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.

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.

Ключевые слова: клинические практические рекомендации; матери; новорожденные; уход за новорожденными высокого риска; отделениях интенсивной терапии новорожденных; развивающиеся страны; клинические исходы

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 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.

Литература/References

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