Peru is a country in western South America. It is bordered in the north by Ecuador and Colombia, in the east by Brazil, in the southeast by Bolivia, in the south by Chile, and in the south and west by the Pacific Ocean. Peru is a megadiverse country with habitats ranging from the arid plains of the Pacific coastal region in the west to the peaks of the Andes mountains extending from the north to the southeast of the country to the tropical Amazon Basin rainforest in the east with the Amazon river. Peru has a population of 33 million, and its capital and largest city is Lima. At 1.28 million km2 (0.5 million mi2), Peru is the 19th largest country in the world, and the third largest in South America.
The sovereign state of Peru is a representative democratic republic divided into 25 regions. Peru is a developing country, ranking 82nd on the Human Development Index, with a high level of human development with an upper middle income level and a poverty rate around 19 percent. It is one of the region’s most prosperous economies with an average growth rate of 5.9% and it has one of the world’s fastest industrial growth rates at an average of 9.6%. Its main economic activities include mining, manufacturing, agriculture and fishing; along with other growing sectors such as telecommunications and biotechnology. Peru ranks high in social freedom; it is an active member of the Asia-Pacific Economic Cooperation, the Pacific Alliance, the Trans-Pacific Partnership and the World Trade Organization; and is considered as a middle power.
Peru has a decentralized healthcare system that consists of a combination of governmental and non-governmental coverage. Five sectors administer healthcare in Peru today: the Ministry of Health (60% of population), EsSalud (30% of population), and the Armed Forces (FFAA), National Police (PNP), and the private sector (10% of population).
In 2009, the Peruvian Ministry of Health (MINSA) passed a Universal Health Insurance Law in an effort to achieve universal health coverage. The law introduces a mandatory health insurance system as well, automatically registering everyone, regardless of age, who living in extreme poverty under Integral Health Insurance (Seguro Integral de Salud, SIS). As a result, coverage has increased to over 80% of the Peruvian population having some form of health insurance. Health workers and access to healthcare continue to be concentrated in cities and coastal regions, with many areas of the country having few to no medical resources. However, the country has seen success in distributing and keeping health workers in more rural and remote regions through a decentralized human resources for health (HRH) retention plan. This plan, also known as SERUMS, involves having every Peruvian medical graduate spend a year as a primary care physician in a region or pueblo lacking medical providers, after which they go on to specialize in their own profession.
PRETERM BIRTH RATES –PERU
Rank: 148 –Rate: 7.3% Estimated # of preterm births per 100 live births
(USA – 12 %, Global Average: 11.1%)
Newborn babies, whose mothers are infected with coronavirus, at the National Perinatal and Maternal Institute. Photograph: Rodrigo Abd/AP
Hidden pandemic’: Peruvian children in crisis as carers die
Mon 16 Aug 2021
With 93,000 children in Peru losing a parent to Covid, many face depression, anxiety and poverty.
When Covid-19 began shutting down Nilda López’s vital organs, doctors decided that the best chance of saving her and her unborn baby was to put her into a coma.
Six months pregnant, López feared she would not wake up, or that if she did, her baby would not be there.
Her partner had already died of the virus, and doctors predicted that López would too.
But whether due to the expertise of the intensive-care unit’s medical team, López’s will to cling to life for her children – or, as she sees it, divine intervention – doctors were able to save the mother and the baby, María Belén, who was three months premature, with an emergency caesarean.
“It really is a miracle of God,” says López, who lives in a settlement of ramshackle wooden and concrete-block houses in the dusty mountains skirting the northern edge of Lima. “Maybe he didn’t want me to die for my kids, so I could continue fighting for them. They are the ones that really need me.”
Mental health in the life of this population is likely to be marked by various breakdowns
The scars remain for López. She has not yet processed the loss of her partner and has to provide for her three children – including 12-year-old twins from a previous marriage – while Covid-19 has impaired her ability to walk.
María Belén, now six months old, is one of an estimated 99,000 children in Peru and 1.6 million globally who have lost a caregiver to Covid-19, according to a study published in the Lancet in July.
Covid-19 orphanhood is a “hidden pandemic”, say researchers. Obscured by the more visible tumult of the pandemic, it is damaging the mental and physical health and economic future of the next generation.
Peru faces a particularly severe crisis. High levels of informal labour, intergenerational housing and poverty have made it fertile ground for the coronavirus. It has recorded 197,000 Covid-19 deaths – the highest number in the world per capita.
By the end of April this year, almost 93,000 Peruvian children – more than one in 100 – had lost a parent, according to the Lancet study.
Experts believe the impact of the pandemic on children has been overlooked as they are usually less badly affected than adults by the illness itself, even though more than 1,000 Peruvian children have died from Covid-19.
Yuri Cutipé, executive director of mental health at Peru’s ministry of health, says: “If we add the loss of a parent or caregiver to the mental health impact of the pandemic in the context of weakening family and community networks and economic shortcomings, mental health throughout the life of this population is likely to be marked by various breakdowns and some complex difficulties.”
Lengthy lockdowns have caused a sharp increase in domestic violence as well as anxiety and depression in children. A third of children in Lima “show a high burden of mental health risk”, according to a study by Peru’s health ministry and Unicef.
Roxana Pingo, coordinator of Save the Children Peru’s (SCP) Covid response programme, says: “Even before you take into account that more than 1,000 children have died from Covid-19 in Peru, they have been extremely affected by depression and anxiety.”
Latin America and the Caribbean had the largest number of children missing school in the world, according to Unicef’s estimates in March. The educational hiatus is accentuating existing chasms in inequality and setting back life prospects for a generation, the UN agency says.
Children try to get a mobile signal during virtual classes in the Puente Piedra shantytown outside Lima. Latin America and the Caribbean have the world’s highest number of children missing lessons. Photograph: Martín Mejía/AP
The pandemic has plunged families who have lost a breadwinner into deeper poverty. López’s partner, a taxi driver, brought in the main wage and she cannot continue her job cleaning at a local college due to her difficulties walking. “We don’t know what to do,” she says. “I don’t see any economic opportunities.”
So many Peruvian families have lost a caregiver that the government approved an “orphan pension” in March. It pays caregivers of children who have lost one or both parents 200 Peruvian soles (£35) a month until the child is 18 years old. “It’s a lifeline,” says López.
But the delivery of pension payments has been slow. For now, López is relying solely on the goodwill of strangers and donations from SCP for food, milk and nappies.
It could take up to six months for a child who has lost a parent to start receiving payments and longer for those who have lost both parents, says Pingo. There are also insufficient funds to cover the programme, so children under five are prioritised.
The sluggish, fragmented response is typical of Peru, says Nelly Claux, SCP’s director of programme impact. The country became a model for child rights in Latin America during the 1990s, thanks to its progressive legislation. But the government often struggles to bring ideas conceived in Lima into reality in the sprawling slums on its periphery or the towns and villages dotted across the Andes.
“We have no lack of legal framework. It’s world-leading,” Claux says. “What we don’t have is cooperation, officials who know what they are doing, and funds.”
An official at a Child Defence Centre (Defensoría Municipal del Niño y el Adolescente or Demuna) told López that many parents and caregivers did not know that they were entitled to the pension. Demuna, a state-funded office that supports children’s rights at a local level, has been distributing flyers at its centres, posting notices on Facebook and going from door to door to raise awareness.
By the end of July, more than 11,000 families were receiving the payment, according to Peru’s ministry for women.
The government estimates that 35,000 children are eligible, which is below the Lancet study’s findings of 99,000. Terre des Hommes, a child development agency, puts that number at 70,000.
Children who lose a caregiver are more likely to be institutionalised in an orphanage or care home, and experience broader short- and long-term adverse effects on their health, safety and wellbeing, say experts.
Girls become more vulnerable to sexual exploitation and boys to illegal mine work. “The Peruvian response must be comprehensive, protecting against damage to mental health, education, exploitation and crime,” says Pingo.
“We know that they are out there and that the quicker we get to them, the more we can help. But we just don’t know where they are. We’ve got to find them.”
Early intervention minimises the impact. But first, they have to find the children. All the while, the list keeps growing. In the week to 10 August, more than 500 Covid deaths were recorded, meaning hundreds more children have likely lost a parent or caregiver.
Respectful Maternity Care and Maternal Mental Health are Inextricably Linked
September 15, 2021 By Sara Matthews
A positive birth experience is not a luxury, but a necessity, said Hedieh Mehrtash, consultant for the Department of Sexual and Reproductive Health and Research at the World Health Organization (WHO), at a panel during the Maternal Mental Health Technical Consultation hosted by the United States Agency for International Development’s (USAID) MOMENTUM Country and Global Leadership, in collaboration with WHO and the United Nations Population Fund.
Much is still unknown about the connections between respectful maternity care and maternal mental health outcomes, said Patience Afulani, Assistant Professor at the University of California, San Francisco. Nevertheless, existing research indicates that women who have negative birth experiences are at higher risk of developing post-traumatic stress disorder, postpartum depression, and other perinatal mental health issues. “When women are treated in a way that is responsive to their needs, their preferences, and values; when providers are compassionate and respectful and supportive, a woman feels engaged in their care,” she said. “They feel satisfied. They feel valued. They feel empowered, which promotes positive emotional health.”
There is a complex “cyclic relationship” between respectful maternity care and maternal mental health, said Afulani. For example, due to provider discrimination, women with pre-existing mental health issues may be more likely to have negative birth experiences. Negative birth experiences may also deter women from seeking care in the future, making it less likely that mental health issues will be properly identified and addressed, she said.
Although supporting mothers and parents is incredibly important, “caring for the carers” is also essential, said Mary Ellen Stanton, Senior Maternal Newborn Health Advisor at USAID. Partially due to provider burnout, health care workers often lack the role models, skills, and resources needed to provide the highest standard of respectful care, said Charity Ndwiga, Program Officer III in the Reproductive and Maternal Health Program at the Population Council. When providers are burnt out, they are less able to communicate with and listen to patients. This damages the patient-provider relationship and can worsen health outcomes. In light of this reality, interventions need to target both mothers and providers, said Ndwiga.
Although supporting mothers and parents is incredibly important, “caring for the carers” is also essential.
Developing measurement tools is a crucial next step, said the panelists. Concerns about the impact of respectful maternity care on maternal mental health outcomes are widespread but evidence remains fairly anecdotal, said Dr. Mary Sando, Chief Executive Officer of the Africa Academy of Public Health. More research will help stakeholders “name and frame” the problem and determine its extent. This knowledge can then be used to develop solutions and inform implementation strategies, she said. For this to happen, research tools need to be consolidated, validated, and standardized, said Mehrtash. Tools must also be critically examined based on the context in which they are being employed, especially given that most mental health instruments were developed in high-income countries and are now being imported to low- and middle-income settings, said Afulani.
Nevertheless, this pursuit of further evidence does not preclude present action, said Afulani. We cannot wait until we have perfect measurement tools in place before beginning to think about the mechanisms driving provider stress and poor maternal outcomes, she said. Instead, stakeholders must recognize the ways in which research and advocacy can support each other and pursue the two in tandem, said Stanton. “Women will tell their stories, while the research provides a growing body of evidence about what works in different environments. That will encourage policymakers and healthcare providers and society at large to tackle these problems with skill, compassion, and respect.”
Learn more about perinatal mental health at the Wilson Center’s Maternal Health Initiative’s upcoming event: Maternal Mental Health: Providing Care and Support in the Perinatal Period
Gravens By Design: Standards, Competencies and Best Practices for Infant and Family Developmental Care in Intensive Care: The Time Has Come
Joy Browne, Ph.D., PCNS, IMH-E(IV)
As evidence mounts to ensure the quality of care for hospitalized infants, and as families become more central to their baby’s caregiving, the time has come for assuring that such data are identified, examined, and standards set for family integration into all aspects of care. Neurodevelopmental and family-centered care now have a scientific base, practical application, and, most importantly, humane caregiving approaches that provide a basis for the development and implementation of neuroprotective standards to intensive care.
Excellence in neonatal care has produced remarkable outcomes in both mortality and morbidity, but optimal neurodevelopmental and social and emotional outcomes for the most vulnerable babies remain elusive. We have learned from basic and developmental science that early nurturing and caregiving impact neurophysiologic and epigenetic outcomes; however, these important findings are only beginning to be fully understood by medical professionals and applied to fragile newborns.
Recent advances in neuroprotection and developmental caregiving have provided significant opportunities to enhance early brain development and subsequent neurodevelopmental outcomes, yet applying those findings in intensive care is inconsistent and spotty at best. Without recognizing the available evidence, application to clinical care, and integration into all aspects of medical and nursing policies and procedures, the potential benefits will be lost. Global recognition of the need for guidelines and standards for developmental care has resulted in the publication of the European Foundation for the Care of Newborn Infants (EFCNI) Standards of Care for Newborn Health
(https://www.efcni.org/health-topics/ in-hospital/developmental-care/) and the Canadian Guidelines for Developmental Care (https://extranet.ahsnet.ca/teams/policydocuments/1/clp-neonatology-devcare-developmental-care-hcs-203-01.pdf). Until recently, the United States has not established standards or guidelines for developmental, family-centered care. Instead, various disciplines and organizations have developed their own expectancies and competencies for intensive care developmental care and family-centered care practices (for example, from NIDCAP, OT, PT, Speech and Parent groups).
In recognizing the need for evidence-based standards, competencies, and practice guidelines for infant and family-centered developmental care, an interprofessional group including representatives from all intensive care practice leading organizations and parents came together in 2015 to begin to determine if evidence for a variety of aspects of developmental care, neuroprotection, and family-centered care warranted identification, development, and publication of standards of care. After review of over 1000 publications, classification of quality of studies, and review by national and international professionals, the Standards, Competencies and Best Practice Guidelines for Infant and Family-Centered Developmental Care (IFCDC) process and articulation were published (1) and made readily available on the web (https://nicudesign.nd.edu/nicu-care-standards/).
Development of the Standards was based on the scientific principles that 1. Baby is an active participant and the primary focus of caregiving, 2. Family as integral and inseparable from the baby, 3. Neuroprotection of the developing brain; 4. Environmental impact, 5. Infant mental health; and 6. Individualized care. These principles can be demonstrated in intensive care only with appreciation for the change process and application to the system in which it is integrated.
The panel additionally identified six content areas that exemplified the aforementioned principles and for which IFCDC is well represented in the literature. The six areas that have ample evidence for the development of standards and competencies for practice include:
• Systems Thinking; • Positioning and Touch; • Sleep and Arousal; • Skin-to-Skin Contact with Intimate Family Members; • Reducing and Managing Pain and Stress in Newborns and Families; and • Feeding, Eating, and Nutrition Delivery.
IFCDC Standards in each content area include measurable competencies, appropriate references, and instruments by which an intensive care professional, administrator, or manager can assess current practice. Additionally, it includes reflective opportunities for improvement of practices, including policy change toward integration into all aspects of intensive caregiving. The evidence is now beyond hearsay and is based on stringent scientific review, so it cannot be relegated to an “add-on practice when the situation is right.”
The panel of professionals agrees that the time has come to become serious about the opportunities that IFCDC affords for optimizing the outcomes of babies and families who experience intensive care at birth, so they not only will survive but thrive. The evidence is based on stringent scientific review, so it cannot be considered “nice but not essential” or an “add-on practice when the situation is right.” The IFCDC standards and competencies are readily accessible and should raise a call to action for intensive care professionals, managers, quality assurance administrators, and families alike.
More information and resources can be found at the website: (https://nicudesign.nd.edu/nicu-care-standards/).
Reference 1. Browne JV, Jaeger CB, Kenner C. Executive summary: standards, competencies, and recommended best practices for infant- and family-centered developmental care in the intensive care unit. Journal of perinatology : official journal of the California Perinatal Association. 2020;40(Suppl 1):5-10.
Arriba Perú – Daniela Darcourt, Eva Ayllón, Renata Flores, Tony Succar
Premiered Jul 26, 2021 Daniela Darcourt
I really wanted to make a union song, and with that idea in mind, “Arriba Peru” was born. Music is the best language of union. Proof of this is that to my admired Eva Ayllón, as soon as I commented on the idea of the song, she agreed to accompany me on this path and when Renata Flores is added, the sweetness of Quechua and Renata’s enormous interpretive capacity, round off a song of the nos we are all very proud. With the musical direction of Tony Succar, Oscar Cavero and Mudo Venegas, we believe that Arriba Peru manages to express itself in a way that is very exciting for us. A special recognition to the maestro Oscar Cavero, for teaching us so much about our rhythms from the coast and giving this song his unique stamp. I love you dani
Reverting five years of progress: Impact of COVID-19 on maternal mortality in Peru
Camila Gianella, Jorge Ruiz-Cabrejos, Pamela Villacorta, Andrea Castro, Gabriel Carrasco-Escobar (2021)
Bergen: Chr. Michelsen Institute (CMI Brief no. 2021:1) 4 p.
Peru has moved back at least five years on its road to reducing maternal mortality, due to the profound impact COVID-19 has had on the capacity of health services. Our research shows that the health system needs urgent reengineering. Among other things, we recommend including pregnant woman in the COVID-19 risk groups.
Since the early 1990s, Peru has seen a major decline in the maternal mortality ratio. In fact, the country was well on its way to achieving Sustainable Development Goal 3 (SDG3) target 3.1, which aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. But the COVID-19 pandemic has led to dramatic setbacks. Peru swiftly implemented strict measures to control the spread of the virus, such as closing borders, restricting freedom of movement nationwide, banning crowds, and closing schools, universities, and churches. It also restricted all non-essential activities or services, including non-emergency primary health services. Despite these actions, it is among the countries with the highest COVID-19 incidence and mortality rates in Latin America and the Caribbean, as well as globally (Johns Hopkins University Coronavirus Resource Center 2020, The Economist 2020). This Brief aims to show the impact that the COVID-19 pandemic has had on the maternal mortality trajectory in Peru.
Maternal health not considered core in COVID response
This analysis contributes to the COVID-19 debate by analysing the pandemic’s direct and indirect impact on maternal mortality in Peru. There are a number of reasons why we focus on maternal mortality. First, in an emergency context where health systems have been put under pressure, it is important to understand what has been prioritised, as well as the different ways in which shutting down essential health services affect different population groups disproportionally. There is an emerging body of literature describing the impact on emergency services, including antenatal and neonatal services (Garrafa, Levaggi et al. 2020, Reinders, Alva et al. 2020). The effect that this has had on health outcomes needs to be understood more thoroughly. Second, the literature describes how maternal mortality indicators are sensitive to the health system’s capacity to provide quality health services, at the primary level, as well as its capacity to refer to complex care. What is more, maternal mortality is sensitive to social inequity and socioeconomic marginalisation.
Maternal mortality focuses on a group in the population, women, of reproductive age, that in the context of the pandemic has not been identified as a high-risk group by most health authorities, in Peru or worldwide. At the beginning of the pandemic, the main concern around pregnant women was to prevent the exposure of the foetus to the disease. Health agencies did not consider maternal health or mortality risk to be a core issue. Early evidence showed a lower risk for women (grouping all of them and neglecting particular vulnerable groups). Meanwhile, the data collected, mainly from China, and Europe, did not indicate that pregnant women were at higher risk to develop severe symptoms due to SARS-CoV-2. There were almost no reported maternal deaths (Takemoto et al. 2020). Importantly, researchers excluded pregnant women from COVID-19 treatment trials, even when the treatment being evaluated had no or low safety concerns during pregnancy (Taylor, Kobeissi et al. 2020).
Increased risk of maternal deaths
By the end of 2020, evidence was showing that pregnant women were potentially more likely to need intensive care treatment for COVID-19 (Allotey et al. 2020). In addition, conditions related to high-risk pregnancies (such as pre-existing comorbidities, high maternal age, and high body mass index) now seemed to be risk factors for severe COVID-19 (Allotey, Stallings et al. 2020, Zambrano, Ellington et al. 2020). Evidence from low- and middle-income countries that are highly affected by the pandemic, like Iran or Brazil, indicates that there is a possibility of increased risk of maternal deaths due to COVID-19 (Takemoto, Menezes et al. 2020). However, there is still limited information on the effect of the pandemic response on maternal services and maternal health. This is within a context where across the globe, many countries, including middle- and low-income countries, are facing second waves of COVID-19 outbreaks. Therefore, it is important that studies generate evidence to correct COVID-19 responses and protect vulnerable groups of the population.
As with other health conditions, including COVID-19, maternal mortality is unevenly distributed across Peru. Reports from 2019 show that the Amazon regions of Ucayali, Amazonas, Madre de Dios, and Loreto reported maternal mortality ratios (MMR) that are far above the national indicators (Gil 2018).
The main causes of maternal deaths in Peru are haemorrhage, hypertension (related to eclampsia and pre-eclampsia), and abortion complications. In the case of pregnancy-related death, the causes are suicide, cancer, and respiratory tract infections (Gil 2018, Centro Nacional de Epidemiología Prevención y Control de Enfermedades 2020). In Peru, three out of five maternal deaths occur in the puerperium period (42 days after delivery) (UNFPA 2020).
Restrictions on preventive and emergency services
Formally, all pregnant women residing in the country have the right to access to antenatal and postnatal health care. In April 2020, Peru’s Ministry of Health (MoH), issued an order to guarantee access to antenatal, perinatal, and postpartum care during the COVID-19 emergency. Yet preventive services, as part of primary health care, were suspended for around two and a half months(Mesa de Consertación de Lucha Contra la Pobreza 2020). Despite the MoH plans, across the country obstetric outpatient services also remained restricted up until the end of 2020(Reinders, Alva et al. 2020, UNFPA 2020). Within the context of COVID-19 second wave, it is still uncertain when the services will be reopened. At the same time, access to emergency health care was also limited for many months due to the absence of health personnel. It has been reported that intensive care units for pregnant women have been reallocated to COVID-19 patients (UNFPA 2020).
The Ministry of Health has reported an increase in maternal deaths (see Figure 1). However, it is not yet clear how many of these were directly linked to COVID-19 infection and/or as a consequence of lack of timely access to health care.
Study method and findings
We used the data from the national death registry information system (SINADEF is the Spanish acronym) from 2017 to the 28 November 2020. SINADEF contains individual data on gender, age, district of residence, civil status, insurance, and education at the moment of death, along with the causes of death (direct, underlying, or associated) in ICD-10 codes (World Health Organization 2019). However, 22.72% of registered deaths did not have any cause of death reported. For our analysis, the inclusion criteria for a record to be classified as a ‘maternal death’ was any woman, between the age of 12 and 57 (the oldest reported maternal age by the MoH)(Ministerio de Salud and Centro Nacional de Epidemiología Prevención y Control de Enfermedades 2020), that had at least one cause of death labelled as ‘pregnancy, childbirth and postnatal’, which includes all ICD-10 codes in the range O00–O99. Additionally, a registered death was categorised as a ‘COVID-19 related death’ if at least one of the six causes of death was coded under chapter U07 (ICD-10 code for SARS-CoV-2). After including those that fulfilled these criteria, we selected a total of 442 registered deaths for further analysis.
Our analysis shows an increase in maternal deaths, from 83 deaths in 2019, up to 146 during 2020 (to November). This is a 75% increase. When adjusted for live births, the increase in maternal mortality ratio (MMR) goes from 17 maternal deaths per 100,000 live births in 2019 to 34 maternal deaths per 100,000 live births. This shows a 102% increase in the data collected by SINADEF. The MMR increased from 62 to 92 when calculated from the MoH totals. This increase represents a major disruption given that maternal mortality in the country had previously reduced two years in a row.
COVID not the main cause of increase in maternal deaths
Out of the 146 maternal deaths reported in the period included in this analysis, 35 (23.97%) were categorised as COVID-19 cases. The mean age for both groups at the moment of death was similar, with a mean of 31 for COVID-19 cases and a mean of 30 for those for whom COVID-19 was not recorded. The age ranges went form 15 – 45 for COVID cases and 16 – 48 for non COVID cases.
The data on cause of death indicate that COVID-19 infection was not the main reason behind the increase in maternal deaths. Without the COVID-19 cases, there was an increase of 33% in the number of maternal deaths between 2019 and 2020. Our analysis of causes of death shows that women lacked timely health care. Figure 3 (graph A corresponds to the years 2017–19 while graph B corresponds to 2020), shows an increase on the proportion of cases where preeclampsia/eclampsia appeared as the main, or principal, underlying cause of deaths in 2020. It should be noted that the principal risk factors for death in women with preeclampsia/eclampsia are a lack of prenatal care, associated with chronic hypertension (Amorim, Santos et al. 2001). Lack of antenatal care does not allow timely diagnosis of high-risk pregnancies due to for example preeclampsia. The rise in childbirth complications (including preterm delivery, intrauterine growth restriction, abnormal placenta, detection of congenital malformations, and haemorrhage, among others) also indicates lack of antenatal control for timely diagnosis of some conditions, as well as a lack of access to emergency obstetric care. During the COVID-19 pandemic, health services have been saturated and intensive care units for pregnant women have decreased (UNFPA 2020).
Conclusion and policy recommendations
COVID-19, as a health condition, contributes to maternal mortality. Peru has moved back at least five years on its path to reducing maternal mortality (see Figure 1). Although pre-pandemic trajectories could be recovered once extensive vaccinations have been undertaken, this Brief highlights the weakness of a health system that needs urgent re-engineering to guarantee access to health services to those that require care.
Following on from this study, the authors make the following recommendations:
- The need to re-examine COVID-19 risk groups to include pregnant women, and to call governments to develop and implement measures to protect this group of the population from COVID-19 infections. This is especially given that there are valid safety concerns to include pregnant women as priority group for COVID-19 vaccines.
- That truly comprehensive approaches to pregnant women should be developed. Diseases, such as malaria, have already show the risks that pregnancy creates for women. The health of pregnant women should receive the same level of interest as vertical transmission from the medical community.
- In the context of calls for new lockdown measures as a means to control second waves of COVID-19, there is a need to guarantee the provision of essential services such as antenatal care.
- It is also important that open data sources inform decisions. SINADEF is a positive example; however, the superposition of different records of death limits the capacity to perform comprehensive analyses. National registers such as SINADEF must include all deaths, including maternal deaths. Some of the weakness of this analysis – for example, the differences between the gross data reported on maternal deaths by the MoH and the data from SINADEF – are rooted in the lack of clarity or omission in the initial reports, and the presence of different overlapping systems. Accurate information on maternal deaths is registered as part of the Surveillance System of the National Center for Epidemiology and Disease Control (CDC-Peru). This information is not open access and is under control of Peru’s Ministry of Health (the team in charge of this study formally asked for access to the information, but the request was not answered). However, as mentioned above, when compared annually, both sources follow a consistent trend.
- It is important to assess the impact of COVID-19 pandemic, beyond the number of COVID related deaths. The devastating effects of COVID-19 on health systems are contributing to excess mortality. It is important to understand how this is distributed among the population, which groups are more vulnerable.
PREEMIE FAMILY PARTNERS
This positive support resource for Preterm Birth Families provides a variety of NICU and Bereavement resources and services. Check them out!
Welcome to Project Sweet Peas
CHANCES ARE YOU ARE VISITING US BECAUSE YOU OR SOMEONE YOU KNOW IS EXPERIENCING A STAY IN THE NICU OR THE LOSS OF A BABY. WE ARE HERE TO HELP.
PLEASE EXPLORE OUR WEBSITE AND LEARN MORE ABOUT OUR EFFORTS.
Project Sweet Peas is a 501(c)3 national non-profit organization coordinated by volunteers, who through personal experience have become passionate about providing support to families of premature or sick infants and to those who have been affected by pregnancy and infant loss.
Project Sweet Peas acknowledges the importance of parental involvement in caregiving and decision-making in the neonatal intensive care unit (NICU), and seeks to promote family-centered care (FCC) competencies in hospitals nationwide. Care packages, hospital events, peer-to-peer support, financial aid, educational materials, and other Project Sweet Peas services, support the cultural, spiritual, emotional, and financial needs of families as they endure life in the NICU.
Project Sweet Peas makes a lifelong commitment to support families experiencing pregnancy and infant loss. In a baby’s last moments, families are encouraged to make cherished memories with custom Project Sweet Peas keepsake items. Healing and remembrance continue to be fostered through programming such as peer-to-peer support, and our annual candlelight vigil.
Through our services, we give from our hearts, to inspire families with the hope of tomorrow.
Good Morning America – Jan 13, 2021
After her child underwent heart surgery at 4 months old, Kate Bowen decided to create a line of comfortable clothes for struggling newborns.
Benefits of healthy lifestyle interventions in improving maternal and infant health outcomes
POSTED ON 02 AUGUST 2021
The review reports evidence from meta-analyses on smoking cessation, alcohol reduction, diet and physical activity at reducing the risk of adverse health outcomes. The outcomes vary, yet diet and physical activity appear to be the variables with the most significant impact on maternal and infant health.
Fetal and infant health is related to maternal behaviours during pregnancy. Some adverse pregnancy outcomes such as maternal and perinatal mortality, low birthweight, and preterm birth share common risk factors associated with an unhealthy lifestyle. International guidelines for pregnancy behaviour recommendations exist but need some clarification in some cases like alcohol consumption.
Furthermore, there is a lack of data on recognising similarities or differences between interventions for specific behaviours, which motivated a systematic review of 602 English language meta-analyses published since 2011. The review was set to examine the effectiveness of interventions on improving health-related outcomes for women and infants and explore shared behavioural techniques of those interventions. Pregnant women were the target population for the reviewed papers’ inclusion criteria. As for the intervention, the included papers needed to relate to maternal smoking, alcohol, diet or physical activity behaviours.
At the end of the selection, 332 meta-analyses of maternal health outcomes related to maternal weight, gestational diabetes (GDM), hypertensive disorders, mode of delivery and “others” were analysed. The other 270 meta-analyses presented the infant health outcomes and included fetal growth, gestational age at delivery, mortality and admission to the neonatal intensive care unit (NICU). Moreover, most of the evidence identified with this review was related to diet and physical activity intervention. Unfortunately, there were only two systematic reviews on evidence for smoking interventions and health outcomes, and no reviews on health outcomes from alcohol interventions.
Regarding the outcome itself, physical-activity-only interventions had the most effective impact on maternal health outcomes, reducing GDM. Within the infants’ outcomes, fetal growth and gestational age at delivery were highly impacted. By comparing the behaviours and population subgroups, evidence suggests particular effectiveness of smoking cessation for increasing birthweight. In contrast, diet-only interventions appear most effective at reducing weekly gestational weight gain (GWG). Concerning preterm deliveries, meta-analyses of the effectiveness of diet and physical activity interventions showed a significantly reduced risk of preterm delivery. Other interventions like counselling, feedback, or incentives had no significant effect. Interventions on women with a Body Mass Index (BMI) in the overweight or obese categories had the most considerable GWG and GDM reductions.
Previous reports have shown promising effects of smoking and alcohol interventions at changing maternal health outcomes. This systematic review reports the opposite trend and sets physical activity and diet to be the docking point for improvement. Explanations for the conflicting findings in the meta-analyses might be related to unmeasured factors. It is also worth mentioning that the review’s data gap from lower-middle-income and low-income countries compromises the validity and effectiveness of the interventions strategies globally.
One of the aims of a systematic review of systematic reviews is to describe the current evidence’s extent and gaps to inform future research. There is a clear necessity to conduct further analyses on the benefits of a healthy lifestyle for maternal and infant health outcomes.
Paper available at: MDPI, Journal Nutrients
Full list of authors: Louise Hayes, Catherine McParlin, Liane B Azevedo, Dan Jones, James Newham, Joan Olajide, Louise McCleman and Nicola Heslehurst
Mom, baby doing great after giving birth on Delta flight to Honolulu with help of doctor, three NICU
May 3, 2021 KHON2 News
It could’ve been a worse case scenario: a woman giving birth to a baby, who arrived early, on an airplane. But a physician and three nurses trained to care for premature babies were on board that same flight — and they did an amazing job to keep mom and baby safe.
HEALTH CARE PARTNERS
COVID-19 Gave Birth to Changes in Neonatal Intensive Care Units
August 20, 2021
Testing of the infant of the COVID-19–positive mother requires 2 negative COVID-19 tests 2 days apart. This time delay adds to the challenge of ensuring available isolation beds.
The emergence of the SARS-CoV-2 virus swiftly effected change in every facet of society, with health care delivery being the frontline to the COVID-19 pandemic. This agent of change spared no population. Rapid process changes infiltrated neonatal intensive care units (NICUs) to protect the most vulnerable newborn babies who made their entry into the world during a global pandemic. Just as the virus has adapted to its global host with variant strains, health care delivery in the NICU has adapted with evolving and sustainable practices.
The NICU at the Hospital of the University of Pennsylvania provides care to a level 3 NICU patient population. The American Academy of Pediatrics defines a level 3 NICU as a hospital setting that offers expertise of care providers and specialized equipment needed to provide “comprehensive care for infants born <32 weeks gestation and weighing <1500 g and infants born at all gestational ages and birth weights with critical illness.” Four open bays comprise the 38-bed unit with only 2 negative pressure capable isolation rooms located in 1 of the bays. The NICU includes a separate resuscitation space adjacent to the labor and delivery (L&D) unit with 3 available bed spaces. To adapt to potential census fluctuations, many bed spaces are capable of accommodating overflow and multiple gestation infants in a single-bed space footprint.
Operational challenges in the NICU were quickly unveiled with the emergence of COVID-19. Staff illness or exposures to COVID-19 from community and workplace venues resulted in prolonged furlough periods.Severe supply chain shortages in personal protective equipment (PPE) and disinfectant products compounded these operational challenges, prompting conservation and reuse. The NICU was thrust into a crisis capacity mode from a baseline of conventional capacity operations. Unlike other areas of the hospital, the NICU could not reduce admissions or defer scheduled procedures. This prompted emergent planning for contingency operations.
To continue safe delivery of care, immediate process changes were developed by a collaborative multidisciplinary team. Expert guidance was enlisted from the NICU and L&D nursing leadership and physician provider teams along with hospital partners from infection prevention and control, lab and pathology services, perioperative services, environmental services (EVS), facilities, and materials management (MM). Internal and external supply chain shortages of disinfectant products prompted EVS and MM to forge a plan to make and distribute disinfectant wipes.
Infection prevention in the NICU begins in the L&D setting. Prior to the availability of universal COVID-19 testing for the antepartum population upon admission, the patient history and physical (H&P) included screening for community exposure to COVID-19 and presence of signs or symptoms of COVID-19 infection. Any positive findings on the H&P resulted in a person under investigation (PUI) for COVID-19 status with laboratory testing to confirm diagnosis.6
Three negative pressure L&D rooms were designated for PUIs or COVID-19–positive patients. An operating room (OR) for cesarean-section deliveries was also designated for this patient population, with terminal cleaning commencing at the end of the case or upon discharge of the patient from the L&D room. A hospital nursing team of subject-matter experts (SMEs) was deployed to enhance PPE training with donning and doffing procedures as well as safe handling of N95 masks that were reused.
An infant who was born to a mother who was a PUI required airborne and contact isolation pending the maternal COVID-19 result. This challenged the limitation of 2 NICU isolation rooms, prompting the conversion of the adjacent open bay to a negative pressure airflow to accommodate a third infant who would require isolation. Precipitous deliveries leave little time for the NICU to prepare for an admission, requiring airborne isolation resources to be in a state of readiness.
The admission of a third patient to the negative pressure bay requires imminent transfer of up to 4 other patients to other locations in the NICU. For this reason, the goal is to preserve this open bay for the most stable patients. Testing of the infant of the COVID-19–positive mother requires 2 negative COVID-19 tests 2 days apart. This time delay adds to the challenge of ensuring available isolation beds.
How to COPE
Because of the highly specialized nature of the neonatal population, the NICU adapted the hospital nursing SME model and implemented a unit specific team of SMEs. This core group of RNs served as trained observers for appropriate donning and doffing of PPE in the delivery room and during the admission and stabilization of the infant in the isolation bed space. This role quickly evolved into a dedicated resource for the interprofessional staff of the NICU. The acronym COPE was coined by a team member,Jennifer Roman, BSN, RN, CBC, to describe the team of COVID-19 operations and patient-care experts. In this role, nurses served as communication liaisons for unit leadership to disseminate the rapid evolution of guidance in the initial wave of the pandemic, which led to rapid process changes.
The COPE team was tasked with remaining knowledgeable on current processes, readily guiding the interprofessional team to unit resources and protocols and providing direct and indirect support to staff. In order to sustain preparedness, the COPE team created specific checklists and supply par levels that are utilized by all staff members to ensure isolation admission spaces are always at the ready. Identifying appropriate supply par levels and paring down admission supplies to the necessities also aided preserving supplies and minimizing waste during the terminal cleaning process of isolation spaces.
This population based SME team allowed for streamlined and systematic information communication to the unit staff members. The COPE team members were able to filter out the overwhelming volume of information being shared hospital-wide, much of which did not pertain to the specialized neonatal patient population, and provide concise, timely, and pertinent information to the neonatal team.
Ongoing assessments of patient and staff safety prevailed as more information about the transmission of SARS-CoV-2 virus and supply chain challenges became available.The interdepartmental collaboration and frequent virtual communications sustained the contingency plans and required resources through the peak of the pandemic, providing a pathway to a new conventional capacity operations model. Increased testing capacity and widespread vaccination for the SARS-Cov-2 virus has alleviated the contingency capacity operations with improved supply chain and decreased staffing burdens.
Sustained changes in the delivery of care in the NICU have forged new conventional capacity operations in the setting of the COVID-19 pandemic. Negative pressure in L&D rooms is no longer a requirement because updated information became available. A designated OR remains in use for COVID-19 positive patients as intubation may take place. Terminal cleaning procedures follow use of the L&D room or designated OR used for a COVID-19–positive patient. Infant resuscitation continues to be performed in the delivery room or in the OR. Delivery teams for COVID-19–positive patients continue to be limited to essential personnel with N95 masks used in aerosolizing procedures. The responding neonatal team has expanded to include pre-pandemic staff level participation.
Due to the increased potential for a neonate to require an aerosolizing procedure including initial resuscitation steps, neonatal responders continue to utilize N95 masks and viral filters for all neonatal respiratory equipment in L&D. Clean supply carts are maintained outside the room with a “clean” team member to hand off the supplies as needed to the delivery team.A daily checklist for supplies in each NICU isolation room is utilized to ensure capacity for airborne and contact isolation. Universal testing for hospital admissions continues. Visitors and employees are screened for symptoms of COVID-19 infection or exposure to sick contacts upon entry to the facility.
COPE team members continue to provide the necessary emotional support for the interprofessional staff during times of extraordinary stress and anxiety.The team serves as a sounding board for the other staff members and were able to bring forth staff concerns to unit based leadership for discussion and potential solution creation. Having dedicated “experts” who were specific to the unique population and space constrains of the NICU alleviated much of the staff worry, anxiety, and concern related to providing safe patient care. The COPE team continues to support the NICU interprofessional staff and has helped sustain unit readiness throughout several waves of COVID-19.
Surveillance for all hospital acquired infections as required by the state of Pennsylvania continued throughout the pandemic. No central line associated bloodstream infections (CLABSIs) were identified in over 400 days, nor were any other device-associated infections identified. There was no increase in non-device–associated infections. Recent hand hygiene observations conducted by college co-op/volunteer students on all shifts revealed 95% compliance in 175 observations for 1 month.
This infection surveillance data indicates proven success in both contingency and new capacity models, with COVID-19 serving as an agent of change to facilitate improvement in infection prevention.A recently published study demonstrates the increased risk of maternal complications and preterm birth when Covid-19 infection occurs in pregnancy. This is a critical reminder that contingency planning and sustained operations are essential to the needs of our maternal and NICU population.
Intro to abdominal ultrasound for necrotizing enterocolitis
Video Author: Belinda Chan
Published on: 09.06.2021
Associated with: Advances in Neonatal Care. 21(5):365-370, October 2021
Necrotizing enterocolitis (NEC) can be life threatening and x-ray may miss up to 50% of the early signs of NEC. The use of ultrasound can expedite diagnosis and improve clinical management. This video abstract provides a brief introduction to the use of ultrasound for diagnosis and management of necrotizing enterocolitis.
Being a gift- Multilingual healthcare professionals in neonatal care
23 April 2021 KatarinaPatrikssonabStefanNilssondHelenaWigertce
Parents said that they sometimes wished they had a multilingual physician as an interpreter, because the physician would understand the child’s care and treatment and share a language with the parents.
To understand and describe the lived experience of multilingual neonatal healthcare professionals dealing with interpreting in their workplace, performing as interpreters in addition to their regular work.
Interviews with multilingual neonatal healthcare professionals and analysed using a phenomenological reflective lifeworld approach.
Multilingual healthcare professionals understood the interpreting experience as being a gift, comprising three themes: feeling satisfaction – happiness from helping workplace colleagues; identifying with families – empathy from having been in the same situation; and expected to be available – colleagues expected them to provide interpreting services.
This study found that it is common in neonatal care to use multilingual healthcare professionals to interpret communication with parents when language barriers exist.
Stressed Healthcare Workers Face Another Threat: Harassment
by Sophie Putka, Enterprise & Investigative Writer, MedPage Today
September 15, 2021
Healthcare workers across the country, already strained by the demands of caring for COVID-19 patients, face another threat in the workplace: medical conspiracy theorists harassing them with phone calls, and even showing up at their hospitals.
Last week, a Chicago hospital treating known anti-vaxxer and QAnon supporter Veronica Wolski for COVID became the target of such threats.
AMITA Health Resurrection Medical Center reportedly received hundreds of phone calls from Wolski’s followers, demanding she receive alternative medical care, including the antiparasitic ivermectin.
The hospital declined to comment to MedPage Today, but in a statement released to Chicago TV station NBC5, AMITA said it’s following CDC and FDA guidelines in the treatment of COVID-19, and also confirmed earlier this month that it wasn’t administering ivermectin for COVID-19.
Wolski died Monday morning from pneumonia from “novel corona (COVID-19) viral infection” with hypothyroidism, according to a report from the Cook County Medical Examiner’s office.
Fueling the flood of calls to the hospital was a right-wing lawyer, Lin Wood, who harnessed his more than 800,000 Telegram followers with a call to “go to war” against what he called “medical tyranny in our country and around the world,” although he said on his Telegram channel he did not mention ivermectin in connection to Wolski’s treatment. Wood’s message called her death a “medical murder.”
Wolski’s supporters began calling the hospital to complain about her medical care, according to the NBC5 report and Wolski’s Telegram channel.
According to a Freedom of Information officer for Chicago’s Office of Emergency Management and Communications (OEMC), at least nine 911 calls were made related to the incident.
At least one of those calls was from hospital staff on Sunday, who were concerned about an “irate” person who wouldn’t leave the hospital, the officer said.
“Security’s trying to remove them from the location, the person was screaming, people are showing up to the hospital,” the officer said, reading from the call report. “There was a lot going on that day, I guess.”
According to one Telegram user, 20 to 30 cars showed up at Resurrection Hospital.
Other calls, the officer said, were from people calling on Wolski’s behalf, telling dispatchers that the patient was “being held against her will” and that they “wanted to make sure she’s being treated fairly. … There were a bunch of calls about her.”
Though a reporter for the Daily Beast tweeted about police being called “amid bomb threats,” the officer said she didn’t see a record of bomb threats related to the incident. No police reports were filed, according to a representative from the Chicago Police Department.
One of Wolski’s supporters on Telegram wrote in her channel, “The receptionist hung up on me … as soon as I said Veronica Wolski’s name. How freakin rude. We need to start a campaign THAT NO ONE . IF THEY CAN at all HELP it BE ADMITTED TO THAT HOSPITAL.”
Another wrote on September 12, “Resurrection has horrible reception, likely on purpose. Cannot understand menu. CALL POLICE INSTEAD!!!!!!”
Other commenters shared the physical address of the hospital.
With healthcare workers increasingly targeted as misinformation about treatments for COVID-19 swirls, incidents like this one are a cause for concern, experts said.
“We did see a rise in cases of violence and harassment when the COVID-19 pandemic broke out, and such cases continue to this day,” Jason Straziuso, a media representative for the International Committee of the Red Cross, which collected data on violent incidents against healthcare workers related to COVID-19 last year, wrote in an email. “This puts healthcare workers in harm’s way and under increased stress at a time when they are sorely needed, in particular in COVID-19 hotspots.”
Can EEG accurately predict 2-year neurodevelopmental outcome for preterm infants?
Correspondence to Professor Geraldine B Boylan, Department of Paediatrics and Child Health, INFANT Research Centre, University College Cork, Cork T12 DFK4, Ireland; email@example.com
Establish if serial, multichannel video electroencephalography (EEG) in preterm infants can accurately predict 2-year neurodevelopmental outcome.
Design and patients
EEGs were recorded at three time points over the neonatal course for infants <32 weeks’ gestational age (GA). Monitoring commenced soon after birth and continued over the first 3 days. EEGs were repeated at approximately 32 and 35 weeks’ postmenstrual age (PMA). EEG scores were based on an age-specific grading scheme. Clinical score of neonatal morbidity risk and cranial ultrasound imaging were completed.
Neonatal intensive care unit at Cork University Maternity Hospital, Ireland.
Main outcome measures
Bayley Scales of Infant Development III at 2 years’ corrected age.
Sixty-seven infants were prospectively enrolled in the study and 57 had follow-up available (median GA 28.9 weeks (IQR 26.5–30.4)). Forty had normal outcome, 17 had abnormal outcome/died. All EEG time points were individually predictive of abnormal outcome; however, the 35-week EEG performed best. The area under the receiver operating characteristic curve (AUC) for this time point was 0.91 (95% CI 0.83 to 1), p<0.001. Comparatively, the clinical course AUC was 0.68 (95% CI 0.54 to 0.80, p=0.015), while abnormal cranial ultrasound was 0.58 (95% CI 0.41 to 0.75, p=0.342).
Multichannel EEG is a strong predictor of 2-year outcome in preterm infants particularly when recorded around 35 weeks’ PMA. Infants at high risk of brain injury may benefit from early postnatal EEG recording which, if normal, is reassuring. Postnatal clinical complications can contribute to poor outcome; therefore, we state that a later EEG around 35 weeks has a role to play in prognostication.
Association of Blood Donor Sex and Age With Outcomes in Very Low-Birth-Weight Infants Receiving Blood Transfusion
Ravi M. Patel, MD, MSc1; Joshua Lukemire, PhD2; Neeta Shenvi, MS2; et alConnie Arthur, PhD3,4; Sean R. Stowell, MD, PhD3,4,5; Martha Sola-Visner, MD6; Kirk Easley, MApStat2; John D. Roback, MD, PhD3,4; Ying Guo, PhD2; Cassandra D. Josephson, MD3,4
Original Investigation Pediatrics September 3, 2021
JAMA Netw Open. 2021;4(9):e2123942. doi:10.1001/jamanetworkopen.2021.23942
Is the sex or age of a blood donor associated with morbidity or mortality in very low-birth-weight infants receiving blood transfusion?
In this cohort study of 181 very low-birth-weight infants at 3 centers, infants receiving red blood cell transfusion from female donors had a lower risk of death or serious morbidity compared with those who received transfusion from male donors. The protective association between female donor and adverse outcomes increased with increasing donor age, but diminished with increasing number of blood transfusions.
These findings suggest that characteristics of blood donors, such as sex and age, may be associated with recipient outcomes in very-low-birth weight infants receiving blood transfusions.
There are conflicting data on the association between blood donor characteristics and outcomes among patients receiving transfusions.
To evaluate the association of blood donor sex and age with mortality or serious morbidity in very low-birth-weight (VLBW) infants receiving blood transfusions.
Design, Setting, and Participants
This is a cohort study using data collected from 3 hospitals in Atlanta, Georgia. VLBW infants (≤1500 g) who received red blood cell (RBC) transfusion from exclusively male or female donors were enrolled from January 2010 to February 2014. Infants received follow-up until 90 days, hospital discharge, transfer to a non–study-affiliated hospital, or death. Data analysis was performed from July 2019 to December 2020.
Donor sex and mean donor age.
Main Outcomes and Measures
The primary outcome was a composite outcome of death, necrotizing enterocolitis (Bell stage II or higher), retinopathy of prematurity (stage III or higher), or moderate-to-severe bronchopulmonary dysplasia. Modified Poisson regression, with consideration of covariate interactions, was used to estimate the association between donor sex and age with the primary outcome, with adjustment for the total number of transfusions and birth weight.
In total, 181 infants were evaluated, with a mean (SD) birth weight of 919 (253) g and mean (SD) gestational age of 27.0 (2.2) weeks; 56 infants (31%) received RBC transfusion from exclusively female donors. The mean (SD) donor age was 46.6 (13.7) years. The primary outcome incidence was 21% (12 of 56 infants) among infants receiving RBCs from exclusively female donors, compared with 45% (56 of 125 infants) among those receiving RBCs from exclusively male donors. Significant interactions were detected between female donor and donor age (P for interaction = .005) and between female donor and number of transfusions (P for interaction < .001). For the typical infant, who received a median (interquartile range) of 2 (1-3) transfusions, RBC transfusion from exclusively female donors, compared with male donors, was associated with a lower risk of the primary outcome (relative risk, 0.29; 95% CI, 0.16-0.54). The protective association between RBC transfusions from female donors, compared with male donors, and the primary outcome increased as the donor age increased, but decreased as the number of transfusions increased.
Conclusions and Relevance
These findings suggest that RBC transfusion from female donors, particularly older female donors, is associated with a lower risk of death or serious morbidity in VLBW infants receiving transfusion. Larger studies confirming these findings and examining potential mechanisms are warranted.
New research on preventing infant deaths due to neonatal sepsis
Aug 10, 2021
Information about the most effective antibiotics to use in low and middle income countries (LMICs) for neonatal sepsis has been discovered uniquely combining epidemiological, genomic and pharmacodynamic data. The research could be applied to potentially save many lives globally by increasing the effective treatment – currently neonatal sepsis causes an estimated 2.5 million infant deaths annually. This research also highlights economic issues, specifically regarding treatment costs and other barriers to treatment.
The research published today in The Lancet Infectious Diseases, combined microbiology, genomic, epidemiological, pharmacodynamic and economic data for the first time to study the efficacy of various antibiotic treatments for neonatal sepsis in seven Low- and Middle- Income Countries (LMICs) across Africa and South Asia. This research was done by an international network led by the microbiologists at the Division of Infection and Immunity, Cardiff, in collaboration with researchers at the University of Oxford, the paper proposes alternative antibiotics for septic neonates which could drastically decrease new-born mortality.
This research, funded by the Bill and Melinda Gates Foundation, studied over 36,000 infants over seven countries, making it the largest study of its kind. Data was procured by Burden of Antibiotic Resistance in Neonates from Developing Societies (BARNARDS), a project run by Professor Tim Walsh, which collected data across seven countries between April 2015 and March 2018. Prof. Walsh joined the University of Oxford in 2021 to help established the Ineos Oxford Institute of Antimicrobial Research. BARNARDS collected data from Nigeria, Pakistan, Bangladesh, Rwanda, South Africa, Ethiopia, and India, allowing researchers to have a vast amount of data to analyse.
Neonatal sepsis causes an estimated 2.5 million infant deaths annually, with LMICs in sub-Saharan Africa and Asia having the highest mortality rates. These countries often have reduced access to resources such as laboratory facilities to assess what sepsis-causing pathogens are present, and to discover more about associated antimicrobial resistance.
The World Health Organisation recommends the use of ampicillin and gentamicin for the empirical treatment of neonatal sepsis. Whilst these may be effective in Higher Income Countries (HICs), there has long been speculation that they were less effective in LMICs due to different levels of antibiotic resistance and variation in common pathogens.
Researchers discovered that some sites are already using different antibiotics to those endorsed by the WHO, due to high resistance against these antibiotics. Those prescribed the recommended combination of ampicillin and gentamicin had a survival rate of 75% over 60 days. Conversely, where those prescribed ceftazidime and amikacin had a survival rate of over 90% over the same time period.
Previous research found that globally an estimated 214,000 neonatal sepsis deaths are attributable to resistant pathogens each year, so changing the recommendations to ceftazidime and amikacin could drastically reduce this number.
These findings will lead to additional follow-up studies; not least, intervention studies related to treatment and ensure that sepsis is treated with appropriate antibiotics and Infection Prevention and Control practices.
The study also investigated the frequency of resistance to various antibiotics, which shows how frequently resistance may arise in susceptible bacteria against different antibiotics. Whilst varied antibiotics have been suggested for neonatal sepsis, this is the first study that has incorporated frequency of resistance data, allowing insight into how quickly a certain antibiotic could become redundant following extensive use, if selected as an alternative, allowing for more accurate recommendations on which antibiotics to be used.
Lead author Kathryn Thomson says, ‘Extremely high resistance (>97%) was found against ampicillin in Gram-negative sepsis causing isolates analysed from BARNARDS sites. Furthermore, only 28.5% of Gram-negative isolates were susceptible to at least one of the combined antibiotic therapy of ampicillin and gentamicin. While this may be a suitable empirical treatment for neonatal sepsis in high income countries, this data showcases that it is not an effective option for LMICs, who have different common pathogens and vastly increased resistance against these antibiotics. Many LMIC sites depend on recommended therapies, due to a lack of microbiology facilities to detect common species or resistance profiles. Therefore, further work is urgently needed to improve the sparsity of data in LMICs regarding prevalence and AMR in neonatal sepsis, a major contributor to neonatal mortality and to determine more effective alternative empirical treatments, taking affordability into account.’
The other factor investigated in this study is economic impact on antibiotic use. The study examined the average earnings of people in LMICs. This was used to contextualise the impact of antibiotic costs on the average person, by comparing average wages with the vast discrepancies in costs of certain antibiotics in different countries. For example, piperacillin-tazobactam costs $2.60 per day in India, which is a massive 76% of the average daily wage. By contrast, it costs $20 a day in Nigeria, representing between 219% and 741% of the average daily wage depending on the area of the country.
The economic data raises questions about who should be responsible for costs of antibiotic treatment, given that more effective alternative antibiotic treatments are often inaccessible in LMICs due to lack of universal healthcare. When asked, six of the seven countries studied stated that the cost of antibiotics influenced which are prescribed. This is shown by the continued wide use of ampicillin and gentamicin, as they are consistently the most affordable antibiotics, despite being considered less effective than other antibiotic regimes for some time now.
Professor Tim Walsh says, ‘Whilst this study uniquely combined sets of data to help address critical issues around the treatment of neonatal sepsis in LMICs, this study also highlighted gaps and the need for further critical data; not least, how the accessibility and cost of antibiotics impacts on therapeutic treatments and outcomes. The newly established IOI is committed to undertake such studies and establish new and dynamic international networks to provide the rigor of data that will hopefully further our understanding and address one of the most pressing issues in a critical patient population across LMICs.’
This raises the ethical dilemma of how to maximise the number of lives saved whilst minimising the economic burden on both the patient and the state.
Follow-up studies will be undertaken by the newly formed Ineos Oxford Institute at the University of Oxford, which will focus on new drug development for both human health and replacement of clinically relevant antibiotic use in agriculture, in addition to studying antibiotic resistance and ways of promoting more responsible and effective uses of antibiotics.
This month’s recommended resource for personal awareness (a look inside):
Guided Sleep Meditation, Manifest In Your Sleep Spoken Meditation with Sleep Music and Affirmations
Aug 22, 2021 Jason Stephenson – Sleep Meditation Music
A guided sleep meditation to help you manifest your dreams in your sleep. Includes affirmations and sleep music. For a comforting sleep, download your FREE guided sleep meditation!
Trucking Through 2021 – Hello Heroes!
As nature moves into the Fall season, I am reminded of the importance of finding balance within the transitions life brings our way.
Immersed in a world experiencing long, ongoing, and unpredictable pandemic challenges I seek to increase my engagement in learning ways to better support the health and wellness of myself and others.
Many preemies, I included, have a history of being taken care of. We may feel challenged at times to trust our own intuition, experience, and education to secure our individual and unique self-care capacities and confidence. Awareness and effort are required in order to build and sustain a dynamic foundation of self-care. In other words, let’s take it on!
My challenges towards managing my own health and well-being include my tendencies to detach from how I am feeling, and “freezing” when I feel I am over-stimulated. This makes sense considering the types of touching and often a lack of positive touch a preterm baby may experience. We had/have no control over our environment and were/are not able to “defend” ourselves from painful physical encounters. The stress/anxiety reactions of detachment and “freeze” are developmental. In order to transition these reactions, we have the responsibility and opportunity to choose to do the work required to gain conscious control. Because there are not strong protocols or treatment resources developed specifically for our community at this time, we need to and can explore, identify, and engage in positive behavioral and personal development activities. Be your own sleuth in this regard.
The sun rising over London at 6 AM beckons a new day. My morning sanctuary, the Thames River, is a runner’s paradise. Here, I experience my strength and fragilities, the beauty and wonder of an everchanging horizon, and the complexities, creativities, and unpredictable characteristics of mankind. When I run, I experience me. As I meditate, I see deeper aspects of myself and create broader capacities for change. When do you most feel present with yourself?
The Hero within us lies in the small actions we take each day to be authentically present within ourselves and the world around us. We are Warriors.
Surfing Ancient-Style Surfboards In Peru w/Red Bull team
Red Bull Surfing – Jun 1, 2010
Originally used by fishermen, the caballitos de Totora original surfboards are a versatile tool to navigate the waters of Peru. Sofia Mulanovich together with world-class surfer Sally Fitzgobbons and junior Nadja de Col exchanged their boards for the ancient type to test the surfing quality of these Peruvian boats that have thousands of years of history.