Resource Library

NEST360 is an international alliance united to end preventable newborn deaths in African hospitals. The alliance works to deliver a package of technologies and services that enable local governments to save newborn lives, improve newborn outcomes, and empower the medical workforce for the future. There are a number of resources available to support clinicians, engineers and administrators to implement an evidence-based model for sustainable, high-quality hospital-based newborn care in limited resource settings, including clinical and technical resources, technology resources, implementation resources, and COVID-19 related resources.

Summary

Implementation of KMC is central to achievement of the SDGs for the survival, health and well-being of preterm or LBW infants, both well and sick, through its successful scale-up at all levels of facility care and in the community. Based on the new evidence on successful scale-up of KMC in programmatic settings from several countries, complemented by the joint wisdom and experience of global stakeholders, this implementation strategy is intended to guide the way forward for universal coverage of KMC for all preterm or LBW infants, both well and sick. This implementation strategy is meant to inspire a renewed vision in which mothers and infants are kept and cared for together from birth, and where parents and families play a central role in the care of their infants, thus humanizing health care.

Highlights

Achieving KMC implementation at scale requires:

• A system-wide perspective and structural changes to place mothers and infants at the center of care by keeping and caring for them together after birth
• A commitment by political and program leadership to implement KMC as the foundation of small and/or sick newborn care
• A dedicated budget for implementing KMC as part of small and/or sick newborn care in national maternal, newborn and child health programs
• Developing and implementing a monitoring and evaluation framework to track progress.

How to Use

KMC has been shown to be an essential intervention superior to standard radiant warmer/incubator care in all settings. All countries, irrespective of their income setting and resource availability, should adapt this strategy to their health system contexts to realize the full impact of KMC in improving the survival, health and well-being of mothers and preterm or LBW infants alike.

Summary

The purpose of this document is to put forward the joint position and vision of an expert, global, multi-stakeholder working group on implementing KMC for all preterm or LBW infants as the foundation for small and/or sick newborn care within maternal, newborn and child health programs, and spur collaborative global action. Reversing the long-standing inequities in health care will require prolonged efforts; the scale-up of KMC as an essential service for all mothers and their preterm or LBW infants as a critical component of universal health coverage can serve as the key starting point.

Highlights

• Kangaroo mother care (KMC) is an intervention that enables the mother to take a central role in her own and her newborn’s care, thereby ensuring the power stays with the mother, and health workers support and respond to the mother’s and newborn’s needs.
• It humanizes maternal and newborn care by empowering and involving those who care most for the infant, rather than focusing predominantly on technological solutions.
• KMC can serve as a starting point for broader health-system redesign and service delivery transformation for maternal and newborn care, and a model of what can be accomplished when relevant stakeholders are empowered to play the roles naturally entrusted to them in the care of their newborns.

How to Use

Operationalizing this concept can serve as a strong foundation of highly efficient health systems that are rooted in the communities they serve and focus not only on preventing and treating illness but also on improving well-being and quality of life.

The following is intended to assist decision-makers in analyzing a country’s current situation. This will assist in making a decision about whether to introduce/ scale up OB U/S services and ultimately in developing an implementation plan for introducing OB U/S.

Column 1 outlines factors that will need to be considered – Review the factors that are listed. As you review them, delete any that are not relevant to your country situation and add any factors you think need to be considered when introducing U/S into your country.

Column 2 provides checklists to guide a situational analysis as well as make decisions on how to introduce U/S – Review the items listed and check any boxes that apply to your country context. If necessary, add additional items to assist in developing an implementation plan.

Column 3 provides a space to outline action items/activities to introduction into the health system – Review the situational analysis/decisions made and then write action items/activities that will ensure a sustainable and efficient introduction.

“Kangaroo mother care,” a type of newborn care involving skin-to-skin contact with the mother or other caregiver, reduces mortality in infants with low birth weight (<2.0 kg) when initiated after stabilization, but the majority of deaths occur before stabilization. The safety and efficacy of kangaroo mother care initiated soon after birth among infants with low birth weight are uncertain.

The results of this new clinical trial published in May 2021 provide evidence in support of starting KMC immediately after birth, a clear message that keeping mothers and babies together helps babies to survive and thrive.

Key Findings

• Starting KMC immediately after birth in newborns with birthweight of 1000 grams to 1799 grams has the potential to save up to 150,000 more lives each year (a further increase in survival of 25%), compared with the current recommendation of starting it only once a baby is stable.
• Mother-Newborn Intensive Care Units will be critical to support the mother, or a surrogate, in providing this immediate, ongoing skin-to-skin contact from birth.

Understanding of the lifesaving benefits of KMC for babies born early or small and its continued importance during the COVID-19 pandemic are further strengthened with this new evidence on the benefits of starting the intervention immediately after birth. Among preterm or low birthweight infants, KMC has been shown to reduce infant deaths by as much as 40%, hypothermia by more than 70%, and severe infections by 65%.

Evidence from this updated 2020 Cochrane review supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. Treatment with antenatal corticosteroids reduces the risk of perinatal death, neonatal death and RDS and probably reduces the risk of IVH. 

This review (of 27 randomized trials including 11,272 women and 11,925 neonates) assessed the effect of administering a course of corticosteroids to women prior to anticipated preterm birth (before 37 weeks) on fetal and neonatal morbidity and mortality, maternal morbidity and mortality, and childhood development later in life. Evidence supports the continued use of a single course of ACS to accelerate fetal lung maturation in women at risk of preterm birth to reduce the risk of serious respiratory illness and death in neonates in low- and middle-income countries.

Neonatal outcomes from this analysis found:

• Reduced risk of perinatal death (numbers of stillbirths and babies dying in the first 28 days of life)
• Reduced risk of early neonatal death (numbers of babies dying in the first 28 days of life)
• Reduced risk of severe respiratory distress at 24 hours after birth
• Minor effect on babies’ birth weight

In 2015, the World Health Organization (WHO) recommended that antenatal glucocorticoids should be used only under certain conditions, including the accurate assessment of gestational age, imminent preterm birth, the absence of maternal infection, and adequate care for childbirth and preterm newborns. The guideline panel and an expert panel that was subsequently convened by the WHO identified the conduct of efficacy trials in hospitals in low-resource countries as a research priority in order to resolve this controversy and guide clinicians and policymakers on the use of antenatal glucocorticoids. We conducted the WHO ACTION-I (Antenatal Corticosteroids for Improving Outcomes in Preterm Newborns) trial, a randomized trial to assess the safety and efficacy of dexamethasone in women in hospitals in low-resource countries who were at risk for early preterm birth.

 The Action 1 trial found that among women in low-resource countries at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection. 

The WHO ACTION-I trial makes clear that there are many areas in low- and middle-income countries where antenatal glucocorticoids can be prescribed safely and effectively. Facilities that meet the clinical standards of the trial sites (or to which resources could be provided to meet these standards) should use them. 

The investigators of ACT, which was conducted in sub-Saharan Africa, South Asia, and Latin America, used a pragmatic, cluster-randomized design to assess whether antenatal dexamethasone could be safely and effectively administered in community and primary care settings where access to obstetricians and neonatal intensive care was limited. 

The primary audience for this guideline includes health-care professionals who are responsible for developing national and local health-care protocols and policies, as well as managers of maternal and child health programmes and policy-makers in all settings. The guideline will also be useful to those directly providing care to pregnant women and preterm infants, such as obstetricians, paediatricians, midwives, nurses and general practitioners. The information in this guideline will be useful for developing job aids and tools for pre- and in-service training of health workers to enhance their delivery of maternal and neonatal care relating to preterm birth.

The authors comment on WHO’s 2015 recommendations on interventions to improve preterm newborn outcomes including antenatal corticosteroids, tocolytics, magnesium sulfate, antibiotics, and move of delivery. They also discuss care for preterm neonates including thermal care, continuous positive airway pressure (CPAP), surfactant administration, and oxygen therapy. They stress the importance of health systems and providers reliably assessing gestation age, recognizing signs of preterm labor, provide prompt and effective newborn care, and use interventions to minimize harm. Finally, they acknowledge key evidence gaps as related to antenatal corticosteroids and tocolytics in resource-limited settings.

Antenatal corticosteroids for pregnant women at risk of preterm birth are among the most effective hospital-based interventions to reduce neonatal mortality. We aimed to assess the feasibility, effectiveness, and safety of a multifaceted intervention designed to increase the use of antenatal corticosteroids at all levels of health care in low-income and middle-income countries.

Results of the ACT Trial to assess the feasibility, effectiveness, and safety of a multifaceted intervention designed to increase the use of antenatal corticosteroids at all levels of health care in low-income and middle-income countries. 

This brief has answers to some of the most frequently asked questions regarding antenatal corticosteroids including special circumstances responses.