Weight gain in low-birth-weight newborns and associated factors in Central Benin settings

INTRODUCTION

The world health organization (WHO) defines LBW as a birth weight of less than 2,500 grams. LBW is a public health concern worldwide, most notably in low-income countries.¹ Around 14.6% of newborns had LBW worldwide in 2015.² In sub-Saharan Africa, around 14% of babies are born with low birthweight.³ In Benin, the prevalence of LBW was 12% in 2017.⁴ The survival of LBW newborns depends on their nutritional status and the prevention of hypothermia.⁵ Weight gain enabling these newborns to exceed the 2,500-gram threshold could help reduce neonatal morbidity and mortality.⁵ Compared to normal-weight newborns, LBW infants are born with insufficient energy and micronutrient reserves for their development, and therefore require considerable energy for tissue synthesis. Low weight gain thus exposes newborns to wasting and stunted growth. On the other hand, rapid weight gain in the first few weeks will enable these newborns to reach normal birth weight, and build a more effective immune system capable of fighting off disease. Accordingly, UNICEF Benin, in collaboration with the ministry of health, has set up an "optimized mother-newborn care model" in Bohicon health district located in central Benin.⁶

An evaluation of the model's results, carried out between September 2018 and February 2019, showed that 52% of low-birth-weight newborns experienced a weight gain that enabled them to reach the weight threshold of 2500 grams after 4 weeks of follow-up, compared with 48%.⁵ In the current study, the aim was to investigate the associated factors for low weight gain in LBW newborns benefiting from this model.

METHODS

Settings

The survey was performed within Bohicon health district located in central Benin's Zou department. The health district had a population of 471,927 and 32 public health centers. Out of these 32 health centers, 20 were involved in the implementation of the "optimized mother-newborn care model", whose main objective is to improve the survival of both mother and newborn. The model includes care at the health center complemented by community follow-up, including:- early breastfeeding and exclusive breastfeeding, -systematic "kangaroo mother" care (KMC) and hypothermia treatment; -systematic wearing of an electronic hypothermia detection bracelet; - mandatory 48-hour hospital stay and -home visits by community health workers.

Children's discharge criteria were: well-tolerated kangaroo position, weight gain 15 grams/kg/day for 3 successive days. Weight at the end of the four-week follow-up period must exceed 2,500 grams.

The "kangaroo mother" method: consists of carrying a premature baby on the stomach in the skin-to-skin contact.

Study design

This was a retrospective, analytical study. The study population consisted of LBW newborns benefiting from the "optimized mother-newborn care model", their mothers as well as the health workers from the health district.

To be included in the study, you had to be: an LBW newborn benefiting from the "optimized mother-newborn care model" with weight monitoring during the first four weeks of life. -a mother of an LBW newborn benefiting from the "optimized mother-newborn care model" with weight monitoring during the first four weeks of life; -a health worker involved in the "optimized mother-newborn care model" during the study period.

LBW newborns with a chronic disease (HIV infection, sickle cell disease, heart disease) were not included in the study.

Selecting newborns

Of the 20 health centers in the health district involved in the optimized mother-newborn care model, 12 were retained by simple random selection. All newborns meeting the inclusion criteria and born in the chosen health centers were surveyed.

Selecting mothers

The mothers selected were those who delivered an LBW newborn enrolled in the optimized care model. Their selection was made by convenience.

Selecting health workers

By reasoned choice, the midwife responsible for implementing the model was surveyed.

Study variables

The dependent variable was weight gain in LBW newborns. Weekly weight measurements during the four-week follow-up period were used to assess weight gain: adequate weight (greater than 2,500 grams) and low weight (less than or equal to 2,500 grams).

Independent variables were: socio-demographic and economic factors: mother's age, marital status, mother's level of education, household size, mother's occupation, monthly income, income-generating activities, father's profession; health system factors: allocation of a "Bempu" electronic bracelet, monitoring during the first 48 hours, temperature monitoring of newborns, monitoring of newborns admitted to KMC, home visits by community outreach workers; newborn characteristics : birth weight, colostrum consumption, postnatal hospital stay, Bempu bracelet worn, hypothermia episodes, sucking capacity, morbidity, vaccination status, weekly weights; mother-related factors: parity, inter-gestational interval, LBW experience, "kangaroo mother" care practices, newborn feeding knowledge and practices, basic hygiene, mother's diet.

The occurrence of hypothermia was assessed through the ringing or non-ringing of the Bempu electronic bracelet given to newborns by health workers. It signals hypothermia in the child and prompts mothers to perform "mother kangaroo care".

The number of KMCs performed by mothers during the follow-up period was collected on newborn follow-up sheets in the health centers.

The method of feeding was assessed by the following modalities: sucking of breast milk by the newborn, milk expressed directly into the infant's mouth and milk expressed using a cup. The consumption of hindmilk by the newborn was assessed by the "yes" and "no" modalities. Hindmilk is the breast milk remaining in the breast after the first milk (breast milk secreted first during breastfeeding) has been extracted.

Data collection

Data were collected through documentary review and a questionnaire survey led by two nutritionist-dietitians and two socio-anthropologists. An appointment was made with the newborn mothers, after which the team went to their homes to collect the data.

Data analysis

Data were analyzed using STATA 11 software. The chi-square test was used to compare proportions and look for statistical relationships between dependent and independent variables. The student’s t test was used to compare means. Multivariate logistic regression was applied to identify factors associated with the weight gain.

RESULTS

General features of the sample

A total of 124 newborns were monitored, 54.84% of whom were female. Mean birth weight was 2110.24±217.05 grams. Hypothermia was reported in 64.52% of newborns, and the average number of SMKs performed was 30.65±24.27 times. The mean weight at discharge from the health center was 2105.27±216.02 grams, with extremes ranging from 1500 to 2450 grams. The median number of hypothermia episodes recorded was 9 (0; 39) times. The mean duration of KMC performed by the mothers was 48.59±15.67 minutes. The duration of postnatal hospitalization was greater than or equal to 48 hours for all newborns surveyed. All newborns surveyed had up-to-date vaccination status at the end of follow-up.

A total of 101 mothers were surveyed, with a mean age of 23.47±5.23 years, 32.67% had never attended school and 57.43% were housewives. Most households (61.39%) consisted of 1 to 4 people, and 87.13% of mothers lived in couples. The predominant feeding method (86.14%) was sucking by the newborn, and 67.33% of newborns received hindmilk from their mothers (Table 1).

As far as care providers were concerned, 12 midwives were surveyed, all of whom had been trained in the implementation of the model. Among the children surveyed, 65.32 percentages had benefited from the Bempu bracelet and 48.39% from home visits by the community relays.

Weight gain in low-birth-weight newborns

Overall, out of 124 newborns surveyed, 103 (83.06%) exceeded the weight threshold of 2500 g at the end of the four-week follow-up period, compared with 21 (16.94%). Weight gain was therefore adequate in the majority of newborns.

Factors associated with weight gain

Bivariate analysis

Sociodemographic and economic variables associated with weight gain in low-birth-weight newborns at the 10% threshold were ethnicity, mother's marital status, father's occupation and household size (Table 2).

The health system variables associated with weight gain in low-birth-weight newborns at the 10% threshold were, wearing of the Bempu bracelet to the newborn and home visit by methodology completely, including sample collection, processing, lab analysis, statistical tests used for data analysis etc.

Use section headings or subheadings in a logical order to entitle each category of the community relays shows in Table 3.

Among neonatal factors, birth weight, occurrence of hypothermia and number of KMCs performed were associated with weight gain. The mean birth weight of newborns with adequate weight gain was statistically higher (2172.41±164.76 g) than that of newborns with low weight gain (1793.75±217.46 g), and this difference was statistically significant (p=0.00).

Mean number of KMCs performed in newborns with adequate weight gain (33.01±25.58 times) was statistically higher than in newborns with low weight gain (19.04±6.59 times), and this difference was statistically significant (p=0.007).

Newborns who had a hypothermic episode reported by the bracelet were less likely to have a low weight gain than those who had no hypothermic episode (OR=0.15 with CI95%: [0.05-0.44]).

Mother-related variables associated with weight gain in low-weight newborns at the 10% threshold were: traditional practices, early breastfeeding, newborn's consumption of hind milk, feeding method, frequency of suckling, newborn's consumption of herbal tea, mothers' knowledge of the importance of colostrum, mothers' knowledge of early breastfeeding, presence of garbage in homes, distance between latrines and water sources, dietary diversity, frequency of mother's water consumption, mother's alcohol consumption and quantity of alcohol consumed (Table 4).

Multivariate analysis

The final logistic regression model shows that household size, home visits by community relays, feeding method and consumption of hindmilk were statistically associated with weight gain (Table 5).

*Reference modality for comparison; ND: number of modalities too small for comparison.

DISCUSSION

A This study examined the factors associated with weight gain in low-weight newborns followed by the model within Bohicon health district. Adequate weight gain was 83.06% and low weight gain was 16.94%. Household size, occurrence of hypothermia, number of "kangaroo mother" care sessions, home visits by community relays, feeding method and consumption of hind milk by newborns were the factors associated with weight gain in the present study.

Weight gain determinants

Household size

Newborns living in households with a size greater than 4 were more likely to have the low weight gain after four weeks of follow-up compared to those living in households with a size less than or equal to 4. A study carried out in Indonesia by Mahmudiono et al found evidence that children living in larger households would be at greater risk of stunting and food insecurity.⁷ Another study in Ivory Coast by Kinimo et al reported similar results.⁸

Hypothermia onset and "kangaroo mother" care

Newborns experiencing hypothermia episodes reported by the bracelet were less likely to have low weight gain than others without hypothermia episodes. This could be explained by the fact that hypothermia episodes were not followed up in newborns not wearing the Bempu bracelet. However, each time a hypothermia signal is given, mothers perform KMCs, which implies breastfeeding. The average number of KMCs performed in newborns with adequate weight gain was statistically higher than in newborns with low weight gain. These findings support the observed relationship between the occurrence of hypothermia and low weight gain. The relationship between the number of KMCs and weight gain is consistent with the results of other studies carried out in Nigeria, Benin, Ethiopia and Nepal, which showed that adequate weight was achieved more quickly in newborns who received KMCs.^9-12

Home visits by community relays

Newborns not reached by community health promoters' home visits were more likely to have a low weight gain at the end of four weeks' follow-up than those who did. This association supports the strategy of using community relays to bring health promotion issues closer to vulnerable populations.¹³ It is attributable to the importance of the parameters (the baby's actual wearing of the bracelet, the mothers' performance of KMC, the types of difficulties encountered by the mothers in performing KMC and using the bracelet, the mothers' actual practice of exclusive breastfeeding, the baby's state of health) monitored by the community relays during their home visits and their psychological support for the mothers. Home visits by community relays would therefore enable mothers to take better care of their children, to practice KMC as much as necessary, and to breastfeed them regularly so that the right weight is reached at the end of the follow-up.

Feeding methods

During follow-up, newborns whose mothers were forced to express milk directly from the breast into the infant's mouth were more likely to have low weight gain after four weeks' follow-up than those who were able to suck breast milk on their own throughout the follow-up period. A study by Emond and al. in the UK also concluded that the sucking ability of newborns was related to their growth.¹⁴ The amount of milk sucked voluntarily by the newborn would be better adapted to his or her needs than the quantity expressed by the mother.

Consumption of hindmilk

Newborns who did not consume hind milk were more likely to have low weight gain after four weeks' follow-up than those who did. As this milk has a higher fat content and average caloric density than the first milk, it would promote faster weight growth in the newborn.¹⁵

CONCLUSION

More than half of the newborns followed by the "optimized mother-newborn care model" were able to reach the weight threshold of 2,500 grams after four weeks. Low weight gain was associated with socio-demographic, health system and maternal factors. Addressing these factors could improve the effectiveness of the "optimized mother-newborn care model" within the health district.

ACKNOWLEDGEMENTS

Author would like to thanks to health workers in Bohicon health district and community participants in study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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