The goal of this clinical trial is to learn if extended admission to the Kangaroo Mother Care (KMC) ward helps to prevent postpartum depression in mothers of low birthweight infants in a low-resource setting whose newborns were admitted to the neonatal intensive care unit (NICU) more than standard of care KMC. The main questions it aims to answer are: * Does longer KMC decrease the incidence of postpartum depression in mothers of low birthweight infants in a low-resource setting? * Does longer KMC improve neurodevelopmental outcomes of low birthweight infants at 6, 12, and 18 months in a low-resource setting? * What are the barriers to practicing KMC in low birthweight infants following hospital discharge in a low-resource setting? * What is the prevalence of paternal depression in a low resource setting? * Is it cost effective to admit preterm mother-infant dyads to the KMC ward following NICU discharge? Researchers will compare (extended admission to the KMC ward) to (standard of care KMC) to see if extended KMC decreases PPD in mothers of preterm infants in low-resource settings. Participants (infants) will: * At time of discharge from the NICU, when clinically stable, spend either \< 2 days in the KMC ward with their mothers or spend longer in the KMC ward until discharge. * Return to clinic at routine follow-up visits (at 2 weeks and at 6-8 weeks) where mothers will be screened for postpartum depression and fathers will be screened for depression. * Return to clinic for neurodevelopmental screening at 6, 12, and 18 months where mothers will be screened for postpartum depression and perceived social support and fathers will be screened for depression.
The overarching objective is to determine whether initiation of Kangaroo Mother Care (KMC) at the neonatal intensive care unit (NICU) followed by admission to the KMC ward for continued support for more than 2 days before discharge home reduces maternal postpartum depression (PPD) and other maternal and infant adverse outcomes in low-resource settings. The central hypothesis is that NICU KMC plus admission of mother-infant (preterm) dyads to the KMC ward following NICU discharge for more than 2 days will reduce the risk of maternal PPD as compared to NICU KMC followed by admission of the mother-infant dyad to the KMC ward for up to 2 days only. The study aims are: Aim 1: To determine the effect of admission of mother-infant dyads to the KMC ward following NICU for more than 2 days on maternal PPD at 2-weeks, 6-8 weeks, 6 months, and 12 months. Aim 2: To determine the effect of admission of mother-infant dyads to the KMC ward on infant's developmental outcomes at 6-,12-, and 18 months of age. Aim 3: To characterize the feasibility and barriers to uptake of KMC at the hospital and following discharge. Aim 4: To determine the prevalence of paternal depression. Aim 5: To estimate the cost and effectiveness of admission of low birthweight infants to the KMC ward: 1. Estimate costs from a health systems perspective and explore cost drivers of KMC and NICU care for low birthweight newborns 2. Assess out-of-pocket expenditure incurred by households due to admission of low birthweight infants to the KMC and NICU 3. Estimate the incremental cost-effectiveness of screening for postpartum depression among women with low birthweight infants admitted to the KMC compared to the status quo Study design This study is a randomized controlled trial of newly delivered women whose preterm newborns have been admitted to the neonatal intensive care unit (NICU) with admission to the Kangaroo Mother Care (KMC) ward for up to 2 days (control) or with admission to the KMC ward for more than 2 days (intervention) prior to discharge home. The study will enroll a total of 1908 study participants from both study arms pulled from 612 mothers (aim #1), 612 infants (aim #2), 72 participants for in-depth interviews (aim #3), and 612 fathers (aim #4).
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
SINGLE
Enrollment
1,908
Admission to the kangaroo mother care (KMC) ward with continued support of kangaroo mother care, breastfeeding, and preterm infant care for greater than 2 days prior to discharge home
Admission to the kangaroo mother care (KMC) ward with continued support of kangaroo mother care, breastfeeding, and preterm infant care for less than 2 days prior to discharge home
Women and Newborn Hospital - University Teaching Hospitals
Lusaka, Lusaka Province, Zambia
RECRUITINGPercentage of Mothers with Postpartum Depression (PPD)
Score on Edinburgh Postnatal Depression Scale (EPDS) screening tool obtained by interview with mother. This screening tool is a 10-question tool validated for use among pregnant women in low resource countries. It can be used for screening of perinatal depression, beginning from antenatal period up to 6-8 weeks postnatal age. Each question is scored between 0-3, the highest cumulative score being 30. Cut-off score for mothers with suspected postpartum depression (PPD) will be 11. All mothers who screen 11+ will be categorized to have PPD, all mothers scoring below 11 will be categorized as negative for PPD.
Time frame: 8 weeks
Percentage of Mothers with Postpartum Depression (PPD)
Score on Edinburgh Postnatal Depression Scale (EPDS) screening tool obtained by interview with mother. This screening tool is a 10-question tool validated for use among pregnant women in low resource countries. It can be used for screening of perinatal depression, beginning from antenatal period up to 6-8 weeks postnatal age. Each question is scored between 0-3, the highest cumulative score being 30. Cut-off score for mothers with suspected postpartum depression (PPD) will be 11. All mothers who screen 11+ will be categorized to have PPD, all mothers scoring below 11 will be categorized as negative for PPD.
Time frame: 2 weeks, 6 months, 12 months
Hours spent practicing Kangaroo Mother Care (KMC) in the neonatal intensive care unit (NICU)
Time in hours and minutes spent practicing kangaroo mother care (KMC) per day by the mother obtained by interview with mother.
Time frame: 2 weeks
Hours spent practicing Kangaroo Mother Care (KMC) in the KMC Ward
Time in hours and minutes spent practicing kangaroo mother care (KMC) per day by the mother obtained by interview with mother.
Time frame: 2 weeks
Hours spent practicing Kangaroo Mother Care (KMC) at home
Time in hours and minutes spent practicing kangaroo mother care (KMC) per day by the mother obtained by interview with mother.
Time frame: 2 weeks, 8 weeks, 6 months, 12 months
Time of initiation of breastfeeding
Time in hours and minutes after delivery, when infant is initially put to breast for feeding
Time frame: 2 weeks
Number of months breastfeeding
Number of months of any breastfeeding reported by the mother in an interview
Time frame: 8 weeks, 6 months, 12 months
Number of barriers to kangaroo mother care (KMC) initiation at the birth hospital
A pre-defined set of questions will be asked to all the mothers to determine the barriers contributing to kangaroo mother care (KMC) initiation at the birth hospital. The Investigators will enroll mothers (n=24), fathers (n=24), and family members (n=24) to undergo in-depth interviews (IDIs).
Time frame: 12 months
Number of barriers to kangaroo mother care (KMC) initiation at home
A pre-defined set of questions will be asked to all the mothers to determine the barriers contributing to kangaroo mother care (KMC) initiation at home. The Investigators will enroll mothers (n=24), fathers (n=24), and family members (n=24) to undergo in-depth interviews (IDIs).
Time frame: 12 months
Average Infant/child developmental assessment
Score on "Ages and Stages Questionnaire" (ASQ) obtained by interview with parent developmental assessment tools which scores items (Y = 10, Sometimes = 5, Not Yet = 0) in areas of Communication, Gross motor, Fine Motor, Problem Solving and Personal-Social. Scoring of items are totaled and placed on a graph indicating cut off score. If score is above cut-off, the child's development appears to be on schedule; near the cutoff, may provide learning activities and monitor; and below cutoff, requiring further assessment. 6-month cutoffs (Communication 29.65; Gross Motor 22.25; Fine Motor 25.14; Problem Solving 27.72 and Personal-Social 25.34); 12-month cutoffs (Communication 15.64; Gross Motor 21.49; Fine Motor 34.50; Problem Solving 27.32 and Personal-Social 21.73); 18-month cutoffs (Communication 13.06; Gross Motor 37.38; Fine Motor 34.32; Problem Solving 25.74 and Personal-Social 27.19).
Time frame: 6 months,12 months, 18 months
Average weight in grams
Weight in grams, weighed on a digital scale
Time frame: birth, up to 8 weeks, 6 months, 12 months, 18 months
Average length in centimeters (cm)
Length in centimeters, top of head to heel, measured with paper tape measure
Time frame: birth, up to 8 weeks, 6 months, 12 months, 18 months
Average head Circumference in centimeters (cm)
Head Circumference in centimeters (cm), occipital-frontal, measured with paper tape measure
Time frame: birth, up to 8 weeks, 6 months, 12 months, 18 months
Percentage of all cause 28-day neonatal mortality
Report of neonatal vital status within 28 days, obtained in maternal interview
Time frame: 28 days
Percentage of neonatal morbidity
Report of neonatal health status, obtained in maternal interview (e.g., neonatal sepsis, diarrhoea, breathing difficulties)
Time frame: 28 days
Percentage of infant readmission to facility
Neonatal rehospitalization after initial discharge from the hospital assessed by maternal interview or medical records documentation
Time frame: 18 months
Percentage of infant mortality
Documentation of or report of infant death, assessed through medical records or maternal interview
Time frame: 18 months
Percentage of infant morbidity
Report of infant morbidity, assessed through maternal interview (e.g., diarrhoea, pneumonia, sepsis, respiratory infections)
Time frame: 18 months
Percentage of vaccine adherence
Report of infant's adherence to the required vaccinations per national guidelines in Zambia through maternal interview - Bacille Calmette-Guérin (BCG) - at birth Polio (Oral Polio Virus 0, 1, 2, 3) - birth, 6, 10, and 14 weeks Diphtheria, tetanus, whooping cough (pertussis) or DTP, polio, hepatitis B and Haemophilus influenzae type b (Hib) - DPT-HepB-HiiB (1, 2, 3) - at 6, 10, and 14 weeks Measles - at 9 and 18 months Rotavirus 1, 2 - at 6 and 14 weeks Preumococcal Vaccine (PCV) 1, 2 - at 6, 10, and 14 weeks
Time frame: 12 months
Number of barriers to practicing kangaroo mother care (KMC() at the hospital
A pre-defined set of questions will be asked to determine the barriers contributing to practicing kangaroo mother care (KMC) initiation at the hospital. The Investigators will enroll mothers (n=24), fathers (n=24), and family members (n=24) to undergo in-depth interviews (IDIs).
Time frame: 12 months
Number of facilitators to practicing kangaroo mother care (KMC) at the hospital
A pre-defined set of questions will be asked to determine the facilitators contributing to practicing kangaroo mother care (KMC) initiation at the hospital. The Investigators will enroll mothers (n=24), fathers (n=24), and family members (n=24) to undergo in-depth interviews (IDIs).
Time frame: 12 months
Number of barriers to practicing kangaroo mother care (KMC) at home
A pre-defined set of questions will be asked to determine the barriers contributing to practicing kangaroo mother care (KMC) initiation at home. The Investigators will enroll mothers (n=24), fathers (n=24), and family members (n=24) to undergo in-depth interviews (IDIs).
Time frame: 12 months
Number of facilitators to practicing kangaroo mother care (KMC) at home
A pre-defined set of questions will be asked to all the mothers to determine the facilitators contributing to practicing kangaroo mother care (KMC) initiation at home. The Investigators will enroll mothers (n=24), fathers (n=24), and family members (n=24) to undergo in-depth interviews (IDIs).
Time frame: 12 months
Percentage of fathers with postpartum depression
Score on Edinburg Postnatal Depression Scale (EPDS) screening tool obtained by interview with mother. This screening tool is a 10-question tool validated for use among pregnant women in low resource countries. It can be used for screening of perinatal depression, beginning from antenatal period up to 6-8 weeks postnatal age. Each question is scored between 0-3, the highest cumulative score being 30. Cut-off score for fathers with suspected postpartum depression (PPD) will be 9. All fathers who screen 9+ will be categorized to have PPD, all fathers scoring below 9 will be categorized as negative for PPD.
Time frame: 2 weeks, 8 weeks, 6 months, 12 months
Hours of time father spent with newborn daily
Time (hours/minutes) spent interacting with the newborn/infant each day obtained by interview with the father
Time frame: 8 weeks, 6 months, 12 months
Percentage of mothers with depression
Patient Health Questionnaire (PHQ-9) is a 9-question patient-administered screening tool for the assessment of depression among mothers and fathers. Since PHQ-9 can be used repeatedly to monitor depressive symptoms among the same patient/study participant, it will be used at different time points throughout the study. The severity scale is as follows: 1. None: 0-4 2. Mild: 5-9 3. Moderate: 10-14 4. Moderate-Severe: 15-19 5. Severe: 20-27
Time frame: 2 weeks, 8 weeks, 6 months, and 12 months
Percentage of mothers with self-reported perceived social support
Multidimensional Scale of Perceived Social Support (MSPSS) is a tool for screening of perceived social support from family, friends, and significant other.\] It, a brief and easy-to-follow self-report measure, is a 12-question tool using a 5-point Likert scale (0 = strongly disagree, 5 = strongly agree). It uses positive and negative phrasing to limit response set bias of agreement. Mothers enrolled in the study will be screened using the MSPSS screening tool at 6 and 12 months following enrolment. This total score can also be calculated as a mean score (divide by 12). To calculate the mean subscale scores: * Significant Other Subscale: Sum across items 1, 2, 5, \& 10, then divide by 4. * Family Subscale: Sum across items 3, 4, 8, \& 11, then divide by 4. * Friends Subscale: Sum across items 6, 7, 9, \& 12, then divide by 4. Scores are divided into: 1. Low support: 1 to 2.9 2. Moderate support: 3 to 5 3. High support: 5.1 to 7
Time frame: 6 months, 12 months
Cost of admission to kangaroo mother care (KMC) ward
Government funds spent by the government for admission of one newborn to the kangaroo mother care (KMC) ward per day obtained from government sources. This will estimate the average cost per patient admitted to the KMC ward.
Time frame: Through KMC discharge of up to 8 weeks
Cost of readmission to the neonatal intensive care unit (NICU)
Funds spent by the government for readmission of one newborn to the neonatal intensive care unit (NICU) per day obtained from government sources. This will estimate the average cost per patient admitted to the NICU.
Time frame: Through NICU discharge of up to 8 weeks
Cost associated with hospital readmissions
Funds spent by the government for readmission of one infant to the hospital per day obtained from government sources. This will estimate the average cost per patient readmitted to the hospital.
Time frame: 12 months
Out-of-pocket family costs associated with hospital readmissions
Funds spent by the family associated with readmission of one infant to the hospital per day obtained from maternal interview. This will estimate the average funds spent by the family per patient readmitted to the hospital.
Time frame: 12 months
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