Evaluation of low birth weight infant post-discharge outcomes and development of community-based follow-up and monitoring strategies in Africa

Background: Every year 2.5 million newborns die worldwide. Low birth weight infants (birth weight< 2,500g, LBW) have the highest risk of dying in the newborn period and those who survive often suffer from poor growth and development, particularly in impoverished communities of sub-Saharan Africa and Southern Asia. However, the rate of progress in reducing newborn deaths in sub-Saharan Africa has been much slower than in other regions of the world. In addition, once discharged from hospital care, the follow-up of LBW infants is hampered by the weak linkage between the community and the health system. As a result, mothers may feel isolated when they return to the community with these infants whose care needs are often not prioritised due to community misconceptions of their potential to survive and thrive. Consequently, their problems are not addressed in a timely manner due to limited contact with health services and by the time they present to services they have established growth failure (commonly in the form of stunting, where they are too short for their age) and disabilities that can often not be adequately addressed or reversed. The mechanisms by which growth failure and disabilities co-exist in these LBW infants is not fully understood therefore limiting the design and timing of interventions. Empowering community health teams to provide support to these vulnerable babies and their mothers, particularly in impoverished communities where regular access to health facilities may not be possible due to financial constraints or physical distance, is a priority. Community-based mother-to-mother peer support is effective in improving breastfeeding practices in non-LBW infants in sub-Saharan Africa and Asia and could therefore improve feeding and care-giving practices for LBW infants.

Previous work: To test the feasibility and acceptability of mother-to-mother peer support (peer mothers) for LBW infants in Kenya, I recently completed a study in a rural community in western Kenya. Over a period of 6 months, we collected data on 60 LBW infants post-discharge and followed up by a team of 14 peer mothers. We also spoke to 18 mothers, 5 health care providers and 14 peer mothers to explore their views on community-based support for newborns and their perceptions on peer support for mothers of LBW infants in the community. This intervention was valued and accepted by mothers, peer mothers and health care providers and all infants gained weight during the period of follow-up with no adverse events.

Current project: This project aims to explore and evaluate community-level strategies to improve the survival, growth and developmental outcomes of LBW in impoverished communities in sub-Saharan Africa. In the first study, we will evaluate the growth and development of LBW infants from foetal life to 24 months and compare them with non-LBW infants, with detailed assessments of possible predictors of poor outcomes including infant feeding and maternal mental health. In the second study, we will test the feasibility and acceptability of integrating LBW peer support into community quality improvement strategies for maternal and child health that will focus on improving the quality of data on maternal and child health indicators. This will involve training of peer mothers and community health teams on LBW feeding and care strategies as well as on the principles of collecting, understanding and using their data to improve the health of mothers and their children in the community. We will conduct interviews with mothers, community health teams and other stakeholders to explore their perceptions on the acceptability of this strategy. We will also evaluate the effect of this strategy on the follow-up and monitoring of LBW infants using the community health team registers and summary reports. This project will inform the design of a community-based pragmatic trial to rigorously evaluate the effect of these interventions on LBW outcomes.

Globally, every year 2.5 million newborns die. Low birth weight (LBW) infants (birth weight< 2,500g) who constitute 15% of all newborns, have the highest risk of mortality and adverse long-term growth, health and neurodevelopmental outcomes. They include both preterm and intrauterine growth restricted infants and majority are born in low-and middle-income countries (LMICs) in sub-Saharan Africa and Southern Asia. Over the past two decades, interventions to improve facility-based care in LMICs for LBW infants have been tested and implemented, but the scarcity of longitudinal data to determine the predictors of poor outcomes and inform the design and timing of interventions have hampered progress in improving their post-discharge outcomes. LBW infants in impoverished communities are particularly vulnerable and community-based strategies to monitor and address gaps in their care in a timely manner have the potential to improve their outcomes. Community-based peer support for mothers is effective in improving breast feeding practices in infants in low resource settings and has the potential to improve post-discharge survival outcomes for LBW infants.

We propose to evaluate the predictors of stunting and neurodevelopmental impairment among LBW infants using a cohort of well-characterised mother-infant dyads recruited from one rural and two urban health facilities in Kenya and The Gambia over a period of 30 months. In addition, using a mixed methods approach, we will explore the feasibility and acceptability of embedding mother-to-mother peer support for LBW infants in community-level quality improvement strategies for maternal and child health in Kenya over a 12-month period. The data from these two studies will enable us to refine a community-based package of interventions for LBW infants and inform the design of a cluster randomised trial to rigorously evaluate the impact of these interventions on LBW infant survival, growth and neurodevelopmental outcomes.