur in low- and middle-income countries. Most of these deaths are attributable to respiratory illnesses and complications of preterm birth. The available data suggest that non-invasive continuous positive airway pressure (CPAP) is a safe and cost-effective therapy to reduce neonatal morbidity and mortality in these settings. Bubble CPAP compared to mechanical ventilator-generated CPAP reduces the need for subsequent invasive ventilation in newborn infants. There are limited data on the safety and efficacy of high-flow nasal cannulae in low- and middle-income countries, requiring further study prior to widespread implementation.
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Affiliation(s)
- Erik A Jensen
- The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA.
| | - Aasma Chaudhary
- The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Nutritional Sciences, University of Toronto, Ontario, Canada; Aga Khan University, Karachi, Pakistan
| | - Haresh Kirpalani
- The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA; Neonatal Trials Unit, Department of Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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