Care of the newborn in Uganda : studies of the use of simple affordable effective interventions

Abstract

Background: There are evidence based cost effective interventions available, which could decrease neonatal mortality, if scaled up and delivered under ideal conditions.

Aim: To determine the causes of perinatal deaths, risk factors for neonatal hypothermia and explore the acceptability and feasibility of recommended perinatal practices in hospital and community settings in Uganda. Settings: St. Raphael of St. Francis Hospital, Nsambya in Kampala and rural villages in Ntungamo, Kayunga and Soroti district.

Methods: The study period was from 1997-2008. A data form with a checklist and structured written questionnaires were used to collect data for studies I, II, III. 235 hospital records of women who had experienced a perinatal death in study I were reviewed. A perinatal audit and feedback was also conducted in study I. In studies II and III, 300 babies and 249 babies were recruited, and rectal and tympanic temperature measurements were performed on babies at specific time points post delivery in both studies. Babies of mothers in study III were randomized to receive early bathing after 1 hour or no bathing. Purposive sampling was done and Focus group discussions conducted in studies IV and V. In addition six in depth interviews were performed for selected respondents in study V. Uni-, bi- and multi-variable analyses were carried out, using Epi info and Stata 10 for studies I, II and III, and content analysis for studies IV and V.

Findings: A high perinatal mortality was noted in the hospital at 68.3 per 1000 total births. The still birth rate was 40.9 per 1000 total births, and the early neonatal death rate was 29.3 per 1000 live births in study I. In study II the proportions of hypothermic newborns at 10, 30, 60 and 90 minutes were 29%, 82%, 83%, and 79 %, respectively. Babies who had not been bathed were associated with an odds reduction of experiencing hypothermia of 68% at 70 minutes (OR 0.32; 95% CI 0.17-0.60) and 63% at 90 minutes post delivery (OR 0.37; 95% CI 0.20-0.67) compared to bathed babies in study III. The odds of being exposed to hypothermia for a baby weighing less than 2500 grams was five times greater compared to a baby with a birth weight of more than 2500grams over the different time points. The odds of being exposed to hypothermia if a baby was female increased more than 1.5 times at the different time points. This gender difference was also observed at 90 minutes in study III. Some of the recommended newborn practices were deemed to conflict with traditional and cultural practices. It was noted that promotion of delayed bathing and dry cord were unlikely to be accepted without local adaptation. In studies IV and V, cultural and spiritual beliefs were attached to the use of local herbs for bathing or smearing of the baby´s skin. Traditional birth attendants reportedly did engage in a number of positive practices when caring for newborn babies, which were in agreement with biomedical recommendations, including thermo-protection of the newborn, early referrals to the health units and advising mothers to take the newborns for immunization in study V.

Conclusion: There was a high perinatal mortality rate at the hospital. Thermoprotective guidelines were not being practiced well, and the prevalence of hypothermia was high. Bathing of babies within the first hour of life is associated with an increased risk of hypothermia. It may be necessary to modify some of the recommended evidence based practices, before they are accepted at community level.