Vietnam, officially the Socialist Republic of Vietnam, is the easternmost country on the Indochina Peninsula. With an estimated 94.6 million inhabitants as of 2016[update], it is the 15th most populous country in the world. Life expectancy has risen by two years for males and females in Vietnam between 2000 and 2012. This is half of the average rise in life expectancy for other parts of the world during the same time period.
Malnutrition is still common in the provinces, and the life expectancy and infant mortality rates are stagnating. In 2001 government spending on health care corresponded to just 0.9 percent of gross domestic product (GDP). Government subsidies covered only about 20 percent of health care expenses, with the remaining 80 percent coming out of individuals’ own pockets.
Estimated Preterm Birth Rates – Born Too Soon
Vietnam: Rate: 9.4% Rank: 103 Global Average: 11.1 USA: 12.0
WHO-recommended newborn care cuts life-threatening infections by two thirds –15 January 2019
A study in Viet Nam by the World Health Organization (WHO) shows that hospitals can reduce life-threatening infections in newborns by over two thirds and admissions to the neonatal intensive care unit (NICU) by one third by implementing Early Essential Newborn Care (EENC).
Published in EClinicalMedicine (The Lancet journal focused on clinical and public health research), the study titled “Early Essential Newborn Care is associated with reduced adverse neonatal outcomes in a tertiary hospital in Da Nang, Viet Nam: A pre-post intervention study” presents evidence that EENC strengthens health workers’ skills and improves care. These lead to increased rates of skin-to-skin contact and exclusive breastfeeding, and significant reductions in hypothermia, sepsis and NICU admissions.
“A newborn dies every 2 minutes in this Region, but full implementation of EENC could prevent up to half of these deaths,” explained Dr Howard Sobel, Coordinator for Reproductive, Maternal, Newborn, Child and Adolescent Health in WHO’s Western Pacific Region and co-author of the study.
Other studies in Asia have shown that health worker practices around birth are often outdated and harmful, leading to increased risks for babies of sepsis (a dangerous infection in the bloodstream), hypothermia (dangerously low body temperature) or death. Despite the availability of knowledge and tools, the quality of care can be compromised by the lack of clear policy guidelines, availability and allocation of staff, supportive work environments, and other issues.
EENC is a package of simple, evidence-based clinical care practices recommended by WHO. It focuses on improving the quality of care during and immediately after birth. Central to EENC is the “First Embrace” – a prolonged skin-to-skin cuddle between mother and baby, which allows proper warming, feeding and umbilical cord care. Key actions include: thorough drying; immediate skin-to-skin contact; clamping the cord after pulsations stop; cutting the cord with a sterile instrument; and initiating exclusive breastfeeding when the baby shows feeding cues, such as drooling, tonguing, rooting and biting of their hand.
Aside from the bond it fosters, the First Embrace helps transfer warmth, placental blood, protective bacteria, and through colostrum (the first breast milk) essential nutrients and immune cells to protect from infection. All babies can benefit, including those born preterm, sick or by caesarean section.
The Da Nang Hospital for Women and Children in central Viet Nam, where about 14 000 babies are born every year, implemented EENC through on-the-job coaching of staff on appropriate childbirth and newborn care in 2014 and 2015. A quality improvement approach was subsequently implemented to address factors such as local policies, organization of work spaces, health worker roles, sequencing of tasks, and availability of supplies and equipment.
“EENC has transformed the care that babies receive in our hospital. The package of procedures is practical, and it can be implemented anywhere,” said Dr Hoang Tran, Deputy Director, Da Nang Hospital for Women and Children.
The study compared live birth outcomes and NICU admissions in the 12 months before and after EENC was introduced. Data revealed that, after EENC implementation, sepsis cases fell by two thirds (from 3.2% to 0.9% of babies born in the hospital), NICU admissions fell by one third (from 18.3% to 12.3%), and hypothermia cases fell by one quarter (from 5.4% to 3.9% of babies admitted to the NICU).
Before EENC was introduced, skin-to-skin contact was not practised. Babies born vaginally were routinely separated from their mothers for at least 20 minutes, and those delivered by caesarean section for 6 hours or more. After implementation of EENC, 100% of babies received immediate skin-to-skin contact regardless of route of delivery.
The percentage of babies in the NICU born preterm (less than 37 weeks of gestation) or with low birthweight (less than 2.5 kilograms) receiving “kangaroo mother care” increased by 15% after EENC was introduced. Kangaroo mother care – continuous skin-to-skin contact for more than 20 hours per day, early and exclusive breastfeeding, and close monitoring of illness – reduces newborn deaths by up to half.
With EENC, the rate of exclusive breastfeeding in the NICU almost doubled. Exclusive breastfeeding is when a baby receives breast milk only – no formula, water or anything else. WHO and UNICEF recommend this as the ideal way to feed babies for their first 6 months. These improvements occurred during the study period despite a significant increase in the proportion of babies born by caesarean section and with low birthweight, which are barriers to breastfeeding.
Direct and indirect savings
The study also found additional benefits of EENC for hospitals and families. As a result of increased breastfeeding, parents of babies in the NICU and those on the postnatal ward spent 78% and 96% less on infant formula, respectively. Families also saved money thanks to shorter hospital stays and less time off work. As a result of reduced NICU admissions, the hospital saved more than US$ 300 000 and reduced staff workload. There was also reduced antibiotic use.
“The findings of our study are relevant way beyond Viet Nam. All hospitals – in rich and poor countries alike – can learn from this experience to improve newborn health. I’ve seen harmful practices across more than 20 low- and middle-income countries. Our job is to help health authorities, doctors, nurses and midwives replace those practices with evidence-based ones. We know that EENC works. We now need to finish the job and make it available to every mother and newborn across the Region,” Dr Sobel added.
US opposition to UN breastfeeding resolution defies evidence and public health practice
Date: Jul 09 2018 – Contact: David Fouse, 202-777-2501
Statement from Georges Benjamin, MD, Executive Director, American Public Health Association
Washington, D.C., July 9, 2018 – “We are stunned by reports of U.S. opposition to a resolution at the World Health Assembly this spring aimed at promoting breastfeeding. According to news stories, U.S. officials attempted to block a resolution encouraging breastfeeding and warning against misleading marketing by infant formula manufacturers.
“Fortunately, the resolution was adopted with few changes, but it is unconscionable for the U.S. or other government to oppose efforts that promote breastfeeding. The consequences of low rates of breastfeeding are even greater for the health of children in resource-poor countries.
“Breastfeeding is one of the most cost-effective interventions for improving maternal and child health. Breastfeeding provides the best source of infant nutrition and immunologic protection. Babies who are breastfed are less likely to become overweight and obese, and have fewer infections and improved survival during their first year of life. Breastfed infants often need fewer sick care visits, prescriptions and hospitalizations. In addition maternal bonding is increased, a benefit to both mother and child.
“The scientific evidence overwhelmingly supports breastfeeding and its many health benefits for both child and mother. The American Public Health Association has long supported exclusive breastfeeding for the first six months and continued breastfeeding through at least the first year of life. APHA also strongly supports policies that encourage breastfeeding at home, maternity hospitals and birth centers and the workplace, and help identify women most in need of support of breastfeeding practices.
“In cases where mothers are unable to breastfeed, there are evidence-based solutions to protect the mom and ensure the baby thrives. The solution to malnutrition and poverty is not infant formula, but improved economic development and access to domestic and international nutrition and food programs.”
APHA champions the health of all people and all communities. We strengthen the public health profession. We speak out for public health issues and policies backed by science. We are the only organization that influences federal policy, has a nearly 150-year perspective and brings together members from all fields of public health. Learn more at www.apha.org.
Aspirin for all pregnant women may reduce preterm birth
Bob Kronemyer Jul 9, 2018
Growing evidence that aspirin can prevent preterm birth (PTB) was presented at the 3rd European Spontaneous Preterm Birth Congress in Edinburgh, Scotland. Adding to data later this summer will be results from an open-label randomized, controlled trial (RCT) of low-dose aspirin with early screening for preeclampsia and growth restriction.
A review of the current evidence and perspective on its clinical implications were presented by Fionnuala McAuliffe, MB BCh BAO (Honours) DCH MD FRCPI, FRCOG FRPI. Dr. McAuliffe is principal investigator of the RCT and chair and professor of obstetrics and gynecology at University College Dublin in Ireland. The trial is an acceptability and feasibility study of low-risk women taking aspirin and their compliance and scheduled to be published in BMJ Open.
Addressing the Congress attendees, she said that “a number of studies point to the effectiveness of aspirin taken by pregnant women. At the moment, the data shows that aspirin reduces preeclampsia and preterm birth in women who are at risk for preeclampsia.”
In the United Kingdom, aspirin is often prescribed to prevent preeclampsia, but not as often in the United States. “Aspirin reduces both preeclampsia and preterm deliveries in women at risk for preeclampsia,” Dr. McAuliffe said. “If preeclampsia is reduced, then preterm birth is also reduced…You could argue that it might simply be cheaper to give everyone aspirin rather than trying to figure out if a certain individual is at risk of pre-eclampsia or not by conducting expensive blood and ultrasound tests in early pregnancy,” she said.
Aspirin is an antiplatelet agent that improves blood flow and vascular formation in the placenta by reducing the thromboxane and increasing the vasodilator prostacyclin. “Preeclampsia, of course, is a disease of the placenta that results from a placenta not developing properly from very early in pregnancy,” Dr. McAuliffe explained. “The association between preterm birth and preeclampsia is strong. If a woman develops preeclampsia prior to 37 weeks, she will need to deliver because of the risk to her health.”
As for safety, many studies conclude that aspirin has no adverse fetal sequelae in doses less than 150 mg per day and that aspirin does not increase the risk of congenital malformations. However, one study found that vaginal bleeding is more common: 3.9% for low-dose aspirin versus 1.3 for placebo.
The data to support aspirin date back more than 10 years, showing that the drug reduces risk of PTB by 7% to 14%. “This is robust data compiled from more than 40,000 women at risk of preeclampsia,” Dr. McAuliffe said. “The question then becomes can we extrapolate the data to all pregnant women?”
Dr. McAuliffe cited examples of women who are given aspirin only during a follow-up pregnancy after experiencing preeclampsia during their previous pregnancy. “These women are concerned that they were not offered aspirin to begin with,” she said. “Thus, there is interest in offering aspirin to all pregnant women.”
However, currently there is no concrete evidence that aspirin reduces the rate of preeclampsia in low-risk women.
Numerous studies of women who are at risk for preeclampsia show a risk reduction with daily aspirin, with a decrease in preeclampsia ranging from 17% to 24%, a decrease in PTB of between 8% and 14% and a reduction in small for gestational age (SGA) spanning from 10% to 20%.
Specifically, a multicenter, randomized placebo-controlled trial of low-dose aspirin (80 mg) to prevent recurrent preterm labor in 406 women found that incidence of PTB < 37 weeks’ gestation was reduced by 35%, as reported in BMC Pregnancy and Childbirth in 2017.
Similarly, for the same gestation period, incidence of PTB fell by 20%, according to a study of 11,920 nulliparous mothers in seven low- and middle-income countries who were given aspirin supplementation during pregnancy, again as reported in BMC Pregnancy and Childbirth in 2017.
Dr. McAuliffe was co-author of a viewpoint in the American Journal of Obstetrics and Gynecology in 2016 that posed the question: Should we recommend universal aspirin for all pregnant women? In support of the proposal, the authors listed efficacy in at-risk women, safety, cost and international impact. “Aspirin is incredibly inexpensive,” Dr. McAuliffe said. “It can be easily stored at room temperature, so potentially there is a huge international impact.”
Two reasons against the recommendation are lack of evidence of efficacy in low-risk women and potential side effects.
The trial of aspirin to prevent preeclampsia (TEST), for which Dr. McAuliffe is the principal investigator, was carried out at two hospitals in Ireland to determine if low-risk, first-time mothers would be interested in taking aspirin during pregnancy and actually adhere to the protocol of once-daily aspirin (75 mg).
Of the 1,054 eligible women approached to participate in the study, 52.8% agreed. And of the 179 women who were randomized to take aspirin, 96% complied with the protocol. “In the United States, the dose is quite similar at 80 mg,” Dr. McAuliffe noted. When study patients were asked if they would be willing to take aspirin during a subsequent pregnancy, 92.5% of those who took aspirin and 91.5% of those who did not said yes.
A separate study conducted by Dr. McAuliffe and colleagues, which has been submitted for publication, is a cost-effectiveness analysis of aspirin in 21,641 low-risk nulliparous women in Ireland. The economic analysis compared universal aspirin to a Fetal Medicine Foundation screening test and then offering aspirin to those who screened positive.
“We found that it was less expensive to give everyone aspirin rather than detecting within the population those who are at risk of preeclampsia, and then prescribing low-dose aspirin,” Dr. McAuliffe said.
The universal aspirin net savings was estimated as roughly $1.8 million, whereas universal screening and treatment tallied about $1.7 million annually for Ireland. “These data, if extrapolated to the United States, would amount to very considerable savings,” Dr. McAuliffe said.
However, before recommending universal aspirin, “we need to research and further consider the consequences,” Dr. McAuliffe said. “But it is important to start that conversation. I am cautiously optimistic that both clinicians and patients may embrace aspirin for all pregnant women.”
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Managing Low Birth Weight in Rwanda
Posted July 25, 2018
“It would have been very painful and harmful if we had lost our firstborn,” Laurence Uwamahoro says as she breastfeeds her newborn son.
Laurence lives in Murehe, a rural region of eastern Rwanda, with her husband, Jean d’Amour Nduwimana, and their newborn, Yvan. Jean d’Amour sits next to his wife as she breastfeeds, continually smiling at his son.
“We have to keep enjoying our union,” he says of life with their new son. “We would have been narrating a very sad story, but it didn’t happen.”
The story of this new family began two months after Laurence and Jean d’Amour married, when a test confirmed Laurence’s pregnancy. But as the couple began enthusiastically preparing for birth, Laurence felt increasingly ill. She sought care at the nearest health center, but continued to worsen until she was six months pregnant – and felt the symptoms of her labor beginning.
“On my way to the hospital, my mind was elsewhere. I was only thinking of funeral ceremonies, because I had no hope that my baby could survive,” Laurence says. By the time she arrived at the health center, her membranes had prematurely ruptured and she was bleeding – signs of placenta abruption.
She soon delivered a very premature Yvan. Weighing only 800 grams (1.7 pounds) at birth, he met the World Health Organization’s definition as “extremely low birth weight” (less than two pounds, three ounces). The nurses who helped Laurence deliver immediately transferred both mother and baby to Kibungo Hospital to receive higher-level care only available in the hospital’s neonatal unit.
Thankfully, Laurence and Yvan were received at Kibungo Hospital by MCSP-trained nurses and midwives, who confidently continued their care. In collaboration with the Rwanda Ministry of Health, Rwanda Biomedical Center, and national professional associations (including the Rwandan Pediatric Association), MCSP is improving the capacity of the country’s health care providers to manage the acute care needs of babies like Yvan through on-site trainings and clinical mentorship.
Kibungo Hospital’s neonatal ward staff had benefited from multiple weeks of targeted MCSP training on Basic Emergency Obstetric Care and Essential Newborn Care, after which a mentor had visited each trainee bi-monthly for several months to ensure they were applying their new skills correctly. These efforts are part of MCSP’s overarching capacity building strategy for Rwanda, which uses clinical training to address the leading causes of death for children under five and pregnant women. To date, the Program has trained more than 12,000 doctors, nurses, midwives, lab technicians, and community health workers from 16 districts in areas such as infection control, resuscitation, and newborn treatment protocols.
One such provider is Midwife Christine Mujawimana, who used her new skills to continue Yvan’s treatment for three months, as his weight steadily rose to 2 kilograms (4.4 pounds). “That was my first time I received such a low weight baby,” she said. “But with the training from MCSP, we all felt confident that Laurence’s baby had to survive.”
The care Yvan required to survive was extensive, but the trained hospital staff was up to the task. After placing him in an incubator, they began implementing Yvan’s treatment according to national neonatal protocols: administering intravenous fluids, diagnosing and treating an infection with antibiotics, giving him a blood transfusion due to anemia and phototherapy for jaundice, and placing him on a Continuous Positive Airway Pressure machine for respiratory distress syndrome.
They also knew to give him expressed breast milk by nasogastric tube. Thanks to their MCSP training, the hospital’s providers learned to use this method for all low birth weight babies who lack a sucking reflex – typically those who weigh less than 1.5 kilograms (3.3 pounds) at birth. Later, when babies acquire a sucking reflex, the providers know to encourage breastfeeding and supplementation with expressed breast milk using a feeding cup (until breastfeeding alone meets a baby’s needs).
After stabilizing Yvan, the staff taught Laurence how to hold him in Kangaroo Mother Care. This continuous skin-to-skin contact not only keeps low birth weight babies warm, it also increases their nutrition by promoting frequent and exclusive breastfeeding.
Three weeks after he was discharged from the hospital, Yvan’s weight had increased to a stable 3 kilograms (6.6 pounds). Laurence and Jean d’Amour were thrilled! And as their concerns about their son’s weight faded, they finally began to enjoy parenthood as they imagined it when Laurence was first pregnant.
“Our baby is healthier now. We thank all the nurses and everybody who played a big role in having our baby survive,” Jean d’Amour says.
Written by Evariste Bagambiki, MCSP Communications Assistant, Rwanda
(with support from Ingabire Muziga Mamy, MCSP Communication Specialist, Rwanda)
My Neonatal Story – From a Novice to Advanced Neonatal Nurse Specialist
My story started seven years ago when I graduated from nursing school as a general nurse at the University of Rwanda in 2011. Shortly afterwards, I was appointed by Ministry of Health to work at the Rwanda Military Hospital (RMH) and when I arrived at the hospital I was allocated to work in the Neonatal Unit. It was not my choice to work in the Neonatal Unit. My preference was to work with adults and not neonates, but it was an order and I had to follow it.
I was terrified to work in the neonatal unit! I did not have any prior knowledge or skills to care for neonates. I did not get any neonatal training course during my nursing studies and it was my first time to enter a neonatal unit. So when I entered the neonatal unit, every thing was new to me. There was no identified person in charge of my orientation or an orientation program for new graduates. Instead, I was given the task to read the National Neonatal Guidelines; though I could not understand all the content. The senior nurses on the unit were too busy and did not have time to train me. However, I did my best to learn some neonatal skills from senior nurses, though due to the staff shortage I only had two weeks orienting to the neonatal unit.
Consequently, every single day spent on the neonatal unit was filled of worries, as my lack of neonatal knowledge and skills made me fearful to be alone monitoring the neonates. I hated lunchtimes as someone had to stay on the unit mentoring neonates and I did not like being that one nurse left behind by myself.
After one year of working in the neonatal unit, I had the first opportunity to be trained in neonatal resuscitation, though the expression, “the more you know, the more you fear” suddenly applied to me. After the training, I realized that my skills were harmful to neonates rather than helpful. I was saddened to realize that I had spent the whole year on neonatal unit without knowing how to hold the Ambubag and mask, and to provide positive pressure ventilation to the neonate. I could not stop blaming myself, thinking about all the neonates I had seen dying and perhaps with good skills I may have been able to save them.
A few months later in 2012, I had the opportunity to meet a neonatal nurse from the USA who came as a mentor at RMH as part of the Human Resources for Health (HRH) program. I was most fortunate to work with Vicky Albit a neonatal nurse. It was through her mentorship that enhanced my abilities and confidence to care for neonates. Since then, caring for neonates has become my passion!
My hospital organized a critical care workshop for nurses who wanted to work in neonatal and adult intensive care units, which were new services to the hospital. Selected nurses had intensive care courses and neonatal courses during a three-week period. After the workshop, only five nurses were interested in working in the Neonatal Intensive care unit (NICU) and they were sent for four-weeks training at King Faisal Hospital (KFH), the only hospital in Rwanda with a NICU. For the first time, I saw a neonate on mechanical ventilation. I was afraid to touch the baby, but through help with my mentor, I was taught how to care for a neonate on mechanical ventilation. Even though the clinical placement was brief, I gained the knowledge and skills to care for very sick neonates.
After the clinical placement at KFH, we were ready to open our NICU at RMH. We had more training sessions on medical equipment to use in our NICU including monitors, incubators, radiant warmers, CPAP machines, ventilator machines, syringe pumps, infusions pumps, ABG machine and others. At the opening of our NICU, I was given the hard task of unit manager of the new service and worked with my mentor to create clinical guidelines, protocols and policies. I faced many challenges to mange our new four- bed capacity NICU with shortages of trained staff, and lack of essential consumables and drugs. In addition, it was hard for the hospital administration to understand the needs of the new NICU in terms of nurses, consumables and drugs.
I remember how we prepared to receive our first NICU patient; we were ready with the medical equipment, drugs, nursing team and doctors. After many efforts to save the first patient – who was in septic shock with severe neonatal sepsis – the patient died. I remember how disappointed and discouraged I felt after that first attempt ended in failure. I was wrong to think that by having a NICU we would be able to provide life-saving care to all babies.
After the opening of our NICU, I worked with the neonatal nurse for another two months and I did my best to learn as much as I could, as I was the one now mentoring my colleagues. I could not imagine how we would be able to take care of the very sick neonates without our mentor. I had to take hold and control of everything; supervising and mentoring both the experienced and new nurses on the unit. A few days after our mentor had left RMH, a nurse who was caring for a sick neonate on mechanical ventilation called me, “Chief, please come and help me with the endo-tracheal tube as it is not well fixed and may displace easily.” I responded to the nurse, but I was terrified as I was not good at taping the ETT. But I said to myself, I have done this with my mentor, so I have to do it. I helped the nurse secure the ETT and we did it well. I was forced to do many skills because I was the assigned leader.
Even though I was considered to be the one with knowledge and skills in our NICU, I felt a gap in my training and I wished I could go to university to study neonatology. I had a role model in mind; I wanted to be like Vicky Albit the HRH neonatal nurse that I had met. After two years of leading our NICU, I finally had the opportunity to be in the first cohort of the Master’s of Science of Nursing – neonatology track – at the University of Rwanda.
It was not easy to study in the masters program; as I had to go to school three days a week and work four days a week. Though I was now a bedside nurse taking care of neonates in the NICU and no longer dealing with unit manager responsibilities. It was difficult balancing the demands of school, work, and family, but nothing could stop me! I was truly committed and I wanted to become a neonatal nurse. After two years of working hard, I graduated with a Master’s of Science in Nursing, in the specialty track of Neonatology. I am proud to be a neonatal nurse; I have gained a lot of knowledge and skills from school and the experiences of working in the NICU.
I have returned to the NICU unit manager position at RMH, where we still have the four- bed capacity due to limited medical equipment, with only two working CPAP machines and two ventilator machines. Our NICU is always full and we have a high demand for NICU services.
We face many challenges including lack of trained health care providers. There is only one neonatologist in the country; unfortunately he does not work at RMH, though I wish I could work with him.
The care that we provide to our neonates is limited as many times we have low or lack resources in our clinical settings. I see babies who could have been saved with surgical interventions, if we had more surgical resources. I see babies who died after surgery because of poor post-surgical management, such as lack of total parenteral nutrition. I see many preterm babies who died because they needed advanced therapy like surfactant. I see babies who died because they needed antibiotics that were not available or the family could not afford them. I see babies who died because of limited medical equipment such as ventilators or CPAP machines.
To work and manage a NICU in a resource-limited country is not easy; each day we struggle to give the best care we can to our neonates. The flowing is an example of our on-going situation.
A preterm baby who recovered well in the NICU post CPAP progressed to Kangaroo Mother Care (KMC). All of the NICU team was happy for such an achievement and I was happy to see the mother holding the baby in KMC. The following morning I entered the unit to see the nurses doing resuscitation and I was shocked to see that the baby that they were resuscitating was our KMC baby. I remained calm and quiet, and did not ask how the baby had gone in to respiratory failure. I was busy thinking ahead about the possibility of a ventilator machine, as we only had two and they were being used.
Neonates are amazing. The baby was moving the limbs, but without any spontaneous breathing needed intubation, as well as a ventilator machine. When I looked around I saw the baby’s mother in tears and I remembered how happy she was the previous day holding her baby. Then the on-call pediatrician notified me that King Faisal Hospital, the other hospital with ventilator machines, had no available machines for our KMC baby. The pediatrician advised me to inform the family that we did not have a ventilator machine and that we were going to discontinue positive pressure ventilation. It was a very sad situation to let a baby die because we did not have a ventilator machine. I told the pediatrician that we would find a ventilator machine for our baby. We had two machines in our NICU that were not in use because they were lacking spare parts. I was thinking that with the help of a biomedical technician we could find a working machine. I was trying to assemble the necessary equipment, when I saw the baby’s mother in tears. I did not want to face her, but I did, and I told her that we were doing everything possible to find a ventilator machine that could help her baby breathe. During that time of comfort, she wiped her tears and told me that she trusts us.
While we waited for the biomedical technician to come, I instructed the resident Pediatrician to intubate the baby for better ventilation. I was confident that we would have a working ventilator machine soon. The nurses on the ward alternated doing hand ventilation. After two hours the biomedical technician had repaired one machine and we put the baby on. The baby was doing well on the ventilator machine and all the team was happy. Unfortunately, the machine only worked for about four hours, when a nurse told me, “Your machine crashed, it’s no longer ventilating the baby.” I was very sad as the nurse said, “YOUR machine crashed;” it was my responsibility to find another machine. The remaining machine was missing some spare parts that had been requested, but not yet delivered. In the meantime, I pushed the chief of biomedical services to do all he could to get the missing spare parts; it took more hours to get the spare parts and to repair the machine. Finally, the machine was repaired, and the baby was put on the machine again. The day was full of stress with many ups and downs, but finally ended well with success. The following days, I was happy to see the baby improving and to see the mother joyful once again. The baby had a quick recovery; was discharged from the NICU and is now doing well in KMC.
To be a neonatal nurse is not only delivering routine nursing care to sick neonates, it is going that extra mile (kilometer) and being present for babies and their families in NICU. In my daily activities, I am supportive of families that are worried about the outcome of their sick babies and I grief with families when we cannot save a baby. I feel happy when a baby recovers and graduates from the NICU; by either going to KMC in neonatal unit or going home. I work with a formidable team of nurses and midwives, who have not had the same opportunities as me to study neonatal, but they work hard day and night, and are dedicated to the care of neonates.
They are enthusiastic and willing to learn and I wish that they could all have an advanced neonatal course.
We have many challenges as nurses and midwives trying to establish a professional neonatal career path as it is still under development in Rwanda; there is no clear scope of practice, and even the MScN neonatal degree is not yet recognized by all Rwanda institutions. I am a member of the newly formed Rwanda Association of Neonatal Nurses (RANN). It is a new association, but I have a strong conviction that it will go far to promote a neonatal professional career and will undoubtedly improve neonatal outcomes in Rwanda.
I am working at a national referral hospital in Rwanda, one of the best neonatal units in the country, though our level of care is limited. I know the evidence based practice and I wish I could see and learn from other NICUs, both in resource-limited countries and high-income countries, where they use advanced technologies and practice. I will never be discouraged because I know that one day neonatal care will be a priority in my country and that we will have a high standardized NICU with well-trained health care providers and enough advanced medical equipment to save more lives.
This blog is cross-posted from the COINN website. This blog is also part of the HNN collection, Telling Your Story: transforming care for small and sick newborns. If you have a story to share about transforming care for small and sick newborns, send a 300-600-word blog about your experience or research to firstname.lastname@example.org.
Decision-making at the limit of viability: Differing perceptions and opinions between neonatal physicians and nurses
RESEARCH ARTICLE-Open Access Decision-making at the limit of viability: differing perceptions and opinions between neonatal physicians and nurses Hans Ulrich Bucher1*, Sabine D. Klein1, Manya J. Hendriks1,2, Ruth Baumann-Hölzle3, Thomas M. Berger4,Jürg C. Streuli2, Jean-Claude Fauchère1and on behalf of the Swiss Neonatal End-of-Life Study Group
Abstract Background: In the last 20 years, the chances for intact survival for extremely preterm infants have increased in high income countries. Decisions about withholding or withdrawing intensive care remain a major challenge in infants born at the limits of viability. Shared decision-making regarding these fragile infants between health care professionals and parents has become the preferred model today. However, there is an ongoing ethical debate on how decisions regarding life-sustaining treatment should be reached and who should have the final word when health care professionals and parents do not agree. We designed a survey among neonatologists and neonatal nurses to analyze practices, difficulties and parental involvement in end-of-life decisions for extremely preterm infants. Methods: All 552 physicians and nurses with at least 12 months work experience in level III neonatal intensive care units (NICU) in Switzerland were invited to participate in an online survey with 50 questions. Differences between neonatologists and NICU nurses and between language regions were explored. Results: Ninety six of 121 (79%) physicians and 302 of 431(70%) nurses completed the online questionnaire. The following difficulties with end-of-life decision-making were reported more frequently by nurses than physicians: insufficient time for decision-making, legal constraints and lack of consistent unit policies. Nurses also mentioned a lack of solidarity in our society and shortage of services for disabled more often than physicians. In the context of limiting intensive care in selected circumstances, nurses considered withholding tube feedings and respiratory support less acceptable than physicians. Nurses were more reluctant to give parents full authority to decide on the course of action for their infant. In contrast to professional category (nurse or physician), language region, professional experience and religion had little influence if any on the answers given. Conclusions: Physicians and nurses differ in many aspects of how and by whom end-of-life decisions should be made in extremely preterm infants. The divergencies between nurses and physicians may be due to differences in ethics education, varying focus in patient care and direct exposure to the patients. Acknowledging these differences is important to avoid potential conflicts within the neonatal team but also with parents in the process of end-of-life decision-making in preterm infants born at the limits of viability.
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The Power of Breast Milk in the NICU (Full)
Medela US – Published on Nov 20, 2017
For premature babies, breast milk is more than food – it’s medicine. See how it’s transforming lives in the NICU.
Breastfeeding a Boon to Preemies’ Hearts: Study
Improvements seen in function and size 20 years later – By Alan Mozes – HealthDay Reporter
TUESDAY, June 14, 2016 (HealthDay News) — Breast-feeding premature babies appears to increase the likelihood that those infants will have healthier hearts in young adulthood, new research suggests.
The finding was based on an analysis involving just over 200 men and women in their early- to mid-20s. It suggests that premature infants fed just breast milk during infancy ultimately have better heart volume and overall function compared to preemies raised on formula or a mixture of formula and breast milk.
“It was completely unknown that breast milk would provide this particular protective effect on the development of the heart in babies born preterm,” said study author Paul Leeson. He’s the clinical director of the Cardiovascular Medicine Division of the Cardiovascular Clinical Research Facility at the University of Oxford, in England.
“We suspected it might, but were surprised by the size of the effect,” he added.
The study authors pointed out that premature babies often go on to develop long-term heart abnormalities. Those can include small heart chambers, thicker heart walls and impaired heart function. The first few months of life are considered a critical period in terms of development of the heart, the researchers said.
To see what effect breast-feeding during infancy might have, the researchers followed 102 people born preterm in the 1980s who were part of a larger study on feeding regimens. At the time, half of that group was assigned to receive breast milk, while the other half was given formula. Ultimately, 30 were fed solely breast milk, while 16 were given “nutrient-enriched” formula only during early postnatal life.
They were compared with another 102 people born full-term from the same time period.
The researchers conducted heart testing when all the participants were between 23 and 28 years old.
As expected, participants who were born premature had reduced heart volume and function compared with those carried to term. But those born premature and fed exclusively with breast milk had greater heart volume than preemies fed only formula.
The study only found an association between heart health and breast milk. And, the impact of breast milk appeared to be incremental. That meant that those whose feeding mix included more breast milk than formula ended up with greater heart volume and better functioning hearts than those whose diets included more formula. What we have now found is that, although exclusive breast milk does not alter the wall thickness, it does mean the hearts of adults who were born preterm get closer in size to those of adults born at term and the function of their hearts is better,” Leeson said.
Dr. Jennifer Wu, an obstetrician-gynecologist at Lenox Hill Hospital in New York City, said “the benefits [of breast milk] for premature infants are enormous.” Wu was not involved with the study.
“In the short term, there are protective antibodies and the production of important gut flora,” she said. “In the long term, breast-feeding improves heart structure and function.”
But at the same time, Wu added that “breast-feeding can be a challenge for moms with premature infants.”
“Due to Newborn and Infant Critical Care Unit admissions and longer hospital stays, breast-feeding can be difficult to initiate and maintain,” she said. “Extra support and lactation consultations are needed.”
The study was published online June 14 in Pediatrics. WebMD News from HealthDay
Bonding With Your NICU Baby
MountainStar Health Published on Nov 30, 2016
Christine Van Orden is a Registered Nurse in the NICU at Eastern Idaho Regional Medical Center, and shares what you can do to bond with your NICU baby.
Parents’ Hearts Melt Seeing 6-Year-Old Boy Give Preemie Baby Brother Skin-To-Skin 1010 Wins Published on Jul 25, 2018
After years of asking his parents for a baby brother, Mikey finally got his wish. And this photo of him cuddling little Jake is melting hearts. Mikey’s parents Jessica and Michael had complications arise during the pregnancy. Little Jake was born premature at 30 weeks and weighed just one pound, 12 ounces and was only 12-inches-long. He spent over two months in the NICU.
Impact of preterm birth on parental separation: a French population-based longitudinal study
Objective The objective of this study was to investigate both the effects of low gestational age and infant’s neurodevelopmental outcome at 2 years of age on the risk of parental separation within 7 years of giving birth.
Setting 24 maternity clinics in the Pays-de-la-Loire region.
Participants This study included 5732 infants delivered at <35 weeks of gestation born between 2005 and 2013 who were enrolled in the population-based Loire Infant Follow-up Team cohort and who had a neurodevelopmental evaluation at 2 years. This neurodevelopmental evaluation was based on a physical examination, a psychomotor evaluation and a parent-completed questionnaire.
Outcome measure Risk of parental separation (parents living together or parents living separately).
Results Ten percent (572/5732) of the parents reported having undergone separation during the follow-up period. A mediation analysis showed that low gestational age had no direct effect on the risk of parental separation. Moreover, a non-optimal neurodevelopment at 2 years was associated with an increased risk of parental separation corresponding to a HR=1.49(1.23 to 1.80). Finally, the increased risk of parental separation was aggravated by low socioeconomic conditions.
Conclusions The effect of low gestational age on the risk of parental separation was mediated by the infant’s neurodevelopment.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.
EDUCATIONAL NEONATAL WOMB COMMUNITY RESOURCES MANDATE: Maternal and Neonatal Directed Assessment of Technology The Mandate Approach and Goal
Team members include RTI economists, epidemiologists and engineers, as well as consultants and subcontractors, including Dr. Robert Goldenberg, an obstetrician with broad clinical and research experience in low-resource settings and Dr. Alan Jobe, a neonatologist with extensive research experience in newborn health. MANDATE also utilizes input from key frontline practitioners in India and sub-Saharan Africa.
MANDATE included an Advisory Group with expertise in maternal and neonatal health, technology development and implementation, modeling, and philanthropy.
MANDATE includes an interactive, computer-based, quantitative model that compares the potential number of lives saved across maternal and neonatal technologies. Users can identify and isolate the potential impact of a technology by patient category, region, and setting. The tool is available for public use free of charge.
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Gregg Braden and Bruce Lipton speak on The Truth, The Journey Within
Gregg Braden & Bruce Lipton speak on the science of the mind-heart connection. Modern science shows that the human heart creates the single most powerful electrical field in the human body, about 60-100 times more powerful than the human brain.
Did my entrance into the world, my subsequent heart surgery, my preemie experiences, the amazing healers that touched my soul guide my path towards becoming a surgeon? How do I know this path is the right one for me?
I know this path is right direction at this time because on this path my heart expands and the beat of my heart excites me and carries me forward into the mystery that awaits. I feel passion and a yearning to serve.
This past weekend on my way to cadaver anatomy lab I ran into a professor/surgeon who was stuck in the hallway (he forgot his access card in his office and was locked in). This doctor whom I had not met previously is involved in the type of surgical care systems work that captures my attention. The meet-cute was a reminder to me that no meeting is accidental, and mindfulness and presence allows us to connect in wonderful mysterious ways.
Kiteboarding Trip in Vietnam-Windsurfing also Filmed by DGapone