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Table of Contents
CONCEPTS AND ISSUES
Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 113-117

Impact of COVID-19 on the care of pre-term babies: Issues, challenges and strategies for comprehensive care


1 Professor & Head, Department of Child Health Nursing, B.L.D.E.A's Shri B. M. Patil Institute of Nursing Sciences, Vijayapur, Karnataka, India
2 Professor, Department of Pediatrics, Department of Child Health Nursing, B.L.D.E.A's Shri B. M. Patil Institute of Nursing Sciences, Vijayapur, Karnataka, India
3 Professor, Department of Child Health Nursing, B.L.D.E.A's Shri B. M. Patil Institute of Nursing Sciences, Vijayapur, Karnataka, India

Date of Submission29-Sep-2021
Date of Decision07-Dec-2022
Date of Acceptance08-Dec-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Dr. K Kavitha
Department of Child Health Nursing, B.L.D.E.A's Shri B. M. Patil Institute of Nursing Sciences, Vijayapur, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_94_21

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  Abstract 

The impact of the pandemic on maternal and newborn health-care services is problematic given the target of sustainable developmental goals. The present review was undertaken to assess the status of pre-term care during the COVID-19 pandemic. The literature search was done using various databases. Standard guidelines were followed to extract, synthesise and report the findings. A total of 20 articles that met the selection criteria were included in the review. The recent research threw light on the decrease in antenatal care services and the increase in pre-term birth during the pandemic lockdown period. Pre-term babies are more vulnerable to infections and development-associated morbidities. During the beginning of the pandemic, there were no clear guidelines regarding the dos and don'ts of pre-term care and policies that were evidence-based that resulted in the disruption of routine care within a chaotic environment. Currently, child welfare agencies and governmental and non-governmental health-care organisations are undertaking vigorous research and providing updates on the care of pre-term babies. As updates on newborn care policies based on research emerged, the continuation of breastfeeding, promotion of rooming-in, hygienic practices, digital-based health care, counseling and follow-up care were advocated for promoting pre-term babies' health and reducing morbidity and mortality. Capacity-building of the health workforce in managing pre-term babies during the pandemic period is crucial. More research is warranted to face such kind of situations in the future also. Above all, there is an urgent need for multi-sectorial and multi-disciplinary coordination in rendering essential services to the most vulnerable population i.e. pre-term babies.

Keywords: Challenges, COVID-19, holistic care, pandemics, pre-mature birth, providers


How to cite this article:
Kavitha K, Patil MM, Sikandar BJ. Impact of COVID-19 on the care of pre-term babies: Issues, challenges and strategies for comprehensive care. Indian J Cont Nsg Edn 2022;23:113-7

How to cite this URL:
Kavitha K, Patil MM, Sikandar BJ. Impact of COVID-19 on the care of pre-term babies: Issues, challenges and strategies for comprehensive care. Indian J Cont Nsg Edn [serial online] 2022 [cited 2023 Feb 3];23:113-7. Available from: https://www.ijcne.org/text.asp?2022/23/2/113/366611


  Introduction Top


The birth of a baby before the completion of 37 weeks of gestation is called pre-term birth. Every year, an estimated 15 million babies are born pre-term. Pre-term birth accounts for nearly 11% of total birth globally.[1] The developmental immaturity in these newborns makes them more vulnerable to both short-term and long-term consequences such as infection and neurodevelopmental deficit.[2] The complications related to prematurity are the leading cause of death among children below 5 years of age.[3] Hence, pre-term babies need facility-based comprehensive care to minimise vulnerability and promote optimal growth and development. They need admission to a neonatal intensive care unit (NICU) or special neonatal care unit for prevention, early detection and management of complications of prematurity and associated low birth weight. The occurrence of the COVID-19 pandemic has created many setbacks in the optimal care of these tiny individuals. The understanding of COVID-19 and its impact on different age groups are continuing to evolve. Health-care organisations are bringing out various guidelines on pre-term care. However, how it is been practiced in every NICU is not known. Hence, the present review was undertaken to understand the issues involved in pre-term care during the lockdown period, and various challenges faced by health-care providers (paediatricians, neonatologists, nurses and community health workers) and to synthesise the pre-term care approaches that were practiced during the pandemic.

Aim

This review is aimed to critically appraise the findings reported by various articles related to the care of pre-term babies during COVID-19. This review focused on the data related to different approaches used by health-care facilities to optimise pre-term care during the COVID-19 pandemic and the imposed lockdown period.

Objectives

  • To describe the issues and challenges faced by the health-care providers in providing optimal care to pre-term babies during the COVID-19 pandemic
  • To organise the care approaches under various headings highlighting their possible limitations.



  Methodology Top


Search strategy

The search strategy using text words, thesaurus headings and MeSH terms relating to COVID-19, pre-term babies, care and health-care providers were developed for various databases. A literature search for articles was performed and published from 2019 to 2021, in the English language. The databases used for the present review were PubMed, Research gate, Proquest, Index Medicus and Google scholar. A concept synthesis method was used to synthesise the literature and organise the findings of various studies.

Outcomes

To find out the effect of the COVID-19 pandemic on pre-term care, new possibilities, issues and challenges faced by health-care providers and their responsibilities. Pre-term for this review was defined as any baby born before 37 weeks of gestation.

Inclusion criteria

  • Studies related to antenatal care, and post-natal care
  • Comparative studies on different approaches for better pre-term care during the COVID-19 pandemic
  • Studies using randomised control trials, quasi-experimental and pre-experimental designs, systematic reviews and policies published by health organisations
  • Hospital-based and community-based studies.


Exclusion criteria

  • Articles published in a language other than English
  • Conference proceedings and abstracts.


A total of 1835 records were identified from various databases during the initial search after applying the criteria.

Of these, 141 duplicate records were removed using the manual method and Microsoft Excel sheet. 1740 were excluded at the title level itself. Eleven reports were excluded as they were abstracts. Twenty-three studies were removed during the final stage due to inadequate information regarding pre-term care. The final review included 20 studies [Figure 1].
Figure 1: PRISMA flow chart depicting the study selection process. PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analyses

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  Discussion Top


The results of critically reviewed articles are synthesised and presented under the following headings.

Current issues and challenges in routine care of pre-term babies

The unexpected and abrupt incidence of COVID-19 has caused extensive loss of human life and poses a huge challenge to public health around the world. The already overburdened health-care systems of the nations are exhausted by this pandemic and its associated comorbidities.

The COVID-19 pandemic had direct or indirect effects on maternal and newborn outcomes.[4] The confused and scary situation challenged all aspects of the neonatal care network causing anxiety and stress among all those involved in newborn care.[5] The fear of contracting infection, lack of antenatal visits during the lockdown, delayed health-seeking behavior and high incidence of COVID-19 infection in pregnant mothers resulted in the increased rate of pre-term birth.[6],[7],[8] An American-based retrospective study noted that COVID-19 during pregnancy was associated with a 40% increased risk of pre-term and a 60% increased risk of very pre-term birth.[9] The adverse outcomes also included increased incidence of caesarean section, low birth weight, asphyxia and other neonatal morbidities.[10]

Moreover, the diversions of health resources including the nurses to care for COVID-19 clients have disrupted the antenatal, intra-natal and post-natal health services.[11] This can be a big obstacle in achieving Millennium sustainable developmental goals (SDGs) as the deterioration in essential maternal and newborn services may lead to an increase in maternal and neonatal mortality and morbidity rate.[12]

The chances for vertical transmission of COVID-19 infection from the mother to the foetus were reported to be minimal. However, the cases of transmission of COVID from mother to baby through breast milk were shown in a few studies, no effort was made to establish the presence of the virus in culture.[13],[14]

Lack of evidence in the initial stage of the pandemic contributed to the separation of mother and newborn. COVID-19 restrictions had an impact on the infant and family-centred developmental care of pre-term newborns.[15] In many health settings around the world, low and middle-income countries, in particular, healthcare personnel reported overwhelming stress due to a lack of clarity and proper guidelines regarding the care of high-risk newborns during the pandemic. Sub-optimal preparation led to disruption in evidence-based interventions such as Kangaroo mother care (KMC) and follow-up care.[16] Health-care professionals in some facilities reported on modifications in the maternal and newborn care processes, some of which were not based on evidence.[17] The pandemic fear-driven strict hospital policies led to interrupted breastfeeding, lack of parent-newborn bonding and inability to participate in newborn care.[18] These policies resulted in a lack of trust among the public regarding the health-care system and an increased number of home births [Figure 2].
Figure 2: Impact of COVID-19 on maternal and newborn health

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Role of health-care providers

Keeping in mind, the vulnerability of this precious group and the WHO's aim of achieving SDGs by 2030, essential newborn care must be maintained as a priority during this unprecedented pandemic. The use of a comprehensive and multi-disciplinary approach to the care of pre-term babies during the COVID-19 pandemic is very much advocated.[18] The management and monitoring of pre-mature babies with COVID-positive status should be as that of term newborns in a NICU.[19] Based on the available literature, the care of pre-term care during the COVID-19 pandemic is categorised into five components [Table 1].
Table 1: Approach to pre-term care during the COVID-19 pandemic

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Promoting breastfeeding

Evidence from current studies suggests continuing breastfeeding by maintaining proper techniques such as washing hands, wearing triple-layer masks, practicing rooming-in and maintaining personal hygiene.[20] There should be a collaborative effort between the health team members and the parents in initiating and sustaining breastfeeding, especially for mothers under treatment for COVID-19.[21] Feeding the pre-term with expressed breast milk of COVID-19-positive mother was found to be useful in the baby's weight gain.[22] However, the breast pump must be cleaned before and after the expression of breast milk. The immunological and antimicrobial components of breast milk can minimise the chance of infection in high-risk newborns. Wearing personal protective equipment during the delivery of the baby is recommended to reduce the risk of horizontal transmission.[33] A recent study found of an increase in hand hygiene practices of health-care professionals during childbirth was an encouraging sign during the lockdown.[34]

Moreover, the long-term benefits of breastfeeding on health, growth and cognitive development must also be taken into account when determining public health policies regarding KMC, mother-newborn separation and infant feeding. Expressed breast milk is advised in the case of severely ill mothers who cannot give direct breastfeeding.[23]

Human milk banks can also play an important role in the present scenario to meet the nutritional needs of the most vulnerable pre-term babies.[35] Pasteurised human donor milk is recommended over formula feeds until the COVID-19 mother re-establishes her lactation after recovery.[24]

Technology-assisted care

Technology-based care such as telemedicine, telenursing, mass media awareness and community sensitisation programmes played an important role in minimising morbidity and mortality of pre-term babies associated with COVID-19. At present, mobile phones are a very popular gadget among the public. Hence, with mobile phone popularity, the mobile was handier in times of COVID-19 outbreak and lockdown. Mobile devices could help in capturing and sharing texts, videos, audio and images of antenatal, intra-natal and post-natal care.[27] Tele-intervention enhanced the parenting knowledge and skills, and also minimised their anxiety in caring for newborns during the lockdown period.[36] However, this might be challenging in under-resourced settings.[37]

It is important to note that the use of remote care videoconferencing and phone consultations may be challenging to implement for under-resourced families. Hence, psychological support and dedicated counseling services are essential to reduce the parental burnout of pre-term babies.[26]

Provision of resources for pre-term care

Adequate resources such as doctors, nurses and personal protective equipment can reduce the horizontal transmission of COVID-19 infection in pre-term babies.[29] The roles of midwives as health advocates are very crucial to protect the health of newborns and their parents through family-centred care and breastfeeding advocacy.[28] There is an urgent need to consider the active engagement of community health-care workers in the promotion of maternal and newborn welfare during such lockdown periods. They must be provided with adequate information, training and kits for the management of home deliveries by taking necessary COVID-19 precautions.[30] Capacity building of paediatricians, neonatal nurses, community health workers and other frontline worriers is crucial in managing pre-term babies and reducing neonatal mortality.

Enhancing parent–child bond

Zero separation policy is recommended by the researchers.[14] The practice of separating the pre-term newborn from the COVID-19-positive mother is not indicated. Because the separation can put the pre-term babies at risk of developing some other complications like hypothermia. Even, KMC is advised in low birth weight babies of COVID-19-positive mothers as the benefits outweigh the risk of disease transmission.[25] A comparative risk analysis has shown that direct breastfeeding and prolonged skin-to-skin contact had significantly averted pre-term death during the pandemic period.[31]

Sustaining maternal and newborn services

Prioritising the health needs of pregnant women, an equity approach and two-way discussions between health-care professionals and antenatal mothers regarding COVID-19 vaccination are recommended.[9] Evidence-based information on maternal-newborn services, situational analysis on service disruption of such services, and estimating the impact is essential to guide the care in present circumstances.[38]

Discharge health education on warning signs of newborn illness such as fever, poor feeding, respiratory discomfort and altered sensorium is essential.[39] Newborns with suspected or confirmed COVID-19, or ongoing exposure, require close outpatient follow-up after discharge.[32] The neonatal outcomes should be tracked using a post-natal care checklist.[40]


  Conclusion Top


Continuity of high-quality care through a robust primary health-care system linked to specialist care, systematic approaches to digital health-care facilities, and resilient maternal and newborn health services are important in the COVID pandemic scenario. Ensuring adequate supplies, maintaining core interventions and expanding the health workforce are imperative. The importance of family-centred care should not be neglected. Transitional care programmes and follow-up care can play important role in tracking the newborns' health. Pregnant mothers should be encouraged for regular antenatal visits. Adequate counseling services and alleviating myths about COVID-19 during pregnancy and labour can prevent pre-term birth. The concept of community-based ambulatory services must be explored for better maternal and newborn health services during lockdown kind of situations. Multi-centre studies are needed to improve the cost-effective evidence-based practice in pre-term care during unexpected circumstances like a pandemic.

Financial support and sponsorship

We would like to acknowledge that the work is funded by BLDE (Deemed) University, Vijayapur, Karnataka, India.

Conflicts of interest

There are no conflicts of interest.



 
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