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Kangaroo mother care (KMC) is an evidence-based method to improve newborn survival. However, scale-up even for stable newborns has been slow, with reported barriers to implementation. We examined facilitators and barriers to initiating KMC before stabilisation amongst neonates recruited to the OMWaNA study in Uganda. The OMWaNA study was a randomised controlled trial that examined the mortality effect of KMC prior to stabilisation amongst newborns weighing ≤2000 grams. At the four trial hospitals, we conducted focus group discussions (FGD) separately with caregivers and healthcare providers, in-depth interviews (IDI) with caregivers and key informant interviews (KII) with hospital administrators and healthcare providers. The World Health Organisation (WHO) Health Systems Building Blocks were used to guide thematic analysis. Eight FGDs (4 caregivers, 4 healthcare providers), 41 caregiver IDIs (26 mothers, 8 grandmothers, 7 fathers), and 23 KIIs were conducted. Key themes based on the building blocks were; family and community support/ involvement, health workforce, medical supplies and commodities, infrastructure and design, financing, and health facility leadership. We found that the presence of a family member in the hospital, adequate provision of healthcare workers knowledgeable in supporting KMC prior to stability, and adequate space for KMC beds where neonatal care is being delivered, can enable implementation of KMC before stability. Implementation barriers included fear of inadvertently causing harm to the newborn, inadequate space to practice KMC in the neonatal unit, and a limited number of trained healthcare workers coupled with insufficient medical supplies.

An estimated 5.0 million children aged under 5 years died in 2020, with 82% of these deaths occurring in sub-Saharan Africa and southern Asia. Over one-third of Mumbai's population has limited access to healthcare, and child health outcomes are particularly grave among the urban poor. We describe the implementation of a digital technology-based child health programme in Mumbai and evaluate its holistic impact. Using an artificial intelligence (AI)-powered mobile health platform, we developed a programme for community-based management of child health. Leveraging an existing workforce, community health workers (CHW), the programme was designed to strengthen triage and referral, improve access to healthcare in the community, and reduce dependence on hospitals. A Social Return on Investment (SROI) framework is used to evaluate holistic impact. The programme increased the proportion of illness episodes treated in the community from 4% to 76%, subsequently reducing hospitalisations and out-of-pocket expenditure on private healthcare providers. For the total investment of Indian Rupee (INR) 2,632,271, the social return was INR 34,435,827, delivering an SROI ratio of 13. The annual cost of the programme per child was INR 625. Upskilling an existing workforce such as CHWs, with the help of AI-driven decision- support tools, has the potential to extend capacity for critical health services into community settings. This study provides a blueprint for evaluating the holistic impact of health technologies using evidence-based tools like SROI. These findings have applicability across income settings, offering clear rationale for the promotion of technology-supported interventions that strengthen healthcare delivery.

BackgroundLow birthweight (birthweight MethodsInfants aged 8-27 days of age weighing ≥2500 g at enrollment in Burkina Faso were randomized 1:1 to a single, oral dose of azithromycin (20 mg/kg) or matching placebo. We evaluated mortality and anthropometric outcomes in four subgroups: 1) both low birthweight and underweight at enrollment; 2) low birthweight-only; 3) underweight-only; 4) neither low birthweight nor underweight.FindingsOf 21,832 enrolled infants, 21,320 (98%) had birthweight measurements and included in this analysis. Of these, 747 (3%) were both low birthweight and underweight, 972 (5%) were low birthweight-only, 825 (4%) were underweight-only, and 18,776 (88%) were neither low birthweight nor underweight. Infants who were both low birthweight and underweight receiving azithromycin had lower odds of underweight at 6 months compared to placebo (OR 0.65, 95% CI 0.44 to 0.95), but the treatment group by subgroup interaction was not statistically significant (P = 0.06). We did not find evidence of a difference between groups for other outcomes in any subgroup.InterpretationAzithromycin may have some growth-promoting benefits for the highest risk infants, but we were unable to demonstrate a difference in most outcomes in low birthweight and underweight infants. As a secondary analysis of a trial, this study was underpowered for rare outcomes such as mortality.Trial registrationClinicalTrials.gov NCT03682653.

Introduction The COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers’ experiences and proposed mitigation strategies.Methods Using a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions.Results We analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother–baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families’ fear of visiting hospitals (~73%).Conclusion Newborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better.

Background Use of simulation in neonatal resuscitation (NR) training programmes has increased throughout low-income and middle-income countries. Many of such programmes have demonstrated a positive impact on NR knowledge and skill acquisition along with reduction of early neonatal mortality and fresh stillbirth rates. However, NR skill retention after simulation programmes remains a challenge.Methods This study assessed facility level NR skill retention after PRONTO International’s simulation training in Bihar, India. Training was conducted within CARE India’s statewide in-job, on-site Apatkaleen Matritva evam Navjat Tatparta mentoring programme as part of a larger quality improvement and health systems strengthening initiative. Public sector facilities were initially offered training, facilitated by trained nursing graduates, during 8-month phases between September 2015 and January 2017. Repeat training began in February 2018 and was facilitated by peers. NR skills in simulated resuscitations were assessed at the facility level at the midpoint and endpoint of initial training and prior to and at the midpoint of repeat training.Results Facilities administering effective positive pressure ventilation and assessing infant heart rate increased (31.1% and 13.1%, respectively, both p=0.03) from midinitial to postinitial training (n=64 primary health centres (PHCs) and 192 simulations). This was followed by a 26.2% and 20.9% decline in these skills respectively over the training gap (p≤0.01). A significant increase (16.1%, p=0.04) in heart rate assessment was observed by the midpoint of repeat training with peer facilitators (n=45 PHCs and 90 simulations). No significant change was observed in other skills assessed.Conclusions Despite initial improvement in select NR skills, deterioration was observed at a facility-level post-training. Given the technical nature of NR skills and the departure these skills represent from traditional practices in Bihar, refresher trainings at shorter intervals are likely necessary. Very limited evidence suggests peer simulation facilitators may enable such increased training frequency, but further study is required.

Abstract Background Preterm birth complications result in > 1 million child deaths annually, mostly in low- and middle-income countries. A World Health Organisation (WHO)-led trial in hospitals with intensive care reported reduced mortality within 28 days among newborns weighing 1000–1799 g who received immediate kangaroo mother care (iKMC) compared to those who received standard care. Evidence is needed regarding the process and costs of implementing iKMC, particularly in non-intensive care settings. Methods We describe actions undertaken to implement iKMC, estimate financial and economic costs of essential resources and infrastructure improvements, and assess readiness for newborn care after these improvements at five Ugandan hospitals participating in the OMWaNA trial. We estimated costs from a health service provider perspective and explored cost drivers and cost variation across hospitals. We assessed readiness to deliver small and sick newborn care (WHO level-2) using a tool developed by Newborn Essential Solutions and Technologies and the United Nations Children’s Fund. Results Following the addition of space to accommodate beds for iKMC, floor space in the neonatal units ranged from 58 m2 to 212 m2. Costs of improvements were lowest at the national referral hospital (financial: $31,354; economic: $45,051; 2020 USD) and varied across the four smaller hospitals (financial: $68,330-$95,796; economic: $99,430-$113,881). In a standardised 20-bed neonatal unit offering a level of care comparable to the four smaller hospitals, the total financial cost could be in the range of $70,000 to $80,000 if an existing space could be repurposed or remodelled, or $95,000 if a new unit needed to be constructed. Even after improvements, the facility assessments demonstrated broad variability in laboratory and pharmacy capacity as well as the availability of essential equipment and supplies. Conclusions These five Ugandan hospitals required substantial resource inputs to allow safe implementation of iKMC. Before widespread scale-up of iKMC, the affordability and efficiency of this investment must be assessed, considering variation in costs across hospitals and levels of care. These findings should help inform planning and budgeting as well as decisions about if, where, and how to implement iKMC, particularly in settings where space, devices, and specialised staff for newborn care are unavailable. Trial registration ClinicalTrials.gov, NCT02811432 . Registered: 23 June 2016.

Abstract Background and aims The American Academy of Pediatrics describes late preterm infants, born at 34 to 36 completed weeks' gestation, as at‐risk for rehospitalization and severe morbidity as compared to term infants. While there are prediction models that focus on specific morbidities, there is limited research on risk prediction for early readmission in late preterm infants. The aim of this study is to derive and validate a model to predict 7‐day readmission. Methods This is a population‐based retrospective cohort study of liveborn infants in California between January 2007 to December 2011. Birth certificates, maintained by California Vital Statistics, were linked to a hospital discharge, emergency department, and ambulatory surgery records maintained by the California Office of Statewide Health Planning and Development. Random forest and logistic regression were used to identify maternal and infant variables of importance, test for association, and develop and validate a predictive model. The predictive model was evaluated for discrimination and calibration. Results We restricted the sample to healthy late preterm infants (n = 122,014), of which 4.1% were readmitted to hospital within 7‐day after birth discharge. The random forest model with 24 variables had better predictive ability than the 8 variable logistic model with c‐statistic of 0.644 (95% confidence interval 0.629, 0.659) in the validation data set and Brier score of 0.0408. The eight predictors of importance length of stay, delivery method, parity, gestational age, birthweight, race/ethnicity, phototherapy at birth hospitalization, and pre‐existing or gestational diabetes were used to drive individual risk scores. The risk stratification had the ability to identify an estimated 19% of infants at greatest risk of readmission. Conclusions Our 7‐day readmission predictive model had moderate performance in differentiating at risk late preterm infants. Future studies might benefit from inclusion of more variables and focus on hospital practices that minimize risk.

Abstract Background There are 2.5 million neonatal deaths each year; the majority occur within 48 h of birth, before stabilisation. Evidence from 11 trials shows that kangaroo mother care (KMC) significantly reduces mortality in stabilised neonates; however, data on its effect among neonates before stabilisation are lacking. The OMWaNA trial aims to determine the effect of initiating KMC before stabilisation on mortality within seven days relative to standard care. Secondary objectives include exploring pathways for the intervention’s effects and assessing incremental costs and cost-effectiveness between arms. Methods We will conduct a four-centre, open-label, individually randomised, superiority trial in Uganda with two parallel groups: an intervention arm allocated to receive KMC and a control arm receiving standard care. We will enrol 2188 neonates (1094 per arm) for whom the indication for KMC is ‘uncertain’, defined as receiving ≥ 1 therapy (e.g. oxygen). Admitted singleton, twin and triplet neonates (triplet if demise before admission of ≥ 1 baby) weighing ≥ 700–≤ 2000 g and aged ≥ 1–

Background: COVID-19 is disrupting health services for mothers and newborns, particularly in low- and middle-income countries (LMIC). Preterm newborns are particularly vulnerable. We undertook analyses of the benefits of kangaroo mother care (KMC) on survival among neonates weighing ≤2000 g compared with the risk of SARS-CoV-2 acquired from infected mothers/caregivers. Methods: We modelled two scenarios over 12 months. Scenario 1 compared the survival benefits of KMC with universal coverage (99%) and mortality risk due to COVID-19. Scenario 2 estimated incremental deaths from reduced coverage and complete disruption of KMC. Projections were based on the most recent data for 127 LMICs (~90% of global births), with results aggregated into five regions. Findings: Our worst-case scenario (100% transmission) could result in 1,950 neonatal deaths from COVID-19. Conversely, 125,680 neonatal lives could be saved with universal KMC coverage. Hence, the benefit of KMC is 65-fold higher than the mortality risk of COVID-19. If recent evidence of 10% transmission was applied, the ratio would be 630-fold. We estimated a 50% reduction in KMC coverage could result in 12,570 incremental deaths and full disruption could result in 25,140 incremental deaths, representing a 2·3–4·6% increase in neonatal mortality across the 127 countries. Interpretation: The survival benefit of KMC far outweighs the small risk of death due to COVID-19. Preterm newborns are at risk, especially in LMICs where the consequences of disruptions are substantial. Policymakers and healthcare professionals need to protect services and ensure clearer messaging to keep mothers and newborns together, even if the mother is SARS-CoV-2-positive. Funding: Eunice Kennedy Shriver National Institute of Child Health & Human Development; Bill & Melinda Gates Foundation; Elma Philanthropies; Wellcome Trust; and Joint Global Health Trials scheme of Department of Health and Social Care, Department for International Development, Medical Research Council, and Wellcome Trust.