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 _____________

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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.

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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.

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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.

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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

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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

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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

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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

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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

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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

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(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.

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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).

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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).

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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