Newborn Care Practices in Northern Uganda : Studies on breastfeeding, decision-making and hypothermia
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Background: Early initiation and exclusive breastfeeding reduce neonatal morbidity and mortality. One of the key mechanisms through which optimal breastfeeding reduces neonatal mortality is by reducing neonatal hypothermia. However, there are no proper estimates of neonatal hypothermia in sub-Saharan Africa. Interventions that promote optimal breastfeeding are listed as priority interventions for achieving sustainable development target 3.2 of reducing neonatal mortality to less than 12 deaths/1,000 live births and mortality of children less than five years to less than 25 deaths/1,000 live births. There is a dearth of data on how to deliver effective interventions that promote optimal breastfeeding in sub-Saharan Africa and the agents through which these interventions should be delivered. Objectives: 1) To assess the prevalence and determinants of delayed breastfeeding initiation 2) To determine the incidence and predictors of neonatal hypothermia 3) To determine the effect of peer counseling, mobile phone messages and mama kits on early initiation of and exclusive breastfeeding 4) To determine key decision makers and actors in selected newborn care practices. Methods: We conducted a survey that included 930 mothers with infants less than two years old, and assessed the prevalence of delayed breastfeeding initiation, and the key decision makers and actors in selected newborn care practices. We then conducted a cluster randomized controlled study where we randomized 30 clusters to an intervention (peer counseling, mobile phone messaging, and distribution of mama kits) or control arm (standard of care). Mothers were enrolled during pregnancy and followed up until birth when the outcome (early breastfeeding initiation) was assessed. We assessed for neonatal hypothermia by taking a high axillary temperature using a lithium battery-operated digital thermometer. All statistical analyses were done while factoring in clustering. We used logistic regression models and generalised estimation equations for the Poisson family, with a log and identity link, assuming an exchangeable correlation. Results: Almost half [448/930: 48.2% (95% Confidence Interval (CI) 44.3,52.1)] of mothers delayed initiation of breastfeeding. The incidence of hypothermia was 678/1330 [51.0%: 95% CI (46.9-55.1)]. Of these 32% (429/1330), 95%CI (29.5-35.2)] had mild hypothermia (temperature 36.0°C - <36.5°C), while 18.7% (249/1330), 95% CI (15.8-22.0) had moderate hypothermia (temperature 32.0°C - <36.0°C). At multivariable analysis, the factors associated with neonatal hypothermia included: home birth [Adjusted Risk Ratio (ARR) 1.9, 95% CI (1.4-2.6)], low birth weight [ARR 1.7, 95%CI (1.3-2.3)], and delayed breastfeeding initiation [ARR 1.2, 95%CI (1.0-1.5]. Sixty-four percent (337/511) of participants in the intervention arm initiated breastfeeding within the first hour after birth compared to 60% (255/423) in the control arm whereas 89% (804/904) of participants in the intervention arm exclusively breastfed their infants in the first month of life compared to 81% (656/813) in the control arm. Fathers most commonly decided on where a mother gave birth (54.3%, n = 505), but the mothers (31.1%, n = 289) were also common decision makers. Fathers also most commonly decided on whether to seek care for a sick newborn child (47.7%, n = 92). Grandmothers most commonly bathed the baby immediately after birth (55.5%, n = 516), while mothers most commonly decided on when to initiate breastfeeding (53.7%, n = 499) and on whether to bottle-feed or not (73.6%, n = 684). Health workers were also commonly cited in the decision to initiate breastfeeding and to practice bottle-feeding. Conclusion: The incidence of neonatal hypothermia was high, demonstrating that communities in tropical climates should not ignore neonatal hypothermia. Only half of mothers practiced early breastfeeding initiation, a protective factor for neonatal hypothermia. An intervention consisting of peer counseling, mobile phone messaging and mama kits delivered to both the mother and significant others like husbands and mothers-in-law increased the proportion of mothers who exclusively breastfed at one-month postpartum, but did not increase the proportion of women who initiated breastfeeding within the first hour after birth. Interventions that promote early breastfeeding initiation should consider involvement of people who conduct the deliveries if they are to be successful. Fathers, grandmothers, health workers and traditional birth attendants were key decision makers in newborn care, and should be targeted for interventions promoting newborn care.
Består avPaper I: David Mukunya, James K. Tumwine, Victoria Nankabirwa, Grace Ndeezi, Isaac Odongo, Josephine Tumuhamye, Justin Bruno Tongun, Samuel Kizito, Agnes Napyo, Vincentina Achora, Beatrice Odongkara, Thorkild Tylleskar: Factors Associated With Delayed Initiation of Breastfeeding: a Survey in Northern Uganda. Glob Health Action.2017; 10(1): 1410975. The article is available in the thesis file. The article is also available at: http://hdl.handle.net/1956/18198.
Paper II: David Mukunya, James K. Tumwine, Thorkild Tylleskar, Agnes Anna Arach, Josephine Tumuhamye, Justin Bruno Tongun, Agnes Napyo, Vivian Zalwango, Vincentina Achora, Beatrice Odongkara, Grace Ndeezi, Victoria Nankabirwa: Incidence and factors associated with neonatal hypothermia in Northern Uganda: a community based Cohort. The article is not available in the thesis file.
Paper III: David Mukunya, Thorkild Tylleskar, Grace Ndeezi, Agnes Anna Arach, Josephine Tumuhamye, Justin Bruno Tongun, Agnes Napyo, Vivian Zalwango, VincentinaAchora, Beatrice Odongkara, James K. Tumwine and Victoria Nankabirwa: Effects of peer counseling, mobile phone messages, and mama kits on early and exclusive breastfeeding in Northern Uganda: a cluster randomized controlled study. The article is not available in the thesis file.
Paper IV: David Mukunya, Victoria Nankabirwa, Grace Ndeezi, Isaac Odongo, Josephine Tumuhamye, Justin Bruno Tongun, Samuel Kizito, Agnes Napyo, Vincentina Achora, Beatrice Odongkara, Thorkild Tylleskar, James K. Tumwine: Key Decision Makers and Actors in Selected Newborn Care Practices: A Community-Based Survey in Northern Uganda. Int J Environ Res Public Health. 2019; Pii: E1723. The article is available in the thesis file. The article is also available at: http://doi.org/10.3390/ijerph16101723.