| 1. |
- Ahlsson, Fredrik, 1967-
(författare)
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Being Born Large for Gestational Age : Metabolic and Epidemiological Studies
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Obesity is a major health problem in the Western world. Mean birth weight has increased during the last 25 years. One explanation is that the proportion of large for gestational age (LGA) infants has increased. Such infants risk developing obesity, cardiovascular disease and diabetes later in life. Despite the risk of neonatal hypoglycemia, their postnatal metabolic adaptation has not been investigated. Our data, obtained with stable isotope labeled compounds, demonstrate that newborn LGA infants have increased lipolysis and decreased insulin sensitivity. After administration of glucagon, the plasma levels of glucose and the rate of glucose production increased. The simultaneous increase in insulin correlated with the decrease in lipolysis, indicating an antilipolytic effect of insulin in these infants.We also demonstrated an intergenerational effect of being born LGA, since women born LGA, were at higher risk of giving birth to LGA infants than women not born LGA. Further, the LGA infants formed three subgroups: born long only, born heavy only, and born both long and heavy. Infants born LGA of women with high birth weight or adult obesity were at higher risk of being LGA concerning weight alone, predisposing to overweight and obesity at childbearing age. In addition we found that pregnant women with gestational diabetes were at increased risk of giving birth to infants that were heavy alone. This could explain the risk of both perinatal complications and later metabolic disease in infants of this group of women.To identify determinants of fetal growth, 20 pregnant women with a wide range of fetal weights were investigated at 36 weeks of gestation. Maternal fat mass was strongly associated with insulin resistance. Insulin resistance was related to glucose production, which correlated positively with fetal size. The variation in resting energy expenditure, which was closely related to fetal weight, was largely explained by BMI, insulin resistance, and glucose production. Lipolysis was not rate limiting for fetal growth in this group of women. Consequently, high maternal glucose production due to a high fat mass may result in excessive fetal growth.
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| 2. |
- Austeng, Dordi
(författare)
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Retinopathy of Prematurity in Infants Born Before 27 Weeks of Gestation : A National Population-based Study in Sweden During 2004-2007
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Improved neonatal care has resulted in an increasing population of surviving infants. Neonatal morbidity in preterm infants is, however, high, and retinopathy of prematurity (ROP) is one of the major neonatal morbidities. Observations have suggested that ROP might have a different course in extremely preterm compared to more mature infants. Aims: To study the incidence, natural history and treatment of the disease, and the implications regarding screening recommendations for the population of extremely preterm infants. Methods: A national, population-based study of neonatal morbidity in infants born before 27 gestational weeks was performed in Sweden during 2004 to 2007. ROP screening started in the 5th postnatal week and continued until the retina was completely vascularized. Results: Of the 506 infants surviving until the first ROP examination, 73% developed ROP; 38% mild ROP and 35% severe ROP. Ninety-nine infants (20%) were treated. A log-linear relationship was found between severe ROP and gestational age (GA) at birth, and the risk of ROP was reduced by 50% for each week of increase in GA at birth (Paper I). Postmenstrual age (PMA) at onset of ROP was significantly related to GA at birth, as was the site of onset of ROP. ROP had a predilection to start in the nasal retina in the most immature infants. There were significant relations between PMA at onset of ROP and severity of ROP as well as between the site of onset of ROP and severe ROP (Paper III). The most immature infants had a higher risk of reaching treatment criteria for ROP, a higher risk of progression from ROP 3 to treatment criteria, and they reached these criteria at an earlier PMA than the less immature infants (Paper II). According to our results, the first examination can be postponed until a PMA of 31 weeks in infants born before 27 weeks of gestation, since onset of ROP 3 did not occur before this age, and criteria for treatment were not reached before 32 weeks. The majority of infants (75%) were treated during a limited period, i.e. before a PMA of 39 weeks (Paper IV).
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| 3. |
- Brunell, Olivia
(författare)
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Improving neonatal health care in Nepal
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Every year, millions of newborns die globally due to poor quality of care around the time of birth. The overall aim of this thesis was to inform and test design of quality improvement (QI) interventions in Nepal. Contextual factors of importance for implementation of evidence-based newborn care practices were investigated, and the effect of a package of QI interventions on provision and experience of care was evaluated. In Paper I, we used focus group discussions and key informant interviews with delivery care staff to identify barriers and enablers for delayed umbilical cord clamping (DCC). Results indicate that delivery care staff needed knowledge of the benefits of DCC to gain motivation for change. Training, supervision and evaluation were requested to be able to change old routines, and they wanted authorized guidelines to bring uniformity in clinical practice. In Paper II, individual interviews with staff working with newborn infants were used to explore factors affecting parent-infant closeness in hospitals. Informants thought that offering a comfortable environment, privacy and counselling would enhance parent-infant closeness, but hospital resources were insufficient to achieve this. They described routines in the hospitals, and traditions and cultural beliefs in the society, which separated parents and newborns. In Paper III, a stepped-wedge randomized control design was applied to evaluate the effect of a QI package including training, facilitation and feedback, on patient satisfaction. The likelihood of women being overall satisfied with care during childbirth increased (aOR 1.66 [CI: 1.59-1.73, ICC: 0.275]) but the overall proportion of satisfaction was low, increasing from 58% to 62%. In Paper IV, clinical observations of early essential newborn care (EENC) practices were done before and after the introduction of the QI package. Overall, the rate of initiation of breastfeeding within one hour increased from 5% to 12%, and DCC increased from 22% to 33%. In conclusion, when designing interventions to improve quality of care, in Nepal or similar settings, it is important to use authorized guidelines and include education, training, supervision and evaluation. Hospital resources, routines and cultural beliefs need to be considered. The results indicate that a multi-pronged QI package can improve quality of newborn care in Nepal.
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| 4. |
- Eriksson, Leif
(författare)
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Knowledge Translation in Vietnam : Evaluating facilitation as a tool for improved neonatal health and survival
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Neonatal mortality remains a problem worldwide, despite the existence of low-cost and evidence-based interventions. Unfortunately, the translation of these interventions into practice is deficient.The aim of this thesis was to study aspects of knowledge translation (KT) before and during the Neonatal Knowledge Into Practice (NeoKIP) trial in Quang Ninh, Vietnam. Over a period of three years, this trial evaluated the use of facilitators from the Women’s Union who supported maternal and newborn health groups (MNHG) comprised of eight local stakeholders, as an intervention for improved neonatal survival.In the first two studies (before intervention) we assessed primary health care staff’s knowledge and material preparedness regarding evidence-based neonatal care and explored how primary health care staff translated knowledge into practice. The last two studies (during intervention) were process evaluations aimed at describing the implementation, process and mechanism of the NeoKIP intervention.Primary health care workers achieved 60% of the maximum score in the knowledge survey. Two separate geographical areas were identified with differences in staff levels of knowledge and concurrent disparities in neonatal survival, antenatal care and post-natal home visits. Staff perceived formal training to be the best way to acquire knowledge but asked for more interaction between colleagues within the healthcare system. Traditional medicine, lack of resources, low workload and poorly paid staff constituted barriers for the development of staff knowledge and skills.Eleven facilitators were trained to cover eight facilitator positions. Of the 44 MNHGs, 43 completed their activities to the end of the study. In total, 95% of the monthly meetings with a MNHG and a facilitator were conducted with attendance at 86%. MNHGs identified 32 unique problems, mainly families’ knowledge/behavior, and implemented 39 unique actions, mostly regarding communication. MNHGs experienced that the group was strategically composed to influence change in the communes and facilitators were identified as being important to sustaining activities over time. The facilitators’ lack of health knowledge was regarded as a deficit in assisting the MNHGs, but their performance and skills increased over time.This low-cost model, building on local stakeholder involvement, has the capacity to be scaled up within existing healthcare structures.
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| 5. |
- KC, Ashish, 1982-
(författare)
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Neonatal Resuscitation : Understanding challenges and identifying a strategy for implementation in Nepal
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Despite the unprecedented improvement in child health in last 15 years, burden of stillbirth and neonatal death remain the key challenge in Nepal and the reduction of these deaths will be crucial for reaching the health targets for Sustainable development goal by 2030.The aim of this thesis was to explore the risk factors for stillbirth and neonatal death and change in perinatal outcomes after the introduction of the Helping Babies Breathe Quality Improvement Cycle (HBB QIC) in Nepal.This was a prospective cohort study with a nested case-control design completed in a tertiary hospital in Nepal. Information were collected from the women who had experienced perinatal death and live birth among referent population; a video recording was done in the neonatal resuscitation corner to collect information on the health workers’ performance in neonatal resuscitation. Lack of antenatal care had the highest association with antepartum stillbirth (aOR 4.2, 95% CI 3.2–5.4), births that had inadequate fetal heart rate monitoring were associated with intrapartum stillbirth (aOR 1.9, CI 95% 1.5–2.4), and babies who were born premature and small-for-gestational-age had the highest risk for neonatal death in the hospital (aOR 16.2, 95% CI 12.3–21.3). Before the introduction of the HBB QIC, health workers displayed poor adherence to the neonatal resuscitation protocol. After the introduction of HBB QIC, the health workers demonstrated improvement in their neonatal resuscitation skills and these were retained until six months after training. Daily bag-and-mask skill checks (RR 5.1 95% CI 1.9–13.5), preparation for birth (RR 2.4, 95% CI 1.0–5.6), self-evaluation checklists (RR 3.8, 95% CI 1.4–9.7) and weekly review and reflection meetings (RR 2.6, 95% 1.0–7.4) helped the health workers to retain their neonatal resuscitation skills. The health workers demonstrated improvement in ventilation of babies within one minute of birth and there was a reduction in intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and first-day neonatal mortality (aOR 0.51, 95% CI 0.31–0.83). The study provides information on challenges in reducing stillbirth and neonatal death in low income settings and provides a strategy to improve health workers adherence to neonatal resuscitation to reduce the mortality. The HBB QIC can be implemented in similar clinical settings to improve quality of care and survival in Nepal, but for primary care settings, the QIC need to be evaluated further.
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| 6. |
- Målqvist, Mats, 1971-
(författare)
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Who can save the unseen? : Studies on neonatal mortality in Quang Ninh province, Vietnam
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Globally, neonatal mortality has remained basically unchanged for the last three to four decades and every year almost four million newborns die before reaching one month of age. This persistent mortality is related to an invisibility of the newborn child in policies and statistics and a neglect of health care decision-makers, planners and practitioners to deliver a perinatal continuum of care. In recent years attention has however been brought to the unchanged neonatal mortality in an effort to improve survival. The present thesis seeks to increase understanding of obstacles for better neonatal survival. The studies performed are undertaken as sub-studies to the NeoKIP project in Quang Ninh province in northern Vietnam, a randomized controlled trial of knowledge implementation for improved neonatal survival (Neonatal Health – Knowledge Into Practice, ISRCTN 44599712). In the first paper we investigated and discussed the scope of invisibility of neonatal mortality through measuring the accuracy of official statistics on neonatal deaths. The second paper reports an inquiry of determinants of neonatal mortality by use of a population-based case-referent design. Paper III and IV analyse delivery care utilization and care seeking patterns prior to and at delivery using narratives and GIS technique. There was a substantial under-reporting of neonatal mortality in the official statistics, with study results showing a four times higher neonatal mortality rate in Quang Ninh province than reported to the Ministry of Health. This neonatal mortality rate of 16/1000 live births (as compared to 4.2/1000 in official reports) was unevenly distributed in the province, showing large geographical discrepancies. In the rural and remote areas of Vietnam education level is lower and the concentrations of ethnic minorities and poor households are higher. Ethnic minority belonging was associated with a more than doubled risk of neonatal death compared to the hegemonic group of Kinh (OR 2.08 CI 95 % 1.39 – 3.10). This increased risk was independent of household economic status or maternal education level. Neonatal mortality was also associated with home deliveries, non-attendance to antenatal care and distance to the health care facilities. However, ethnic minority mothers still had an increased risk of experiencing a neonatal death even if they attended antenatal care, delivered at or lived close to a health facility. The invisibility of the neonatal period in health information systems hides the true width of the neonatal mortality challenge. By not acknowledging the problem, the marginalization of already disadvantaged groups continues, leaving ethnic minority babies with an elevated risk of dying during the first month in life. This example of ethnic inequity highlights the importance to target those most in need. The studies of the present thesis should therefore be looked upon as a contribution to the struggle to illuminate the global burden of neonatal mortality.
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| 7. |
- Strand Brodd, Katarina, 1956-
(författare)
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Delayed Development of Visuomotor Capacity in Very Preterm Infants
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- To coordinate visual perception and motor control in daily life where we are constantly surrounded by motion, we are dependent on normal visuomotor capacity. One essential prerequisite for normal visuomotor capacity is smooth pursuit eye movements (SP). Infants born very preterm (VPT = born <32 gestational weeks) are at high risk of developing disabilities in higher brain functions i.e. perception, cognition, concentration and coordination. In this thesis visuomotor capacity was investigated in a cohort of VPT infants (n = 113) and compared to control groups of full term (FT) infants. Levels of SP were measured at 2 and 4 months’ corrected age (CA). At 8 months’ CA reaching capacity toward a moving object was evaluated as this represents an executive activity guided by vision that develops at an early age. Lower levels of SP were found in the VPT infants compared to FT controls. The VPT boys showed higher levels of SP compared to the VPT girls. In VPT infants without major neonatal morbidities lower levels of SP was found compared to the FT controls. No difference in total capacity of gaze tracking was found, although the VPT infants lagged the object more at 4 months’ CA and used more saccades at 2 months’ CA. With age the VPT infants’ SP levels increased, but with a wider dispersion compared to the FT controls, and the levels of SP at 4 months’ CA corresponded to the levels of the FT infants at 2 months. A number of perinatal risk factors were found to be negatively associated to lower levels of SP, and this effect was more pronounced in VPT infants with multiple risk factors,. When evaluating the capacity to reach a moving object at 8 months’ CA, the VPT infants showed significantly more bimanual reach and more curved reaching paths to catch the object as compared to the FT control group. In conclusion, a delayed visuomotor capacity was found in VPT infants compared to FT control infants at 2, 4 and 8 months’ CA. Some VPT infants with perinatal risk factors did not develop in levels of SP between 2 and 4 months’ CA.
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| 8. |
- Thernström Blomqvist, Ylva, 1974-
(författare)
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Kangaroo Mother Care : Parents’ experiences and patterns of application in two Swedish neonatal intensive care units
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Kangaroo Mother Care (KMC) is an alternative model of care that prevents parent-infant separation when preterm infants need neonatal intensive care by skin-to-skin contact between infants and their parents. KMC is also a strategy that involves parents in their infants’ care and enables them to assume the responsibility for the care. Furthermore, KMC promotes parent-infant bonding and attachment.The overall aim of this thesis was to gain a deeper understanding and knowledge about parents’ capacity, willingness, and experiences of KMC and to which extent parents choose to use KMC throughout their infants' hospital stay. These studies were conducted in the NICUs at two Swedish university hospitals (NICU A and NICU B).Mothers of infants cared for at NICU A (n=17) answered a questionnaire about their experiences of KMC (Paper I). Twenty parents of infants cared for at NICU A recorded the duration of each KMC session during a period of 24 hours and the identity the KMC provider (Paper II). Seven fathers were interviewed about their experiences of KMC (Paper III) and 76 mothers and 74 fathers completed a questionnaire about what facilitated or rendered it difficult to perform KMC (Paper IV). The time of initiation of KMC and duration in minutes, and the identity of the KMC providers was recorded continuously during the infants’ (n=104) hospital stay: 83 mothers and 80 fathers also completed a questionnaire during their infants’ hospital stay (Paper V).This thesis provides new knowledge about parents’ practice of KMC, also continuously day and night, in a high tech NICU in an affluent society, with good resources for infant care in an incubator by trained staff. The accuracy of parents’ records of KMC were comparable to nurses’ records. The results indicate that parents want to be together with their infant in the NICU and be actively involved in the infants’ care. Although parents may experience KMC as exhausting and uncomfortable, they still prefer KMC to conventional neonatal intensive care as it supports their parental role. Early initiation of KMC after birth appears to result in a longer total duration of KMC during the infants’ hospital stay.
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