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Delayed cord clamping in Nepal-Evidence for implementation
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aims of this thesis were to investigate effects of timing of umbilical cord clamping on newborn health, and on infant outcomes up to 12 months of age in a high-risk population and to explore the context of implementing changed umbilical cord clamping practices in Nepal.

A randomised controlled trial with 540 late preterm and term infants born by normal vaginal delivery was set up at a maternity hospital in Kathmandu, Nepal. Infants were enrolled in two parallel groups (1:1 ratio), randomised to early (ECC) (≤60 seconds) or delayed cord clamping (DCC) (≥180 seconds).

To get a deeper understanding of barriers and enablers for change in clinical practise in relation to cord clamping, a qualitative study with delivery staff was set up. Focus group discussions and key informant interviews were conducted at two major delivery hospitals in Kathmandu.

Paper I showed that DCC was an effective intervention to reduces anaemia at 8 and 12 months of age in a high-risk population, which may have major positive effects on infants’ health and development.

Paper II utilised the Ages and Stages Questionnaire (ASQ) to assess neurodevelopment in infants at 12 months of age. The result showed DCC was associated with an improvement of the overall neurodevelopment at 12 months of age as compared to infants in the ECC group.

Paper III showed that DCC was not associated with an increased risk of hyperbilirubinemia during the first day of life or risk of jaundice within 4 weeks compared with the ECC group.

Paper IV demonstrated how a positive attitude towards DCC and a will to rely on research evidence when striving to do good are facilitators of change in clinical practice. However, the participants in the study were hesitant to apply DCC due to lack of national or institutional protocols and formal training. Consequently, they were forced to take informal decisions and rely on alternate sources of information.

In conclusion, delaying umbilical cord clamping for 180 seconds is safe and associated with a significantly reduced risk of anaemia at 8 and 12 months which may have neurodevelopmental effects at a later age and is not associated with an increased risk of hyperbilirubinemia during the first days of life or risk of jaundice within 4 weeks of age. In order to change cord clamping practices to comply with evidence and policies health-care staff needs to be better supported by the governance structures of the health system, with clear and approved guidelines made available and coherent training and support.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. , p. 66
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1557
Keywords [en]
Attitude, Clinical Practice, Ferritin, Haemoglobin, Iron deficiency, Iron deficiency anaemia, Iron status, Jaundice, Neonatal hyperbilirubinemia, Newborn, Neurodevelopment, Randomized controlled trial, Umbilical cord clamping.
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-379616ISBN: 978-91-513-0611-7 (print)OAI: oai:DiVA.org:uu-379616DiVA, id: diva2:1298869
Public defence
2019-05-22, Rudbeckssalen, Akademiska sjukhuset, Rudbeck entréplan, C11, Uppsala, 09:15 (English)
Opponent
Supervisors
Funder
Swedish Research Council, 2014-04229The Swedish Foundation for International Cooperation in Research and Higher Education (STINT), PT2016-6639Available from: 2019-04-26 Created: 2019-03-25 Last updated: 2019-06-18
List of papers
1. Effect of Delayed Cord Clamping of Term Babies on Neurodevelopment at 12 Months: A Randomized Controlled Trial.
Open this publication in new window or tab >>Effect of Delayed Cord Clamping of Term Babies on Neurodevelopment at 12 Months: A Randomized Controlled Trial.
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2019 (English)In: Neonatology, ISSN 1661-7800, E-ISSN 1661-7819, Vol. 115, no 1, p. 36-42Article in journal (Refereed) Published
Abstract [en]

Background: Delayed cord clamping (DCC) is associated with an improved iron status at 8 months, a reduction of anemia at 12 months, and an improved development at 4 years. Assessment of the development after DCC has not been performed earlier in a setting with a high prevalence of iron deficiency.

Objective: The aim of this paper was to investigate the effects of DCC compared to early cord clamping (ECC) on the development evaluated with the Ages and Stages Questionnaire (ASQ) at 12 months of age.

Method: We conducted a randomized controlled trial investigating the effect of DCC (≥180 s) versus ECC (≤60 s) in 540 full-term deliveries. Twelve months after delivery, the parents reported their infant’s development by ASQ. Infants having a score < 1 standard deviation (SD) under the mean score were considered “at risk” of affected neurodevelopment.

Results: At 12 months of age, 332 (61.5%) infants were assessed. Fewer children in the DCC group were “at risk” of having affected neurodevelopment measured by the ASQ total score, 21 (7.8%) versus 49 (18.1%) in the ECC group. The relative risk was 0.43 (0.26–0.71). Infants in the DCC group had higher mean total scores (SD), 290.4 (10.4) versus 287.2 (10.1), p = 0.01. Significantly fewer infants in the delayed group were “at risk” and had higher scores in the domains “communication”, “gross motor”, and “personal-social”. Conclusions: DCC after 3 min was associated with an improvement of the overall neurodevelopment assessed at 12 months of age as compared to infants in the group with cord clamping within 1 min.

Keywords
Ages and Stages Questionnaire, Delayed umbilical cord clamping, Improved neurodevelopment
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-364661 (URN)10.1159/000491994 (DOI)000456665100006 ()30278462 (PubMedID)
Funder
Swedish Society of MedicineSwedish Society for Medical Research (SSMF)
Available from: 2018-10-30 Created: 2018-10-30 Last updated: 2019-03-25Bibliographically approved
2. Effects of Delayed Umbilical Cord Clamping vs Early Clamping on Anemia in Infants at 8 and 12 Months: A Randomized Clinical Trial
Open this publication in new window or tab >>Effects of Delayed Umbilical Cord Clamping vs Early Clamping on Anemia in Infants at 8 and 12 Months: A Randomized Clinical Trial
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2017 (English)In: JAMA pediatrics, ISSN 2168-6203, E-ISSN 2168-6211, Vol. 171, no 3, p. 264-270Article in journal (Refereed) Published
Abstract [en]

Importance: Delayed umbilical cord clamping has been shown to improve iron stores in infants to 6 months of age. However, delayed cord clamping has not been shown to prevent iron deficiency or anemia after 6 months of age.

Objective: To investigate the effects of delayed umbilical cord clamping, compared with early clamping, on hemoglobin and ferritin levels at 8 and 12 months of age in infants at high risk for iron deficiency anemia.

Design, Setting, and Participants: This randomized clinical trial included 540 late preterm and term infants born vaginally at a tertiary hospital in Kathmandu, Nepal, from October 2 to November 21, 2014. Follow-up included blood levels of hemoglobin and ferritin at 8 and 12 months of age. Follow-up was completed on December 11, 2015. Analysis was based on intention to treat.

Interventions: Infants were randomized to delayed umbilical cord clamping (≥180 seconds after delivery) or early clamping (≤60 seconds after delivery).

Main Outcomes and Measures: Main outcomes included hemoglobin and anemia levels at 8 months of age with the power estimate based on the prevalence of anemia. Secondary outcomes included hemoglobin and anemia levels at 12 months of age and ferritin level, iron deficiency, and iron deficiency anemia at 8 and 12 months of age.

Results: In this study of 540 infants (281 boys [52.0%] and 259 girls [48.0%]; mean [SD] gestational age, 39.2 [1.1] weeks), 270 each were randomized to the delayed and early clamping groups. At 8 months of age, 212 infants (78.5%) from the delayed group and 188 (69.6%) from the early clamping group returned for blood sampling. After multiple imputation analysis, infants undergoing delayed clamping had higher levels of hemoglobin (10.4 vs 10.2 g/dL; difference, 0.2 g/dL; 95% CI, 0.1 to 0.4 g/dL). Delayed cord clamping also reduced the prevalence of anemia (hemoglobin level <11.0 g/dL) at 8 months in 197 (73.0%) vs 222 (82.2%) infants (relative risk, 0.89; 95% CI, 0.81-0.98; number needed to treat [NNT], 11; 95% CI, 6-54). At 8 months, the risk for iron deficiency was reduced in the delayed clamping group in 60 (22.2%) vs 103 (38.1%) patients (relative risk, 0.58; 95% CI, 0.44-0.77; NNT, 6; 95% CI, 4-13). At 12 months, delayed cord clamping still resulted in a hemoglobin level of 0.3 (95% CI, 0.04-0.5) g/dL higher than in the early cord clamping group and a relative risk for anemia of 0.91 (95% CI, 0.84-0.98), resulting in a NNT of 12 (95% CI, 7-78).

Conclusions and Relevance: Delayed cord clamping reduces anemia at 8 and 12 months of age in a high-risk population, which may have major positive effects on infants' health and development.

Trial Registration: clinicaltrials.gov Identifier: NCT02222805.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-329087 (URN)10.1001/jamapediatrics.2016.3971 (DOI)000396202400017 ()28114607 (PubMedID)
Funder
Swedish Society of Medicine
Available from: 2017-09-08 Created: 2017-09-08 Last updated: 2019-03-25Bibliographically approved
3. Implementing delayed umbilical cord clamping in Nepal - Delivery care staff's perceptions and attitudes towards changes in practice
Open this publication in new window or tab >>Implementing delayed umbilical cord clamping in Nepal - Delivery care staff's perceptions and attitudes towards changes in practice
2019 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 6, article id e0218031Article in journal (Refereed) Published
Abstract [en]

Aim: To explore delivery care staff's perceptions and attitudes towards changes in practice of umbilical cord clamping in order to identify work culture barriers and enablers for improved clinical practice and implementation of the new guidelines on cord clamping.

Method: A purposive sampling strategy was used to include delivery staff at two major hospitals in Kathmandu, Nepal for focus group discussions. Key informant interviews were conducted with ward in-charge and Skilled Birth Attendant trainers at the respective hospitals. Data are analysed through qualitative content analysis.

Result: Participants had positive attitudes towards delayed cord clamping as it was not perceived to be a difficult task and as they perceived it to be beneficial for mother and child. The will to do good and a high level of trust in the hierarchical system and in scientific evidence were identified as promoters of change. Several barriers were mentioned, such as maternal or foetal medical conditions and physical settings, as constrains to performing delayed cord clamping. They also mentioned difficulties in adopting new guidelines due to habitual practice, lack of formal training and poor coherence within the work team. In order to bring change to the practice participants highlighted that authorized national and institutional protocols and regular training are crucial.

Conclusion: Due to poor coherence within the health system and lack of national or institutional protocols, delivery staff have to rely on their own skills development and informal decision making, and are therefore hesitant to apply new routines of delayed cord clamping. In order to change cord clamping practices to comply with evidence and policies health-care staff need to be better supported by the governance structures of the health system, with clear and approved guidelines made available and coherent training and support.

Keywords
Implementing delayed cord clamping, Perception, attitude
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-379561 (URN)10.1371/journal.pone.0218031 (DOI)000471234500047 ()31188895 (PubMedID)
Funder
The Swedish Foundation for International Cooperation in Research and Higher Education (STINT), PT2016-6639Swedish Research Council, 2014-04229
Note

Title in dissertation list of papers: Implementing delayed umbilical cord clamping in Nepal - Delivery care staff's perceptions and attitudes towards changes in practice : Implementing delayed umbilical cord clamping in Nepal

Available from: 2019-03-22 Created: 2019-03-22 Last updated: 2019-08-08Bibliographically approved
4. Effect of delayed cord clamping on risk of hyperbilirubinemia in term newborns: A randomsed clinical trial in Nepal
Open this publication in new window or tab >>Effect of delayed cord clamping on risk of hyperbilirubinemia in term newborns: A randomsed clinical trial in Nepal
Show others...
(English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227Article in journal (Other academic) Submitted
Abstract [en]

Aim: The aim of this study is to investigate the effects of delayed cord clamping on the risk of hyperbilirubinemia in term newborns.

Method: Term normal vagainal deliveries (n=540) were randomized in two groups; early (≤ 60 seconds) versus delayed (≥ 180 seconds) cord clamping between 2 October and 21 November, 2014 at Paropakar Maternity and Women's hospital in Kathmandu, Nepal. At discharge, transcutaneous bilirubin was measured on both groups. At four weeks, all parents completed a semi-structured questionnaire, health status of the baby was recorded, and jaundice was assessed and treated.

Result: Based on gestational age and age measured in hours after birth, 32.3% of the early and 33.2% of the delayed group had bilirubin levels high enough for phototherapy to be considered (p=0.78). At four weeks follow up jaundice was reported among 13 (5.1%) in the early, and 17 (6.7%) in the delayed group (p=0.57). Treatment for jaundice was gven to 3 (1.2%) of the early and 1 (0.4%) of the delayed group (p=0.62).

Conclution: Delayed cord clamping was not associated with an increased risk of hyperbilirubinaemia during the first day of the life or risk of jaundice within 4 weeks compared with early cord clamping group.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis
Keywords
Jaundice, Neonatal hyperbilirubinemia, Newborn, Umbilical cord clamping
National Category
Medical and Health Sciences Clinical Medicine
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-379548 (URN)
Funder
Swedish Research Council, 2014-04229The Swedish Foundation for International Cooperation in Research and Higher Education (STINT), PT2016-6639
Available from: 2019-03-25 Created: 2019-03-25 Last updated: 2019-03-28Bibliographically approved

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Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
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  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
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  • Other locale
More languages
Output format
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