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Preterm Babies in Uganda

The enhanced KMC project: Assessing the feasibility and effectiveness of low cost care for preterm babies in central eastern Uganda

Deaths in the first month of life, the neonatal period, now contributes about 40% of child deaths in the first 60 months (five years) of life. Estimates for 2012 show that preterm birth complications have overtaken pneumonia as the most common cause of under-5 deaths (Liu, Johnson et al. 2012). The highest rates are in Africa. Despite these dire needs for care, access to life-saving interventions for mothers and infants remains a major clinical care gap. This is despite existence of low cost evidence-based interventions.

Many of these deaths are preventable even in low resource settings such as Uganda – some studies have found that kangaroo mother care (KMC) can prevent up to half of all deaths in babies weighing less than 2000g (Lawn, Mwansa-Kambafwile et al. 2010; Conde-Agudelo, Belizan et al. 2011), and these make up more than 80% of preterm births. KMC is currently viewed as the highest impact intervention in preterm care together with antenatal corticosteroids and is considered to be highly feasible to scale up in low-resources settings (March of Dimes et al, 2012). KMC has also been promoted as one of the methods for improving infant survival necessary for achieving Millennium Development Goal (MDG) 4 (Kinney et al, 2009). Compared with incubator care, KMC has furthermore been found to reduce severe infection/sepsis, nosocomial infections, hypothermia, and severe illness, lower respiratory tract disease, and length of hospital stay. Babies cared for in KMC also show improved weight and length, head circumference, breastfeeding, and mother-infant bonding compared to babies in incubator care (Conde-Agudelo et al, 2011; Ludington-Hoe et al, 2008; Ruiz, et al, 2007). Our own experience in eastern Uganda supports these finding. As part of the Uganda Newborn Study (UNEST), we started a KMC unit in Iganga district hospital using an existing room on maternity unit (Waiswa, Nyanzi et al. 2010; Waiswa, Peterson et al. 2010; Mbonye, Sentongo et al. 2012). Preliminary findings show that over 80% of KMC babies survive. A key challenge for Uganda is that such a simple intervention has not been scaled up and is inaccessible especially to the poorest in rural areas that are away from the city.

Goal: We aim to develop, cost and evaluate a regional referral care system for preterm babies in central eastern Uganda in order to inform nationwide scale up.

Objectives:

To assess barriers and facilitators to the current care for preterm babies in central eastern Uganda
To design a regional level standardized KMC care strategy for preterm babies in central eastern Uganda
To introduce an enhanced KMC practice in hospitals in central eastern Uganda
To evaluate the process of KMC introduction, implementation and effect of the strategy in central eastern Uganda.

Methodology

This will be a quasi-experiment study employing step-wedge design (meaning that scale up will be in phases where we start at a hospital and the other becomes a control). The study will take place in the Busoga region in eastern Uganda. It is one of the underserved regions. The region has six hospitals for a population of about 3 million people. There are several lower level health facilities that form the referring units for the hospitals. We will focus on a regional referral system staring with hospitals as it is the formal administrative strategy for health care in Uganda. This approach ensures that we are strengthening the available public health care system, thus increasing the likelihood of sustaining the strategy through the Ministry of Health. Our team at Makerere University will work with the Ministry of Health, the Jinja regional hospital, and the district hospitals to implement the intervention.

The process followed will be capacity building of hospitals to implement an enhanced KMC package consisting of capacity building in:

1) Delivery skills for health workers;

2) Resuscitation skills for newborns with birth asphyxia (helping babies breathe);

3) Identification of preterm babies;

4) KMC units;

5) Follow-up for preterm babies through weekly KMC outpatient clinics.

Regional level pediatricians and a national level neonatologist will be supported to provide ongoing support supervision and mentorship to district hospitals. All mothers of preterm babies will be followed up after discharge by trained nurses at home and use of mobile phone calls (we will explore working with mobile phone companies to provide this as part of Corporate Social responsibility). Mothers that are assessed as likely to have more problems will be followed up at home by a trained nurse more often than the rest.

Outcomes

We will assess for the following outcomes:

Neonatal and infant mortality rates
Re-admission rates
Growth monitoring through weight gain and time to key milestones
Cost and cost benefit
Follow up rates
Compliance rates for return visits
Long term effects
Qualitative evaluation (barriers and facilitators)