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Клинические практические рекомендации по вовлечению матерей в уход за новорожденными высокого риска в отделениях интенсивной терапии новорожденных в странах с низким и средним уровнем дохода (в развивающихся странах): дискуссия
Шива Н., Прахарадж М., Трипати П._
Колледж медсестер SUM, Университет Сикша «О» Анусандхан (SOA), Бхубанешвар, 751030, г. Одиша, Индия
Резюме _
Было показано, что участие матерей в уходе за новорожденными значительно улучшает клинические исходы новорожденных высокого риска и способствует благополучию родителей. Однако внедрение данных практик в отделениях интенсивной терапии новорожденных (ОИТН) в странах с низким и средним уровнем дохода (СНСД) (развивающихся странах) является проблемой в связи с ограниченными ресурсами, культурными различиями, инфраструктурными и кадровыми ограничениями. В данной дискуссионной статье описываются стратегии и соображения по эффективному вовлечению матерей в уход за новорожденными высокого риска в отделениях интенсивной терапии новорожденных в СНСД.
Целью данной статьи является обзор существующей литературы, тематических исследований и практических рекомендаций, позволяющий представить комплексную основу для успешного внедрения родительского участия в уходе за новорожденными.
Финансирование. Исследование не имело спонсорской поддержки. Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.
Благодарность. Авторы выражают признательность за техническую помощь и ресурсы, предоставленные Университетом Сикша «О» Анусандхан, Бхубанешвар, Индия.
Для цитирования: Шива Н., Прахарадж М., Трипати П. Клинические практические рекомендации по вовлечению матерей в уход за новорожденными высокого риска в отделениях интенсивной терапии новорожденных в странах с низким и средним уровнем дохода (в развивающихся странах): дискуссия // Неонатология: новости, мнения, обучение. 2024. Т. 12, № 3. С. 86-89. DOI: https://doi.org/10.33029/2308-2402-2024-12-3-86-89 (англ.) Статья поступила в редакцию 06.07.2024. Принята в печать 05.08.2024.
Ключевые слова:
клинические практические рекомендации; матери; новорожденные; уход за новорожденными высокого риска; отделениях интенсивной терапии новорожденных; развивающиеся страны; клинические исходы
Clinical practice guidelines for involving mothers in high-risk neonate care at neonatal intensive care unit in low and middle-income countries: a discussion paper
Siva N., Praharaj M., Tripathy P.
SUM Nursing College, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, 751030, Odisha, India
Шива Н., Прахарадж М., Трипати П.
клинические практические рекомендации по вовлечению матерей в уход за новорожденными высокого риска в отделениях интенсивной терапии новорожденных в странах с низким и средним уровнем дохода (в развивающихся странах): дискуссия
Abstract
Maternal involvement in neonatal care has been shown to significantly improve clinical outcomes for high-risk neonates and promote parental well-being. However, implementing these practices in neonatal intensive care units (NICUs) in low and middle-income countries (LMICs) presents unique challenges due to resource constraints, cultural differences, infrastructural and workforce limitations. This discussion paper describes the strategies and considerations for effectively involving mothers in the care of high-risk neonates in NICUs in LMICs. Through a review of existing literature, case studies, and practical recommendations, this paper aims to provide a comprehensive framework for the successful implementation of parental involvement in neonatal care.
Funding. The study had no sponsor support.
Conflict of interest. The authors declare no conflict of interest.
Acknowledgment. Authors appreciate the technical assistance and resources provided by the Siksha 'O' Anusandhan University, Bhubaneshwar, India.
For citation: Siva N., Praharaj M., Tripathy P. Clinical practice guidelines for involving mothers in high-risk neonate care at neonatal intensive care unit in low and middle-income countries: a discussion paper. Neonatologiya: novosti, mneniya, obuchenie [Neonatology: News, Opinions, Training]. 2024; 12 (3): 86-9. DOI: https://doi.org/10.33029/2308-2402-2024-12-3-86-89 Received 06.07.2024. Accepted 05.08.2024.
Keywords:
clinical practice guidelines; mothers; newborns; high-risk neonate care; neonatal intensive care units; low and middle-income countries; clinical outcomes
Neonatal intensive care units are essential for the survival and health of high-risk neonates during the initial period of adapting to extrauterine life [1]. The involvement of parents in neonatal care has been associated with improved health outcomes, reduced stress for neonates and parents, and enhanced parent-infant bonding [2, 3]. In LMICs, however, the implementation of such practices is often challenged by various factors, including limited resources, cultural beliefs, and inadequate infrastructure [4, 5]. Parental involvement in NICUs has been extensively studied, with evidence showing significant benefits for both neonates and parents [1, 6]. Enhanced infant health outcomes, such as reduced hospital stay, lower infection rates, and improved weight gain, have been linked to active parental involvement [2]. Additionally, parental psychological benefits, including reduced stress and anxiety, improved bonding, and increased confidence in post-discharge care, have been documented [2, 3, 7]. Improved family dynamics and satisfaction with care are further advantages of involving parents in neonatal care [7].
LMICs often face financial constraints and lack healthcare resources, making it challenging to provide quality healthcare [5]. LMICs, including Sri Lanka, India, Iran, Pakistan, Afghanistan, Nepal, Taiwan, Ethiopia, Vietnam, Kazakhstan, and Bangladesh, traditionally follow NICU care protocols that restrict parental involvement to once a day and limit direct breastfeeding and continuous kangaroo mother care (KMC) [8]. However, in keeping with global trends, NICUs in some LMICs, particularly in India and Iran, are transitioning towards family-centered care [9, 10]. For instance, NICUs in South India encourage mothers to participate in neonatal care for at least 8 hours per day, including KMC, which has significantly reduced maternal stress and neonatal salivary cortisol levels (a stress biomarker) [2]. Similarly several studies conducted in Iran, Sri Lanka, Kenya, and Nepal, the implementation of family centred care and neonatal nurse navigator program in NICUs showed significant improvements in reduced neonatal mortality rates, maternal outcomes and improved parent-infant bonding [2, 7, 8, 10-13].
In India, mother and neonatal care services typically keep mothers and babies together in the postnatal ward if the baby is healthy [14]. However, if the baby is sick or has a low birth weight, they are separated, with the baby placed in the special neonatal care
unit while the mother stays in the postnatal ward and visits only on healthcare providers' advice [6]. The medical community feels this model is not ideal for either the baby or the mother. Involving mothers and families in routine neonatal care is crucial for improving health outcomes and the overall care experience [15]. This has led to the concept of 'zero separation' and the establishment of mother-neonatal care units [16].
Significance of parental involvement in neonatal care
Implementing recommended clinical practice guidelines for involving parents in high-risk neonate care at NICUs in LMICs is crucial for improving neonatal outcomes [8]. Studies have shown that parental participation in hospital care is associated with decreased mortality, increased breastfeeding rates, and reduced hospital readmission, particularly in LMICs [2]. However, there are challenges in ensuring adherence to essential neonatal care and postnatal care standards, especially for neonates born at home with a skilled birth attendant in LMICs [17, 18]. To address overcrowding and separation issues in NICUs, a proposed "at-risk" category for neonates could offer cost-effective options for managing stable neonates with risk factors within health facilities in LMICs [4, 5]. Additionally, a collaborative cross-learning quality improvement approach incorporating remote mentoring and coaching has successfully enhanced facility-based neonatal care practices in LMICs, emphasizing the importance of continuous quality improvement methods in improving neonatal care [12, 19].
Mothers, involvement in neonatal care is associated with numerous benefits, including reduced neonatal mortality [8], minimized neonatal stress and maternal stress [2], improved mother and child bonding [3], enhanced infant health outcomes, such as reduced hospital stay [2], lower incidence of infections, increased breastfeeding rates, reduced readmission rates [8], and improved weight gain [2] and developmental outcomes in neonates [1]. Involving mothers in neonatal care activities fosters a sense of inclusion and partnership with healthcare providers [12], improving overall family dynamics and satisfaction with the care provided [19]. A study from China surveyed NICU physicians and nurses and found positive attitudes towards family-centered care
МЕЖДУНАРОДНЫЙ ОПЫТ
Barriers for involving the mothers in neonatal care activities in low and middle-income countries
• Maternal stress, anxiety, and depression [2]
• Undergoing surgical procedures (e.g., LSCS) [11]
• Fear of seeing the baby in NICU [20]
• Face unpleasant feelings [13]
From parents' • Lack of bonding with the baby [3]
perspective • Lack of awareness about the importance of involving in neonatal care activities [7] • Lack of support from family, spouse, and healthcare personnel [15] • Financial challenges in staying at the hospital during neonatal hospitalization [7] • Lack of effective communication with personnel, inefficiency of playing the parental role and inappropriate presence and participation [13]
• Lack of training, awareness, and knowledge on the importance of maternal involvement [6]
From healthcare • High workload [21]
professionals' • Incomplete neonatal care assignments and multiple procedures scheduled for the baby [10]
perspective • Handling several responsibilities simultaneously and lack of support from colleagues in the NICU [12] • Poor communication skills with parents [6]
• Overcrowding in NICU and disturbance in healthcare process [8]
• Infrastructure limitations and inadequate facilities [17]
From the healthcare system's perspective • Resource constraints, including limited financial, technological, and human resources [4] • Failure to create a conducive environment in the NICU [2] • High healthcare costs for mothers to stay in the hospital [7] • Complex NICU environment [22] • Ineffective involvement of parents in the care [13] • Interference of parents in the treatment process [13]
• Cultural barriers and traditional practices [13]
• Distance from home to hospital [7]
Social challenges • Transportation barriers [13] • Alterations in the parental role [2] • Lack of support from family and society [15]
Recommendations for clinical practice
Policy development and advocacy National guidelines establish a structured framework for healthcare providers, outlining clear National expectations and protocols for integrating parental involvement into neonatal care practices guidelines [16, 23]
Advocacy Engaging stakeholders like government agencies, NGOs, and international bodies to advocate for family-centered care to drive policy changes and secure necessary support and resources for implementing the guidelines [9]
Capacity building Implement comprehensive training for healthcare providers on involving parents in neonatal care Training programs [6]. These programs highlight the benefits and teach practical engagement skills [24]
Parent education Provide education and resources to empower parents in their child's care, including workshops, informational materials, and support groups [2, 23]
Navigate the mothers to participate in neonatal care activities during NICU admission and after Navigation model discharge using telephonic follow-ups every two weeks [2].
Cultural sensitivity Community engagement Engage community leaders and use culturally appropriate methods to educate families on the benefits of parental involvement, respecting local norms [25, 26]
Tailored Adapt strategies for parental involvement to align with cultural beliefs, respecting differences and approaches integrating culturally acceptable practices [5, 11]
Infrastructure improvement Facility enhancements Invest in NICU infrastructure to create family-friendly environments, including private spaces for parent-infant interaction to foster bonding and involvement [9]
Ensure NICUs are sufficiently staffed and equipped to support parental involvement, potentially Resource by securing funding for additional staff or resources dedicated to facilitating parental allocation engagement [20]
Technological innovations Telemedicine Use telemedicine to support and educate parents in areas with limited NICU access, allowing them to consult healthcare providers and receive guidance remotely [27]
Develop mobile applications for parents during their child's NICU stay, offering real-time updates, Mobile health educational content, and progress-tracking tools to enhance parental involvement and information applications accessibility [14]
Шива Н., Прахарадж М., Трипати П.
клинические практические рекомендации по вовлечению матерей в уход за новорожденными высокого риска в отделениях интенсивной терапии новорожденных в странах с низким и средним уровнем дохода (в развивающихся странах): дискуссия
but also noted concerns about feasibility due to limited space and infection risks. These concerns are common across all LMICs when promoting increased maternal involvement in neonatal care [10].
Conclusion
Involving mothers in the care of high-risk neonates in NICUs in LMICs is essential for improving neonatal outcomes
and promoting family well-being. Despite the challenges, targeted strategies such as policy development, capacity building, cultural sensitivity, infrastructure improvement, and technological innovations can facilitate the successful implementation of these practices. Collaborative efforts from healthcare providers, policymakers, and communities are crucial to creating a supportive environment for parental involvement in neonatal care.
АВТОР ДЛЯ КОРРЕСПОНДЕНЦИИ
Шива Н. (N. Shiva Kumar) - доцент, отделение сестринского ухода за детьми, Колледж медсестер SUM, Университет Сикша «О» Ану-сандхан (SOA), Бхубанешвар, Одиша, Индия
CORRESPONDING AUTHOR
Dr. N Siva - Associate Professor, Department of Child Health Nursing, SUM Nursing College, Siksha '0' Anusandhan (SOA) University, Bhubaneswar, Odisha, India E-mail: [email protected]
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