Silent voices of the midwives: factors that influence midwives’ achievement of successful neonatal resuscitation in sub-Saharan Africa: a narrative inquiry

Background In Tanzania, birth asphyxia is a leading cause of neonatal death. The aim of this study was to identify factors that influence successful neonatal resuscitation to inform clinical practice and reduce the incidence of very early neonatal death (death within 24 h of delivery). Methods This was a qualitative narrative inquiry study utilizing the 32 consolidated criteria for reporting qualitative research (COREQ). Audio-recorded, semistructured, individual interviews with midwives were conducted. Thematic analysis was applied to identify themes. Results Thematic analysis of the midwives’ responses revealed three factors that influence successful resuscitation: 1. Hands-on training (“HOT”) with clinical support during live emergency neonatal resuscitation events, which decreases fear and enables the transfer of clinical skills; 2. Unequivocal commitment to the Golden Minute® and the mindset of the midwife; and. 3. Strategies that reduce barriers. Immediately after birth, live resuscitation can commence at the mother’s bedside, with actively guided clinical instruction. Confidence and mastery of resuscitation competencies are reinforced as the physiological changes in neonates are immediately visible with bag and mask ventilation. The proclivity to perform suction initially delays ventilation, and suction is rarely clinically indicated. Keeping skilled midwives in labor wards is important and impacts clinical practice. The midwives interviewed articulated a mindset of unequivocal commitment to the baby for one Golden Minute®. Heavy workload, frequent staff rotation and lack of clean working equipment were other barriers identified that are worthy of future research. Conclusions Training in resuscitation skills in a simulated environment alone is not enough to change clinical practice. Active guidance of “HOT” real-life emergency resuscitation events builds confidence, as the visible signs of successful resuscitation impact the midwife’s beliefs and behaviors. Furthermore, a focused commitment by midwives working together to reduce birth asphyxia-related deaths builds hope and collective self-efficacy.

Causes and age of neonatal death and associations with maternal and newborn care characteristics in Nepal: a verbal autopsy study

Background In Nepal, neonatal mortality fell substantially between 2000 and 2018, decreasing 50% from 40 to 20 deaths per 1,000 live births. Nepal’s success has been attributed to a decreasing total fertility rate, improvements in female education, increases in coverage of skilled care at birth, and community-based child survival interventions. Methods A verbal autopsy study, led by the Integrated Rural Health Development Training Centre (IRHDTC), conducted interviews for 338 neonatal deaths across six districts in Nepal between April 2012 and April 2013. We conducted a secondary analysis of verbal autopsy data to understand how cause and age of neonatal death are related to health behaviors, care seeking practices, and coverage of essential services in Nepal. Results Sepsis was the leading cause of neonatal death (n=159/338, 47.0%), followed by birth asphyxia (n=56/338, 16.6%), preterm birth (n=45/338, 13.3%), and low birth weight (n=17/338, 5.0%). Neonatal deaths occurred primarily on the first day of life (27.2%) and between days 1 and 6 (64.8%) of life. Risk of death due birth asphyxia relative to sepsis was higher among mothers who were nulligravida, had <4 antenatal care visits, and had a multiple birth; risk of death due to prematurity relative to sepsis was lower for women who made ≥1 delivery preparation and higher for women with a multiple birth. Conclusions Our findings suggest cause and age of death distributions typically associated with high mortality settings. Increased coverage of preventive antenatal care interventions and counseling are critically needed. Delays in care seeking for newborn illness and quality of care around the time of delivery and for sick newborns are important points of intervention with potential to reduce deaths, particularly for birth asphyxia and sepsis, which remain common in this population.

Women with Severe Anemia in Labor: Fetomaternal Outcomes

Background: Anaemia in pregnancy is the leading medical disorder in developing countries like India. Women with severe anemia in labor is a challenging situation for the obstetrician with increased maternal and perinatal morbidity and mortality. It has multifactorial etiology, Main cause of anemia in obstetrics is iron deficiency. There are specific risks for the mother like preterm labour pain, IUGR baby, preeclampsia, antepartum haemorrhage, sepsis etc and the fetus such as prematurity, lowbirth weight, birth asphyxia etc. Aim and Objectives: To determine the socio-demographic variables and also the maternal and perinatal outcomes of pregnant women admitted to labour room with severe anemia (Hb <7gm%) late in pregnancy. Results: It was seen that out of 50 severely anemic women, 82% had Hb between 4-7 gm% and 18% had Hb < 4gm%. Severe anemia is seen in 82% unbooked patients and only in 18% booked patients. There was increased incidence of preterm delivery, PPH, preeclampsia, eclampsia, mortality in anemic group as compared to non anemic group. Among the adverse fetal outcomes, there was increased incidence of intrauterine deaths, intrauterine growth restriction, NICU admission, low birth weight among the anemic group as compared to non anemic group. Conclusions: Severely anemic women reporting in labor had significantly high maternal and perinatal morbidity and mortality. Even a minor blood loss is much devastating for such patients. Extrapolating our observations, it can be said that a close vigilance, anticipation of complications and appropriate care and interventions during labor and puerperium will help in improving outcomes in these severely anemic women. Awareness and education on early antenatal bookings, regular iron intake and continuous antenatal care should be the goal in tackling anemia in pregnancy. Key words: Anaemia, Iron deficiency, Intrauterine growth retardation, prematurity, maternal outcome, neonatal outcome.

Disease Burden of Neonatal Care Unit at Al-Bayda Medical Center Al-Bayda Libya

This research was conducted to determine the number, disease pattern, and outcome of the patients admitted at the Neonatal Care Unit (NCU) at Al-Bayda medical center (AMC) in Libya. A retrospective cross-sectional descriptive study was carried out on all neonates admitted to the NCU between January 2008 and December 2008. The collected data include age, gender, mode and site of delivery, number of gestations, maturity, duration of stay, cause of admission, and outcome. Total infants delivered were 10075, 620 (6.1%) of them were admitted to NCU with a (6.15%) admission rate, 56.5% were male and 43.5% were female, of whom 613 (98.9%) were inborn and 519 (83.7%) were term neonates; 523 (84.4%) of total born were by normal vaginal delivery (NVD). 48.7% of total admissions occurred during the first 24 hours of life. The average length of hospital stay for term births was 5.6 days (SD 5.4) and for preterm 8.7 days (SD 8.55). The common causes of admission were neonatal jaundice (29.3%), followed by neonatal infections (17.6%) were prematurity accounts for (16.3%), and respiratory distress (11.1%). The majority of the admitted neonates improved and were discharged 517 (83.4%), 37(6%) left against medical advice (LAMA) and nineteen (3%) were referred to other specialized hospitals for further management. The neonatal mortality rate was 0.4%, and the overall hospital neonatal mortality rate was 7.6%. According to the cause-specific death rate analysis, prematurity was the most common cause of death (29.8%), followed by sepsis (17%) and birth asphyxia (12.8%). In conclusion, neonatal jaundice, infection, and prematurity complications were the leading causes of morbidity in neonates. The case-fatality rate was high for prematurity, sepsis, and birth asphyxia. Most of these etiologies are preventable to some extent by regular prenatal visits, healthy delivery practices, and timely referral to hospitals which can reduce NCU burden and improve outcomes

Neonatal and maternal factors associated with hepatic dysfunction after birth asphyxia

Background: Liver cell injury commonly occurs after perinatal asphyxia. This study aimed to identify the neonatal and maternal factors related to hepatic dysfunction associated with birth asphyxia. Methods: A case control study was carried out in Basra comprising 43 asphyxiated newborns, and 57 healthy full terms enrolled as control. Serum levels of liver enzymes [alanine transferase (ALT), aspartate transferase (AST), alkaline phosphatase (ALP)] were measured and compared between the study and control groups. Levels beyond +2SD above the mean of control considered high. Statistical analysis was done using SPSS program version 20. Chi-Square test and ANOVA were used where appropriate, P-value <0.05 was considered as significant. Elevated levels of enzymes were studied in relation to selected neonatal and maternal variables. Results: Higher levels of liver enzymes were found related to gestational age > 40 weeks, newborn’s body weight > 4 Kg, mother’s age>35 years, parity > 4 children and maternal medical disease. The results were statistically significant (P<0.05). However, no statistical differences were detected regarding newborn’s gender and growth status, maternal education and mode of delivery. Conclusion: The study highlights the relationship between maternal and neonatal risk factors and perinatal asphyxia associated with hepatic dysfunction.

Role of Near-Infrared Spectroscopy in Monitoring the Clinical Course of Asphyxiated Neonates Treated with Hypothermia

Objective Hypoxic-ischemic encephalopathy (HIE) affects millions of newborns annually, especially in low-resource settings. Real-time monitoring of hypoxic-ischemic brain damage is urgently needed for assessment of severity and management of neonates with birth asphyxia. Aim of the work is monitoring of near-infrared spectroscopy (NIRS)-measured cerebral regional oxygen saturation (cRSO2) and cerebral fractional tissue oxygen extraction (FTOE) in neonates after birth asphyxia in relation to their clinical course. Study Design Forty asphyxiated-term and near-term neonates with mild to severe HIE admitted at neonatal intensive care unit of Alexandria University Maternity Hospital from March to October 2019, received therapeutic hypothermia (TH) and had continuous NIRS monitoring of cRSO2 for 72 hours. Infants were categorized into HIE with seizing and nonseizing groups, and abnormal and normal magnetic resonance imaging (MRI) groups. Results Clinical seizures (CS) occurred in 15 (37.5%) of HIE neonates and 13.3% of them died (n = 2). In the current study, significantly higher cRSO2 and lower FTOE values were found in the seizing infants as compared with nonseizing group (p < 0.001). NIRS-measured day 2-cRSO2 and day 1-FTOE were associated with CS in newborns with HIE and day 1-cRSO2 and FTOE were associated with abnormal MRI at 1 month of age. cRSO2 values were found to correlate positively with initial Thompson score especially in days 1 and 2. Further, neonates with CS were more likely to have MRI abnormalities at follow-up. Conclusion NIRS measures may highlight differences between asphyxiated neonates who develop CS or later MRI abnormalities and those who do not. Key Points

Perinatal and maternal outcome in meconium stained amnioticfluid (thin and thick) at dhiraj general hospital, a rural tertiary health centre

Background: To determine the perinatal outcome of with Meconium-stained amniotic fluid (MSAF) compared with clear amniotic fluid at Dhiraj Hospital.Methods: A prospective observational study was carried out in obstetrics and gynaecology department of Dhiraj Hospital, Sumandeep Vidyapeeth from March 2021 to August 2021. All patients fulfilling inclusion and exclusion criteria as mentioned above were taken for the study. All the categorial variables were analysed independently with the help of chi square test and fisher’s exact test and all the continuous variables were analysed with independent ‘t test’.Results: Out of 500 patients selected for the present study which had inclusion criteria, 13.6% were meconium stained out of which 50 (73.5%) cases had thin meconium and 18 (26.4%) cases had thick meconium. Fetal CTG abnormalities were more common in MSAF group and were noted in 38.2% of cases which is significantly increased compared to control group with CTG abnormalities in 8.3%. The difference was significant with p value of <0.001. 32(47.0%) patients with meconium-stained amniotic fluid had normal vaginal delivery, while in control group out of 432, 360 (83.3%) delivered normally. Incidence of LSCS and assisted vaginal delivery was more in meconium-stained amniotic fluid.Conclusions: Meconium-stained amniotic fluid is associated with more frequency of operative delivery, birth asphyxia, neonatal sepsis, and neonatal intensive care unit admissions compared to clear amniotic fluid. Better perinatal outcome in clear amniotic fluid compared to meconium stained liquor.

Clinical profile, etiology, type and outcome of neonatal seizures: a hospital-based study

Background: Our study was undertaken to study the etiological factor, clinical profile, types and outcome of newborn with neonatal seizures (NNS).Methods: Our study was hospital based prospective study was done in Sheri Kashmir institute of medical sciences (SKIMS) Bemina from April 2013 to April 2015 in NICU, after obtaining ethical clearance from institutional ethical committee. All neonates fulfilling inclusion criteria were included in our study.Results: In our study, 80 neonates with seizures were included in our study, among them 48 were males and 32 were females. Majority of neonates (57.5%) developed seizures during first 72 hours of life due to birth asphyxia. Commonest types of neonatal seizures observed in our study were subtle observed in 46 cases, followed by tonic (21.2 %), clonic (14.9 %) and mixed (6.2%) seizures. Birth asphyxia was commonest cause (57.5%) of NNS, sepsis with meningitis (18.7%) followed by hypoglycemia (13.7%) and hypocalcemia (5%). Cases of birth asphyxia were associated with higher mortality (58.3%) as compared to cases with metabolic seizures.Conclusions: From our study we conclude that commonest cause of neonatal seizure was birth asphyxia occurring within 72 hours of birth. Sepsis and meningitis were also common infections resulting in neonatal seizure, while as hypoglycaemia and hypocalcemia were common biochemical abnormalities leading to NNS. Early identification and treatment are likely important for long-term outcomes in acute symptomatic seizure.

Impact of the early COVID-19 pandemic on outcomes in a rural Ugandan neonatal unit: A retrospective cohort study

Background During the early COVID-19 pandemic travel in Uganda was tightly restricted which affected demand for and access to care for pregnant women and small and sick newborns. In this study we describe changes to neonatal outcomes in one rural central Ugandan newborn unit before and during the early phase of the COVID-19 pandemic. Methods We report outcomes from admissions captured in an electronic dataset of a well-established newborn unit before (September 2019 to March 2020) and during the early COVID-19 period (April–September 2020) as well as two seasonally matched periods one year prior. We report excess mortality as the percent change in mortality over what was expected based on seasonal trends. Findings The study included 2,494 patients, 567 of whom were admitted during the early COVID-19 period. During the pandemic admissions decreased by 14%. Patients born outside the facility were older on admission than previously (median 1 day of age vs. admission on the day of birth). There was an increase in admissions with birth asphyxia (22% vs. 15% of patients). Mortality was higher during COVID-19 than previously [16% vs. 11%, p = 0.017]. Patients born outside the facility had a relative increase of 55% above seasonal expected mortality (21% vs. 14%, p = 0.028). During this period patients had decreased antenatal care, restricted transport and difficulty with expenses and support. The hospital had difficulty with maternity staffing and supplies. There was significant community and staff fear of COVID-19. Interpretation Increased newborn mortality during the early COVID-19 pandemic at this facility was likely attributed to disruptions affecting maternal and newborn demand for, access to and quality of perinatal healthcare. Lockdown conditions and restrictions to public transit were significant barriers to maternal and newborn wellbeing, and require further focus by national and regional health officials.