Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions

Background

Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up.

Methods

The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC.

Results

Marked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks.

Conclusions

There are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

     

Effects of changing work patterns on general surgical training over the last decade

BACKGROUND There is concern across all medical specialties that shift patterns and reduced working hours are detrimental to training, and that craft specialties have been most affected. This study aimed to examine the effects of these changes to training on the quantity of operating performed by surgical trainees in a UK teaching hospital. METHODS This retrospective study of prospectively collected computerised theatre data examined elective and emergency general surgical operations performed over four time periods: 1996 (Calman), 2001 (New Deal), 2004 and 2009 (European Working Time Directive). Procedures were analysed according to grade of surgeon and time of day. RESULTS In 1996, most appendicectomies (72.2%) were performed by senior house officers (SHOs), compared with 3.8% in 2009. By 2009, SHOs did not perform any emergency procedures other than abscess drainage and appendicectomy. The proportion of emergency operating performed by specialist registrar (SpRs) has remained constant, but elective operating has reduced from 34.6% (1996) to 15.7% (2009). Supervision of both SHOs and SpRs has increased between 1996 and 2009 in both elective and emergency work. CONCLUSIONS The proportion of operating performed by SpRs and SHOs has fallen over the last decade, coinciding with implementation of structural changes to training, the advent of minimally invasive techniques, and the drive for a consultant led health service. Trainees may therefore require increased supervision as well as protected theatre sessions to balance operative training with ward based duties. Education must be integrated into working practice in order for trainees to achieve expected competencies and ultimately produce adequately experienced consultants.     

Thermal,Optical, and Static/Dynamic Mechanical Properties of Linear‐core Crosslinked Star Polymer Blends

Core crosslinked star (CCS) polymers ae synthesized and blended with linear polymers. Constrained mobility is revealed by an increase in modulus and strength with CCS polymer concentration, while creep deformation decreases and permanent strain increases. Storage modulus, loss modulus, and glass transition temperature increase with CCS polymer concentration due to miscibility and linear‐CCS polymer “arm” interactions. Master curves shift to lower frequencies with blends that experience segmental relaxation across a broader time scale due to a range of molecular environments from linear to maximum constraints in the vicinity of the crosslinked cores. Fragility and apparent activation energy increase with CCS polymer content, while fractional free volume and volume expansion decrease.

     

Born Too Soon: The global epidemiology of 15 million preterm births

This second paper in the Born Too Soon supplement presents a review of the epidemiology of preterm birth, and its burden globally, including priorities for action to improve the data. Worldwide an estimated 11.1% of all livebirths in 2010 were born preterm (14.9 million babies born before 37 weeks of gestation), with preterm birth rates increasing in most countries with reliable trend data. Direct complications of preterm birth account for one million deaths each year, and preterm birth is a risk factor in over 50% of all neonatal deaths. In addition, preterm birth can result in a range of long-term complications in survivors, with the frequency and severity of adverse outcomes rising with decreasing gestational age and decreasing quality of care. The economic costs of preterm birth are large in terms of immediate neonatal intensive care, ongoing long-term complex health needs, as well as lost economic productivity. Preterm birth is a syndrome with a variety of causes and underlying factors usually divided into spontaneous and provider-initiated preterm births. Consistent recording of all pregnancy outcomes, including stillbirths, and standard application of preterm definitions is important in all settings to advance both the understanding and the monitoring of trends. Context specific innovative solutions to prevent preterm birth and hence reduce preterm birth rates all around the world are urgently needed. Strengthened data systems are required to adequately track trends in preterm birth rates and program effectiveness. These efforts must be coupled with action now to implement improved antenatal, obstetric and newborn care to increase survival and reduce disability amongst those born too soon.

Declaration

This article is part of a supplement jointly funded by Save the Children's Saving Newborn Lives programme through a grant from The Bill & Melinda Gates Foundation and March of Dimes Foundation and published in collaboration with the Partnership for Maternal, Newborn and Child Health and the World Health Organization (WHO). The original article was published in PDF format in the WHO Report "Born Too Soon: the global action report on preterm birth" (ISBN 978 92 4 150343 30), which involved collaboration from more than 50 organizations. The article has been reformatted for journal publication and has undergone peer review according to Reproductive Health's standard process for supplements and may feature some variations in content when compared to the original report. This co-publication makes the article available to the community in a full-text format.

     

The role of multi-disciplinary teams in decision-making for patients with recurrent malignant disease

Background: It is mandatory in many countries for decisions for all new patients with cancer to be made within multi-disciplinary teams (MDTs). Whether patients with disease recurrence should also routinely be discussed by the MDT is unknown. Aim: This study investigated the role of an upper gastro intestinal (UGI) MDT in decision-making for patients with disease recurrence. Design: A retrospective review of prospectively kept MDT records (2010 to 2011) was performed identifying patients discussed with recurrence of oesophagogastric cancer. Information was recorded about: i) why an MDT referral was made, ii) who made the referral and iii) the final MDT recommendation. Implementation of the MDT recommendation was also examined. Participants: All patients discussed with recurrence of cancer at a central UGI cancer MDT were included. Results: During the study 54 MDT meetings included discussions regarding 304 new patients and 29 with disease recurrence. Referrals to the MDT for patients with recurrence came from outpatient clinics (n=19, 65.5%) or following emergency admission (n=10). Most referrals were made by the surgical team (n=25, 86.2%). MDT recommendations were best supportive care (n=11, 37.9%), palliative chemotherapy (n=9, 31.0%), stent (n=5, 17.2%), palliative radiotherapy (n=3, 10.3%) and further surgery (n=1, 3.4%), with 25 (86.2%) of these implemented. Conclusion: UGI MDTs focus on new referrals and only a small proportion of patients with recurrent disease are re-discussed. Many patients go on to receive further treatments. Whether such patients are optimally managed within the standard MDT is uncertain, however, and warrants further consideration.