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Care Program for Premature and Low Birth Weight Infants in Sub-Saharan Africa

Evaluation of Continuity of Care Program for Premature and Low Birth Weight Infants in Sub-Saharan Africa: A Multicenter Observational Cohort Study in Ashanti Region of Kumasi, Ghana

Participating Centers: Ghana Health Service, Suntreso Government Hospital, Kumasi South Regional Hospital

Investigators: Yolaine A. Civil MD, Ashura Bakari MD, R. Alexander Blackwood MD, and Andrew Campbell MD

Objective: The primary goal of this study will be to establish a system for providing routine outpatient preventive care visits for premature and low birth weight infants at more frequent intervals.  This is a Multicenter Observational Cohort Study. The study population will be newborn infants from Suntreso Government Hospital and Kumasi South Regional Hospital that meet the following criteria: A. Low Birth Weight: Baby born weighing between 500gm and less than or equal to 2.5 kg. B.  Prematurity: Baby born that is less than 37 weeks gestational age by dates or Ballard exam.

Rationale/Significance of the Problem: Severe malnutrition is a significant underlying cause of death in hospitalized preterm infants in low-resource countries. Many of these infants, who survive hospitalization, are discharged with very low birth weights placing these infants at high risk for malnutrition. Severe malnutrition in infancy, especially the early weeks of life, has long-term adverse effects for the individual and the community. Many newborns, including very low birth weight infants, are surviving in these countries because of concerted efforts to achieve the fourth millennium development goal of globally reducing the mortality rate of children less than 5 years old. 2This project will address long term care of these babies once they are no longer hospitalized. During the three year course of this project, we anticipate demonstrating a reduction in infant malnutrition and con-current illness among the babies enrolled in the study.

Study Design and Methods: A partnership between the University of Michigan and Ghanaian Health Service participating hospitals, Suntreso Government Hospital and Kumasi South Regional Hospital, was formed through the support of the University of Michigan Office of Health Equity and Inclusion to study preventive care for low birth weight and premature infants in this context. A total of 560 newborns who meet the study criteria (weighing between 500 grams and ≤2.5 kg or born at <37 weeks gestation) will be randomly assigned to one of four groups (Group A, B, C, D). Each caregiver family will receive 20 cedis per preventive health care visit.

Data Collection: A chart review will be done on each newborn admitted to the study prior to hospital discharge. Pertinent information will include name, sex, birth weight, birth length, birth head circumference, discharge weight, gestational age, mother’s name, mother’s age, region of origin, pregnancy complications, delivery complications, hospital course, history of jaundice, presence of sickle hemoglobin, and date of hospital discharge. Two days after hospital discharge, all the enrolled newborns will have a preventive health care visit. All preventive health care visits will include documented weight, length, head circumference, physical examination and assessment of infant feeding practices using a WHO validated infant feeding survey that has been modified based on cultural practices in Ghana. Socio-demographic information will be collected from each caregiver including participant age, number of children, occupation, education, and distance the family travels to either Suntreso or Kumasi South Regional Hospitals. Documentation will also include caregiver concerns or questions and presence of illness. Nurses will provide breast feeding education and reinforcement. All study participants will watch short videos with information on caring for small babies.

 

Group A and C will return to either Suntreso or Kumasi South Hospital at 3 months of age for a preventive health care visit. The infant feeding survey will be re-administered. It will also include the number of infections treated during the past 3 months, the number of times the primary caretaker sought medical care during the past 3 months, and if the newborn has been hospitalized during the past 3 months. Newborns assigned to Groups A and B will return to Suntreso Government Hospital at 6 months of age for a preventive care visit. For Group A caregivers, survey questions will include the number of infections treated during the past 3 months, the number of times the primary caretaker sought medical care during the past 3 months, and if the newborn has been hospitalized during the past 3 months. Group B survey questions will include the number of times the primary caretaker sought medical care during the past 6 months, the number of times the infant was ill during the past 6 months, and if the newborn has been hospitalized during the past 6 months.

All enrolled patients in Groups A, B, C, and D will return to Suntreso Government Hospital at 12 months of age for a preventive health care visit. All the caregivers will be interviewed to complete the infant feeding survey, with questions including the number of times the infants needed medical care since their last visit, presence of illness, and the number of hospitalizations since the last preventive health care visit.

Data Analysis: All data will be entered into SPSS (Statistical Package for the Social Sciences) statistical software. This software will allow us to determine how data varies between groups using chi square analysis, thereby allowing us to determine which group has the highest rate of infant malnutrition indicated by the presence of stunting, wasting, and underweight. The number of infections diagnosed and treated will be obtained by caregiver infant survey and chart reviews. This data, along with the presence of sickle hemoglobin, the number of hospitalizations, and the number of times the caregiver sought medical care between visits, will be entered into the statistical software and compared between the groups using the Chi-squared test for categorical variables and Wilcoxon rank sum test for continuous variables. To quantify prevalence of breast feeding infants at 12 months of age between the four trial groups, the breast feeding data will be obtained from the results of the infant feeding survey and also compared between groups using the Chi-squared test for categorical variables and Wilcoxon rank sum test for continuous variables.

Proposed Timeline for Project: This is a 3-year project starting in 2017 and running until 2020. It is funded by the Office of Health Equity and Inclusion at the University of Michigan. Recruitment will occur during the first 10 months of the study.

Anticipated undergraduate/Graduate Student Activities on project:

  • Administration of infant feeding surveys and data collection from chart reviews
  • Collection of nutritional data and measurements
  • Data analyses

Techniques/methods students should become familiar with in advance:

  • Knowledge of basic epidemiology concepts
  • Knowledge of common health issues seen in premature and low birth weight infants.
  • Knowledge of Maternal risk factors for delivering a premature of low birth weight infant.
  • Knowledge of most common risk factors for infant mortality in Sub-Saharan Africa, particularly in Ghana.

Suggested readings (Minimum of 3-5 articles)

  1. Aheto JMK, Keegan TJ, Taylor BM, Diggle PJ. Childhood Malnutrition and Its Determinants among Under-Five Children in Ghana. Paediatr Perinat Epidemiol. 2015;29(6). doi:10.1111/ppe.12222.
  2. Enweronu-Laryea CC, Aryee INA, Adei EAP. Severe acute malnutrition in very low birth weight preterm infants. JPEN J Parenter Enteral Nutr. 2012;36(3):354-357. doi:10.1177/0148607111421789.
  3. Mulumba LL, Wilson L. Sickle cell disease among children in Africa: An integrative literature review and global recommendations. Int J Africa Nurs Sci. 2015;3:56-64. doi:10.1016/j.ijans.2015.08.002.
  4. Hyacinth HI, Adekeye O a, Yilgwan CS. Malnutrition in Sickle Cell Anemia: Implications for Infection, Growth, and Maturation. J Soc Behav Heal Sci. 2013;7(1):1-11. doi:10.5590/JSBHS.2013.07.1.02.
  5. Mogre V, Dery M, Gaa PK. Knowledge, attitudes and determinants of exclusive breastfeeding practice among Ghanaian rural lactating mothers. Int Breastfeed J. 2016;11(12):1-8. doi:10.1186/s13006-016-0071-z.
  6. Mulumba LL, Wilson L. Sickle cell disease among children in Africa: An integrative literature review and global recommendations. Int J Africa Nurs Sci. 2015;3:56-64. doi:10.1016/j.ijans.2015.08.002.
  7. Bain LE, Awah PK, Geraldine N, et al. Malnutrition in Sub – Saharan Africa: Burden, causes and prospects. Pan Afr Med J. 2013. doi:10.11604/pamj.2013.15.120.2535.
  8. Lenters LM, Wazny K, Webb P, Ahmed T, Bhutta ZA. Treatment of severe and moderate acute malnutrition in low- and middle-income settings : a systematic review , meta-analysis and Delphi process. 2013;13(Suppl 3).