Effectiveness of self-managed continuous monitoring for maintaining high-quality early essential newborn care compared to supervision visit in Lao PDR: a cluster randomised controlled trial.

BACKGROUND: Thousands of neonatal deaths are expected to be averted by introducing the Early Essential Newborn Care (EENC) in the Western Pacific Region. In Lao People's Democratic Republic (Lao PDR), the government adopted the EENC programme and expanded it to district hospitals. With the expansion, maintaining the quality of EENC has become difficult for the government. METHODS: A cluster randomised controlled trial with four strata based on province and history of EENC coaching was implemented to evaluate the effectiveness of self-managed continuous monitoring compared with supervisory visit in Lao PDR between 20 July 2017 and 2 April 2019. Health workers who were routinely involved in maternity care were recruited from 15 district hospitals in Huaphanh (HP) and Xiangkhouang (XK) provinces. The primary endpoint was the score on the determinants of EENC performance measured by the Theory of Planned Behaviour (TPB). Secondary endpoints were set as the knowledge and skill scores. A linear mixed-effects model was applied to test the effects of intervention over time on the endpoints. RESULTS: Among 198 recruited health workers, 46 (23.2%) did not complete the final evaluation. TPB scores were 180.9 [Standard Deviation: SD 38.6] and 182.5 [SD 37.7] at baseline and 192.3 [SD 30.1] and 192.3 [SD 28.4] at the final evaluation in the intervention and control groups, respectively. There was no significant difference in changes between the groups in the adjusted model (2.4, p = 0.650). Interviews with participants revealed that district hospitals in HP regularly conducted peer reviews and feedback meetings, while few hospitals did in XK. Accordingly, in stratified analyses, the TPB score in the intervention group significantly increased in HP (15.5, p = 0.017) but largely declined in XK (- 17.7, p = 0.047) compared to the control group after adjusting for covariates. Skill scores declined sharper in the intervention group in XK (- 8.78, p = 0.026), particularly in the practice of managing nonbreathing babies. CONCLUSIONS: The study indicates that self-managed continuous monitoring is effective in improving behaviour among district health workers; however, additional measures are necessary to support its proper implementation. To maintain resuscitation skills, repeated practice is necessary. TRIAL REGISTRATION: This trial was registered at UMIN Clinical Trials Registry on 15/6/2017. Registration number is UMIN000027794 .

Establishment of a sustainable newborn TSH-screening program in the People's Democratic Republic of Laos.

BACKGROUND: Neonatal screening programs have been established and are in use in most countries worldwide. Laos belongs to the few countries which still have not established any kind of newborn screening. METHODS: Basis for the current screening was an initial pilot project between 2008 and 2010. Then 11.362 samples of newborn infants were screened, samples were weekly air-shipped to a German screening laboratory. During the current project TSH-measurements take place at the laboratory of the largest delivery hospital in Laos, the Mother & Newborn Hospital in Vientiane. RESULTS: Teaching regarding taking samples and doing measurements started in January 2019, until end of July 2020 altogether 3214 samples were measured. None of the samples was above the predefined cutoff of 20µU/l. CONCLUSIONS: Newborn screening for congenital hypothyroidism with measurements of samples within Laos is feasible. Plausibility control is achieved by regular checks of screening results sent by email to Germany. The most challenging task is to cover all newborns born at participating hospitals and finally to expand the screening beyond the capital to other areas in the country.

Association between early essential newborn care and breastfeeding outcomes in eight countries in Asia and the Pacific: a cross-sectional observational -study.

OBJECTIVE: To explore the association between early essential newborn care (EENC) policy, practice and environmental interventions and breastfeeding outcomes. DESIGN: Cross-sectional observational study. SETTING: 150 national, provincial and district hospitals implementing EENC in eight countries in East Asia and the Pacific. PARTICIPANTS: 1383 maternal interviews, chart reviews and environmental assessments during 2016 and 2017. MAIN OUTCOME MEASURES: Exclusive breastfeeding (EBF), that is, feeding only breastmilk without other food or fluids since birth and before discharge, and, early breastfeeding initiation, that is, during skin-to-skin contact (SSC) with the mother without separation. RESULTS: Fifty-nine per cent of newborns initiated breastfeeding early and 83.5% were EBF. Duration of SSC showed a strong dose-response relationship with early breastfeeding initiation. SSC of at least 90 min was associated with 368.81 (95% CI 88.76 to 1532.38, p<0.001) times higher early breastfeeding. EBF was significantly associated with SSC duration of 30-59 min (OR 3.54, 95% CI 1.88 to 6.66, p<0.001), 60-89 min (OR 5.61, 95% CI 2.51 to 12.58, p<0.001) and at least 90 min (OR 3.78, 95% CI 2.12 to 6.74, p<0.001) regardless of delivery mode. Non-supine position (OR 2.80, 95% CI 1.90 to 4.11, p<0.001), rooming-in (OR 5.85, 95% CI 3.46 to 9.88, p<0.001), hospital breastfeeding policies (OR 2.82, 95% CI 1.97 to 4.02, p<0.001), quality improvement mechanisms (OR 1.63, 95% CI 1.07 to 2.49, p=0.02) and no formula products (OR 17.50, 95% CI 5.92 to 51.74, p<0.001) were associated with EBF. CONCLUSION: EENC policy, practice and environmental interventions were associated with breastfeeding outcomes. To maximise the likelihood of early and EBF, newborns, regardless of delivery mode, should receive immediate and uninterrupted SSC for at least 90 min.

Study protocol of a cluster randomized controlled trial to evaluate effectiveness of a system for maintaining high-quality early essential newborn care in Lao PDR.

BACKGROUND: Reduction in neonatal deaths has been a major challenge globally. To prevent neonatal deaths, improvements in newborn care have been promoted worldwide. The World Health Organization Western Pacific Regional Office has been promoting the Early Essential Newborn Care (EENC), a package of specific simple and cost-effective interventions, in their region. However, mere introduction of EENC cannot reduce neonatal deaths unless quality of care is ensured. In Lao PDR, the government introduced self-managed continuous monitoring as a sustainable way to improve the quality of care described in the EENC. METHODS: A clustered randomized controlled trial was designed to compare the effectiveness of self-managed continuous monitoring with external supervisory visits to monitor health workers' satisfactory EENC performance and their knowledge and skills related to the EENC in Lao PDR. Determinants of EENC performance will be measured with a structured questionnaire developed based on the Theory of Planned Behaviour, which predicts future behaviour. During self-managed continuous monitoring activities, health workers in each district hospital will conduct periodical peer reviews and feedback sessions. Fifteen district hospitals will be randomly allocated into the self-managed continuous monitoring (intervention) and the supervision (control) groups. Fifteen health workers routinely involved in maternity and newborn care including physicians, midwives and other health staff will be recruited from each hospital (effect size 0.6, intra-cluster correlation coefficient 0.06, 5% alpha error and 80% power). We will compare the change in the mean score of the determinants before and one year after randomisation between the two groups. We will also compare the retention of knowledge and skills related to the EENC between the two groups. The expected enrolment period is July 20th, 2017 to July 20th, 2018. DISCUSSION: This is the first cluster randomized trial to evaluate a self-managed continuous monitoring system for quality maintenance of newborn care in a resource-limited country. This research is conducted in collaboration with the Ministry of Health and international organizations; therefore, if effective, this intervention would be applied in larger areas of the country and the region. TRIAL REGISTRATION: This trial was registered at UMIN-CTR on 15th of June, 2017. Registration number is UMIN000027794 .

HIGH RATE OF HEPATITIS B VIRUS MOTHER-TO-CHILD TRANSMISSION IN LAO PEOPLE'S DEMOCRATIC REPUBLIC.

Hepatitis B virus infection is endemic in Lao People's Democratic Republic (PDR). Among 3,000 pregnant women attending an antenatal clinic at Mother and Child Hospital in Vientiane, Lao PDR, 5.8% were HBsAg positive by a rapid test. Among serum samples of 47 infants aged 9-12 months born to HBsAg-positive mothers, 38% were anti-HBs negative. Percent anti-HBs negative children is significantly higher in those born to HBeAg positive mothers than in those born to HBeAg negative mothers (60% vs 25%, p < 0.05). Out of 47 HBsAg-positive mothers, 10 had infants who were HBsAg positive. None of the infants born to HBsAg negative mothers became HBsAg positive but 10/19 (52.6%) of infants born to HBeAg positive mothers became HBsAg positive. This high rate of mother-to-child transmission of HBV in an endemic country is of concern and indicates that routine vaccination program for Lao infants needs strengthening.

Neonatal Mortality and Morbidity in Regional Provincial Hospitals in the People's Democratic Republic of Laos.

OBJECTIVE: The aim of this study was to identify the causes and incidences of neonatal diseases and deaths in five provincial hospitals in People's Democratic Republic of Laos retrospectively for the years 2010-12. METHODS: Data of neonatal patients were collected before a 3-year-training program for medical and nursing staff involved in the care of newborn infants in the provincial and associated district hospitals. RESULTS: In the years 2010-12, a total of 1673 neonatal patients were treated in the provincial hospitals. The reasons of treatment were as follows: 48% infections, 17% complications of prematurity, 14% intrapartum-related complications and 9% other, not categorized diseases. The average mortality rate in all hospitals was 6.5%. The main causes of death were complications because of prematurity, infectious diseases and asphyxia. CONCLUSION: These data could be the basis for any teaching program aimed at reducing neonatal mortality. Furthermore, they enable an evaluation of the ongoing teaching program.

Barriers to neonatal care in developing countries: parents' and providers' perceptions.

AIM: Hospital care and advanced medical technologies for sick neonates are increasingly available, but not always readily accessible, in many countries. We characterised parents' and providers' perceptions of barriers to neonatal care in developing countries. METHODS: We interviewed parents whose infant was hospitalised within the first month of life in Cambodia, Malaysia, Laos and Vietnam, asking about perceived barriers to obtaining newborn care. We also surveyed health-care providers about perceived barriers to providing care. RESULTS: We interviewed 198 parents and 212 newborn care providers (physicians, nurses, midwives, paediatric and nursing trainees). Most families paid all costs of newborn care, which they reported as a hardship. Although newborn care is accessible, 39% reported that hospitals are too distant; almost 20% did not know where to obtain care. Parents cited lack of cleanliness (46%), poor availability of medications (42%) or services (36%), staff friendliness (42%), poor infant outcome (45%), poor communications with staff (44%) and costs of care (34%) as significant problems during prior newborn care. Providers cited lack of equipment (74%), lack of staff training (61%) and poor infrastructure (51%) as barriers to providing neonatal care. Providers identified distance to hospital, lack of transportation, care costs and low parental education as barriers for families. CONCLUSIONS: Improving cleanliness, staff friendliness and communication with parents may diminish some barriers to neonatal care in developing countries. Costs of newborn care, hospital infrastructure, distance to hospital, staffing shortages, limited staff training and limited access to medications pose more difficult barriers to remedy.