Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study.

OBJECTIVES: Kangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage. DESIGN: This study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge. PARTICIPANTS: 3804 infants of birth weight under 2000 g who survived the first 3 days, were available in the study area and whose mother resided in the study area. MAIN OUTCOME MEASURES: The primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7 days postdischarge. RESULTS: Key barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%-86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7 days postdischarge, KMC was provided to 53%-65% of infants in all sites, except Oromia (38%) and Karnataka (36%). CONCLUSIONS: This study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers' conviction that KMC is the standard of care, women's and families' acceptance of KMC, and changes in infrastructure, policy, skills and practice. TRIAL REGISTRATION NUMBERS: ISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

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

INTRODUCTION: The 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. METHODS: Using 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. RESULTS: We 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%). CONCLUSION: Newborn 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.

Neonatal care and community-level treatment seeking for possible severe bacterial infection (PSBI) in Amhara, Ethiopia.

BACKGROUND: In Ethiopia, neonatal mortality accounts for approximately 54% of under-five deaths with the majority of these deaths driven by infections. Possible Severe Bacterial Infection (PSBI) in neonates is a syndromic diagnosis that non-clinical health care providers use to identify and treat newborns with signs of sepsis. In low- and middle-income countries, referral to a hospital may not be feasible due to transportation, distance or finances. Growing evidence suggests health extension workers (HEWs) can identify and manage PSBI at the community level when referral to a hospital is not possible. However, community-based PSBI care strategies have not been widely scaled-up. This study aims to understand general determinants of household-level care as well as household care seeking and decision-making strategies for neonatal PSBI symptoms. METHODS: We conducted eleven focus group discussions (FGDs) to explore illness recognition and care seeking intentions from four rural kebeles in Amhara, Ethiopia. FGDs were conducted among mothers, fathers and households with recruitment stratified among households that have had a newborn with at least one symptom of PSBI (Symptomatic Group), and households that have had a newborn regardless of the child's health status (Community Group). Data were thematically analyzed using MAXQDA software. RESULTS: Mothers were described as primary caretakers of the newborn and were often appreciated for making decisions for treatment, even when the father was not present. Type of care accessed was often dependent on conceptualization of the illness as simple or complex. When symptoms were not relieved with clinical care, or treatments at facilities were perceived as ineffective, alternative methods were sought. Most participants identified the health center as a reliable facility. While designed to be the first point of access for primary care, health posts were not mentioned as locations where families seek clinical treatment. CONCLUSIONS: This study describes socio-contextual drivers for PSBI treatment at the community level. Future programming should consider the role community members have in planning interventions to increase demand for neonatal care at primary facilities. Encouragement of health post utilization could further allow for heightened accessibility-acceptability of a simplified PSBI regimen.

Improving coverage of postnatal care in rural Ethiopia using a community-based, collaborative quality improvement approach.

INTRODUCTION: Ethiopia has high maternal and neonatal mortality and low use of skilled maternity care. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), a 3.5-year learning project, used a community collaborative quality improvement approach to improve maternal and newborn health care during the birth-to-48-hour period. This study examines how the promotion of community maternal and newborn health (CMNH) family meetings and labor and birth notification contributed to increased postnatal care within 48 hours by skilled providers or health extension workers. METHODS: Baseline and endline surveys, monthly quality improvement data, and MaNHEP's CMNH change package, a compendium of the most effective changes developed and tested by communities, were reviewed. Logistic regression assessed factors associated with postnatal care receipt. Monthly postnatal care receipt was plotted with control charts. RESULTS: The baseline (n = 1027) and endline (n = 1019) surveys showed significant increases in postnatal care, from 5% to 51% and from 15% to 47% in the Amhara and Oromiya regions, respectively (both P < .001). Notification of health extension workers for labor and birth within 48 hours was closely linked with receipt of postnatal care. Women with any antenatal care were 1.7 times more likely to have had a postnatal care visit (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.10-2.54; P < .001). Women who had additionally attended 2 or more CMNH meetings with family members and had access to a health extension worker's mobile phone number were 4.9 times more likely to have received postnatal care (OR, 4.86; 95% CI, 2.67-8.86; P < .001). DISCUSSION: The increase in postnatal care far exceeds the 7% postnatal care coverage rate reported in the 2011 Ethiopian Demographic and Health Survey (EDHS). This result was linked to ideas generated by community quality improvement teams for labor and birth notification and cooperation with community-level health workers to promote antenatal care and CMNH family meetings.

Building district-level capacity for continuous improvement in maternal and newborn health.

INTRODUCTION: The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) adapted a collaborative improvement strategy to develop woreda (district) leadership capacity to support and facilitate continuous improvement of community maternal and neonatal health (CMNH) and to provide a model for other woredas, dubbed "lead" woredas. Community-level quality improvement (QI) teams tested solutions to improve CMNH care supported by monthly coaching and regular meetings to share experiences. This study examines the extent of the capacity built to support continuous improvement in CMNH care. METHODS: Surveys and in-depth interviews assessed the extent to which MaNHEP developed improvement capacity. A survey questionnaire evaluated woreda culture, leadership support, motivation, and capacity for improvement activities. Interviews focused on respondents' understanding and perceived value of the MaNHEP improvement approach. Bivariate analyses and multivariate linear regression models were used to analyze the survey data. Interview transcripts were organized by region, cadre, and key themes. RESULTS: Respondents reported significant positive changes in many areas of woreda culture and leadership, including involving a cross-section of community stakeholders (increased from 3.0 to 4.6 on 5-point Likert scale), using improvement data for decision making (2.8-4.4), using locally developed and tested solutions to improve CMNH care (2.5-4.3), demonstrating a commitment to improve the health of women and newborns (2.6-4.2), and creating a supportive environment for coaches and QI teams to improve CMNH (2.6-4.0). The mean scores for capacity were 3.7 and higher, reflecting respondents' agreement that they had gained capacity in improvement skills. Interview respondents universally recognized the capacity built in the woredas. The themes of community empowerment and focused improvement emerged strongly from the interviews. DISCUSSION: MaNHEP was able to build capacity for continuous improvement and develop lead woredas. The multifaceted approach to building capacity was critical for the success in creating lead woredas able to serve as models for other districts.