WHO standards-based tool to measure women's views on the quality of care around the time of childbirth at facility level in the WHO European region: development and validation in Italy.

OBJECTIVES: A comprehensive WHO standards-based tool to measure women's perceived quality of maternal and newborn care (QMNC) in health facilities is needed to allow for comparisons of data across settings and over time. This paper describes the development of such a tool, and its validation in Italy. DESIGN: A multiphase, mixed-methods study involving qualitative and quantitative research methods. SETTING: Nine health facilities in Italy. METHODS: The questionnaire was developed in six phases: (1) Defining the scope, characteristics and a potential list of measures for the tool; (2) initial content and construct validation; (3) first field testing to assess acceptability and perceived utility for end-users (1244 women, 35 decision makers) and further explore construct validity; (4) content optimisation and score development; (5) assessment of face validity, intrarater reliability and internal consistency and (6) second field testing in nine maternity hospitals (4295 women, 78 decision-makers). RESULTS: The final version of the tool included 116 questions accounting for 99 out of the 350 of the extended lists of WHO Quality Measures. Observed face validity was very good, with 100% agreement for 101 (87%) questions and Kappa exceeding 0.60 for remaining ones. Reliability was good, with either high agreement or Kappa exceeding 0.60 for all items. Cronbach alpha values ranged from 0.84 to 0.88, indicating very good internal consistency. Acceptability across seven hospitals was good (mean response rate: 57.4%, 95% CI 44.4% to 70.5%). The questionnaire proved to be useful, driving the development of actions plan to improve the QMNC in each facility. CONCLUSIONS: Study findings suggest that the tool has good content, construct, face validity, intrarater reliability and internal consistency, while being acceptable and useful. Therefore, it could be used in health facilities in Italy and similar context. More research should investigate how effectively use the tool in different countries for improving the QMNC.

Evaluation of the educational impact of the WHO Essential Newborn Care course in Zambia.

OBJECTIVES: To evaluate the effectiveness of the World Health Organization (WHO) Essential Newborn Care (ENC) course in improving knowledge and skills of nurse midwives in low-risk delivery clinics in a developing country. METHODS: The investigators identified the content specifications of the training material, developed both written and performance evaluations and administered the evaluations both before and after training clinical nurse midwives in Zambia. FINDINGS: Based on these evaluations, both the knowledge and skills of the nurse midwives improved significantly following the course (from a mean of 65% correct pretraining to 84% correct post-training and from 65% to 77% correct on the performance and written evaluations, respectively). The ENC course written evaluation was validated and both tools allowed evaluation of the ENC course training. CONCLUSIONS: We found significant improvements in trainees' knowledge and skills in essential newborn care following the WHO ENC course; however, lack of basic resources may have limited the application of the ENC guidelines. Implementation of the ENC course should be undertaken in consideration with the local conditions available for newborn care.

Prophylactic versus selective antibiotics for term newborn infants of mothers with risk factors for neonatal infection.

BACKGROUND: Early onset bacterial infection is an important cause of morbidity and mortality in newborn infants. Various factors that increase the risk of neonatal infection have been identified. It is unclear whether asymptomatic newborn infants born to mothers with one or more of these risk factors should receive antibiotics prophylactically rather than selectively if only clinical or microbiological evidence of sepsis emerges. OBJECTIVES: To assess the effect of prophylactic versus selective antibiotic treatment for asymptomatic term neonates born to mothers with risk factors for neonatal infection. SEARCH STRATEGY: We used the standard methods of the Cochrane Neonatal Review Group. We searched MEDLINE (1966 - May 2004), EMBASE (1980 - May 2004), LILACS (1982 - 2003), SciELO (1997 - 2003), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), and Centers for Disease Control and Prevention protocols and guidelines on the subject. SELECTION CRITERIA: Randomized controlled trials, or trials using quasi-random methods of allocation, comparing the use of prophylactic versus selective antibiotics in asymptomatic neonates born to mothers with one or more risk factors for infection. DATA COLLECTION AND ANALYSIS: We extracted the data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by three reviewers and synthesis of data using relative risk and risk difference. The pre-specified primary outcomes were neonatal mortality, systemic neonatal infection, and need for admission to a neonatal intensive care unit. MAIN RESULTS: We identified two small trials undertaken in the 1970s. Both trials had methodological weaknesses. There was no evidence of an effect on any of the primary outcomes, but because the trials were underpowered, clinically important effect sizes may have been missed. REVIEWERS' CONCLUSIONS: There are insufficient data from randomized controlled trials to guide clinical practice. A large randomized controlled trial is needed in asymptomatic term infants born to mothers with risk factors for infection in their babies, which compares the effect of prophylactic versus selective antibiotics on morbidity, mortality and costs.

Kangaroo mother care with limited resources.

Kangaroo mother care (KMC) for low birthweight infants (LBWI) was introduced in a Mozambican hospital with limited resources and without facilities for intensive care. Six months were needed to change policies, organize the ward, train staff and overcome constraints. Facilitating factors were a KMC national policy, the commitment of health authorities, technical assistance and availability of some funds, and the perception of improved quality of care and survival. The obstacles and constraints were resistance to change by the staff, cultural problems, and managerial difficulties. Out of 32 LBWI (< or = 1.800 g) admitted in 3 months, survival was 73 per cent in 22 KMC and 20 per cent in 10 non-KMC infants (p < 0.01). KMC is a feasible and appropriate technology in hospitals with very limited resources.

Impact of season and discharge weight on complications and growth of Kangaroo Mother Care treated low birthweight infants in Mozambique.

This study aimed to determine the impact of season and weight at discharge on growth rate and complications in low birthweight infants treated with Kangaroo Mother Care (KMC) in Maputo, Mozambique. The study population included 246 infants of birthweight < 2000 g. Follow-up until 2400 g was obtained in 64%. There were no seasonal differences in weight gain and the risk of complications of infants treated with KMC in hospital. During the cold season after discharge, the risk of serious complications, including death, was higher (risk ratio 1.96; p = 0.02) and more readmissions occurred (risk ratio 2.77; p = 0.04). We postulate that after discharge mothers are unable to comply with the kangaroo position at all hours of the day and that exposure to low ambient temperatures may explain the more frequent occurrence of complications in the cold season. The weight at discharge did not affect complications or growth rate. We conclude that the current policy to discharge infants when having gained weight on 3 consecutive days, regardless of the actual weight, or whether the weight at birth has been regained, is adequate. In the cold season particularly, more efforts may be needed to ensure compliance with kangaroo position after discharge and to educate mothers on early signs of complications such as bronchopneumonia to encourage timely care seeking. With this method, low birthweight infants can grow adequately.

Thermal control of the newborn: knowledge and practice of health professional in seven countries.

Hypothermia is a common problem in neonates, particularly in developing countries where it is an important contributory factor to neonatal mortality and morbidity. An evaluation of the knowledge and practices of health professionals on the thermal control of newborns was carried out in seven countries: Brazil, India, Indonesia, Kazakhstan, Mozambique, Nepal and Zimbabwe. The evaluation, conceived as a preliminary phase for a one-day training course on thermal control, involved 28 health facilities and 260 health professionals (61 doctors and 199 nurses and midwives). It included an assessment of thermal control practices carried out in each health facility by external investigators and a questionnaire on knowledge about thermoregulation administered to health professionals involved in newborn care. The findings of the evaluation were consistent across countries and showed that thermal control practices were frequently inadequate in the following areas: ensuring a warm environment at the time of delivery; initiation of breastfeeding and contact with mother, bathing; checking the baby's temperature; thermal protection of low birth weight babies, and care during transport. Knowledge on thermal control was also insufficient, especially concerning the physiology of thermoregulation and criteria for defining hypothermia. During the one-day course that followed the evaluation, participants were able to recognize the existing gaps and to identify appropriate interventions. Knowledge and practice on the thermal control of the newborn are currently insufficient. However, awareness of the importance of thermal control and basic knowledge on thermal regulation and thermal protection can be easily acquired and on this basis motivation for improving thermal control practices can be developed.

Neonatal and post-neonatal onset of early congenital syphilis: a report from Mozambique.

Congenital syphilis (CS) has been and continues to be a principal public health problem in developing countries. Despite the wide experience acquired, physicians still have problems in diagnostic evaluation. We report 145 cases of CS at the Central Hospital, Maputo, emphasizing the differences in clinical features and in the results of serological and X-ray examinations between the neonatal and post-neonatal age groups. In the post-neonatal age group, the clinical expression of CS is mostly overt. It is commonly recognized that manifestations of CS in the neonatal age group are often poor or negative, yet a relevant percentage of CS that we report were fully symptomatic. In the neonatal age, the Venereal Disease Research Laboratory (VDRL) test in the mother and characteristic osteochondritic lesions on X-ray examination of the long bones help to make the diagnosis; in the post-neonatal age group, the VDRL test in the child is more often positive than in the mother and X-ray examination shows most periostitic lesions.

PIP: Even though congenital syphilis (CS) has been and remains a key public health problem in developing countries, physicians continue to have trouble diagnosing it. Experience with 145 cases of CS reported over the period May 1989-May 1990 at the Central Hospital in Maputo are discussed with particular emphasis and attention given to differences in clinical features and in the results of serological and X-ray examinations between neonatal and post-neonatal age groups. 51% of the newborns were diagnosed with CS on the basis of clinical features of systemic congenital infection; the diagnosis of remaining cases was based upon history or isolated and nonspecific signs such as fever, low birth weight for gestational age, or skin lesions. Condition characteristics were mostly overtly expressed among the post- neonates. While it may be commonly recognized that manifestations of CS among neonates tend to be poor or negative, analysis of the data found a relevant percentage of subjects to be fully symptomatic. The Venereal Disease Research Laboratory (VDRL) test in the mother and characteristic osteochondritic lesions on X-ray examination of the long bones help make the diagnosis at neonatal age. Among post-neonates, the VDRL test in the child is more often positive than in the mother and X-rays show most periostitic lesions.