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Study Protocol Effectiveness of Kangaroo

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Study Protocol Effectiveness of Kangaroo STUDY PROTOCOL EFFECTIVENESS OF KANGAROO CARE EDUCATION PROGRAMME ON MOTHERS, NURSES, AND INFANTS OUTCOMES IN A NEONATAL INTENSIVE CARE UNIT 8/6/2017 1 CHAPTER 1: INTRODUCTION 1.1 Background A neonatal intensive care unit (NICU) is a unit that specializes in the treatment of ill preterm infants. The World Health Organization (WHO) 2013 defined a preterm birth as one where an infant is born alive prior to 37 weeks of pregnancy. Preterm infants are sub-categorised depending on gestational age: extremely preterm (below 28 weeks), extremely preterm (28- <32 weeks), moderately preterm (32-<34 weeks), and late preterm (34-37 weeks) WHO (2013). Generally, preterm or premature infants have a low birth weight (LBW), weighing less than 2500 grams. To achieve a balance of fluids and nutrients, premature infants are placed in an incubator and observed closely until they reach a predetermined weight according to hospital protocol. 1.1.2 Premature infant According to the WHO (2012) Global Action Report on premature births, it is estimated that 15 million infants (1 in 10) are born prematurely each year (that is before 37 weeks of gestation) and this number is escalating. Prematurity is the world's leading cause of newborn deaths and many prematurely surviving babies face the possibility of disability for a lifetime. Complications of premature birth are the dominant cause of death for children under the age of 5, accounting for about 1 million deaths in 2015. Premature birth prevalence ranges from 5 to 18% of all infants born over 184 countries. In Malaysia, based on the National Obstetrics Registry, the incidence of premature births for 14 tertiary care hospitals in 2012 was 11.3%, and this was deemed a serious health issue (New Straits Times, 2014). 1.1.3 Kangaroo care 2 Kangaroo care (KC) is a simple evidence-based nursing practice intervention that can benefit premature newborns’ lives by helping to increase weight gain, reducing the length of hospitalization, and increasing breastfeeding rates. KC was started in Colombia in 1978 as a way to address mother and baby separation issues, overcrowding, and a lack of incubators in infant care hospitals (Charpak, Ruiz-Pelaez & Figueroa de Calume, 1996). KC is termed for its similarity to how kangaroos carry their babies and was originally designed to look after preterm infants in places where incubators were either inaccessible or unreliable. Basically, KC is introduced in order to simulate an incubator whilst naturally fostering mother-infant attachment. This is supported by the theory that neonates, as well as preterm infants, should not be separated from their mothers. Therefore, KC is essentially a natural incubator used by the mother. According to this principle, a preterm infant is positioned in a vertical position on its mother's bare chest or in a slightly upturned position between her breasts with head turned to one side; its arms and legs flexed (frog-leg position), and with its umbilicus and abdomen on the upper belly of its mother. The infant is then covered to keep it warm, and so that the maternal body heat can help control its body temperature (Ludingtone-Hoe, 2008). In KC, the preterm infant is stimulated by mechanisms such as vestibular stimulus of the mother's breathing and chest movements, hearing stimulus of the mother's voice, normal respiratory sounds and her heartbeat, and mother's skin touch stimulation. These types of stimulation are essential for the growth and development of the preterm infant. KC provides a biological environment where the infant can get the basic needs of its early days i.e. warmth for development, nutrition such as breast milk for growth and close observation for example, apnoea in prematurity. According to WHO (2015), nearly three- quarters of premature birth-related deaths can be avoided by a cost-effective intervention that involves giving KC treatment, antenatal corticosteroids, and antibiotics to premature infants. 3 Antenatal corticosteroids, early initiation of continuous positive airway pressure (CPAP), and KC have enhanced preterm infant survival and are a cost-effective treatment (Bhutta, Das Bahl, Lawn, Salam, Paul, Sankar, Sankar, Blencowe, Rizvi, Chou, & Walker, 2014). KC may be safely started at greater than 28 weeks of postconceptional age (Cattaneo, Davanzo, Uxa., & Tamburlini;1998 & 2007). KC is a simple type of nursing care starting from the Neonatal Intensive Care Unit(NICU). which assists preterm infants throughout the whole process of growth and development. Contact with and assistance from the preterm infant's mother is essential in order for her to demonstrate strong accountability in her attention to her preterm newborn. The KC techniques implemented by the postnatal mother in this universe of neonatal care come from her context of life, even though her behaviors originate from the guidance of health professionals. Nevertheless, in order to continue exclusive breastfeeding, the socio-cultural network seeks to have a greater influence on the treatment of premature infants. KC is now available for premature infants who need neonatal intensive care, including those who are extremely premature and with a ventilator assistance as well. In addition, it was stated at the second International Workshop on KC held in Bogota, Colombia, that KC is a fundamental right of the neonatal as an integral part of LBW management, in all settings and at all care levels in all countries. To support this, KC training must, therefore, be structured and involve mothers’ and nurses’ initiatives for KC application to be successful in the neonatal setting and after the mothers return home. In addition, this can also be achieved by providing KC guidelines and protocol information through high- quality public health programs and through home-visiting as a central service for young mothers with LBW infants. According to Purbasary, Rustina, and Budiarti, (2017) home visiting will support and determine the capacity of young mothers to apply KC with their LBW infants. 4 Over the past three decades, KC has been known as a safe and effective technique for infant care; practicable for increasing the survival of LBW newborns, especially in low- and middle-income countries. Despite, much investment in implementation, education, and training, some countries find it hard to increase their efforts to support KC, and individual organizations are still struggling to institutionalize KC in a sustainable manner. A greater understanding has developed over the past decade about the health system mechanisms to be followed in implementing KC. KC may be started early once the infant is clinically stable. However, for those with a severe illness or for those unstable preterm infants requiring special treatment, it is recommended to wait until the infant has stabilized before initiation of KC. This is supported by Thukral, Chawla, Agarwal, Deorari, & Paul, (2008). Although many researchers have stated that KC is a fundamental element developmentally congruous with therapy for hospitalized preterm care which has short and long-term beneficial effects for infants (Ludington-Hoe, 2013), resource limitations, increased staff turnover and an inadequate supply of trained nurses inhibits the implementation of KC in the hospital setting. Limitations, such as facilities, staff shortages, high turnover of experienced staff, and insufficient numbers of nurses qualified in KC inhibits the performance of KC in the hospital setting (Lee, Martin-Anderson, Dudley, 2012). According to Ghani, Edvardssonb & Amir (2020), current or potential obstacles include the absence of a clear framework or guidelines for supporting KC techniques, lack of ability and incentive to adopt KC practices, mothers not interested in KC, lack of professional coordination, staffing and time constraints, and a medical birth environment that prioritizes interventions over KC. As well as the limited resources for enforcing KC, the perceptions of mothers and nurses must also be at the forefront of KC's success in the NICU. Accordingly, nurses are the key drivers in providing relevant information and positive views on reactions to KC, knowledge 5 on KC, and ability to perform the KC technique. Furthermore, nurses in the NICU must be dedicated to successfully implementing KC as a continuous basic quality neonatal care practice. According to Cho, Kim, Kwon, Cho, Kim, Jun, & Lee (2016), KC has substantial positive effects on physiological functions, such as respiratory rhythm, enhances bonding, and health, and has the capability to relieve mother’s stress, as well as contributing to infant’s weight gain. Mothers of LBW infants lack confidence to care for their babies (Smith, Bergelson, Constantian, Valsangkar, & Chan, 2017). This might mean that young mothers do not realize the big impact the nature and effect of their attachment with their premature infant has, because they have insufficient information, experience, and strength, and they might not be physically or psychologically mature, psychologically or physically (Kuo, Chuang, Lee, Liao, Chang, & Lee, 2012). Therefore, this study aims to identify the perceptions, knowledge, and perceived barriers that primipara or multipara mothers with premature infants face when implementing KC in relation to to their confidence and ability to perform KC until their premature infants reach 3-months-old. A study was done by Norimah, Marlina, & Rashidah (2018) on infant weight gain patterns at PPUKM Malaysia. The mean gestational age score for infants in the experimental group was M=38.13;(SD=2.05) while the mean gestational age in control group was M=37.6 (SD= 2.26). The findings revealed that, within four weeks, there was a significant (p<0.00) difference in improvement in weight gain pattern beween the groups. In the experimental group, the weight increased from 2.89 kg to 3.38kg in contrast with the control group, where there was a slight gain from 2.98kg to 3.33kg after the four week study period. However, the study explored only the efficacy of breastfeeding and weight gain patterns among term babies.
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