Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned.

Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs) remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU) and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals

Quality of routine health facility data used for newborn indicators in low- and middle-income countries: A systematic review

Background High-quality data are fundamental for effective monitoring of newborn morbidity and mortality, particularly in high burden lowand middle-income countries (LMIC). Methods We conducted a systematic review on the quality of routine health facility data used for newborn indicators in LMIC, including measures employed. Five databases were searched from inception to February 2021 for relevant observational studies (excluding case-control studies, case series, and case reports) and baseline or control group data from interventional studies, with no language limits. An adapted version (19-point scale) of the Critical Appraisal Tool to assess the Quality of Cross-Sectional Studies (AXIS) was used to assess methodological quality, and results were synthesized using descriptive analysis. Results From the 19572 records retrieved, 34 studies in 16 LMIC countries were included. Methodological quality was high (>14/19) in 32 studies and moderate (10-14/19) in two. Studies were mostly from African (n = 30, 88.2%) and South-East Asian (n = 24, 70.6%) World Health Organization (WHO) regions, with very few from Eastern Mediterranean (n = 2, 5.9%) and Western Pacific (n = 1, 2.9%) ones. We found that only data elements used to calculate neonatal indicators had been assessed, not the indicators themselves. 41 data elements were assessed, most frequently birth outcome. 20 measures of data quality were used, most along three dimensions: 1) completeness and timeliness, 2) internal consistency, and 3) external consistency. Data completeness was very heterogeneous across 26 studies, ranging from 0%-100% in routine facility registers, 0%-100% in patient case notes, and 20%-68% in aggregate reports. One study reported on the timeliness of aggregate reports. Internal consistency ranged from 0% to 96.2% in four studies. External consistency (21 studies) varied widely in measurement and findings, with specificity (6.4%-100%), sensitivity (23.6%-97.6%), and percent agreement (24.6%-99.4%) most frequently reported

Stillbirths: Where? When? Why? How to make the data count?

Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible-not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2·65 million stillbirths (uncertainty range 2·08 million to 3·79 million) were estimated worldwide in 2008 (≥1000 g birthweight or ≥28 weeks of gestation). 98% of stillbirths occur in low-income and middle-income countries, and numbers vary from 2·0 per 1000 total births in Finland to more than 40 per 1000 total births in Nigeria and Pakistan. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. In total, an estimated 1·19 million (range 0·82 million to 1·97 million) intrapartum stillbirths occur yearly. Most intrapartum stillbirths are associated with obstetric emergencies, whereas antepartum stillbirths are associated with maternal infections and fetal growth restriction. National estimates of causes of stillbirths are scarce, and multiple (>35) classification systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specific perinatal certificates and revised International Classification of Disease codes, are needed. A simple, programme-relevant stillbirth classification that can be used with verbal autopsy would provide a basis for comparable national estimates. A new focus on all deaths around the time of birth is crucial to inform programmatic investment

Prognosis of neonatal tetanus in the modern management era: an observational study in 107 Vietnamese infants.

OBJECTIVES: Most data regarding the prognosis in neonatal tetanus originate from regions where limited resources have historically impeded management. It is not known whether recent improvements in critical care facilities in many low- and middle-income countries have affected indicators of a poor prognosis in neonatal tetanus. We aimed to determine the factors associated with worse outcomes in a Vietnamese hospital with neonatal intensive care facilities. METHODS: Data were collected from 107 cases of neonatal tetanus. Clinical features on admission were analyzed against mortality and a combined endpoint of 'death or prolonged hospital stay'. RESULTS: Multivariable analysis showed that only younger age (odds ratio (OR) for mortality 0.69, 95% confidence interval (CI) 0.48-0.98) and lower weight (OR for mortality 0.06, 95% CI 0.01-0.54) were significantly associated with both the combined endpoint and death. A shorter period of onset (OR 0.94, 95% CI 0.88-0.99), raised white cell count (OR 1.17, 95% CI 1.02-1.35), and time between first symptom and admission (OR 3.77, 95% CI 1.14-12.51) were also indicators of mortality. CONCLUSIONS: Risk factors for a poor outcome in neonatal tetanus in a setting with critical care facilities include younger age, lower weight, delay in admission, and leukocytosis

Perinatal mortality associated with use of uterotonics outside of Comprehensive Emergency Obstetric and Neonatal Care: a cross-sectional study.

BACKGROUND: Prior studies have shown that using uterotonics to augment or induce labor before arrival at comprehensive Emergency Obstetric and Neonatal Care (CEmONC) settings (henceforth, "outside uterotonics") may contribute to perinatal mortality in low- and middle-income countries. We estimate its effect on perinatal mortality in rural Bangladesh. METHODS: Using hospital records (23986 singleton term births, Jan 1, 2009-Dec 31, 2015) from rural Bangladesh, we use a logistic regression model to estimate the increased risk of perinatal death from uterotonics administered outside a CEmONC facility. RESULTS: Among term births (≥37 weeks gestation), the risk of perinatal death adjusted for key confounders is significantly increased among women reporting uterotonic use outside of CEmONC (OR = 3 · 0, 95 % CI = 2 · 4,3 · 7). This increased risk is particularly high for fresh stillbirths (OR = 4 · 0, 95 % CI = 3 · 0,5 · 3) and intrapartum-related causes of early neonatal deaths (birth asphyxia) (OR = 3 · 1, 95 % CI = 2 · 2,4 · 5). CONCLUSIONS: In this sample, outside uterotonic use was associated with substantially increased risk of fresh stillbirths, deaths due to birth asphyxia, and all perinatal deaths. In settings of high uterotonic use outside of controlled settings, substantial improvement in both stillbirth and early neonatal mortality may be made by reducing such use

Classifying caesarean section to understand rising rates among Palestinian refugees: results from 290,047 electronic medical records across five settings

BACKGROUND: Rising caesarean-section rates worldwide are driven by non-medically indicated caesarean-sections. A systematic review concluded that the ten-group classification system (Robson) is the most appropriate for assessing drivers of caesarean deliveries. Evidence on the drivers of caesarean-section rates from conflict-affected settings is scarce. This study examines caesareans-section rates among Palestinian refugees by seven-group classification, compares to WHO guidelines, and to rates in the host settings, and estimates the costs of high rates. METHODS: Electronic medical records of 290,047 Palestinian refugee women using UNRWA's (United Nations Relief and Works Agency for Palestine Refugees in the Near East) antenatal service from 2017-2020 in five settings (Jordan, Lebanon, Syria, West Bank, Gaza) were used. We modified Robson criteria to compare rates within each group with WHO guidelines. The host setting data were extracted from publicly available reports. Data on costs came from UNRWA's accounts. FINDINGS: Palestinian refugees in Gaza had the lowest caesarean-section rates (22%), followed by those residing in Jordan (28%), West Bank (30%), Lebanon (50%) and Syria (64%). The seven groups caesarean section classification showed women with previous caesarean-sections contributed the most to overall rates. Caesarean-section rates were substantially higher than the WHO guidelines, and excess caesarean-sections (2017-2020) were modelled to cost up to 6.8 million USD. We documented a steady increase in caesarean-section rates in all five settings for refugee and host communities; refugee rates paralleled or were below those in their host country. INTERPRETATION: Caesarean-section rates exceed recommended guidance within most groups. The high rates in the nulliparous groups will drive future increases as they become multiparous women with a previous caesarean-section and in turn, face high caesarean rates. Our analysis helps suggest targeted and tailored strategies to reduce caesarean-section rates in priority groups (among low-risk women) organized by those aimed at national governments, and UNRWA, and those aimed at health-care providers

Classifying caesarean section to understand rising rates among Palestinian refugees: results from 290,047 electronic medical records across five settings

Background: Rising caesarean-section rates worldwide are driven by non-medically indicated caesarean-sections. A systematic review concluded that the ten-group classifcation system (Robson) is the most appropriate for assessing drivers of caesarean deliveries. Evidence on the drivers of caesarean-section rates from confictafected settings is scarce. This study examines caesareans-section rates among Palestinian refugees by seven-group classifcation, compares to WHO guidelines, and to rates in the host settings, and estimates the costs of high rates.Methods: Electronic medical records of 290,047 Palestinian refugee women using UNRWA’s (United Nations Relief and Works Agency for Palestine Refugees in the Near East) antenatal service from 2017–2020 in fve settings (Jordan, Lebanon, Syria, West Bank, Gaza) were used. We modifed Robson criteria to compare rates within each group with WHO guidelines. The host setting data were extracted from publicly available reports. Data on costs came from UNRWA’s accounts.Findings: Palestinian refugees in Gaza had the lowest caesarean-section rates (22%), followed by those residing in Jordan (28%), West Bank (30%), Lebanon (50%) and Syria (64%). The seven groups caesarean section classifcation showed women with previous caesarean-sections contributed the most to overall rates. Caesarean-section rates were substantially higher than the WHO guidelines, and excess caesarean-sections (2017–2020) were modelled to cost up to 6.8 million USD. We documented a steady increase in caesarean-section rates in all fve settings for refugee and host communities; refugee rates paralleled or were below those in their host country.Interpretation: Caesarean-section rates exceed recommended guidance within most groups. The high rates in the nulliparous groups will drive future increases as they become multiparous women with a previous caesareansection and in turn, face high caesarean rates. Our analysis helps suggest targeted and tailored strategies to reduce caesarean-section rates in priority groups (among low-risk women) organized by those aimed at national governments, and UNRWA, and those aimed at health-care providers

Implementing a Care Pathway for small and nutritionally at-risk infants under six months of age: A multi-country stakeholder consultation

Nutritional vulnerability under the age of 6 months is prevalent in low- and middle-income countries with 20.1% infants underweight, 21.3% wasted and 17.6% stunted in a recent review. A novel Care Pathway for improved management of small and nutritionally at-risk infants under 6 months and their mothers (MAMI) has recently been developed to provide outpatient care at large coverage. We aimed to investigate stakeholders' views on the feasibility of its implementation and to identify barriers and enablers. This was an early stage formative mixed-methods study: an online survey plus in-depth interviews with country-level stakeholders in nutrition and child health from different geographical regions and stakeholder groups. 189 stakeholders from 42 countries responded to the online survey and 14 remote interviews were conducted. Participants expressed an urgent need for improved detection and care for small and nutritionally at-risk infants under 6 months. Whilst they considered the MAMI Care Pathway feasible and relevant, they noted it was largely unknown in their country. The most mentioned implementation barriers were: community-specific needs and health care seeking barriers, health workers' lack of competence in breastfeeding counselling and the absence of a validated anthropometric screening method. Possible enablers for its implementation were: patients' preference for outpatient care, integrating the MAMI care pathway into existing maternal and child health programmes and the possibility of a local pilot project. Adaptation to the local context was considered crucial in further scale-up

Recognition of and Response to neonatal intrapartum-related complications in home-birth settings in Bangladesh.

Intrapartum-related complications (previously called 'birth asphyxia') are a significant contributor to deaths of newborns in Bangladesh. This study describes some of the perceived signs, causes, and treatments for this condition as described by new mothers, female relatives, traditional birth attendants, and village doctors in three sites in Bangladesh. Informants were asked to name characteristics of a healthy newborn and a newborn with difficulty in breathing at birth and about the perceived causes, consequences, and treatments for breathing difficulties. Across all three sites 'no movement' and 'no cry' were identified as signs of breathing difficulties while 'prolonged labour' was the most commonly-mentioned cause. Informants described a variety of treatments for difficulty in breathing at birth, including biomedical and, less often, spiritual and traditional practices. This study identified the areas that need to be addressed through behaviour change interventions to improve recognition of and response to intrapartum-related complications in Bangladesh

Recognition of and Response to Neonatal Intrapartum-related Complications in Home-birth Settings in Bangladesh

Intrapartum-related complications (previously called \u2018birth asphyxia\u2019) are a significant contributor to deaths of newborns in Bangladesh. This study describes some of the perceived signs, causes, and treatments for this condition as described by new mothers, female relatives, traditional birth attendants, and village doctors in three sites in Bangladesh. Informants were asked to name characteristics of a healthy newborn and a newborn with difficulty in breathing at birth and about the perceived causes, consequences, and treatments for breathing difficulties. Across all three sites \u2018no movement\u2019 and \u2018no cry\u2019 were identified as signs of breathing difficulties while \u2018prolonged labour\u2019 was the most commonly-mentioned cause. Informants described a variety of treatments for difficulty in breathing at birth, including biomedical and, less often, spiritual and traditional practices. This study identified the areas that need to be addressed through behaviour change interventions to improve recognition of and response to intrapartum-related complications in Bangladesh