Addressing Critical Knowledge Gaps in Newborn Health

Research Round-Up: February 2013

By Alexandra Shaphren on February 26, 2013

* T. Aung, W. McFarland, H. Khin and D. Montagu, Incidence of pediatric diarrhea and public–private preferences for treatment in rural Myanmar: a randomized cluster survey, Journal of Tropical Pediatrics (February, 2013).

The incidence of pediatric diarrhea in countries neighboring Myanmar is high (>9%). No national data exist in Myanmar, however hospital treatment data indicate that diarrhea is a major cause of morbidity. Objective: This study seeks to determine diarrhea incidence among children in rural Myanmar and document health-seeking behavior and treatment costs. Methods: We surveyed 2033 caregivers in households with under-five children, in 104 randomly selected villages in rural Myanmar. Findings: The incidence of diarrhea in the 2 weeks prior to the survey was 4.9%. Home treatment was common (50.6%); among those who consulted a professional 35.6% went to government clinics, 28.8% to private clinics and 28.0% to a community health worker. The cost of treatment was highest ($15) at government clinics and lowest ($1.3) for self-treatment at home. Conclusion: Pediatric diarrhea is an important cause of morbidity in rural Myanmar. Self-treatment and treatment by private providers is common.

*G. Bender, D. Koestler, H. Ombao, et al. Neonatal intensive care unit: predictive models for length of stay, Journal of Perinatology 33, 147-153 (February 2013).

Objective: Hospital length of stay (LOS) is important to administrators and families of neonates admitted to the neonatal intensive care unit (NICU). A prediction model for NICU LOS was developed using predictors birth weight, gestational age and two severity of illness tools, the score for neonatal acute physiology, perinatal extension (SNAPPE) and the morbidity assessment index for newborns (MAIN). Study Design: Consecutive admissions (n=293) to a New England regional level III NICU were retrospectively collected. Multiple predictive models were compared for complexity and goodness-of-fit, coefficient of determination (R 2) and predictive error. The optimal model was validated prospectively with consecutive admissions (n=615). Observed and expected LOS was compared. Result: The MAIN models had best Akaike's information criterion, highest R 2 (0.786) and lowest predictive error. The best SNAPPE model underestimated LOS, with substantial variability, yet was fairly well calibrated by birthweight category. LOS was longer in the prospective cohort than the retrospective cohort, without differences in birth weight, gestational age, MAIN or SNAPPE. Conclusion: LOS prediction is improved by accounting for severity of illness in the first week of life, beyond factors known at birth. Prospective validation of both MAIN and SNAPPE models is warranted.

*A. Chary et al. "The changing role of indigenous lay midwives in Guatemala: New frameworks for analysis." Midwifery (February, 2013).

Objectives: to examine the present-day knowledge formation and practice of indigenous Kaqchikel-speaking midwives, with special attention to their interactions with the Guatemalan medical community, training models, and allopathic knowledge in general. Design/participants: a qualitative study consisting of participant-observation in lay midwife training programs; in-depth interviews with 44 practicing indigenous midwives; and three focus groups with midwives of a local non-governmental organization. Setting: Kaqchikel Maya-speaking communities in the Guatemalan highlands. Findings: the cumulative undermining effects of marginalization, cultural and linguistic barriers, and poorly designed training programs contribute to the failure of lay midwife-focused initiatives in Guatemala to improve maternal-child health outcomes. Furthermore, in contrast to prevailing assumptions, Kaqchikel Maya midwives integrate allopathic obstetrical knowledge into their practice at a highlevel. Conclusions and implications: as indigenous midwives in Guatemala will continue to provide a large fraction of the obstetrical services among rural populations for many years to come, maternal-child policy initiatives must take into account that: (1)Guatemalan midwife training programs can be significantly improved when instruction occurs in local languages, such as Kaqchikel, and (2)indigenous midwives' increasing allopathic repertoire may serve as a productive ground for synergistic collaborations between lay midwives and the allopathic medical community.

*S. Goudar, M. Somannavar, R. Clark. Stillbirth and Newborn Mortality in India After Helping Babies Breathe Training, PEDIATRICS Vol. 131 No. 2 (February, 2013).

OBJECTIVE: This study evaluated the effectiveness of Helping Babies Breathe (HBB) newborn care and resuscitation training for birth attendants in reducing stillbirth (SB), and predischarge and neonatal mortality (NMR). India contributes to a large proportion of the worlds annual 3.1 million neonatal deaths and 2.6 million SBs. METHODS: This prospective study included 4187 births at >28 weeks’ gestation before and 5411 births after HBB training in Karnataka. A total of 599 birth attendants from rural primary health centers and district and urban hospitals received HBB training developed by the American Academy of Pediatrics, using a train-the-trainer cascade. Pre-post written trainee knowledge, posttraining provider performance and skills, SB, predischarge mortality, and NMR before and after HBB training were assessed by using χ2 and t-tests for categorical and continuous variables, respectively. Backward stepwise logistic regression analysis adjusted for potential confounding. RESULTS: Provider knowledge and performance systematically improved with HBB training. HBB training reduced resuscitation but increased assisted bag and mask ventilation incidence. SB declined from 3.0% to 2.3% (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59–0.98) and fresh SB from 1.7% to 0.9% (OR 0.54, 95% CI 0.37–0.78) after HBB training. Predischarge mortality was 0.1% in both periods. NMR was 1.8% before and 1.9% after HBB training (OR 1.09, 95% CI 0.80–1.47, P = .59) but unknown status at 28 days was 2% greater after HBB training (P = .007).
CONCLUSIONS: HBB training reduced SB without increasing NMR, indicating that resuscitated infants survived the neonatal period. Monitoring and community-based assessment are recommended.

*D. Henry, T. McElrath and N. Smith. Preterm severe preeclampsia in singleton and twin pregnancies. Journal of Perinatology 33, 94-97 (February 2013).

Objective: We aimed to evaluate rates of delivery and clinical manifestations of preterm severe preeclampsia in singleton and twin gestations. Study Design: This retrospective cohort study included 86 765 deliveries from 2000 to 2009, including 3244 twins. Rates of delivery for severe preeclampsia among infants born 24 to 31+6, and 32 to 36+6 weeks gestation were calculated, and diagnostic criteria were compared. Result: Re-term severe preeclampsia was more common in twin pregnancies (2.4% vs 0.4%, P<0.001, relative risk 5.70 (95% confidence interval 4.47 to 7.26)). This was also true for deliveries from 24 to 31+6 (0.8% vs 0.2%, P<0.001) and 32 to 36+6 weeks (1.7% vs 0.3%, P<0.001). Diagnostic criteria and disease manifestation including hemolysis elevated liver enzymes low platelet count syndrome, abruption and growth restriction were similar between groups.  Conclusion: Twin pregnancies are significantly more likely than singletons to be delivered preterm for severe preeclampsia. Diagnostic criteria and disease manifestation were similar in singletons and twins, at all gestational ages.

*M. Johri, et al. "Use of measles supplemental immunization activities (SIAs) as a delivery platform for other maternal and child health interventions: Opportunities and challenges." Vaccine 31(9): 1259-1263. (February, 2013).

Measles supplementary immunization activities (SIAs) offer children in countries with weaker immunization delivery systems like India a second opportunity for measles vaccination. They could also provide a platform to deliver additional interventions, but the feasibility and acceptability of including add-ons is uncertain. We surveyed Indian programme officers involved in the current (2010-2012) measles SIAs concerning opportunities and challenges of using SIAs as a delivery platform for other maternal and child health interventions. Respondents felt that an expanded SIA strategy including add-ons could be of great value in improving access and efficiency. They viewed management challenges, logistics, and safety as the most important potential barriers. They proposed that additional interventions be selected using several criteria, of which importance of the health problem, safety, and contribution to health equity figured most prominently. For children, they recommended inclusion of basic interventions to address nutritional deficiencies, diarrhoea and parasites over vaccines. For mothers, micronutrient interventions were highest ranked.


The briefing draws on BBC Media Action’s experience in Bihar, India, to explore how, where and when low-tech mobile phones can best help reduce maternal and child mortality.  Mobile health (mHealth) projects are increasingly common across the developing world.  This briefing highlights how the project, funded by the Bill and Melinda Gates Foundation, has sought to overcome two problems that have proved particularly challenging in this area: those of scale and sustainability. Bihar has some of the highest maternal and child mortality rates in India.  It also has low radio and television penetration, but high access to mobile telephony.  The project is on track to help train up to 200,000 community health workers over five years, and to reach almost 7 million pregnant women and mothers of children under the age of two with potentially life-saving information.   The briefing argues that, especially when used as part of clearly thought out and well-developed health communication strategies, mobile telephony can add real value in saving lives.  Authors Yvonne MacPherson and Sara Chamberlain show how the model utilises widely available basic handsets, localised content and a public-private partnership between the state government and the mobile sector to deliver services with real reach and resonance. The model has been developed specifically for hard-to-reach, poor communities with low literacy levels and little access to health services and information.  The Health on the Move briefing, which was prepared thanks to funding from the UK Department for International Development, is part of a broader series focused on the role of media and communication in achieving governance, health, humanitarian and resilience outcomes.


*H. Morris, J. Tyson, D. Stevenson, et al. Efficacy of phototherapy devices and outcomes among extremely low birth weight infants: multi-center observational study, Journal of Perinatology 33, 126-133 (February 2013).

Objective: Evaluate the efficacy of phototherapy (PT) devices and the outcomes of extremely premature infants treated with those devices. Study Design: This substudy of the National Institute of Child Health and Human Development Neonatal Research Network PT trial included 1404 infants treated with a single type of PT device during the first 24±12 h of treatment. The absolute (primary outcome) and relative decrease in total serum bilirubin (TSB) and other measures were evaluated. For infants treated with one PT type during the 2-week intervention period (n=1223), adjusted outcomes at discharge and 18 to 22 months corrected age were determined. Result: In the first 24 h, the adjusted absolute (mean (±s.d.)) and relative (%) decrease in TSB (mg dl−1) were: light-emitting diodes (LEDs) −2.2 (±3), −22%; Spotlights −1.7 (±2), −19%; Banks −1.3 (±3), −8%; Blankets −0.8 (±3), −1%; (P<0.0002). Some findings at 18 to 22 months differed between groups. Conclusion: LEDs achieved the greatest initial absolute reduction in TSB but were similar to Spots in the other performance measures. Long-term effects of PT devices in extremely premature infants deserve rigorous evaluation.

*D. Simkiss, Kangaroo Mother Care Revisited, Journal of Tropical Pediatrics (February, 2013).

Thirteen years ago I wrote an editorial in this journal on Kangaroo Mother Care (KMC). In 2003, the World Health Organization produced a practical guide to KMC, describing the key features as: Early, continuous and prolonged skin-to-skin contact between the mother and the baby; Exclusive breastfeeding (ideally); Initiated in hospital and can be continued at home; Small babies can be discharged early; Mothers at home require adequate support and follow-up; It is a gentle, effective method that avoids the agitation routinely experienced in a busy ward with preterm infants [2]
That year, 2003, a Cochrane collaboration systematic review did not find evidence for KMC reducing neonatal mortality and did not report neonatal-specific data [3]. However, the research base supporting the approach has evolved considerably over the past 10 years. In 2010, a meta-analysis of 15 KMC studies reporting mortality and/or morbidity outcomes was published [4].

J. Spector, J.  Reisman, S. Lipsitz et al. Access to essential technologies for safe childbirth: a survey of health workers in Africa and Asia. BMC Pregnancy and Childbirth, (February, 2013).

Background: The reliable availability of health technologies, defined as equipment, medicines, and consumable supplies, is essential to ensure successful childbirth practices proven to prevent avoidable maternal and newborn mortality. The majority of global maternal and newborn deaths take place in Africa and Asia, yet few data exist that describe the availability of childbirth-related health technologies in these regions. We conducted a cross-sectional survey of health workers in Africa and Asia in order to profile the availability of health technologies considered to be essential to providing safe childbirth care. Methods: Health workers in Africa and Asia were surveyed using a web-based questionnaire. A list of essential childbirth-related health technologies was drawn from World Health Organization guidelines for preventing and managing complications associated with the major causes of maternal and newborn mortality globally. Demographic data describing each birth center were obtained and health workers reported on the availability of essential childbirth-related health technologies at their centers. Comparison analyses were conducted using Rao-Scott chi-square test statistics. Results: Health workers from 124 birth centers in 26 African and 15 Asian countries participated. All facilities exhibited gaps in the availability of essential childbirth-related health technologies. Availability was significantly reduced in birth centers that had lower birth volumes and those from lower income countries. On average across all centers, health workers reported the availability of 18 of 23 essential childbirth-related health technologies (79%; 95% CI, 74%, 84%). Low-volume facilities suffered severe shortages; on average, these centers reported reliable availability to 13 of 23 technologies (55%; 95% CI, 39%, 71%). Conclusions: Substantial gaps exist in the availability of essential childbirth-related health technologies across health sector levels in Africa and Asia. Strategies that facilitate reliable access to vital health technologies in these regions are an urgent priority.