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FACTORS ASSOCIATED WITH MORTALITY AMONG
NEONATES IN KANGAROO MOTHER CARE SERVICE AT
GIHUNDWE DISTRICT HOSPITAL, RWANDA
NSHAMAMBA MUBALAMA GUY
MPH/0330/13
A Thesis Submitted in Partial Fulfillment for the Award of a Degree in
Master of Public Health (Epidemiology) of Mount Kenya University
JUNE 2017
ii
DECLARATION
This research is my original work and has not been presented to any other institution. No
part of this research should be reproduced without the authors’ consent or that of Mount
Kenya University.
Students Name: Nshamamba Mubalama Guy
Sign ____________________ Date _____________
Declaration by the supervisor
This research has been submitted with my approval as the Mount Kenya University
Supervisor.
Name: Dr. Connie Mureithi
Sign ____________________ Date _____________
iii
DEDICATION
I dedicate this work to my beloved wife Diane Bapolisi Binja and our Children Ines and
Carol Nshamamba, my Parents Jean Nshamamba and Kasi Jacqueline for unconditional
love support and patience. Without your constant encouragement I would never have
achieved my dreams.
iv
ACKNOWLEDGEMENT
I am indebted to my supervisor, Connie Mureithi, for her continuous invaluable guidance
during the entire work. My sincere gratitude goes to Mount Kenya University staff who
put their effort in helping me to continue and finish my studies. I express my deep
gratitude to the School of Health Science and especially to the Department of Public
Health for their effective coordination of all activities during the whole study period.
My appreciation goes to the Mount Kenya University ethical committee and the Director
General of Gihundwe Hospital for the permission to conduct this study
In addition, I would like to thank all the personnel in Kangaroo Mother Care and
maternity services of Gihundwe Hospital for all the best contribution in extracting the
recorded delivery data and other information related, which is recognized as a very
useful source of information for my research study. Your great job is also really
appreciated.
I also thank my Brother Ciza Nshamamba for the love and mental support since to make
complete this study.
Finally, I thank all people not appearing on this page, but who took part in any way or
another in my studies. I have to recognize that without prayers of brethren from
everywhere, this work would not have been accomplished.
To all of you, who helped me in a way or another, God bless you.
v
ABSTRACT
Neonatal deaths account for 40% of deaths under the age of 5 years worldwide, of which
28% are attributable to neonates. Kangaroo Mother Care is an alternative method used in
Neonatology to decrease neonate mortality. Studies on neonatal mortality have been
done in other provinces in Rwanda and no studies were done in Rusizi Western Province.
Information found in this study will be useful in providing additional literature on factors
associated with neonatal mortality in a rural set up. The general objective of this study
was to examine the factors associated with mortality among neonates in Kangaroo
Mother Care facility at Gihundwe District Hospital; while the specific objective were to
describe socio-demographic characteristics of neonate in KMC; to determine mother
factors associated with mortality among neonate with LBW; to determine neonate factors
associated with mortality among neonate with LBW and to determine mortality rate of
neonate in KMC during the study period. The study will contribute to the efforts of the
government of Rwanda in reducing child mortality rates which may occur as a result of
the adverse maternal and newborn factors. A group of neonate, who died in less than 28
days postpartum, was identified as cases and, for purposes of comparison, a group of
LBW who did not die was identified as controls. The study was limited to only 183
neonates and their mothers who took care in Gihundwe Hospital, from January 2015 to
December 2016 regarding factors associated with neonatal mortality. Due to the
occurrence of 33 cases in the study population of 183 newborns, systematic random
sampling was used to select 66 controls among 150 survivors. For each one case two
controls were selected to increase the power of the study, this method resulted to a total
sample size of 99 containing 33 cases and 66 controls. All data were extracted from
mother’s newborns' cards of Gihundwe District Hospital using a check list as research
instrument. Data have been analyzed using STATA computer package version 13.0 and
presented in form of tables. Odds ratio (OR) and 95% CI were calculated by means of
bivariate and multivariate logistic regression and were used as estimates associated
factors for neonatal death. Study findings showed that maternal factors associated with
neonatal mortality were, about marital status, unmarried mothers OR= 5.7, 95% CI
[(2.29-14.25); p< 0.0001]; an educational level under or equal primary OR= 2.7, 95%CI
[(1.02-7.78); p= 0.030]; the occupation of mothers, who were jobless OR= 22.0, 95% CI
[(4.20-115.01); p< 0.0001]. A significant statistical relationship was found between
primiparity and mortality in neonates (p =0.0003). There was a strong association
between neonatal mortality in Kangaroo Mother Care and the place of delivery
especially when it takes place at home (p=0.001). The newborn factors associated with
neonatal mortality were, the presence of complications aOR=179,2, 95% CI[(21,9-
1464,9); p=0,0001]; the resuscitation aOR=4,2, 95% CI[(1,45-12,24)]; the parental
nutrition aOR=14,5, 95% CI[(5,23-40,49); p=0,0001]. From the study, unmarried
mothers, LBW babies who got complications in Kangaroo Mother Care and those who
used parenteral nutrition were associated factors of mortality in Kangaroo Mother Care
at Gihundwe Hospital. Social mobilization of the community on reproductive health
issues through health education to enhance family planning to avoid undesired
pregnancies. Women should be educated on various factors that may lead to low
gestation delivery so as to avoid preterm births. Care of Low Birth Weight needs to be
reinforced in order to avoid occurrence of complications.
vi
TABLE OF CONTENTS
DECLARATION .......................................................................................................................... ii
DEDICATION ............................................................................................................................. iii
ACKNOWLEDGEMENT .......................................................................................................... iv
ABSTRACT.................................................................................................................................... v
LIST OF FIGURES ....................................................................................................................... x
LIST OF ABBREVIATIONS ..................................................................................................... xi
CHAPTER ONE: INTRODUCTION .......................................................................................... 1
1.0. Introduction ............................................................................................................................... 1
1.1. Background to the study ........................................................................................................... 1
1.2. Statement of the problem .......................................................................................................... 4
1.3. Research objectives .................................................................................................................. 6
1.3.1 General objectives .................................................................................................................. 6
1.3.2 Specific objectives .................................................................................................................. 6
1.4 Research questions ..................................................................................................................... 6
1.5. Significance of the study .......................................................................................................... 7
I.6 Study limitations......................................................................................................................... 8
1.7 Organization of the study ........................................................................................................... 9
CHAPTER TWO: REVIEW OF RELATED LITERATURE ............................................... 10
2.0 Introduction .............................................................................................................................. 10
2.1 Theoretical literature ................................................................................................................ 10
vii
2.1.1 Causes of neonatal deaths ..................................................................................................... 10
2.1.2 History Kangaroo Mother Care ............................................................................................ 14
2.1.3 The International Kangaroo Mother Care Awareness .......................................................... 15
2.1.4 Eligibility criteria of Kangaroo Mother Care ....................................................................... 18
2.1.5 Techniques used in Kangaroo Mother Care ......................................................................... 19
2.1.6 Benefits of Kangaroo Mother Care ....................................................................................... 23
2.2 Empirical review ...................................................................................................................... 27
2.3 Critical review .......................................................................................................................... 32
2.4 Theoretical framework ............................................................................................................. 33
2.5 Conceptual framework ............................................................................................................. 36
2.6 Summary .................................................................................................................................. 37
CHAPTER THREE: RESEARCH METHODOLOGY .......................................................... 38
3.0 Introduction .............................................................................................................................. 38
3.1 Research design ....................................................................................................................... 38
3.2 Target population ..................................................................................................................... 38
3.3 Sample design .......................................................................................................................... 39
3.3.1 Sample size determination .................................................................................................... 39
3.3.2 Sampling procedure. ............................................................................................................. 40
3.4 Inclusion and exclusion criteria ............................................................................................... 41
3.5 Data collection procedures ...................................................................................................... 41
3.6 Validity and reliability of the study ......................................................................................... 41
3.7 Data analysis procedure ........................................................................................................... 42
viii
3.8 Ethical considerations .............................................................................................................. 42
CHAPTER FOUR: RESEARCH FINDINGS .......................................................................... 43
4.0. Introduction ............................................................................................................................. 43
4.1. Socio-demographic characteristics of neonate with Low Birth Weight in Kangaroo
Mother Care service at Gihundwe Hospital fron January 2015 to December 2016. ..................... 43
4.2. Factors associated with mortality among low birth weight neonates in Kangaroo. ............... 45
4.5. Discussion ............................................................................................................................... 49
CHAPTER FIVE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ............. 52
5.0. Introduction ............................................................................................................................. 52
5.1. Summary of Findings ............................................................................................................. 52
5.2 Conclusion ............................................................................................................................... 53
5.3. Recommendations ................................................................................................................... 54
5.4. Suggestions for Further Study ................................................................................................ 54
REFERENCES ............................................................................................................................ 55
APPENDICES .............................................................................................................................. 60
APPENDEX A: Authorization Letter from the School of Post Graduate Studies of Mount
Kenya University ........................................................................................................................... 61
APPENDEX B: Authorization Letter from Gihundwe Hospital ................................................... 62
APPENDEX C: Data Collection sheet .......................................................................................... 63
APPENDEX D: MAP of Gihundwe Hospital ............................................................................... 67
ix
LIST OF TABLES
Table 4. 1 Socio-democratic characteristics of study population ..................................... 43
Table 4. 2 Maternal factors associated with mortality among low birth weight in
kangaroo ........................................................................................................................... 45
Table 4. 3 Neonatal factors associated with mortality among low birth weight in
kangaroo ........................................................................................................................... 47
Table 4. 4 Logistic regression determining factors associated with mortality among low
birth weight in kangaroo mother care at gihundwe hospital…………………………….50
x
LIST OF FIGURES
Figure 2. 1 Conceptual framework ................................................................................... 36
Figure 2.2 Distribution of target population…………………………………………………………………………..39
xi
LIST OF ABBREVIATIONS
ANC : Antenatal Care
AOR : Adjusted Odd Ratio
BFHI : Baby friendly hospital initiative
CI : Confidence Interval
EMOC : Emergency Obstetric Care
GDH : Gihundwe District Hospital
ICU : Intensive care unit
INK : International network of Kangaroo Mother Care
KMC : Kangaroo Mother Care
LBW : Low birth weight
MCHIP : Maternal and child integrated program
MDG : Millennium Development Goals
NICU : Neonatal Intensive Care units
NBW : Normal Birth Weight
NMR : Neonatal Mortality Rate
NNM : Neonatal mortality
OR : Odd ratio
SSA : Sub- Saharan Africa
STSC : Skin-to-Skin care.
SNCU : Specialized Neonatal Intensive Care Unit
UNICEF : United Nations Children’s Fund
WHO : World Health Organization
xii
OPERATIONAL DEFINITIONS OF KEY TERMS
Alternative feeding method : Not breastfeeding but feeding the baby
with expressed breast milk by cup or tube;
expressing breast milk directly into
baby’s mouth.
Apgar score : refers to the method of judging the condition of
a newborn baby in which the baby is given a
maximum of two points on each of five
criteria: color of the skin, heartbeat,
breathing, muscle tone and reaction to stimuli.
Antenatal : refers to the minimum of four antenatal
appointments with health care.
Asphyxia : refers to the failure to breathe in a newborn baby.
Associated factor : is an independent variable that is causally
related to a change in the probability of neonatal
mortality
Dystocia : unusually difficult childbirth
Extremely low-birth-weight infant : Infant with birth weight lower than 1000g (up to
and including 999g), regardless of gestational age
Fetal presentation : refers to the part of fetal body that first enters the
pelvis during perinatal period.
Foremilk : Breast milk initially secreted during a breast feed.
Gestational age : Age or duration of the gestation, from the la
menstrual period to birth.
Gravidity : refers to the number of times that a woman.
has been pregnant: primigravida
xiii
(first pregnant), multigravida (second
to fourth), and grandmultigravida
(fifth and more).
Hind milk : Breast milk remaining in the breast when the
foremilk has been remove (hind milk has a fat
content and a mean color density higher.
Hypothermia : Body temperature below 36.5°C.
Live-born infant : describes an infant born at any gestational
age with a heartbeat or respiratory effort.
Low-birth-weight infant : Infant with birth weight lower than 2.500g (up to
and including 2.499g), regardless of
gestational age.
Maternal associated factors : refers to the characteristics of mother that
may contribute to neonatal mortality.
Neonatal mortality : refers to the death in a baby who is born live
and dies in hospital before he/she is 28 days old.
Newborn associated factors : refer to the clinical characteristics of a
newborn baby that may contribute to his death
before 28 days old.
Parity : refers to the number of children that a woman
have given birth to: primipara (1),
multipara (2 – 4), grandmultipara (≥ 5).
Postpartum : refers to the period after the birth of a child
Preterm birth : refers to the any birth occurring between
24 and 37 weeks of gestation.
xiv
Very low-birth-weight infant : Infant with birth weight lower than 1500g (up to
and including 1499g), regardless of gestational
age.
1
CHAPTER ONE: INTRODUCTION
1.0. Introduction
This chapter provides the background for the study, the problem statement, research
objectives and research questions. The significance and limitations for the study as well
as the scope for study are highlighted.
1.1. Background to the study
In Oct 21–22, 2013, stakeholders in newborn health convened in Istanbul, Turkey (Bill
& Melinda Gates Foundation) to discuss how to accelerate the implementation of
Kangaroo Mother Care (KMC) globally. Focused attention on newborn deaths, which
now account for 44% of under-5 mortality, is required to accelerate progress toward
Millennium Development Goal 4 (to reduce child mortality by two-thirds) and beyond.
KMC has been proven to reduce newborn mortality, but only a very small proportion of
newborns that could benefit from KMC receive it. The Istanbul convening was
assembled to accelerate the uptake of this life- saving intervention.
Prematurity is a major cause of newborn death and disability globally. Live born infants
delivered between 20 to 37 weeks from the 1st day of the last menstrual period are
termed premature by whom (Kliegman et al, 2007). Each year, preterm complications;
such as respiratory distress syndrome, hypotension, hypocalcaemia, electrolyte
imbalance, retinopathies, anemia, infections, jaundice; account for over 1 million deaths,
or 35% of all neonatal mortality(Colin et al, 2003). Additionally, skin-to-skin contact,
exclusive breast feeding and close follow-up after discharge from a health facility are
beneficial for all newborns and mothers, and can further
accelerate reduction of new born deaths, also can avoid the mortality due to the hyaline
2
membrane disease, as the most common cause of respiratory distress in preterm infant
(Elisabeth et al, 2003).
STSC was highly acceptable in rural India when introduced through appropriate cultural
paradigms. STSC may be of benefit to all newborns and for many mothers as well. New
approaches are needed for introduction of STSC in the community compared to the
hospital. Two-thirds of women globally give birth at home, yet little data are available on
use of skin-to-skin care (STSC) in the community. A study conducted in India
(Darmastadt et al, 2006) describe the acceptability of STSC in rural Uttar Pradesh, India,
and measured maternal, newborn, and ambient temperature in the home in order to
inform strategies for introduction of STSC in the community; acceptance of STSC was
assessed through in-depth interviews and focus groups within the community, and
temperature was measured during home visits on day of life. They found that the
incidence of hypothermia (<36.5°C) was high in both low birth weight (LBW) and
normal birth weight (NBW) infants (49.2%, (361/733) and 43% (418/971), respectively).
Mean body temperature of newborns was lower (P<0.01) in ambient temperatures <20°C
(35.9 1.4°C, n=225) compared to 20°C (36.5 0.9°C, n=1450). Among hypothermic
newborns, 42% (331/787) of their mothers had a lower temperature (range -6.7 to 0.1°C,
mean difference 0.4 1.2°C). Acceptance of STSC was nearly universal. No adverse
events from STSC were reported. STSC was perceived to prevent newborn hypothermia,
enhance mother's capability to protect her baby from evil spirits, and make the baby
more satisfied.
Although birth weight is recognized by skilled health professionals as an important
determinant of newborn health, it was found to be nearly irrelevant to members of a rural
Indian community who relied instead on a set of observable criteria and judgment, based
on experience in assessing newborns’ overall well-being. If additional care for and
3
treatment of illness in LBW or VLBW are to be most effective, public health
practitioners must reframe birth weight or size in a locally relevant way.
Referral criteria should take into account the capabilities of the health system to provide
quality care for LBW infants at high risk of morbidity and mortality; behavior change,
community mobilization, Kangaroo Mother Care, neonatal, skin-to-skin care, thermal
care.
The Kangaroo mother method was originally developed by Rey and Martinez in the city
of Bogota in 1979. Once clinically stable, the preterm newborn infant was placed
between its mother's breasts in skin-to-skin contact. Its use was justified by the lack of
incubators and the high mortality rate in Colombian maternity units. From 1984
onwards, the method was widely publicized by the UNICEF. Many different authors
claimed that babies cared for using the Kangaroo mother method had shorter hospital
stays, adequate oxygenation, higher and stabilized body temperature, fewer episodes of
apnea and cried rarely. Furthermore, their mothers breastfed more and felt secure
monitoring the health of their own babies. However, the definitions of the Kangaroo
method or Kangaroo care that these authors have used are not uniform and vary
depending on the institution described. The majority refer merely to the use of skin-to-
skin contact at some point during the baby's hospital stay. Integral care of babies and
their families has become a best practice to be observed while infants are in NICU
(WHO, 2014).
Since 1999, the Rwandan Ministry of Health has been implementing a policy of
humanized care for very low birth weight newborn infants (the Kangaroo mother
method), which is a proposal for humanizing neonatal care based on four basic
principles: welcoming the baby and their family, respecting individual differences,
promotion of skin-to-skin contact (the kangaroo position) and involving the mother in
4
caring for her child. In Rwanda, the Kangaroo mother method is an effort to humanize
care that consists of three stages: admission to the NICU, care in the Kangaroo unit and
outpatients follow-up after hospital discharge until the baby s weight reaches 500 g.
Skin-to-skin contact and breastfeeding are encouraged during all phases. Furthermore,
during the second stage, the mother progressively and continuously assumes
responsibility for caring for her child during the daytime, up until hospital discharge
Bergh et al (2012).
1.2. Statement of the problem
Approximately 38% of deaths in children occur within the 1st month of life, of which
28% are attributable to premature birth. Although there have been dramatic
improvements in reduction of neonatal deaths, the burden of mortality in the first month
of life has remained virtually unchanged (WHO, 2005).
Each year, 4 million newborns die (three-quarters during the first week of which at least
1 million die in their first 24 hours). Most newborn deaths occur at home, in the absence
of any contact with a skilled health care provider and in hospitals due to various newborn
and maternal factors such as gestational age, parity, birth weight, Cesarean section,
gravidity, sex of newborn, maternal age, duration in labor, etc.(Lawn et al, 2006).
Many of the world's 4 million stillbirths and 500,000 maternal deaths also occur close to
the time of birth. About 99 percent of all newborn deaths occur in low and middle
income countries, with two-thirds of those occurring in Asia and Africa (Lawn et al,
2006).
5
Across 21 regions of the world, rates of neonatal, post-neonatal, and childhood mortality
are declining. The global decline from 1990 to 2010 is 2.15 per year for neonatal
mortality, 2.35 for post-neonatal mortality, and 2.2% for childhood mortality.
In their findings, Rajaratnam et al (2010) declared that in 13 regions of the world,
including all regions in sub-Saharan Africa, there is evidence of accelerating declines
from 2000 to 2010 compared with 1990 to 2000. Within sub-Saharan Africa, rates of
decline have increased by more than 1% in Angola, Botswana, Cameroon, Congo,
Democratic Republic of Congo, Kenya, Lesotho, Liberia, Rwanda, Senegal, Sierra
Leone, Swaziland, and Gambia.
In Rwanda infant mortality rates have decreased by 30 % between 2000 and 2010.
Rebecca et al (2013). At Ruhengeri District Hospital (2005-2007) and Kibogora District
Hospital (2007), prematurity were the second cause of neonatal mortality and the first
cause of early neonatal death. The mortality is high with low birth weight (Rebecca et al,
2013).
Reducing child mortality is the fourth MDG, whose target is to reduce the under-five
mortality rate by two-thirds between 1990 and 2015. Despite numerous interventions and
action plans, very little evidence exists on why the NMR is reducing less than under-five
mortality rate (UNICEF, 2009). If Rwanda is committed to achieving the MDG on child
mortality, it is prudent to understand clearly the factors that are contributing to the
neonatal mortality. One of the highest interventions for newborn survival and health is
KMC. KMC has been shown to reduce neonatal mortality by over 50% amongst babies
weighing less than 2000g at birth. (Bland et al, 2002).
6
As there are few studies conducted to know determinants of neonatal deaths in Rwanda’s
hospitals, this study therefore has the purpose of determining factors associated with
neonates deaths in KMC service at Gihundwe District Hospital.
1.3. Research objectives
The following are the objectives of this study:
1.3.1 General objectives
To examine factors associated with mortality among low birth weight in KMC at
GDH.
1.3.2 Specific objectives
i. To determine socio-demographic characteristics of neonates with low birth
weight in KMC at Gihundwe District Hospital from January 2015 to December
2016.
ii. To determine mother factors associated with mortality among neonates with in
KMC at Gihundwe District Hospital from January 2015 to December 2016.
iii. To determine neonate factors associated with mortality among neonates in KMC
at Gihundwe District Hospital from January to December 2016.
iv. To determine mortality rate of neonate in KMC at Gihundwe District Hospital
from January 2015 to December 2016
1.4 Research questions
i. What are socio-demographic characteristics of neonates in KMC at Gihundwe
District Hospital from January 2015 to December 2016?
ii. What are the mother factors associated with mortality among low birth weight in
KMC at Gihundwe District Hospital from January 2015 to December 2016.
7
iii. What are the neonate factors associated with mortality among low birth weight in
KMC at Gihundwe District Hospital from January 2015 to December 2016.
iv. What is the mortality rate of neonate in KMC at Gihundwe District Hospital from
January 2015 to December 2016?
1.5. Significance of the study
Conducting a study on neonatal mortality will come up with some understanding of the
underlying causes of neonatal deaths which might be peculiar to women and neonate in
KMC at Gihundwe District Hospital, so as to formulate strategies for prevention and
addressing the identified challenges.
Since about 75% of neonatal deaths are known to be avoidable the study can help in
finding strategies to reduce the avoidable deaths. The PMR is used as a proxy for the
quality of maternal and child health care services accessible to women during pregnancy,
delivery and the postnatal period hence the study seek to understand why there is an
upward trend in neonatal deaths in GDH. The information will be useful to the
emergency obstetric and neonatal care program as some health workers in GDH were
trained to offer emergency maternal and neonatal care to reduce maternal and neonatal
mortality. Studies on neonatal mortality have been done in other provinces in Rwanda
and no studies were done in Rusizi Western Province. Information found in this study
will be useful in providing additional literature on factors associated with neonatal
mortality in a rural set up. Every scientific work must be justified by the reasons in
relation with the domains in which the topic related. Besides, it must have any interest so
long as it does not undermine the public. This study has four advantages, namely:
Government, Community, Hospital and Personal interest.
8
The findings of this study might also help in influencing the development of appropriate
policies, plans and intervention programmes for the management and treatment of Low
Birth weight. This might improve the quality of care for News born with LBW in order
to improve their quality of life, to decrease their mortality and their morbidity.
The results from this study will be informative in a way that it might provide better ways
of KMC service.
The findings of this study would add to the limited body of knowledge about factors
associated with mortality of Low Birth weight in KMC service and improving the
community health, especially maternal and child health, basing on the identified factors
that are highly associated with the outcome of interest during the study.
This study provides answer to the academic requirement which stipulates that every student
must produce a scientific work named thesis” that is the fruit of a research on field, in view of
the obtaining of master’s degree. It will serve the reference for the future researchers. It
serves as library document for the institution and consulted by the future coming students in
the same domain.
This study will guide researchers to know how neonatal death is distributed in KMC at
Gihundwe Hospital and the factors that influence or determine this distribution. Also findings
will serve to further researchers, in public health area, and other interested people in
documentation, as this study provides a data base of information regarding factors associated
with neonatal mortality in Gihundwe Hospital.
I.6 Study limitations
This study has some limitations, mainly related to the sample. The sample which was
used in this study was selected from a single KMC service and therefore the results may
not be representative and generalizable to the general population of Newborns with LBW
in Rwanda.
9
The study did not focus on other factors which may contribute to neonatal mortality such
as, alcohol abuse and nutritional status of the mothers. Cultural factors, environmental
and biological factors were not involved in this study.
Delimitation
During this study, the researcher tried to collect the all information’s needs in the files
and registers of clients. And the researches have been carried out at GDH as the main
case study.
1.7 Organization of the study
The study proposal has three main chapters:
Chapter One: introduces the study and is composed of the background of the problem,
research objectives, research questions, research significance, and study limitation.
Charter Two: is a literature review and is composed of the theoretical literature,
empirical review, critical review, theoretical framework, conceptual framework and
summary.
Chapter Three: is research methodology which highlights study design of population,
sampling procedures and techniques, sample population, instruments, validity and
reliability testing, data collection method and ethical considerations.
Chapter Four: presents the research findings and discussion to compare them with those
from other studies.
Chapter Five: gives the summary of the study findings, conclusion and recommendation
for the study.
10
CHAPTER TWO: REVIEW OF RELATED LITERATURE
2.0 Introduction
This chapter provides the theoretical literature, the empirical review, the critical review,
the theoretical framework, the conceptual frame work and the summary of the chapter.
2.1 Theoretical literature
2.1.1 Causes of neonatal deaths
WHO (2006) used a review of country, regional, and global estimates of neonatal and
perinatal mortality to explain the general causes of neonatal deaths such as severe
malformation, prematurity, obstetric complications before or during birth or harmful
practices after birth that lead to infections. Low birth weight has long been discussed to
be one of the causes of neonatal deaths. It is associated with the death of many newborn
infants, but is not considered a direct cause. Around 15% of newborn infants weigh less
than 2500 g, the proportion ranging from 6% in developed countries to more than 30% in
some parts of the world. The main reason is preterm birth and the complications
stemming from it, rather than low birth weight itself (WHO, 2006). Complications
during birth, such as obstructed labour and fetal mal presentation, are common causes of
perinatal death in the absence of obstetric care. Birth asphyxia and trauma often occur
together and it is; therefore, difficult to obtain separate estimates. In the most severe
cases, the baby dies during birth or soon after, due to damage to the brain and other
organs. Less severe asphyxia and trauma will cause disability. Modern obstetric practices
have almost eliminated birth trauma (WHO, 2006).
According to WHO (2006), it is estimated that in developing countries, asphyxia causes
around seven deaths per1000 births, whereas in developed countries this proportion is
less than one death per 1000 births. The majority of deaths occur soon after birth, some
11
just before birth. Prolonged labour or prolonged rupture of membranes causes infections
in mothers and babies. However, babies are more susceptible than mothers and infections
in infants are more difficult to detect. The infections that occur around birth cause about
26% of newborn infants to die. In many countries, infections are the main cause of
neonatal death after the first week of life. These are mostly acquired either in hospital as
a complication of treatment for other perinatal conditions, or at home.
Preterm infants are at greatest risk of becoming ill and dying. Harmful cord care
practices cause neonatal tetanus if the mother is not protected by immunization; poor
feeding practices cause diarrhea and poor growth; an unhygienic environment causes
sepsis. The relative contribution of each of these factors varies according to the health of
the pregnant woman and the prevalence of endemic diseases such as syphilis or malaria,
but mostly according to the availability of adequate care during pregnancy, childbirth
and the neonatal period. Early neonatal deaths are mostly due to complications during
pregnancy or childbirth, preterm birth and malformations; late neonatal deaths are due to
neonatal tetanus and infections acquired either at home or in hospital when
complications in special neonatal care occur (WHO, 2006).
A young age of the mother due to early marriage if the mother is only between 14 and
16 years old plays certainly a role in her health care seeking behavior. This is because
she has a poor experience in pregnancy, childbirth and postnatal care, and is dependent
upon her husband and other family members what decisions to take. The decision to
deliver at home is mostly taken by the husband and the other family members. The
complications that can arise during delivery are not properly explained to her, so she will
deliver without a skilled birth attendant, and seeking care will be delayed for her, and
also for the child when getting ill during the first week of life (World Health
Organization (WHO, 2010).
12
According to Mayer (2007), women who are getting an unwanted pregnancy, but carried
to term and not married can have the increased risk of problems. If a pregnancy is not
planned before conception, a woman may not be in optimum health for childbearing. For
example, women with an unintended pregnancy could delay prenatal care that may affect
the health of the baby.
According to Anwa et al (2008), illiteracy of the mother is a very important factor for the
health care seeking behavior. Use of skilled attendance was 18.2% and 74.3% among
mothers with no education, and with higher education, 10 years schooling. The ANC was
also visited more by a literate mother and ANC visits increased in general the use of a
skilled birth attendant. Progress in the achievement of the MDG 4 and 5 is correlated
with education of the mother and the father as well.
According to Jelle et al (2004), the poverty and therefore lack of money for transport and
to pay for a health facility delivery, even if the mother wants to deliver, plays an
important role in many Sub-Saharan Africa (SSA) countries. It makes them to mostly
deliver at home without a skilled birth attendant. There is a user fee to pay in most of the
countries and the facility also asks the mother and family sometimes to bring baby
clothes, maternity pads, clothes, etc. which they cannot afford . Poverty plays an
important role in the low use of maternal health services, so we can conclude that
poverty and the ill health and deaths of newborns are intimately linked. The newborn
health gap between rich and poor is unacceptable high (WHO, 2006).
According to WHO (2006), the families in the poorest quintile experience on average a
68% higher neonatal mortality than the richest quintile. The largest disparity is seen in
Nigeria with an NMR of 23 among the richest quintile compared to 59 in the poorest
quintile, representing a gap of 156% (WHO, 2006). There is a large gap between rich
and poor in both access to services and quality of services. The lowest inequity was for
13
the use of ANC services and the highest for delivery by caesarean section, as a caesarean
section can be very costly for a family (Anwa et al, 2008).
Mother and her family may not get information regarding birth-preparedness and
relevant complication. This should be done at the antenatal clinic visits but is
unfortunately not always done. Antenatal care is only sufficient if it is done as a focused
4 visits and at every visit health education can be given repeatedly (WHO, 2006).
There should be a plan for the following: a skilled attendant at birth, the place of birth
and how to get there. This should also include how to access emergency transportation if
needed, items needed for the birth, money saved to pay the skilled provider and for any
needed medications and supplies; support during and after the birth from family and
potential blood donors in case of emergency (WHO, 2006).
According to Brazzano et al (2008), the cultural practices contribute to NNM. In fact,
preference of the mother and family for a traditional healer plays a role in delayed care
seeking. In some African communities, the family decides when the child needs
treatment if it is ill. They want to start with traditional medicines even for a whole week
before going to a health facility with the child and it is also not always allowed for the
mother and her child to leave the house for some time in some countries. If a newborn is
ill the first week of life, the family sometimes is unwilling to spend much money if they
are poor as this is not beneficial for the family as a whole even though they recognize
that the baby is very ill, and they have more trust in the traditional healer than in the
health facility.
According to Lefeber et al (1998), mothers are encouraged not to mourn for too long if
the baby dies. There is the feeling that some children are not meant for this life,
especially in the first week of life so in some countries people will wait with giving
14
names. Cultural beliefs and practices around pregnancy and birth are everywhere in Asia,
Latin America, and many countries of Africa, Rwanda inclusive. It is very important to
have a good knowledge about these beliefs and practices in order to understand the
health care seeking behavior and utilization of health services in those countries (Lefeber
et al, 1998), some of them are listed below.
2.1.2 History Kangaroo Mother Care
Peter de Chateau in Sweden first described studies of "early contact" with mother and
baby at birth in 1976, articles do not describe specifically that this was skin-to-skin
contact. Klaus and Kennel did very similar work in the USA, better known in the context
of early maternal-infant bonding. The first report use of the term "skin-to-skin contact" is
by Thomson in 1979 and quotes the work of de Chateau in its rationale. This is
contemporary or even precedes the origins of Kangaroo Mother Care in Bogota,
Colombia. This latter did however make the concept more widely known. In 1978, due to
increasing morbidity and mortality rates in the Instituto Materno Infantile NICU in
Bogotá, Colombia, Edgar Rey Sanabria, Professor of Neonatology at Department of
Paediatry – Universidad National de Colombia introduced a method to alleviate the
shortage of caregivers and lack of resources. He suggested that mothers have continuous
skin-to-skin contact with their low birth weight babies to keep them warm and to give
exclusive breastfeeding as needed. This freed up overcrowded incubator space and care
givers.
Another feature of kangaroo care was early discharge in the kangaroo position despite
prematurity. It has proven successful in improving survival rates of premature and low
birth weight newborns and in lowering the risks of no nosocomial infection, severe
illness, and lower respiratory tract disease (Conde, 2003). It also increased exclusive
15
breast feeding and for a longer duration and improved maternal satisfaction and
confidence.
Rey and Martinez published their results in 1979 in Spanish, and used the term Kangaroo
Mother Method. This was brought to the attention of English speaking health
professionals in an article by White law and Sleath in 1985. Gene Cranston Anderson
and Susan Ludington were instrumental in introducing this to North America."Kangaroo
Mother Care" as a term was first defined at a meeting of some 30 interested researchers,
attending a meeting convened (Adriano, 1996).
An International Network of Kangaroo Mother Care (INK) was convened at the Trieste
meeting, and has overseen workshops and conferences every two years. After Trieste,
meetings were held in Bogota Colombia 1998, Yogyakarta Indonesia 2000, Cape Town
South Africa 2002, Rio de Janeiro Brazil 2004, Cleveland USA 2006, Uppsala Sweden
2008,Quebec Canada 2010, Ahmadabad India 2012, and Kigali Rwanda 2014; the
meeting in 2016planned for Trieste Italy. An informal steering committee coordinates
these meetings: Susan Ludington maintains a Kangaroo Mother Care on behalf of INK,
endeavoring to be a complete inventory of any and all publications relevant to Kangaroo
Mother Care. This is also broken down in an analysis of 120 charts, in which specific
outcomes are collated.
2.1.3 The International Kangaroo Mother Care Awareness
Day has been celebrated worldwide on May 15, 2011. It is a day to increase awareness to
enhance practice of Kangaroo Care in NICUS, Post Partum, Labor and Delivery, and any
hospital unit that has babies up to 3 months of age. Scientific rationale Mainstream
clinical medicine has not accepted Kangaroo Mother Care, or skin-to-skin contact, as
more than an adjunct to reliance on advanced technology that requires maternal infant
16
separation. However, in primates, early skin-to-skin contact is part of a universal
reproductive behavior, and early separation is used as a research modality to test the
harmful effects on early development (Wiley et al, 2011).
Research suggests that for all mammals, the maternal environment (or place of care) is
the primary requirement for regulation of all physiological needs(homeostasis),
[maternal absence leads to days regulation and adaptation to adversity .Even for humans,
it would appear that skin-to-skin contact has a better scientific rationale than the
incubator. All other supportive technology can be provided as part of care to extremely
low birth weight babies during skin-to-skin contact, and appears to produce a better
effect.
Based on the scientific rationale, it has been suggested that skin-to-skin contact should
be initiated immediately, to avoid the harmful effects of separation. In terms of
classification and proper defining for research purposes, the following aspects that
categorize and define skin-to-skin contact have been proposed:
Initiation time, (minutes, hours from birth), ideal is zero separation. Dose of skin-to-skin
contact, (hours per day, or as percentage of day), ideal >90%. Duration, (measured in
days or weeks from birth), ideally until infant refuses. Safe technique should ensure that
obstructive apnea cannot occur. Since the mother must be able to sleep to provide
adequate dose, this requires keeping the airway safely open, and close containment to
mother’s bare chest using a garment, several of these are described in the WHO
guidelines. Mother should be the primary provider of skin-to-skin contact, as only she
can breastfeed. However, it is almost necessary that father should also provide skin-to-
skin contact to achieve adequate dose; other family members can also be used. Since
skin-to-skin contact is basic to early bonding and attachment, it should probably not be
done by hospital staff and other surrogates (WHO, 2014).
17
Clinical evidence The Cochrane review on "Early skin-to-skin contact for mothers and
their healthy babies” provides clinical support for the scientific rationale. However,
clinical research studies of early skin-to-skin contact have not been done on "unhealthy"
babies, and very extremely small babies. The available evidence does show that early
skin-to-skin contact produces better outcomes, very specifically with respect to
breastfeeding, but also with regulation of physiological outcomes (all homeostasis). A
randomized controlled trial published in 2004 reports that babies born between 1200 and
2200g became physiologically stable in skin-to-skin contact starting from birth,
compared to similar babies in incubators. In another randomized controlled trial
conducted in Ethiopia, survival improved when skin-to-skin contact was started before 6
hours of age. While Kangaroo Mother Care generally implies care of low birth weight
and preterm infants, skin-to-skin contact should be regarded as normal and basic for all
newly born humans. The original research by Thomson showed increased breastfeeding
rates when skin-to-skin contact started at birth, and when early breastfeeding was
encouraged every two hours currently, the impact of skin-to-skin contact on
breastfeeding is the scientific rationale for Step 4 of the Baby Friendly Hospital Initiative
(BFHI), which requires help to "initiate breastfeeding within one hour of birth".
Four million children die every year worldwide during their first month of life, and in
more than one third of cases, these deaths occur in developing countries and are related
to prematurity and/or low birth weight (less than 2500g). It is here that the injustice
begins. Caring for new born and especially low birth weight children requires a delicate
balance between the use of sophisticated techniques and often aggressive care and
knowledge of the risks associated with the use of such technology to give back to the
family a physically and mental. Kangaroo Mother Care (KMC) offers an alternative to
the traditional method of caring for low birth weight children (Joy, 2010).
18
In short, KMC method can be explained like this; as soon as possible after birth and as
soon as the premature babies tolerate being handled without a change in heart rate or
oxygenation, they are placed in a Kangaroo position on their mother’s chest. The
position is vertical, between the breasts, in direct contact with the skin as long as
possible, and at least 12 hours a day. In case of premature babies they must remain in the
incubator when not on their mother’s skin because they cannot regulate their body
temperature and are therefore likely to hypothermia if left in blankets on a bed, with the
risk of suffering hypoglycemia, which can damage their brain. If there is no incubator
available, the father, the grandparents or other family members are welcome to carry the
frail baby in a kangaroo position 24 hours a day and allowing the mother to rest. If the
babies are not premature but malnourished, the risk of hypothermia is lower when they
are not permanently placed in a kangaroo position since they may already be regulating
there, however, temperature but the complications are the same as well as the advice
given to families. Family solidarity around the frail child is a key element in the success
of KMC (MCHIP, 2010).
2.1.4 Eligibility criteria of Kangaroo Mother Care
Originally babies who are eligible for kangaroo care include pre-term infants weighing
less than 1,500 grams, and breathing independently. Cardiopulmonary monitoring,
oximetry, supplemental oxygen or nasal (continuous positive airway pressure)
ventilation, intravenous infusions, and monitor leads do not prevent kangaroo care. In
fact, babies who are in kangaroo care tend to be less prone to apnea and bradycardiac and
have stabilization of oxygen needs. During the early 1990s, the concept was advocated in
North America for premature babies in NICU and later for full term babies. Research has
been done in developed countries but there is a lag in implementation of kangaroo care
due to ready access of incubators and technology. Restrictions for eligibility to receive
19
skin-to-skin contact are becoming fewer; the main constraint has probably been care
giver confidence and experience (Hake - Brooks, 2008).
2.1.5 Techniques used in Kangaroo Mother Care
In kangaroo care, the baby wears only a small diaper and a hat and is placed in a flexed
(fetal position) with maximal skin-to-skin contact on parent's chest. The baby is secured
with a wrap that goes around the naked torso of the adult, providing the baby with proper
support and positioning (maintain flexion), constant containment without pressure points
or creases, and protecting from air drafts (thermoregulation). If it is cold, the parent may
wear a shirt or hospital gown with an opening to the front and a blanket over the wrap for
the baby. The tight bundling is enough to stimulate the baby: vestibular stimulation from
the parent’s breathing and chest movement, auditory stimulation from the parent s voice
and natural sounds of breathing and the heartbeat touch by the skin of the parent, the
wrap, and the natural tendency to hold the baby. All this stimulation is important for the
baby’s development."Birth Kangaroo Care" places the baby in kangaroo care with the
mother within one minute after birth and up to the first feeding. The American Academy
of Pediatrics recommends this practice, with minimal disruption for babies that don't
require life support. The baby's head must be dried immediately after birth and then the
baby is placed with a hat on the mother's chest (Kligman, 2007).
Measurements, etc. are performed after the first feeding. According to the United of
State Institute of Kangaroo Care, healthy babies should maintain skin-to-skin contact
method for about 3months so that both baby and mother are established in breastfeeding
and have achieved physiological recovery from the birth process. For premature babies,
this method can be used continuously around the clock or for sessions of no less than one
hour in duration (the length of one full sleep cycle.) It can be started as soon as the baby
is stabilized, so it may be at birth or within hours, days, or weeks after birth .Kangaroo
20
care is different from the practice of baby wearing. In kangaroo care, the adult and the
baby are skin-to-skin and chest-to-chest, securing the position of the baby with a stretchy
wrap, and it is practiced to provide developmental care to premature babies for 6months
and full-term newborns for 3 months.
In baby wearing the adult and the child are fully clothed, the child may be in the front or
back of the adult, can be done with many different types of carriers and slings, and is
commonly practiced with infants and toddlers (Friederici, 2006).
Kangaroo training takes place either beside the incubator early on, or in a room of the
neonatal unit where several mothers carrying their babies can sit together and share
learning sessions. The purpose of these training sessions is to prepare the mother and
child to know enough and go back home as soon as possible. The future mother
Kangaroo learns to place and to carry her child in the Kangaroo position, to manually
extract her milk and to feed her young properly with a cup, a syringe or breast, in the
correct position, or eventually by a feeding tube. The baby is fed first by a feeding tube
and then directly at the breast. This is the second component of KMC and not the
easiest. Mom gains confidence in her ability to support her child. The father and other
family members may also carry the baby, alternating with the mother to allow her some
rest. This training is carried out under the direction of lead nurses specializing in KMC
and able to assess whether the criteria for a child to leave the hospital are met. The
collective training also allows the more experienced mothers to share their knowledge
with the newcomers, often very anxious.
The early interaction between the child and his/her mother leads to better breast milk
production, which is vital for better child survival in all countries of the world. Once the
training is completed, the parents are either directed to a mother-child kangaroo hospital
21
or directly to their home with the baby, the latter attached to the mother by a band of
Lycra. However, they have to come to the clinic daily until the baby gains at least 15
grams per kilogram per day, after which the visits can be can spaced out to once per
week until the child reaches the prospective date of birth. This multidisciplinary and
rigorous monitoring is the third stage of the KMC. The choice of 15g per kg per day
simply corresponds to the normal growth of a baby in the mother’s womb. The
subsequent monitoring of the high-risk child is structured along the institution’s existing
protocol in order to detect the occurrence of abnormal psycho-motor, vision, hearing or
somatic development during the first year of life. The management of these disorders
occurs earlier and is more specific to prevent the onset of irreversible damages.
(Charpak et al, 2014)
As the future of Kangaroo mother care shows the main goal remains the humanization
and improvement of care offered to low birth weight children around the world. The
cultural changes induced by the adoption of KMC in health practices foster a more
sensitive behavior among staff responsible for child care and change their attitude
towards the families. The relationship becomes that of a team chiefly concerned with the
welfare of the child where everybody collaborates in mutual respect. Parents become
first responders in the service itself. The KMC increases their self-confidence, reassures
them about their skills and gives them the tools needed to be the best caregivers of their
frail infant. They represent the future of their child, and our role is not to replace them
but to support them.KMC is a powerful, easy to use method to promote the health and
well-being of infants born preterm as well as full term. Its key features are:
Early, continuous and prolonged skin-to-skin contact between the mother and the baby;
Exclusive breastfeeding (ideally);
It is initiated in hospital and can be continued at home;
22
Small babies can be discharged early;
Mothers at home require adequate support and follow up;
Evidence of the effectiveness and safety of KMC is available only for preterm infants
without medical problems, the so-called stabilized newborn (WHO, 2014).
Hospital discharge: infants may be discharged to home while still requiring KMC for
thermoregulation if:
Temperature (and remainder of vital signs)is stable and the method is well tolerated by
newborn and mother.
Follow up:
All LBW newborns <2kg should have follow-up appointment to assess temperature and
weight gain within the week after discharge.
Readmission criteria:
Unable to continue KMC for a newborn <2 kg
Weight <10grams/kg/day weight gain
Presence of any danger signs
Research and experience show that:
KMC at least equivalent to conventional care (incubators), in terms of safety and thermal
protection, if measured by mortality.
KMC, by facilitating breastfeeding, offers noticeable advantages in cases of severe
morbidity.
KMC, contributes to the humanization of neonatal care and to the better bonding
between mother and baby in both low and high-income
23
KMC is in this respect, a modern method of care in any setting, even where expensive
technology and adequate care are available.
Ongoing research and observational studies are assessing the effective use of this method
in situations where neonatal intensive care or referral are not available, and where health
workers are properly trained. In those, settings, KMC before stabilization may present
the best cause of healthy survival (WHO, 2014).
2.1.6 Benefits of Kangaroo Mother Care
For parents: Kangaroo Mother Care is beneficial for parents because it promotes
attachment and bonding, improves parental confidence, and helps to promote increased
milk production and breastfeeding success. Both preterm and full term infants benefit
from skin to skin contact for the first few weeks of life with the baby's father as well. The
new baby is familiar with the father's voice and it is believed that contact with the father
helps the infant to stabilize and promotes father to infant bonding. If the infant's mother
had a caesarean birth, the father can hold their baby in skin-to-skin contact while the
mother recovers from the anesthetic (MCHIP, 2014).
For pre-term and low-birth: Weight infants Kangaroo Mother Care arguably offers
the most benefits for pre-term and low-birth-weight infants, who experience more
normalized temperature, heart rate, and respiratory rate, increased weight gain, fewer
nosocomial infections and reduced incidence of respiratory tract disease. Additionally,
studies suggest that preterm infants who experience kangaroo care have improved
cognitive development, decreased stress levels, reduced pain responses, normalized
growth, and positive effects on motor development. Kangaroo care also helps to improve
sleep patterns of infants, and maybe a good intervention for colic. Earlier discharge from
hospital is also a possible outcome finally; kangaroo care helps to promote frequent
breastfeeding, and can enhance mother-infant bonding. Evidence from a recent
24
systematic review supports the use of kangaroo mother care as a substitute for
conventional neonatal care in settings where resources are limited." Promotes more
successful breastfeeding of full-term infants’ Infant nursing shortly after birth. The
World Health Organization reports that in addition to more successful breastfeeding,
skin-to-skin contact between a mother and her newborn baby immediately after delivery
also reduces crying, improves mother to infant interaction, and keeps baby warm (WHO,
2006).
According to studies quoted by MCHIP, babies have been observed to naturally follow a
unique process which leads to a first breastfeed. After birth, babies who are placed skin
to skin on their mother’s chest will: Initially babies cry briefly – a very distinctive birth
cry Then they will enter a stage of relaxation, recovering from the birth then the baby
will start to wake up then begin to move, initially little movements, perhaps of the arms,
shoulders and head As these movements increase the baby will actually start to crawl
towards the breast (MCHIP, 2014)
For institutions: Kangaroo Mother Care often results in reduced hospital stays, reduced
need for expensive health care technology, increased parental involvement and teaching
opportunities, and better use of health care dollars (MCHIP, 2014).
For the community: Overall, kangaroo care helps to reduce morbidity and mortality,
provides opportunities or teaching during postnatal follow-up visits, and decreases
hospital-associated costs.
Kangaroo care, or skin-to-skin care, is a technique practiced on newborn, usually
preterm, infants where in the infant is held, skin-to-skin, with an adult. It is effective in
preventing hypothermia, establishing breastfeeding, and reducing nosocomial infection
in preterm babies in resource-limited areas. Kangaroo care for pre-term infants may be
25
restricted to a few hours per day, but if they are medically stable that time may be
extended. Some parents may keep their babies in-arms for many hours per day.
Kangaroo care, named for the similarity to how certain marsupials carry their young, was
initially developed to care for preterm infants in areas where incubators are either
unavailable or unreliable (Jelka, 2006).
Kangaroo Mother Care is effective in preventing hypothermia, establishing
breastfeeding, and reducing nosocomial infection in preterm babies in resource-limited
areas. Relatively little is known about long-term morbidity and mortality outcomes
among Ethiopian infants managed with KMC. Aims: To describe the follow up profiles
and outcome of infants managed with KMC and discharged alive. Results: Of the 110
infants included in the study, 9.1% died over the study period and 60% of the deaths
occurred at home. Mortality was 100% in those babies with mothers aged less than 18
years. Thirty five percent of the deaths occurred in those from rural location. Common
medical problems identified in study subjects were respiratory infections (10%),
gastroenteritis (7%), rickets (7%), and anemia (6%). About 20% of infants were
readmitted to hospital at least once. KMC initiation within one week was not found to be
significantly associated with survival, but continued KMC after discharge significantly
decreased mortality in our sample (Worku, 2005).
Frequent follow up is very important especially those with teenage mothers and coming
from a rural location. Follow up should be frequent in the first 2 months after discharge.
Further research is needed to explore the determinants of mortality and morbidity after
hospital discharge.
Regarding delay in KMC initiation was calculated from the time of hospital admission to
the first date of KMC. Type of feeding practiced during hospital admission and discharge
26
was analyzed in relation to medical problems encountered during the study conducted at
Addis Abeba, Ethiopia (Worku, 2005).
The following results were shown about that: A total of 110 infants and toddlers were
included in this study. 57 (51.8%) study subjects were females. The W. Lakew, B.
Worku 145 mean age at evaluation was 12.4 months with a standard deviation of 7.1. 96
(87.3%) study subjects lived in urban areas. 101 (92%) mothers were between 18 and 35
years of age. 3.6% of infants had mothers aged less than 18 years. Spontaneous vaginal
delivery accounted for 52.7% of the cases. The rest were delivered either by assisted
vaginal delivery or caesarean section. Most of the babies were delivered at between
gestational ages of 32 - 36 weeks (51%). The mean birth weight of the study subjects
was 1336.2 grams with standard deviation (SD) of 211.5 grams.
The mean duration of KMC given in the neonatal ward was 14 days with standard
deviation (SD) 9. The mean delay in initiation of kangaroo mother care was 11 days.
KMC was continued at home for an average of 2 weeks in 83.6% of infants. Out of 110
infants, only 79 (71.8%) returned back to the follow up clinic at least once. The
continuation of KMC after discharge was associated with reduced mortality (6.5% vs.
23.5%, P = 0.046). Non-significant increases in mortality were noted among children
that failed to follow-up after discharge. After discharge, 12.7% of them were on
exclusive breast-feeding, 15.5% on formula feeding, 34.5% on mixed feeding and 37.3%
were on family diet. Age appropriate feeding was seen only in 40% of infants. Out of
110 infants, 36.4% had a history of unscheduled hospital visit, and 20% have history of
hospital admissions.
The most common medical problems encountered in live infants during the study were
respiratory infections (10%), rickets (7%), gastroenteritis (7%), anemia (6%) and other
problems account for 14% of the study subjects. Nine percent of the study subjects died.
27
No difference in deaths existed between sexes (5 vs. 5, P = 0.090). Mortality after
discharge was 100% in infants whose mothers were aged less than 18 years (4, P = 0.01).
Mortality was found to be high (90%) within the first 2 months of age, which abruptly
decrease after the age of 4 months. Out of the 10 deaths encountered, 60% of them were
witnessed at home while the rest have died in health institutions (Worku, 2005).
Higher percentage of deaths (35.7%) was encountered in those living in rural areas.
Respiratory problems were mentioned as possible causes of death by caretakers in 6
(60%) of the cases while sudden unexpected death in 3 (30%) of them. Mortality rates
have shown to be higher in infants who were on feeding other than exclusive
breastfeeding at discharge.
2.2 Empirical review
2.2.1. International past studies
A study conducted in Indonesia by Asnawi et al (2013) showed that in that country, the
neonatal mortality was associated by the neonatal complications during birth; mother
noting a health problem during the first 28 days; maternal lack of knowledge of danger
signs for neonates; low Apgar score; delivery at home; and history of complications
during pregnancy.
The similar study occurred in the Orotta Pediatric University in Eritrea by Shetal et al
(2006), found that hypothermia, pneumonia, younger gestational age, 1 min Apgar score
and small size for gestational age are significantly associated with mortality and longer
length of stay in the Eritrean SNCU.
According to Sonia et al (2004), a positive impact of Kangaroo Mother Care on
breastfeeding was found in Brazil. The analysis of randomized trials showed that it
28
consists a protection factor to breastfeeding at discharge (relative risk 0.41, 95%
confidence interval 0.25 to 0.68). The method was always associated with the following
reduced risks: nosocomial infection at 41 weeks corrected gestational age (relative risk
0.49, 95% confidence interval 0.25 to 0.93), severe illness (relative risk 0.30, 95%
confidence interval 0.14 to 0.67), lower respiratory tract disease at 6 months (relative
risk 0.37, 95% confidence interval 0.15 to 0.89) and better gain of weight per day
(weighted mean difference 3.6 g/day, 95% confidence interval 0.8 to 6.4). Psychomotor
development at 1 months’ corrected age was similar in the two groups. There was no
evidence of a difference in infant’s mortality.
Several studies conducted from South Asia including that of Nielsen et al (1997) have
reported reduced care seeking for baby girls female infanticide, and after the neonatal
period there are more data on the existence of practices that have a significant harmful
effect on the survival of girls.
A study done in Brazil, Fernando et al (2008), demonstrated the mean length of hospital
stay (p = 0.14) and inter current clinical conditions in the intermediate or Kangaroo unit
were equal for both groups. Weight (p = 0.012), length (p = 0.039) and head
circumference (p = 0.006) at 36 weeks' corrected gestational age were all lower at the
kangaroo units. The Kangaroo units exhibited superior performance in relation to
exclusive breastfeeding at discharge (69.2 vs. 23.8%,p=0.022).
According to Wiley et al, (2011) KMC resulted in improved weight and length, head
circumference, breastfeeding, mother-infant bonding and maternal satisfaction with the
method of care, as compared with conventional methods. The 2011 Cochrane review
included seven trials that assessed mortality at discharge or 40–41weeks. These trials
29
reported a statistically significant 3.4% reduction in the risk of mortality (Wiley et al,
2011).
Ellen et al, (2014) conducted a study, where 1035 studies were screened; 124 met
inclusion criteria. Among LBW newborns, KMC compared to conventional care was
associated with 36% lower mortality (RR 0.64; 95% [CI] 0.46, 0.89). KMC decreased
risk of neonatal sepsis (RR 0.53, 95% CI 0.34, 0.83), hypothermia (RR 0.22; 95% CI
0.12, 0.41), hypoglycemia (RR 0.12; 95% CI 0.05, 0.32), and hospital readmission (RR
0.42; 95% CI 0.23, 0.76) and increased exclusive breastfeeding (RR 1.50; 95% CI 1.26,
1.78). Newborns receiving KMC had lower mean respiratory rate and pain measures, and
higher oxygen saturation, temperature, and head circumference growth.
2.2.2. Regional past studies
In a study of perinatal mortality in rural Kenya maternal age of less than twenty years
was found to be associated with perinatal deaths (OR 1.19) and this age group consists of
adolescents who have a 50% increased risk of perinatal deaths due to preterm births,
LBW and asphyxia. Strategies such as sex education, school based clinics and family
planning clinics were found to significantly reduce pregnancies in the younger age
groups.
In Tanzania approximately 38% of deaths among children younger than 5 years of age
occur during the first 28 days of life, and 75% of the deaths occur within the first 7 days
(Early neonatal period). Causes and determinants of early neonatal deaths and stillbirths
were attributed to insufficient care during the antenatal and postnatal periods, and during
childbirth, especially in prevention of sepsis and haemorrhage which are common causes
of death as well as lack of new-born care (Mpembeni et al, 2014).
The Kenya Demographic and Health Survey (KDHS) reported that demographic factors
such as age at first birth, parity, birth order and birth interval were the main predictors of
perinatal deaths in their population based study. Mothers aged 35 and above and lack of
30
schooling in women were observed to have higher proportions of perinatal deaths. The
perinatal mortality rate was 118 per 1000 births in a rural Kenyan Hospital. Perinatal
mortality was increased by between eight and 62 times in the presence on prematurity
with labour complications occurring in 53% of the cases (Klasakhala et al, 2007).
In Ethiopia perinatal deaths were related to socioeconomic factors such as education,
religion, accessibility of health services, socioeconomic status and demographic
characteristics like sex of the child, mother’s age at birth, birth order and birth weight
(Chekol, 2011).
According to Faith et al (2013), young age of the mother is a risk factor during a
delivery because, she might have a disproportion of the pelvis due to her young age
which can lead to obstructed labour, so she needs a skilled birth attendant followed by a
referral to a hospital for a caesarean section.
Lawn et al (2006), found that multiple pregnancies, or grandmultigravida, can give
serious complications during delivery and a skilled birth attendant should be available
for EmOC and resuscitation of the baby if necessary. It is preferable that the delivery
takes place at the health facility and not at home. Lawn et al. confirmed that the babies of
a multiple pregnancy are often premature born or small for age or both, so that the
postpartum care should also be given adequately at home, as the mothers once
discharged from a health facility are not always returning for postnatal visits or are asked
to come for a return visit weeks later. Those children should stay for a longer time in the
hospital.
2.2.3. Local past studies.
According to Jha et al (2006), there were typically about 10% more baby boys born than
girls, although this ratio has been distorted further in countries with gender-specific
termination of pregnancy.
31
In Sub Sahara Africa, as reported by Lawn et al (2006), 14 percent of babies is born with
low birth weight (LBW), or a weight at birth of less than 2,500 grams. The babies with a
low birth weight are at risk but low weight as such is not directly related to neonatal
death. They might have low blood sugars and it is very important to start with exclusive
breastfeeding as soon as possible and to give frequent feedings. They might develop
hypothermia and are sometimes difficult to feed but if they get extra care they can
manage better than premature infants who are more at risk for lung problems and
infections. The limited data available suggest that most LBW babies in Africa are
preterm (Lawn et al, 2006).
Lawn et al (2006) analyzed the DHS data for African countries and did not suggest any
loss of the natural survival advantage for girl babies. Besides the 24 percent of neonatal
deaths in Africa which are directly due to specific complications of preterm birth such as
breathing difficulties, intracranial bleeds, and jaundice, many deaths due to other causes,
occur among preterm babies.
The study by Yakoob et al (2010) showed that preterm babies have a risk of death that is
around 13 times higher than full term babies.
In 2012, Rwanda Ministry of Health reported that neonatal asphyxia is the first cause of
neonatal mortality followed by complications of prematurity and neonatal infections. The
second was the congenital abnormalities which represented 8% of all cases (Rebecca et
al, 2010).
32
2.3 Critical review
Childbirth is the time of greatest lifetime risk of mortality for a mother and her baby
(Lawn, 2006). There has been much effort to reduce neonatal mortality; however, there
have been little studies to find out the factors that contribute to neonatal deaths.
According to United Nations Children’s Fund (UNICEF, 009), reducing the global total
of 3.82 million neonatal deaths, particularly the 3 million who die in the first week of life
is crucial to meeting MDG 4.
The solutions to reduce neonatal deaths, especially early deaths, are intimately linked to
maternal health and to provision of effective maternal and neonatal health services
(Ronsmans et al, 2006). Therefore, addressing current global and regional gaps for care
at birth is critical to achieving both MDG 4 and MDG 5.
In a study of perinatal mortality in rural Kenya maternal age of less than twenty years
was found to be associated with perinatal deaths (OR 1.19) and this age group consists of
adolescents who have a 50% increased risk of perinatal deaths due to preterm births,
LBW and asphyxia.19 Strategies such as sex education, school based clinics and family
planning clinics were found to significantly reduce pregnancies in the younger age
groups. The Kenya Demographic and Health Survey (KDHS) reported that demographic
factors such as age at first birth, parity, and birth order and birth interval were the main
predictors of perinatal deaths in their population based study. Mothers aged 35 and above
and lack of schooling in women were observed to have higher proportions of perinatal
deaths. The perinatal mortality rate was 118 per 1000 births in a rural Kenyan Hospital.
Perinatal mortality was increased by between eight and 62 times in the presence on
prematurity with labor complications occurring in 53% of the case.
33
In Tanzania approximately 38% of deaths among children younger than 5 years of age
occur during the first 28 days of life, and 75% of the deaths occur within the first 7 days
(Early neonatal period). Causes and determinants of early neonatal deaths and stillbirths
were attributed to insufficient care during the antenatal and postnatal periods, and during
childbirth, especially in prevention of sepsis and hemorrhage which are common causes
of death as well as lack of new-born care.
In Ethiopia perinatal deaths were related to socioeconomic factors such as education,
religion, accessibility of health services, socioeconomic status and demographic
characteristics like sex of the child, mother’s age at birth, birth order and birth weight.
Rwanda implemented a mobile phone SMS-based system to track pregnancy and
maternal and child outcomes in limited resources setting (Fidele et al, 2012).
Program reports and informal discussions carried out, indicates that some of the factors
that may contribute to neonatal mortality are: traditional beliefs and cultural practices,
illiteracy of mothers, their income, number of parities and number of pregnancies, mode
of delivery and delivery assistance, preexisting conditions, etc. (Aimable et al, 2014).
Thus the need to conduct this study to find out factors influencing neonatal deaths in
Gihundwe District Hospital, a Rwanda’s hospital in rural area. Although a number of
factors have been already associated to neonatal mortality, their association in Rwanda is
largely unknown due to sparsely published studies.
2.4 Theoretical framework
A new analytical approach in corporating both social and medical science methodologies
in to a coherent analytical framework of child survival therefore is clearly needed.
34
Mosley and Chen (2003) propose a new analytical framework for the study of the
determinants of child survival in developing countries. The approach incorporates both
social and biological variables integrate research methods employed by social and
medical scientists. Traditionally, social science research on child mortality has focused
on the association between socioeconomic status and levels and patterns of mortality in
populations. Correlations between mortality and social economic characteristics are used
to generate causal inferences about the mortality determinants. Income and maternal
education for example, are two commonly measured correlates (and inferred causal
determinants) of child mortality in developing country populations.
Medical research focuses primarily on the biological processes of diseases, less
frequently on mortality per es. Studies of cause of death attribute mortality to specific
disease processes (such as infections or malnutrition), using information obtained from
death reports or clinical case records. Nutrition research focuses on breastfeeding, diatery
practices and food availability as they relate nutrition status.
In addition, the theoretical framework was adopted from previous studies conducted and
was the basis for determining potential risk factor variables. Theoretically, neonatal
death may be associated with maternal risk factors, neonatal risk factors, health system
factors, and socio-economic determinants.
Asnawi et al (2013) conducted a pilot study about risks factors associated with neonatal
deaths: a matched case control in Indonesia; Similar to global trends, neonatal mortality
has fallen only slightly in Indonesia over the period 1990 - 2010, with a high proportion
of deaths in the first week of life. This study aimed to identify risk factors associated
with neonatal deaths of low and normal birth weight infants that were amenable to health
service intervention at a community level in a relatively poor province of Indonesia. A
matched case control study of neonatal deaths reported from selected community health
35
centres (puskesmas) was conducted over10months in 2013. Cases were single to n births,
born by vaginal delivery, at home or in a health facility, matched with two controls
satisfying the same criteria. Potential variables related to maternal and neonatal risk
factors were collected from puskesmas medical records and through home visit
interviews.
A conditional logistic regression was performed to calculate odds ratios using the clogit
procedure in Stata 11. As results: Combining all significant variables related to maternal,
neonatal, and delivery factors into a single multivariate model, six factors were found to
be significantly associated with a higher risk of neonatal death. The factors identified
were as follows: neonatal complications during birth; mother noting a health problem
during the first 28 days; maternal lack of knowledge of danger signs for neonates; low
Apgar score; delivery at home; and history of complications during pregnancy. Three
risk factors (neonatal complication at delivery; neonatal health problem noted by mother;
and low Apgar score) were significantly associated with early neonatal death at age 07
days. For normal birth weight neonates, three factors (complications during delivery;
lack of early initiation of breastfeeding; and lack of maternal knowledge of neonatal
danger signs) were found to be associated with a higher risk of neonatal death.
Conclusion: The study identified a number of factors amenable to health service
intervention associated with neonatal deaths in normal and low birth weight infants.
These factors include maternal knowledge of danger signs, response to health problems
noted by parents in the first month, early initiation of breastfeeding, and delivery at
home. Addressing these factors could reduce neonatal deaths in low resource settings.
According to Mbiba et al (2015) study; Factors Associated with Perinatal Mortality in
Umguza and Bubi Rural Areas, 2015; gestational age of less than 36 weeks, not
attending antenatal care, having a male baby and low birth weight were risk factors. The
36
majority of perinatal deaths were macerated. Having early neonatal deaths occurring
during the first 24 hours after delivery might be indicative of the quality of neonatal care
provided.
2.5 Conceptual framework
At this point, there searcher will show independent, dependant and intervening variables.
Independent variables Dependent variables
Intervening var
AGEA INTERVENING
Intervening Factors Intervening variables
Figure 2.1 Conceptual framework
Source: Researcher
The conceptual framework was viewed in three variables. These variables are
independent, intervening and dependent variables. The independent variables are
Mother factors
Age
Marital status
Gravidity
ANC visit
Education status
Parity
Residence
Maternal death
Maternal illness
Occupation
Newborns factors
Age
Sex
Birth weight
Complications
Weight at discharge
Apgar
Resuscitation
Parenteral nutrition
Mode of delivery
Place of delivery
Length of stay in
KMC
Mortality of Neonate
in KMC
37
grouped into maternal and newborn risk factors; the maternal risk factors are age,
antenatal care visits, education status, occupation, marital status, residence, maternal
illness, maternal death, gravidity, parity. The newborn risk factors are gender, birth
weight, weight at discharge, gestational age, Apgar score, resuscitation, complication,
parenteral nutrition. The intervening variables are those associated to both independent
variables and the outcome of interest which is the neonatal mortality. In this study,
variables such as place of delivery, mode of delivery, and length of stay in KMC were
taken as intervening factors.
2.6 Summary
The literature review has described different concepts and theories which were relevant
to the study, and was based on the conceptual framework relating to the maternal and
newborn factors contributing to the neonatal mortality. The literature reviewed indicated
that both maternal and newborn factors associated with the death of neonates either in
first week or in four firsts’ weeks after birth, such as birth asphyxia, low birth weight,
gestational age, infant infections, place of delivery, and mode of delivery.
In addition, the literature revealed some other factors that can influence neonatal death
such health facility factors, socioeconomic factors such as education, occupation of
parents, and socio-demographic factors like sex of the neonate and age of mother at
childbirth.
KMC was found to be the most and easiest practice, with less resource to improve
outcome of premature or LBW infants.
38
CHAPTER THREE: RESEARCH METHODOLOGY
3.0 Introduction
This chapter contains the research design of the study, target population, sample design,
inclusion and exclusion criteria, data collection procedures, data analysis procedure and
validity and reliability of the study.
3.1 Research design
A case-control design was used for collection of data from maternity and KMC unit of
Neonatology department of Gihundwe Hospital. A group of neonates, who died in less
than 28 days postpartum, was identified as cases and, for purposes of comparison, a
group of neonates who did not die was identified as controls. The case-control study
design was chosen, because it is particularly appropriate for studying associated factors
of a rare outcome such as neonatal mortality. Moreover, a case-control study takes less
time and cost less money than for example cohort study, primarily because the control
group is a sample of the source population.
Geographical localization of Gihundwe District Hospital:
The present study took place in Kangaroo Mother Care service and maternity department
of Gihundwe Hospital. This is a hospital localized in rural are, exactly in Rusizi district,
western province of Rwanda (see appendex D).
3.2 Target population
All 183 LBW weighting between 1000gr to 2.500gr admitted in KMC at Gihundwe
District Hospital, in period of 2 years, from January 2015 to December 2016, recorded in
the hospital’s file and registry.
39
Secondary data
Figure: 3.2 Distribution of Target populations.
The figure shows the number of LBW admitted per month from January to December
2015 and those admitted from January to Decembre 2016 in KMC at Gihundwe District
hospital.
3.3 Sample design
3.3.1 Sample size determination
The researcher has selected study data from files and registers of mothers and low birth
weight meeting research inclusion criteria.
The sample size was determined by considering 33 newborns who died (cases) and 66
neonates who did not (controls), as for each one case two controls were chosen.
Therefore the total sample size (n) was obtained by the calculation below.
n = 33 + (33 × 2) = 99
(Source: Gordis, 2014)
Hence the total sample size was 99.
40
3.3.2 Sampling procedure.
Selection of Cases
Cases were selected considering only all neonates who died in KMC unit at GHD, before
reaching 28 days, from January 2015 to December 2016; they were found to be 33.
Selection of Controls
Controls were selected from the neonates who did not die (survivors). For each case, two
controls were selected in order to increase the power of the study. The systematic
random sampling method was used as follows.
Systematic random sampling relies on arranging the card-form of survivors according to
some ordering scheme and then selecting elements at regular intervals through that
ordered list. Systematic sampling involved a random start and then proceeded with the
selection of every k element from then onwards. In this sampling method, the formula
k = N/n
was used. k being the sampling interval size, N the population size and n the sample size.
In this study, the sampling interval size was
k = 150/66 3
Beginning with a randomly selected number between 1 and k, every k unit was selected
in the population for inclusion in the sample (Black, 2004); with the random starting
point of 3, the survivors’ card-form selected were number 3, 6, 9, 12, and so on, until the
last survivor 66.
41
3.4 Inclusion and exclusion criteria
3.4.1 Inclusion Criteria
All neonates with birth weight between 1000 – 2500 gm and their mothers who got the
post neonatal care services in the maternity and neonatology services of Gihundwe
Hospital from January 2015 to December 2016, including those from neighboring health
facilities, and those who were born at home before the arrival at the study area.
3.4.2 Exclusion criteria
Neonates weighting less than 1,000 g and those with congenital malformations were
excluded from the study.
3.5 Data collection procedures
The data collection instrument was a data collection sheet containing all information of
mother and her newborn as recorded on mothers-newborns' cards of Gihundwe Hospital.
3.6 Validity and reliability of the study
Validity:
Validity of the research instrument was ensured through the use of well designed check
list for data collection. The check list was designed to ensure that consistent results
would be achieved. The check list was assessed by obtaining opinion from my supervisor
and experts in research. Appropriate modifications were accordingly made and the tool
was finalized. The achievement was done in the pilot study
Reliability:
The data collected from the neonatal registry book and mothers-newborns’ cards were
checked daily and errors were corrected.
42
3.7 Data analysis procedure
Data were entered, cleaned and analyzed by using STATA software, version 13.0. First
descriptive analyses were carried out for each of the variables. Second, bivariate analyses
were done for the independent variables with the outcome variable to select candidate
variables for the multivariable analyses. Finally, Variables which showed significant
association with the dependent variable on the bivariate analysis were entered to
multivariate logistic regression model to identify their independent effects. Statistical
significance of association was determined by Odds Ratio (OR) with 95% CI, which do
not contain one, at significance level of p < 0.05.
3.8 Ethical considerations
The authorization letter was obtained from Mount Kenya University ethical committee.
The permission to conduct this study at GDH was obtained from the Director General.
Coding system was used instead of using the names and registration numbers of the
neonates. Thus hiding the identification of the neonates and their parents.
43
CHAPTER FOUR: RESEARCH FINDINGS
4.0. Introduction
This chapter presents the results and discussion of the study collected from the study
population. The table 4.1 presents Socio-democratic characteristics of study population.
A number of variables which show the significant associations with neonatal mortality in
Gihundwe District Hospital are presented in tables 4.2, 4.3, and 4.4.
4.1. Socio-demographic characteristics of neonate with Low Birth Weight in
Kangaroo Mother Care service at Gihundwe Hospital fron January 2015 to
December 2016.
Table 4. 1 Socio-democratic characteristics of study population from January 2015 to
December 2016
Characteristics Total (n=99) Case (n=33) Control (n=66)
n (%) n % n %
Sex
Male 59 (59,6) 22 66,7 37 43,9
Female 40 (40,4) 11 33,3 29 56,1
Gestational age in weeks 31,9 ±4,1 31,0 ±5,7 32,3 ± 3,0
< 30 32 (32,5) 11 33,3 21 31,8
30-37 61 (61,6) 20 60,6 41 62,1
> 37 6 (6,1) 2 6,1 4 6,1
Weight at admission in grams 2048,7 ± 328,5 2018 ±367 2064 ±308,7
1000-1500 8 (8,1) 3 9,1 5 7,6
1501-2000 28 (28,3) 12 36,4 16 24,2
2001-2499 63 (63,6) 18 54,5 45 68,2
Weight at discharge in grams 2178 ±4 1909,1 ±343,5 2313 ±151,0
1000-1500 4 (4,0) 4 12,1 0 0,0
1501-2000 16 (16,2) 11 33,3 5 7,6
2001-2499 72 (72,7) 18 54,5 54 81,8
≥ 00 7 (7,1) 0 0,0 7 10,6
Age at admission in days
(Means ±SD)
2,2 ± 2,2 2,2 ± 1,9 2,2 ± 2,3
Length of stay in days (Means
±SD)
9,9 ± 6,9 4,2 ± 3,3 12,0 ± 6,4
Apgar at 1 min < 7 30 (30,3) 16 48,5 14 21,2
Apgar at 5 min < 7 9 (13,6) 9 27,3 0 0,0
Ap ar at 10 min <7 1 (1,0) 1 3,0 0 0,0
44
Secondary data
Table 4.1 shows that the proportion of cases and controls regarding the gender, 59 LBW
(59.6%) were male, while 40 LBW (40,4%) were female. Mean gestational age at birth was
31±9 weeks. On admission in Kangaroo Mother Care, the mean weight was 2,048 ± 328g.
Apgar score remained under 7 for one neonate in case group at tenth minutes. A gain weight
was observed in control group at discharge than in case group.
45
4.2. Factors associated with mortality among low birth weight neonates in Kangaroo.
4.2.1 Maternal factors
Table 4.2 Maternal factors associated with mortality among low birth weight in
Kangaroo Mother at Gihundwe Hospital from January 2015 to December 2016
Factors Total Case Control OR (CI 95%) P
n=
99
% n=3
3
% n=
66
%
Maternal age
< 20 2 2.0 2 6.1 0 0.0 11.5 (0.53-249.19) 0.097
20-34 80 80.8 24 72.7 56 84.8 1.6 (0.55-4.79) 0.399
≥ 35 17 17.2 7 21.2 10 15.2 1
Antenatal care visits
Unrecorded 29 29.3 19 57.6 11 16.7 2.8 (0.46-19.48) 0.243
Incomplete 62 62.6 11 33.3 51 77.3 0.4 (0.06-2.26) 0.192
Complete 8 8.1 3 9.1 5 7.6 1
Marital status
Unmarried 34 34.3 20 60,6 14 21.2 5.7 (2.29-14.25) 0.0001
Married 65 65.7 13 39.4 52 78.8 1
Educational
attainment
Primary 59 59.6 24 72.4 35 53.0 2.7 (1.02-7.78) 0.030
Secondary or higher 40 40.4 8 27.6 32 47.0 1
Occupation
None 16 16.2 12 36.4 4 6.1 22.0 (4.20-115.01) 0.0001
Farmer 58 58.6 18 54.5 40 60.6 3.3 (0.87-12.45) 0.098
Employee 25 25.3 3 9.1 22 33.3 1
Parity
Primiparity (I) 27 27.3 17 51.5 10 15.2 5.9 (1.52-23.14) 0.013
Multiparity (II-IV) 54 54.5 12 36.4 42 63.6 1.0 (0.27-3.60) 1.000
Grandparity (V+) 18 18.2 4 12.1 14 21.2 1
Maternal illness
Yes 37 37.4 15 45.5 22 33.3 1.6 (0.70-3.91) 0.239
No 62 62.6 18 54.5 44 66.7 1
Place of delivery
At home 22 22.2 15 45.5 7 10.6 5.5 (1.60-19.95) 0.001
Health center 34 34.3 6 18.2 28 42.4 0.5 (0.16-1.88) 0.290
Hospital 43 43.4 12 36.4 31 47.0 1
Mode of de livery
Dystocia 25 25.3 10 30.3 15 22.7 1.4 (0.57-3.78) 0.413
Normal 74 74.7 23 69.7 51 77.3 1
Residence
Rural 68 68.7 27 81.8 41 62.1 2.7 (0.99-7.57) 0.056
Urban 31 31.3 6 18.2 25 37.9 1
46
Secondary data
Regarding the marital status of the mothers, the difference of proportion in cases against
controls among unmarried mothers (60.6% versus 21.2%), were statistically significant [OR:
5.7; (2.29-14.25); p< 0.0001]. The difference of proportion in cases versus controls among
mothers who have an educational level under or equal primary 72.4% versus 53.0%) were
statistically significant [OR: 2.7; (1.02-7.78); p= 0.030]. Considering the occupation of
mothers, it was found that the proportional difference between cases and controls among
mothers who were jobless (20.97% versus 5.91%) were statistically significant [OR: 22.0;
(4.20-115.01); p< 0.0001]. A significant statistical relationship was found between
primiparity and mortality in neonates (p =0.0003). There was a strong association between
neonatal mortality in Kangaroo and the place of delivery especially when it takes place at
home (p=0.001).
47
Table 4. 3 Neonatal factors associated with mortality among low birth weight in
Kangaroo Mother Care at Gihundwe Hospital from January 2015 to December 2016
Factors Total Case Control CI 95% P
n=99 % n=33 % n=66 %
Sex
Male 59 59.6 22 66.7 37 56.1 1.5 (0.65-3.74) 0.310
Female 40 40.4 11 33.3 29 43.9 1
Weight at admission
1000-2000 36 36.4 15 45.4 21 31.8 1.8 (0.69-4.61) 0.183
2001-249 63 63.6 18 54.6 45 68.2 1
1rst
minute Apgar score
< 7 57 57.6 23 67.7 34 51.5 2.1 (0.82-5.79) 0.844
≥ 7 42 42.4 10 30.3 32 48.5 1
Gestational age
< 30 32 32.3 11 33.3 21 31,8 1.0 (0.13-9.91) 0.960
30-37 61 61.6 20 60.6 41 62.1 1.0 (0.13-8.47) 0.978
> 37 6 6.1 2 6,1 4 6,1 1
Presence of complication
Yes 42 42.4 32 97,0 10 15,2 179,2 (21.9-1464.9) <0.0001
No 57 57,6 1 3,0 56 84,8 1
Resuscitation
Yes 18 18,2 11 33,3 7 10,6 4,2 (1,45-12,24) 0,005
No 81 81,8 22 66,7 59 89,4 1
Parental
nutrition
Yes 32 32,3 23 69,7 9 13,6 14,5 (5,23-40,49) <0.0001
No 67 67,7 10 30,3 57 86,4 1
Secondary data
48
Considering neonatal factors influencing mortality among LBW neonates in KMC, the
results of table 3 show that presence of complications, the resuscitation and parental nutrition
were found to have a significant relationship with mortality in KMC (p< 0.05).
4.3. Multivariate analysis of factors associated with mortality among low birth weight
in Kangaroo mother care at Gihundwe hospital from January 2015 to December 2016.
Factors OR adjusted CI 95% P
Unmarried 5.5 1.83-16.84 0.008
Parental nutrition 14.2 4.70-43.36 <0.0001
Presence of complications 16.4 5.13-47.60 <0.0001
Resuscitation 3.7 1.11-12.88 0.032
Residence 1.6 0.50-5.67 0.393
Occupation 0.5 0.19-1.59 0.276
Parity 0.3 0.12-1.01 0.053
Educational level 0.9 0.29-3.20 0. 966
Secondary data
In this study, the marital status, the parental nutrition, the presence of complications and the
resuscitation were found to be statistically significant as predictive factors for mortality
among low birth weight in Kangaroo mother care(p<0.05) as it is presented in table 4.
4.4 Determination of Neonatal Mortality rate in KMC
From 1st January 2015 to 31
st December016, Kangaroo Mother Care at Gihundwe district
hospital has recorded 183 low birth weight neonates. Ninety nine neonates were included in
this study with 33 for case group and 66 control group (one case for two controls). Of these,
33 (18.0%) died in Kangaroo Mother Care and 150 were discharged on Kangaroo Mother
Care.
Formula of Neonatal Mortality Rate = The neonatal mortality rate (NMR), is defined as
the number of deaths in the first 8 completed days of life per 1000 livebirths;
that is:
49
NMR = (33 X183)/1000= of 18.0 per 1000 live births: 95% CI [12.4-24.3]
4.5. Discussion
This research “Factors associated with mortality among low birth weight in Kangaroo
mother care in Gihundwe District Hospital in Rwanda” aimed at determining maternal and
newborn factors associated with neonatal mortality in low birth weight. During a period of
two years, data showed real 33 deaths in 183 low birth weight, that is, a neonatal mortality
rate of 18.0 per 1000 live births: 95% CI [12.4-24.3] at Gihundwe district Hospital.
In this study, mortality rate was found to smaller than national statistics (27 per 1000 live
births: 95% CI [23.6-31.0] in 2010 according to the study by Rebecca et al (2013).
There are several explanations for this difference. Initially it may be due to the improvement
of Kangaroo Mother Care services in recent years; improvement in coverage of maternal care
services has increased most, improvement in intervention-related indicators associated with
neonatal mortality delivery by health professionals, delivery in a health facility, use of ANC
services, early initiation of breastfeeding, and ownership of mosquito nets for malaria
prevention (Rebecca, 2013).
In this study, factors that were independently associated with mortality in KMC were
presence of complications, the resuscitation, parental nutrition, marital status, educational
level, occupation.
The findings regarding the association between socio-demographic characteristics and
neonatal mortality are worth noting. The presence of complications is associated with
neonatal death in Gihundwe District Hospital. However, initiatives should continue to
reinforce care of Low Birth weight in order to improve neonatal health outcomes.
50
In studies done by Krishna (2010) and Mbiba et al (2015); the presence of complications has
been reported to be associated with adverse neonatal outcome, death inclusive.
That maybe due to the weakness of the health system or due to the power situation of the
parents.
The finding of this study shows that the parenteral nutrition is also associated with neonatal
deaths. A study conducted by Zingg et al (2012) show the association between parenteral
nutrition and Neonatal mortality. He identified parenteral nutrition as an independent risk
factor for health care associated infection. Breastfeeding is the normal way of providing
young infants with the nutrients they need for healthy growth and development. Virtually all
mothers can breastfeed, provided they have accurate information and the support of their
family, the health care system and society at large (WHO, 2010).
It was also found that education level of mother is associated with mortality of Neonate at
GDH. Mbiba et al (2015), support that maternal education empowers women and is a
measure of socioeconomic status as it influences the mother’s decisions regarding health
matters. Education increases health knowledge and willingness to use of health facilities.
Secondary education was a protective factor and mothers utilized the health facilities. Lack
of schooling and lower levels of education were associated with perinatal deaths. The study
found that the Neonates who received the artificial ventilation were more likely to die than
those who did not receive artificial ventilation.
Rajab et al (2013), found that 80% of neonates who received artificial ventilation in Gharian
Teaching Hospital in Lybia die. Among those who died 10 neonates (0.075%) were exposed
to artificial ventilation, all were premature. Out of 1267 cases admitted to the neonatology
service over one year over one year 58 cases were died with an overall mortality rate
(4.57%). But the overall survival rate for very low birth weight newborns in Japan was
around 90%. This improvement of survival of such infants reflects the improvement in
51
medical care and better knowledge of the pathophysiology of the neonatal medicine.
Unmarried mothers were more at risk to lose their neonates with low birth weight in KMC at
GDH than those who were married. The reason should be because many of them had low
education, power socio economically. A study conducted by Arntzen (1996) found that the
unmarried mothers were younger, less well educated and had a lower socioeconomic status
than the married mothers. The stillbirth, neonatal, and post neonatal mortality rates were
higher among offspring of unmarried mother.
In this study, the sex of Neonates was not associated with mortality in KMC. In comparison
to a study done by Rebecca et al (2013), it was found that male babies were more likely to
die compared to female babies. The reason to this is not clear from available literature.
According to the Six Global Studies on New-borns, this may be related to male short life
spans, male babies were 14% more likely to be born prematurely and they develop slowly in
utero compared to female babies. Hence the possibility of dying from factors associated with
prematurity and complications of prematurity.
The effect follow up system could not be assessed as data were not available.
52
CHAPTER FIVE: SUMMARY, CONCLUSIONS AND
RECOMMENDATIONS
5.0. Introduction
This chapter gives a summary of the findings on factors associated with neonatal death in
Gihundwe District Hospital.
5.1. Summary of Findings
5.1.1. Objective one: Socio-demographic characteristics of study population.
The socio-demographic characteristics shown the statistically significant were :
Regarding the gender, 86 LBW (59.6%) were male. Mean gestational age at birth was 31±9
weeks. At admission in kangaroo, the mean weight was of 2048 ± 328g. Apgar score
remained under 7 for one neonate in case group at Tenth minutes. A gain weight was
observed in control group at discharge than in case group.
5.1.2 Objective two: Maternal factors associated with mortality among neonates in
Kangaroo Mother Care at Gihundwe District Hospital
The characteristics of mothers that were statistically significant between cases and controls
groups, were; regarding the marital status of the mothers, married and unmarried mothers
were statistically significant (p< 0.0001). The difference of proportion in cases versus
controls among mothers who have an educational level under or equal primary were
53
statistically significant (p= 0.030). Considering the occupation of mothers, it was found that
the proportional difference between cases and control groups among women jobless were
statistically significant (p< 0.0001). A significant statistical relationship was found between
primiparity and mortality in neonates (p =0.013). There was a strong association between
neonatal mortality in Kangaroo and the place of delivery especially when it takes place at
home (p=0.001).
5.1.3 Objective three: Neonate factors associated with mortality among neonates
in Kangaroo Mother Care at Gihundwe District Hospital.
The characteristics of Neonate that showed the difference between case and control
groups were statistically significant:
considering neonatal factors influencing mortality among LBW neonates in KMC, the results
of table 3 show that presence of complications (p=0,0001), the resuscitation (p=0,005) and
parental nutrition (p=0,0001) have a significant relationship with mortality in KMC
(p< 0.05).
5.1.4 Objective four: Mortality rate of neonate in Kangaroo Mother Care at Gihundwe
District Hospital from January 2015 to December 2016.
The neonatal mortality rate in KMC at Gihundwe District Hospital was 18.0 per 1000 live
births: 95% CI(12.4-24.3)
5.2 Conclusion
LBW mortality in KMC at Gihundwe District Hospital was found to be associated with
maternal factor such as unmarried (single or divorced) mother, mother with an educational
level under or equal to primary, primiparity and palce of delivery.
The neonatal mortality in KMC at GDH were resuscitated at birth, occurrence of
complications in KMC, LBW babies who received parenteral nutrition.
54
However, occurrence of complications and parenteral nutrition are associated negatively with
neonatal mortality in Gihundwe hospital.
5.3. Recommendations
From these research findings, it is recommended that:
Social mobilization of the community on reproductive health issues should be done through
health education to enhance undesired among married and unmarried mothers.
Improve care or management of LBW who attend the KMC in all Health facilities
Provide good quality of parenteral nutrition for LBW in KMC if possible by lobbing with
the government and donors.
There is need for concerted effort by all the stakeholders and community health workers to
explain to the community on the importance of attending all four ANC visits as this is
avoidable risk factors.
Pregnant women should be well informed and advised to go directly to the hospital for
services to avoid complications which may arise through the lengthy pattern of referral and
home delivery.
5.4. Suggestions for Further Study
There is need to:
Conduct a similar study in other district hospitals for proper generalization of the results.
Identify the other causal factors of neonatal mortalities and other poor pregnancy outcomes
as this study only identified some maternal and newborn factors contributing to neonatal
deaths.
Establish how several factors such as follow up system in KMC, referral system
environmental factors, biological factors and postnatal care factors contribute to neonatal
mortality, women‘s nutritional status at the time of conception, their body mass index,
55
distance to the health facility.
Establish the role of health providers involvement in prevention of adverse pregnancy
outcomes including early neonatal death.
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APPENDICES
61
APPENDEX A: Authorization Letter from the School of Post Graduate Studies of
Mount Kenya University
62
APPENDEX B: Authorization Letter from Gihundwe Hospital
63
APPENDEX C: Data Collection sheet
Use a CROSS symbol (×) as required
Neonate was 1. Died 2. Survived
Fill in provided boxes the LETTER which is corresponding to the variable recorded
on mother and neonate card.
PART ONE: NEONATAL FACTORS
1. Respondent code
2. Sex
a) Female
b) Male
3. Age
Between 0-10 days
Between10 -20 days
Between 20-30 days
30 and above
64
4. Gestational age (weeks):
Below 30
Between 30-37
Above 37
5. What was the baby’s Weight
a) On arrival (admission)
Between 1-1.5k
Between 1.5- 2kg
Between 2-2.5kg
b) At discharge (after 30 days)
Between 1-1.5kg
Between 1.5- 2kg
Between 2-2.5kg
6. Apgar at Birth:
7. Resuscitation at Birth?
Yes
No
8. Length of stay
Between 0 -2 weeks
Between 2 -4 weeks
9. Was there any Complications?
Yes
65
No
If yes? Which of these?
Gastroenteritis
Respiratory problems
Malaria
Others
No problem reported
10. Prognosis?
Died
Added weight?
Normally
Moderately
None
PART TWO: MATERNAL FACTORS
1. Age of Mother (years old)
Under 18
Between 18- 40
Above 40
2. Residence
- Rural
- Urban
3. Marital status of the parents
66
a) Married
b)Unmarried
4. Education level of mother
a) None
b) Primary
c) Secondary
d) University
5. Occupation of mother
a) Trader
b) Farmer
c) Government employee
d) Others specify them
……………………………………………………………………………………………
……………………………………………………………………………………………
…………
6. Parity:
7. Maternal illness
Yes
No
8. Ante natal care visits
Complete
Incomplete
Unrecorded
PART THREE: DELIVERY FACTORS
67
1. Place of delivery
Home
Health center
Hospital
Unrecorded
2. Mode of delivery
Dystocia
Normal
APPENDEX D: MAP of Gihundwe Hospital
Recommended