Quality of inpatient care of small and sick newborns in Pakistan: perceptions of key stakeholders

Background In LMICs including Pakistan, neonatal health and survival is a critical challenge, and therefore improving the quality of facility-based newborn care services is instrumental in averting newborn mortality. This paper presents the perceptions of the key stakeholders in the public sector to explore factors influencing the care of small and sick newborns and young infants in inpatient care settings across Pakistan. Methods This exploratory study was part of a larger study assessing the situation of newborn and young infant in-patient care provided across all four provinces and administrative regions of Pakistan. We conducted 43 interviews. Thirty interviews were conducted with the public sector health care providers involved in newborn and young infant care and 13 interviews were carried out with health planners and managers working at the provincial level. A semi-structured interview guide was used to explore participants’ perspectives on enablers and barriers to the quality of care provided to small and sick newborns at the facility level. The interviews were manually analyzed using thematic content analysis. Findings The study respondents identified multiple barriers contributing to the poor quality of small and sick newborn care at inpatient care settings. This includes an absence of neonatal care standards, inadequate infrastructure and equipment for the care of small and sick newborns, deficient workforce for neonatal case management, inadequate thermal care management for newborns, inadequate referral system, absence of multidisciplinary approach in neonatal case management and need to institute strong monitoring system to prevent neonatal deaths and stillbirths. The only potential enabling factor was the improved federal and provincial oversight for reproductive, maternal, and newborn care. Conclusion This qualitative study was insightful in identifying the challenges that influence the quality of inpatient care for small and sick newborns and the resources needed to fix these. There is a need to equip Sick Newborn Care Units with needed supplies, equipment and medicines, deployment of specialist staff, strengthening of in-service training and staff supervision, liaison with the neonatal experts in customizing neonatal care guidelines for inpatient care settings and to inculcate the culture for inter-disciplinary team meetings at inpatient care settings across the country.

Effect of Sub-inhibitory Dose of Cefotaxime on Multidrug resistant Staphylococcus haemolyticus Isolates

Critical care of neonates involves substantial usage of antibiotics and exposure to multidrug resistant (MDR) nosocomial pathogens. These pathogens are often exposed to sub-MIC doses of antibiotics which might result in a range of physiological effects. Therefore, to understand the outcome of sub-inhibitory dosage of antibiotics on Staphylococcus populations, nasal swab specimens were collected from 34 neonates admitted to the Sick Newborn Care Unit between 2017-2018, a total of 41 non-repetitive isolates were included in this study. Staphylococcus haemolyticus was the prevalent species (58.54%) with high non-susceptibility to cefotaxime (CTX) (79.16%), gentamicin (87.50%), and meropenem (54.17%). Biofilm forming abilities of S. haemolyticus isolates in the presence of sub-optimal CTX (30μg/mL), the predominantly prescribed β-lactam antibiotic, were then determined by crystal violet assays and extracellular DNA (eDNA) quantitation. CTX was found to significantly enhance biofilm production among the non-susceptible isolates (p-valueWilcoxin test- 0.000008) with increase in eDNA levels (p-valueWilcoxin test- 0.000004). Additionally, no changes in non-susceptibility were observed among populations of two MDR isolates, JNM56C1 and JNM60C2 after >500 generations of growth in the absence of antibiotic selection in vitro. These findings demonstrate that sub-MIC concentration of CTX induces biofilm formation and short-term non-exposure to antibiotics does not alter non-susceptibility among S. haemolyticus isolates.

Clinical profile and outcome of neonates admitted in sick newborn care unit with hypernatremic dehydration and association with breastfeeding in a tertiary care hospital in Northern India

Background: Neonatal hypernatremic dehydration is a very commonly seen potentially devastating condition. Inadequate breastfeeding, gastrointestinal losses, warm weather and improperly diluted mixed feeding are the main etiologies linked with neonatal hypernatremic dehydration. We conducted this study to evaluate the etiology, risk factors, clinical symptoms and outcomes of neonates admitted with hypernatremic dehydration and its association with breastfeeding from hilly region in northern India.Methods: The authors retrospectively studied records from extramural sick newborn care unit (SNCU) from April 2018 to June 2019. Inclusion criteria for the study included admitted neonates with documented hypernatremia (serum sodium level >145 mmol/L). Results: Nine hundred and twenty-two neonates were admitted in sick newborn care unit during this study period. One hundred and three (13.39%) newborns were admitted with hypernatremic dehydration at the time of admission. All newborns had deranged kidney function tests at time of admission. Most commonly found presenting complaints were poor feeding (85.71%), fever (45.71%), loose stools (42.8%) and decreased urine output (8%). The mean (SD) sodium on admission was 154.04 (7.41) meq/L. The mean (SD) time taken to correct hypernatremia was 35.6 (14.6) hours. Six of total admitted newborn developed neurological complications (2 had developed cerebral venous thrombosis and 4 had developed seizures). Mortality rate was 4.4%. Top fed neonates (50.41%) had higher percentage of mean sodium level and acute kidney injury at time of admission.Conclusions: Hypernatremic dehydration is preventable and treatable condition. Looking in to and addressing etiology in a timely manner is main step in management. All mothers should be taught correct breastfeeding technique. More breast examination during prenatal and postnatal periods and careful neonatal weight record postnatally could decrease the incidence of neonatal hypernatremic dehydration. Top feeding should be discouraged and only exclusive breastfeeding for 6 months.

Quality Of Referral, Admission Status And Outcome Of Neonates Referred To Pediatric Emergency Of A Tertiary Care Institution In North India

Background: We evaluated quality of referral, admission status and outcome of neonates.Methods: We enrolled newborns admitted between March 2016 and October 2016, excluding neonates referred from outpatient department. Information was collected from referral slips, interviewing accompanying persons and observation.Results: 61% were referred from government hospitals with “Sick Newborn Care Units” contributing to maximum. Main mode of transport was ambulance in 80% and referral notes were available in the majority but incomplete in majority. Sepsis (39%), jaundice (16%) and birth asphyxia (13%) were most common diagnoses. Half of the newborns were hemodynamically unstable. 27% had poor circulation, 15% were hypoxic, 9% hypoglycemic and 8% hypothermic. 22% either died or “Left Against Medical Advice” with a high probability of death.Conclusion: National ambulance service is utilized for transporting newborns. However, there are quality gaps which need attention to develop it into efficient referral system.

Perceptions and practices on newborn care and managing complications at rural communities in Bangladesh: a qualitative study

Background Community misperception on newborn care and poor treatment of sick newborn attributes to neonatal death and illness severity. Misperceptions and malpractices regarding neonatal care and neonatal complications are the leading causes of neonatal deaths in Bangladesh. The study was conducted to explore neonatal care’s perceptions and practices and manage complications among Bangladesh’s rural communities. Methods A qualitative study was conducted in Netrakona district of Bangladesh from April to June 2015. Three sub-districts (Upazilas) including Purbadhala, Durgapur and Atpara of Netrakona district were selected purposively. Five focus group discussions (FGDs) and twenty in-depth interviews (IDIs) were conducted in the rural community. Themes were identified through reading and re-reading the qualitative data and thematic analysis was performed. Results Community people were far behind, regarding the knowledge of neonatal complications. Most of them felt that the complications occurred due to lack of care by the parents. Some believed that mothers did not follow the religious customs after delivery, which affected the newborns. Many of them followed the practice of bathing the newborns and cutting their hair immediately after birth. The community still preferred to receive traditional treatment from their community, usually from Kabiraj (traditional healer), village doctor, or traditional birth attendant. Families also refrained from seeking treatment from the health facilities during neonatal complications. Instead, they preferred to wait until the traditional healers or village doctors recommended transferring the newborn. Conclusions Poor knowledge, beliefs and practices are the key barriers to ensure the quality of care for the newborns during complications. The communities still depend on traditional practices and the level of demand for facility care is low. Appropriate interventions focusing on these issues might improve the overall neonatal mortality in Bangladesh.

Small and sick newborn care during the COVID-19 pandemic: global survey and thematic analysis of healthcare providers’ voices and experiences

IntroductionThe COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers’ experiences and proposed mitigation strategies.MethodsUsing a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions.ResultsWe analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother–baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families’ fear of visiting hospitals (~73%).ConclusionNewborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better.

Quality of Inpatient Care of Small and Sick Newborns in Pakistan: A Qualitative Study With Key Stakeholders

Background In LMICs including Pakistan, neonatal health and survival is a critical challenge, and therefore improving the quality of facility-based newborn care services is instrumental in averting newborn mortality. This paper presents the perceptions of the key stakeholders in the public sector to explore factors influencing the care of small and sick newborn and young infants in inpatient care settings across Pakistan. Methods This exploratory study was part of a larger study assessing the situation of newborn and young infant in-patient care provided across all four provinces and administrative regions of Pakistan. We conducted 43 interviews. Thirty interviews were conducted with the public sector health care providers involved in newborn and young infant care and 13 interviews were carried out with health planners and managers working at the provincial level. A semi-structured interview guide was used to explore participants’ perspectives on enablers and barriers to the quality of care provided to small and sick newborns at the facility level. The interviews were manually analyzed using thematic content analysis. Findings: The study respondents identified multiple barriers contributing to the poor quality of small and sick newborn care at inpatient care settings. This includes an absence of neonatal care standards, inadequate infrastructure and equipment for the care of small and sick newborn, deficient workforce for neonatal case management, inadequate thermal care management for newborns, inadequate referral system, absence of multidisciplinary approach in neonatal case management and need to institute strong monitoring system to prevent neonatal deaths and stillbirths. The only potential enabling factor was the improved federal and provincial oversight for reproductive, maternal, and newborn care. Conclusion This qualitative study was insightful in identifying the challenges that influence the quality of inpatient care for small and sick newborn and the resources needed to fix these. There is a need to equip Sick Newborn Care Units with needed supplies, equipment and medicines, deployment of specialist staff, strengthening of in-service training and staff supervision, liaison with the neonatal experts in customizing neonatal care guidelines for inpatient care settings and to inculcate the culture for inter-disciplinary team meetings at inpatient care settings across the country.

Impact of free newborn care service package on out of pocket expenditure‐evidence from a multicentric study in Nepal

Background Sustainable Development Goal (SDG) aspires to improve universal health coverage through reduction of Out of Pocket Expenditure (OOPE) and improving the quality of care. In the last two decades, there have been several efforts to reduce the OOPE for maternal and newborn care. In this paper, we evaluate the change in the OOPE for treatment of sick newborn at hospital before and after implementation of a free newborn care (FNC) program in hospitals of Nepal. Methods Ministry of Health and Population implemented a free newborn care program which reimbursed the cost of treatment for all sick newborns admitted in public hospitals in Nepal from November 2017. We conducted this pre-post quasi-experimental study with four months of pre-implementation and 12 months of post-implementation of the program in 12 hospitals of Nepal. Logistic regression analysis was conducted for categorical variables and Mann-Whitney test was applied for continuous variables to determine statistically significant differences between pre- and post- intervention period. Results A total of 353 sick newborns were admitted into these hospitals before implementation of the FNC program while 1122 sick newborns were admitted after the implementation. Before implementation, 17 % of mothers paid for sick newborn care while after implementation 15.3 % mothers (p-value = 0.59) paid for care. The OOPE for treatment of sick newborn at hospital before implementation was Mean ± SD: US dollar 14.3 + 12.1 and after implementation was Mean ± SD: USD 13.0 ± 9.6 (p-value = 0.71). There were no significant differences in neonatal morbidity after the implementation of the FNC program. The stay in a hospital bed (in days) decreased after the implementation of FNC program (p-value < 0.001) while the cost for medicine increased (p-value = 0.02). The duration of hospital stay (in days) of sick newborns significantly decreased for Hypoxic Ischemic Encephalopathy (HIE) (p-value = 0.04) and neonatal sepsis (p-value < 0.001) after the FNC program was implemented. Conclusions We found no change in the OOPE for sick newborn care following implementation of the FNC Program. There is a need to revisit the FNC program by the type of morbidity and duration of stay. Further studies will be required to explore the health system adequacy to implement such programs in hospitals of Nepal. Trial registration ISRCTN- 30829654, Registered on May 02, 2017.

Impact of Free Newborn Care Service package on Out of Pocket Expenditure-Evidence from a multicentric study in Nepal.

Background: Sustainable Development Goal ( SDG) aspires to improve universal health coverage through reduction of Out of Pocket Expenditure (OOPE) and improving the quality of care. In the last two decades, there have been several efforts to reduce the OOPE for maternal and newborn care. In this paper, we evaluate the change in the OOPE for treatment of sick newborn at hospital before and after implementation of a free newborn care (FNC) program in hospitals of Nepal. Methods: Ministry of Health and Population implemented a free newborn care program which reimbursed the cost of treatment for all sick newborns admitted in public hospitals in Nepal from November 2017. We conducted this pre-post quasi-experimental study with four months of pre-implementation and 12 months of post-implementation of the program in 12 hospitals of Nepal. Logistic regression analysis was conducted for categorical variables and Mann-Whitney test was applied for continuous variables to determine statistically significant differences between pre- and post- intervention period. Results: A total of 353 sick newborns were admitted into these hospitals before implementation of the FNC program while 1122 sick newborns were admitted after the implementation. Before implementation, 17% of mothers paid for sick newborn care while after implementation 15.3% mothers (p-value=0.59) paid for care. The OOPE for treatment of sick newborn at hospital before implementation was Mean±SD: US dollar 14.3+12.1 and after implementation was Mean±SD: USD 13.0±9.6 (p-value=0.71). There were no significant differences in neonatal morbidity after the implementation of the FNC program. The stay in a hospital bed (in days) decreased after the implementation of FNC program (p-value<0.001) while the cost for medicine increased (p-value=0.02). The duration of hospital stay (in days) of sick newborns significantly decreased for Hypoxic Ischemic Encephalopathy (HIE) (p-value=0.04) and neonatal sepsis (p-value<0.001) after the FNC program was implemented. Conclusion: We found no change in the OOPE for sick newborn care following implementation of the FNC Program. There is a need to revisit the FNC program by the type of morbidity and duration of stay. Further studies will be required to explore the health system adequacy to implement such programs in hospitals of Nepal.

Impact of Free Newborn Care Service package on Out of Pocket Expenditure-Evidence from a multicentric study in Nepal.

Background: Sustainable Development Goal (SDG) aspires to improve universal health coverage through reduction of Out of Pocket Expenditure (OOPE) and improving the quality of care. In the last two decades, there have been several efforts to reduce the OOPE for maternal and newborn care. In this paper, we evaluate the change in the OOPE for treatment of sick newborn at hospital before and after implementation of a free newborn care (FNC) program in hospitals of Nepal. Methods: Ministry of Health and Population implemented a free newborn care program which reimbursed the cost of treatment for all sick newborns admitted in public hospitals in Nepal from November 2017. We conducted this pre-post quasi-experimental study with four months of pre-implementation and 12 months of post-implementation of the program in 12 hospitals of Nepal. Logistic regression analysis was conducted for categorical variables and Mann-Whitney test was applied for continuous variables to determine statistically significant differences between pre- and post- intervention period. Results: A total of 353 sick newborns were admitted into these hospitals before implementation of the FNC program while 1122 sick newborns were admitted after the implementation. Before implementation, 17% of mothers paid for sick newborn care while after implementation 15.3% mothers (p-value=0.59) paid for care. The OOPE for treatment of sick newborn at hospital before implementation was Mean±SD: US dollar 14.3+12.1 and after implementation was Mean±SD: USD 13.0±9.6 (p-value=0.71). There were no significant differences in neonatal morbidity after the implementation of the FNC program. The stay in a hospital bed (in days) decreased after the implementation of FNC program (p-value<0.001) while the cost for medicine increased (p-value=0.02). The duration of hospital stay (in days) of sick newborns significantly decreased for Hypoxic Ischemic Encephalopathy (HIE) (p-value=0.04) and neonatal sepsis (p-value<0.001) after the FNC program was implemented.Conclusion: We found no change in the OOPE for sick newborn care following implementation of the FNC Program. There is a need to revisit the FNC program by the type of morbidity and duration of stay. Further studies will be required to explore the health system adequacy to implement such programs in hospitals of Nepal.