A mixed-methods study to investigate feasibility and acceptability of an early warning score for preterm infants in neonatal units in Kenya: results of the NEWS-K study : Neonatal early warning scores in Kenya.

Preterm birth (< 37 weeks gestation) complications are the leading cause of neonatal mortality. Early-warning scores (EWS) are charts where vital signs (e.g., temperature, heart rate, respiratory rate) are recorded, triggering action. To evaluate whether a neonatal EWS improves clinical outcomes in low-middle income countries, a randomised trial is needed. Determining whether the use of a neonatal EWS is feasible and acceptable in newborn units, is a prerequisite to conducting a trial. We implemented a neonatal EWS in three newborn units in Kenya. Staff were asked to record infants' vital signs on the EWS during the study, triggering additional interventions as per existing local guidelines. No other aspects of care were altered. Feasibility criteria were pre-specified. We also interviewed health professionals (n = 28) and parents/family members (n = 42) to hear their opinions of the EWS. Data were collected on 465 preterm and/or low birthweight (< 2.5 kg) infants. In addition to qualitative study participants, 45 health professionals in participating hospitals also completed an online survey to share their views on the EWS. 94% of infants had the EWS completed at least once during their newborn unit admission. EWS completion was highest on the day of admission (93%). Completion rates were similar across shifts. 15% of vital signs triggered escalation to a more senior member of staff. Health professionals reported liking the EWS, though recognised the biggest barrier to implementation was poor staffing. Newborn unit infant to staff ratios varied between 10 and 53 staff per 1 infant, depending upon time of shift and staff type. A randomised trial of neonatal EWS in Kenya is possible and acceptable, though adaptations are required to the form before implementation.

Introduction of the Ellavi uterine balloon tamponade into the Kenyan and Ghanaian maternal healthcare package for improved postpartum haemorrhage management: an implementation research study.

OBJECTIVES: Use of intrauterine balloon tamponades for refractory postpartum haemorrhage (PPH) management has triggered recent debate since effectiveness studies have yielded conflicting results. Implementation research is needed to identify factors influencing successful integration into maternal healthcare packages. The Ellavi uterine balloon tamponade (UBT) (Ellavi) is a new low-cost, preassembled device for treating refractory PPH. DESIGN: A mixed-methods, prospective, implementation research study examining the adoption, sustainability, fidelity, acceptability and feasibility of introducing a newly registered UBT. Cross-sectional surveys were administered post-training and post-use over 10 months. SETTING: Three Ghanaian (district, regional) and three Kenyan (levels 4-6) healthcare facilities. PARTICIPANTS: Obstetric staff (n=451) working within participating facilities. INTERVENTION: PPH management training courses were conducted with obstetric staff. PRIMARY AND SECONDARY OUTCOME MEASURES: Facility measures of adoption, sustainability and fidelity and individual measures of acceptability and feasibility. RESULTS: All participating hospitals adopted the device during the study period and the majority (52%-62%) of the employed obstetric staff were trained on the Ellavi; sustainability and fidelity to training content were moderate. The Ellavi was suited for this context due to high delivery and PPH burden. Dynamic training curriculums led by local UBT champions and clear instructions on the packaging yielded positive attitudes and perceptions, and high user confidence, resulting in overall high acceptability. Post-training and post-use, ≥79% of the trainees reported that the Ellavi was easy to use. Potential barriers to use included the lack of adjustable drip stands and difficulties calculating bag height according to blood pressure. Overall, the Ellavi can be feasibly integrated into PPH care and was preferred over condom catheters. CONCLUSIONS: The training package and time saving Ellavi design facilitated its adoption, acceptability and feasibility. The Ellavi is appropriate and feasible for use among obstetric staff and can be successfully integrated into the Kenyan and Ghanaian maternal healthcare package. TRIAL REGISTRATION NUMBERS: NCT04502173; NCT05340777.

Parents, healthcare professionals and other stakeholders' experiences of caring for babies born too soon in a low-resource setting: a qualitative study of essential newborn care for preterm infants in Kenya.

OBJECTIVES: Prematurity is the leading cause of global neonatal and infant mortality. Many babies could survive by the provision of essential newborn care. This qualitative study was conducted in order to understand, from a family and professional perspective, the barriers and facilitators to essential newborn care. The study will inform the development of an early warning score for preterm and low birthweight infants in low and middle income countries (LMICs). SETTING: Single-centre, tertiary referral hospital in Nairobi, Kenya. PARTICIPANTS: Nineteen mothers and family members participated in focus group discussions and 20 key-informant interviews with professionals (healthcare professionals and policy-makers) were conducted. Focus group participants were identified via postnatal wards, the newborn unit and Kangaroo Mother Care (KMC) unit. Convenience and purposive sampling was used to identify professionals. OUTCOME MEASURES: Understanding facilitators and barriers to provision of essential newborn care in preterm infants. RESULTS: From 27 themes, three global themes emerged from the data: mothers' physical and psychological needs, system pillars and KMC. CONCLUSION: Meeting mothers' needs in the care of their babies is important to mothers, family members and professionals, and deserves greater attention. Functioning system pillars depended on a standardised approach to care and low cost, universally applicable interventions are needed to support the existing care structure. KMC was effective in both meeting mothers' needs, supporting existing care structures and also provided a space for the resolution of the dialectical relationship between families and hospital procedures. Lessons learnt from the implementation of KMC could be applied to the development of an early warning score in LMICs.

Feasibility of using an Early Warning Score for preterm or low birthweight infants in a low-resource setting: results of a mixed-methods study at a national referral hospital in Kenya.

INTRODUCTION: Fifteen million babies are born prematurely, before 37 weeks gestational age, globally. More than 80% of these are in sub-Saharan Africa and Asia. 35% of all deaths in the first month of life are due to prematurity and the neonatal mortality rate is eight times higher in low-income and middle-income countries (LMICs) than in Europe. Early Warning Scores (EWS) are a way of recording vital signs using standardised charts to easily identify adverse clinical signs and escalate care appropriately. A range of EWS have been developed for neonates, though none in LMICs. This paper reports the findings of early work to examine if the use of EWS is feasible in LMICs. METHODS: We conducted an observational study to understand current practices for monitoring of preterm infants at a large national referral hospital in Nairobi, Kenya. Using hospital records, data were collected over an 8-week period in 2019 on all live born infants born at <37 weeks and/or <2500 g (n=294, 255 mothers) in the first week of life. Using a chart adopted from the EWS developed by the British Association of Perinatal Medicine, we plotted infants' vital signs. In addition, we held group discussions with stakeholders in Kenya to examine opinions on use of EWS. RESULTS: Recording of vital signs was variable; only 63% of infants had at least one temperature recorded and 53% had at least one heart rate and respiratory rate recorded. Stakeholders liked the traffic-light system and simplicity of the chart, though recognised challenges, such as staffing levels and ability to print in colour, to its adoption. CONCLUSION: EWS may standardise documentation and identify infants who are at higher risk of an adverse outcome. However, human and non-human resource issues would need to be explored further before development of an EWS for LMICs.