Born too soon in a resource-limited setting: A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border

BackgroundPreterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC).Materials and methodsThis sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care.ResultsFrom 2008–2017, mortality was reduced by 68% and 53% in very (EGA 28–32 weeks) and moderate (EGA 33–36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting.DiscussionThis study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs

The Healthy Baby Flipbook: piloting home-based counseling for refugee mothers to improve infant feeding and water, sanitation, and hygiene (WASH) practices

Problems in growth and undernutrition manifest in early infancy, with suboptimal breastfeeding and inadequate complementary feeding remaining strong risk factors for chronic undernutrition in infants. No published studies exist on educational interventions to improve infant feeding practices among refugees or displaced persons in low and middle-income (LMIC) settings. The objective of this study was to create and pilot educational materials for home-based counseling of refugee mothers along the Thailand–Myanmar border to improve appropriate infant feeding and water, sanitation, and hygiene (WASH) behaviors. Mothers of infants received counseling on appropriate infant feeding and WASH practices on a monthly basis for a total of six months from infant age three months until nine months. Educational materials were designed to feature a basic script for health workers and photos of locally available, appropriate foods. Of the 20 mothers participating in this pilot, infant feeding and WASH behaviors improved within 1 to 2 months of the first visit, including exclusive breastfeeding, minimum acceptable diet, and safe disposal of infant stool. This pilot demonstrates improvement in maternal infant feeding and WASH practices in a small set of refugee mothers, providing evidence for counseling measures to improve infant health in vulnerable populations. Trial registration: ClinicalTrials.gov identifier: NCT00840502

Born too soon in a resource-limited setting : A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border

Background Preterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC). Materials and methods This sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care. Results From 2008–2017, mortality was reduced by 68% and 53% in very (EGA 28–32 weeks) and moderate (EGA 33–36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting. Discussion This study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs.</p

Table_1_Born too soon in a resource-limited setting: A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border.DOCX

BackgroundPreterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC).Materials and methodsThis sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care.ResultsFrom 2008–2017, mortality was reduced by 68% and 53% in very (EGA 28–32 weeks) and moderate (EGA 33–36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting.DiscussionThis study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs.</p

‘Because the baby asks for it’: a mixed-methods study on local perceptions toward nutrition during pregnancy among marginalised migrant women along the Myanmar–Thailand border

Background: Under- and over-nutrition during pregnancy are known risk factors for pregnancy complications and adverse pregnancy and infant outcomes. Understanding perceptions around nutrition in pregnancy can create culturally appropriate interventions for improved health outcomes. Objective: A mixed-methods study was performed to explore local perceptions and practices of diet and physical activity in pregnancy in a marginalised population along the Myanmar–Thailand border. Methods: From April to July 2017, a cross-sectional survey and focus group discussions were conducted with pregnant women reporting to antenatal care; in-depth interviews were conducted with senior midwives at participating organisations along the Myanmar–Thailand border. Results: A total of 388 pregnant women were interviewed at two clinic sites along the Myanmar–Thailand border. A high proportion of women had limited knowledge of and poor dietary practices. Consuming a sweetened drink in the last 24 hours as well as being a non-teenage, multigravida woman was significantly associated with high body mass index (BMI) compared to normal BMI. Qualitative analysis combined focus group discussions (n = 66) and in-depth interviews (n = 4) summarising emergent themes: common foods eaten or avoided and rationale; benefits of nutrition; perceptions of overweight and weight gain during pregnancy; barriers to a healthy diet; and sources of diet information. Conclusions: There is limited awareness about healthy diets and lifestyle in these marginalised, migrant communities along the Myanmar–Thailand border. This study suggests that simple, culturally appropriate messaging should be provided to women and communities with low health literacy to generate awareness about healthy lifestyles and their effects on pregnancy outcomes as an important element of a broader strategy to address maternal nutrition in this population. However, more studies to determine the effectiveness of a broad range of interventions in low- and middle-income countries (LMIC) are needed, especially in marginalised migrant populations

'Because the baby asks for it': a mixed-methods study on local perceptions toward nutrition during pregnancy among marginalised migrant women along the Myanmar-Thailand border

Background: under- and over-nutrition during pregnancy are known risk factors for pregnancy complications and adverse pregnancy and infant outcomes. Understanding perceptions around nutrition in pregnancy can create culturally appropriate interventions for improved health outcomes.Objective: a mixed-methods study was performed to explore local perceptions and practices of diet and physical activity in pregnancy in a marginalised population along the Myanmar-Thailand border.Methods: from April to July 2017, a cross-sectional survey and focus group discussions were conducted with pregnant women reporting to antenatal care; in-depth interviews were conducted with senior midwives at participating organisations along the Myanmar-Thailand border.Results: a total of 388 pregnant women were interviewed at two clinic sites along the Myanmar-Thailand border. A high proportion of women had limited knowledge of and poor dietary practices. Consuming a sweetened drink in the last 24 hours as well as being a non-teenage, multigravida woman was significantly associated with high body mass index (BMI) compared to normal BMI. Qualitative analysis combined focus group discussions (n = 66) and in-depth interviews (n = 4) summarising emergent themes: common foods eaten or avoided and rationale; benefits of nutrition; perceptions of overweight and weight gain during pregnancy; barriers to a healthy diet; and sources of diet information.Conclusions: there is limited awareness about healthy diets and lifestyle in these marginalised, migrant communities along the Myanmar-Thailand border. This study suggests that simple, culturally appropriate messaging should be provided to women and communities with low health literacy to generate awareness about healthy lifestyles and their effects on pregnancy outcomes as an important element of a broader strategy to address maternal nutrition in this population. However, more studies to determine the effectiveness of a broad range of interventions in low- and middle-income countries (LMIC) are needed, especially in marginalised migrant populations.</p