Figure 1
Essential Newborn Care 2 Assessment and Continuing Care.
Figure 2
Low Literacy Instructions for Preparation and Use of the Dream Warmer (DreamWarmer™ – Global Newborn Solutions).
Figure 3
Study Design.
Table 1
Number of Responses to Surveys and Audits.
| SURVEY / AUDIT | NUMBER OF RESPONSES |
|---|---|
| Hospital Admission Data Pre Warmer | 2398 |
| Hospital Admission Data Post Warmer | 1294 |
| Warmer Use Audit | 281 |
| Warmer Non-Use Audit | 188 |
| HCP Pre Warmer Survey | 49 |
| HCP Post Warmer Survey | 90 |
| Parent Pre Warmer Survey | 49 |
| Parent Post Warmer Survey | 97 |
Table 2
Hospital Admission Data Pre and Post Warmer.
| HOSPITAL DATA PRE AND POST WARMER | ||||||
|---|---|---|---|---|---|---|
| Outcome | Hospital | n: 2398 | n: 1294 | |||
| Pre Warmer | Post Warmer | Pre Warmer | Post Warmer | |||
| % | % | p* | ||||
| Hypothermic | All sites | 34.6 | 34.5 | — | ||
| Euthermic | All sites | 57 | 55.7 | — | ||
| Hyperthermic | All sites | 8.4 | 9.8 | — | ||
| Mean ± SE | Mean ± SE | p* | ||||
| Admission temperature C | Sites w/ pre + post data | 3 | 3 | 36.41 ± 0.03 | 36.53 ± 0.03 | 0.002 |
| All sites | 6 | 3 | 36.46 ± 0.02 | 36.53 ± 0.03 | — | |
| Hospital 1 | 526 | 375 | 36.74 ± 0.04 | 36.84 ± 0.05 | 0.14 | |
| Hospital 2 | 446 | 491 | 36.74 ± 0.05 | 36.76 ± 0.05 | 0.75 | |
| Hospital 3 | 428 | 423 | 35.76 ± 0.05 | 36.00 ± 0.05 | 0.0005 | |
| Hospital 4 | 426 | — | 36.38 ± 0.05 | — | — | |
| Hospital 5 | 302 | — | 36.68 ± 0.06 | — | — | |
| Hospital 6 | 252 | — | 36.45 ± 0.06 | — | — | |
| % ± SE | % ± SE | p* | ||||
| Euthermia at admission† | Hospital 1 | 526 | 375 | 70 ± 2 | 70 ± 2 | 0.88 |
| Hospital 2 | 446 | 491 | 63 ± 2 | 63 ± 2 | 0.97 | |
| Hospital 3 | 428 | 423 | 27 ± 2 | 34 ± 2 | 0.02 | |
| Hospital 4 | 426 | — | 66 ± 2 | — | — | |
| Hospital 5 | 302 | — | 69 ± 3 | — | — | |
| Hospital 6 | 252 | — | 40 ± 3 | — | — | |
| Median (min−max) | Median (min−max) | p* | ||||
| Length of stay | Hospital 1 | 526 | 374 | 5 (0−69) | 6 (0−64) | 0.77 |
| Hospital 2 | 451 | 494 | 5 (1−39) | 5 (0−68) | 0.63 | |
| Hospital 3 | 412 | 402 | 6 (0−60) | 6 (0−77) | 0.46 | |
| Hospital 4 | 426 | — | 4 (0−60) | — | — | |
| Hospital 5 | 302 | — | 5 (1−51) | — | — | |
| Hospital 6 | 252 | — | 4 (0−39) | — | — | |
| % ± SE | % ± SE | p* | ||||
| In-hospital mortality | Hospital 1 | 526 | 375 | 10 ± 1 | 7 ± 1 | 0.19 |
| Hospital 2 | 451 | 494 | 2 ± 1 | 4 ± 1 | 0.2 | |
| Hospital 3 | 433 | 404 | 10 ± 1 | 12 ± 2 | 0.31 | |
| Hospital 4 | 426 | — | 8 ± 1 | — | — | |
| Hospital 5 | 302 | — | 9 ± 2 | — | — | |
| Hospital 6 | 252 | — | 13 ± 2 | — | — |
[i] *From factorial analysis of variance (temperature, log-transformed length of stay) or multiple logistic regression (euthermia, mortality), stratified with interaction terms to allow for variability among hospitals.
[ii] †Euthermia: 36.5−37.5 ºC.
Table 3
Warmer Use Audit.
| WARMER USE AUDIT | N: 281 |
|---|---|
| Pre-existing safety concerns | n: 266 |
| Yes (milial rash) | 2 (1%) |
| No | 264 (99%) |
| Ongoing safety concerns during/after Warmer use | n: 270 |
| Yes (milial rash) | 1 (1%) |
| No | 269 (99%) |
| Mattress placed in thermos prior to adding boiled water | n: 281 |
| Yes | 278 (99%) |
| No | 3 (1%) |
| Mattress prepared in advance of need | n: 280 |
| Yes | 263 (94%) |
| No | 17 (6%) |
| Mean time to prepare the Warmer when not ready in advance (minutes) | |
| 31 minutes | SD: 10 minutes, range: 5–60 | |
| Temperature indicator used correctly | n: 278 |
| Yes | 273 (98%) |
| No | 5 (2%) |
| Deviation from normal use | n: 270 |
| Yes (blanket placed between infant and Warmer) | 2 (1%) |
| No | 268 (99%) |
| Body temperature (°C) at start of Warmer use | |
| mean: 35.9 °C, SD: 0.8°C, range: 32.0 °C–37.2 °C | |
| Maximum body temperature (°C) during Warmer use | |
| mean: 36.7 °C, SD: 0.5°C, range: 33.4° C–37.9 ° C | |
| Duration of Warmer use | |
| mean: 2h 03m, SD: 1h 16 m, range: 02m–6h 0m | |
| Reasons for Warmer discontinuation | n: 276 |
| Mother requested to resume KMC | 178 (64%) |
| Warmer became cold | 43 (16%) |
| Other | 55 (20%) |
| Electric heat source became available | 24 (9%) |
| Warmer used for transport then infant was admitted | 23 (8%) |
| Infant was not warming | 5 (2%) |
| Infant reached euthermia | 3 (1%) |
| Warmer cleaned correctly | n: 260 |
| Yes | 251 (97%) |
| No | 9 (3%) |
| Problems | n: 202 |
| None | 142 (70%) |
| Warmer not available when needed (not prepared in advance) | 17 (8%) |
| Water scarce for use to heat mattress | 10 (5%) |
| Necessary supplies to clean Warmer scarce | 9 (4%) |
| Component of Warmer shows signs of breakdown (leakage…) | 2 (1%) |
| Other | 21 (11%) |
| Not enough kettles | 7 (3%) |
| Lack of training | 6 (3%) |
| Not enough Warmers | 4 (2%) |
| Warmer prep time (too long) | 4 (2%) |
| Baby not warming | 1 (1%) |
Figure 4
Initial and Maximum Temperature on Warmer.
Table 4
Warmer Non-Use Audit.
| WARMER NON-USE AUDIT | N: 216* |
|---|---|
| Warmer not prepared in advance | 61 (28%) |
| Did not have time to use | 37 (17%) |
| Insufficient time to boil water | 36 (17%) |
| Forgot to use Warmer | 35 (16%) |
| All Warmers were already in use | 24 (11%) |
| Absence of electricity | 9 (4%) |
| Warmer efficacy concerns | 9 (4%) |
| Water too scarce | 3 (1%) |
| Family member declined use | 1 (1%) |
| Safety concerns | 1 (1%) |
[i] * 188 respondents provided 216 reasons for Non-Use because they could choose more than 1 answer.
Table 5a
Health Care Provider Survey (Pre and Post).
| HCP PRE AND POST WARMER SURVEY | ||
|---|---|---|
| Pre Warmer – n: 49 (100%) | Post Warmer – n: 90 (100%) | |
| What is the lowest normal temperature for a baby? | n: 48 | n: 22 |
| Correct | 35 (73%) | 15 (68%) |
| < 36.5 | 35 (73%) | 15 (68%) |
| Incorrect | 13 (27%) | 7 (32%) |
| < 35.5 | 3 (6%) | 4 (18%) |
| <34.5 | 5 (10%) | 1 (5%) |
| other | 5 (10%) | 2 (10%) |
| Importance for keeping baby at a normal temperature | n: 49 | n: 23 |
| Very important | 44 (90%) | 21 (91%) |
| Important | 5 (10%) | 2 (9%) |
| Neutral | 0 | 0 |
| Unimportant | 0 | 0 |
| Very unimportant | 0 | 0 |
| Confidence of using KMC to keep baby warm | n: 49 | n: 23 |
| Very confident | 17 (35%) | 16 (70%) |
| Confident | 26 (53%) | 7 (30%) |
| Neutral | 4 (8%) | 0 |
| Unconfident | 2 (4%) | 0 |
| Very unconfident | 0 | 0 |
| Feelings about helping mothers provide KMC | n:49 | n: 23 |
| Like it a lot | 43 (88%) | 23 (100%) |
| Like it a little | 4 (8%) | 0 |
| Neutral | 2 (4%) | 0 |
| Dislike it a little | 0 | 0 |
| Dislike it a lot | 0 | 0 |
| Overall feelings about taking care of a small/sick baby | n: 49 | n: 23 |
| Very confident | 26 (53%) | 16 (70%) |
| Confident | 22 (45%) | 7 (30%) |
| Neutral | 1 (2%) | 0 |
| Unconfident | 0 | 0 |
| Very unconfident | 0 | 0 |
| Rate in which small/sick babies gain weight in hospital/health center | n: 49 | n: 23 |
| Very fast | 10 (20%) | 8 (35%) |
| Fast | 18 (37%) | 15 (65%) |
| Neutral | 7 (14%) | 0 |
| Slow | 12 (24%) | 0 |
| Very slow | 2 (4%) | 0 |
Table 5b
Additional Health Care Provider Post Warmer Survey Questions.
| HCP POST WARMER SURVEY (ADDITIONAL QUESTIONS) | N: 90 | ||||
|---|---|---|---|---|---|
| Very easy | Easy | Neutral | Difficult | Very difficult | |
| Learning and remembering how to use the Warmer | 45 (51%) | 40 (45%) | 2 (2%) | 2 (2%) | 0 |
| Preparing the Warmer | 47 (53%) | 35 (39%) | 2 (2%) | 5 (6%) | 0 |
| Prepare the Warmer in advance | 24 (32%) | 40 (53%) | 4 (5%) | 7 (9%) | 0 |
| Using the temp indicator to determine if safe for use | 47 (53%) | 34 (38%) | 7 (8%) | 1 (1%) | 0 |
| Cleaning the Warmer | 41 (46%) | 41 (46%) | 7 (8%) | 1 (1%) | 0 |
| Warmer’s affect on ability to perform other required duties during shifts | 22 (24%) | 43 (48%) | 14 (16%) | 11 (12%) | 0 |
| Very effective | Effective | Neutral | Ineffective | Very Ineffective | |
| Ability of Warmer to keep baby warm | 43 (48%) | 46 (52%) | 0 | 0 | 0 |
| Very comfortable | Comfortable | Neutral | Uncomfortable | Very Uncomfortable | |
| Comfort of mother using Warmer while providing KMC | 21 (23%) | 52 (58%) | 13 (14%) | 3 (3%) | 1 (1%) |
| Very often | Often | Neutral | Almost never | Never | |
| Warmer used instead of KMC when thermoregulation algorithm indicated to use KMC | 12 (16%) | 21 (27%) | 12 (16%) | 7 (9%) | 25 (32%) |
| Strongly promotes | Promotes | Neutral | Discourages | Strongly Discourages | |
| Warmer effect on: | |||||
| breastfeeding | 24 (31%) | 45 (58%) | 4 (5%) | 5 (6%) | 0 |
| ability to provide KMC | 23 (29%) | 39 (50%) | 9 (12%) | 7 (9%) | 0 |
| mother/infant bonding | 23 (29%) | 41 (52%) | 9 (11%) | 6 (8%) | 0 |
| mother’s sense of well-being | 22 (28%) | 45 (58%) | 10 (13%) | 1 (1%) | 0 |
| mother’s physical recovery after childbirth | 21 (27%) | 53 (67%) | 5 (6%) | 0 | 0 |
| Mother’s confidence baby will survive and thrive | 22 (25%) | 56 (63%) | 9 (10%) | 1 (1%) | 1 (1%) |
| Yes | No | ||||
| Does the Warmer look safe | 81 (100%) | 0 | |||
| Does the Warmer look well built | 82 (100%) | 0 | |||
| Concerns about Warmer working in your setting | 3 (9%) | 27 (90%) |
Table 5c
Healthcare Provider Post Warmer Survey – Free-Response Answers.
| CATEGORY + ANSWER | N: 199 (100%) |
|---|---|
| What did you like? | n: 71 |
| Effectively warms/prevents hypothermia | 45 (63%) |
| Easy to use | 13 (18%) |
| Design (shape, size, material, portability) | 10 (14%) |
| Other | 3 (4%) |
| comfortable with KMC | 1 |
| safe to use in transit from community hospitals | 1 |
| provides heat while mother recovers | 1 |
| What did you dislike? | n: 69 |
| Preparation (time) | 27 (39%) |
| Difficult to use | 6 (9%) |
| Design (shape, size, color) | 3 (4%) |
| Uncomfortable | 2 (3%) |
| Other | 9 (13%) |
| make electric | 1 |
| not functioning properly (leakage) | 1 |
| concerned about water usage | 3 |
| need more training | 1 |
| cleaning | 2 |
| transportation is not easy | 1 |
| No dislikes | 22 (32%) |
| What would you change? | n: 59 |
| Design | 20 (34%) |
| length | 12 |
| shorter | 2 |
| unspecified | 10 |
| shape | 1 |
| color | 6 |
| weight | 1 |
| Duration of warmth | 3 (5%) |
| More training | 2 (3%) |
| Decrease prep time | 8 (14%) |
| Other | 3 (5%) |
| increase quantity of Warmers | 2 |
| make it single use | 1 |
| No changes | 23 (42%) |
Table 6a
Parent Survey (Pre and Post).
| PARENT PRE AND POST WARMER SURVEY | ||
|---|---|---|
| Pre Warmer – n: 49 (100%) | Post Warmer – n: 97 (100%) | |
| Is it important to keep your baby’s temperature in a normal range? | n: 48 | n: 31 |
| Yes | 48 (100%) | 29 (94%) |
| No | 0 | 0 |
| I don’t know | 0 | 2 (6%) |
| Have you been providing KMC?* | n: 49 | n: 97 |
| Yes | 48 (98%) | 20 (21%) |
| No | 1 (2%) | 11 (11%) |
| Missing | 0 | 66 (68%) |
| How much do you like providing KMC for your baby? | n: 47 | n: 20 |
| Very much | 32 (68%) | 15 (75%) |
| Much | 15 (32%) | 5 (25%) |
| Neutral | 0 | 0 |
| Little | 0 | 0 |
| Very little | 0 | 0 |
| Do you feel confident providing warmth through KMC? | n: 48 | n: 20 |
| Very confident | 29 (60%) | 12 (60%) |
| Confident | 17 (35%) | 7 (35%) |
| Neutral | 2 (4%) | 1 (5%) |
| Unconfident | 0 | 0 |
| Very unconfident | 0 | 0 |
| How well do you think your baby is gaining weight in the hospital? | n: 49 | n: 31 |
| Very well | 21 (43%) | 12 (38%) |
| Well | 25 (51%) | 14 (45%) |
| Neutral | 3 (6%) | 4 (13%) |
| Poorly | 0 | 1 (3%) |
| Very poorly | 0 | 0 |
| Do you feel confident in having an adequate milk supply? | n: 49 | n: 31 |
| Very confident | 18 (37%) | 7 (23%) |
| Confident | 22 (45%) | 18 (58%) |
| Neutral | 8 (16%) | 1 (3%) |
| Unconfident | 1 (2%) | 4 (13%) |
| Very unconfident | 0 | 1 (3%) |
| Overall how do you feel as the parent of your newborn baby? | n: 49 | n: 31 |
| Very confident | 32 (65%) | 15 (48%) |
| Confident | 14 (29%) | 13 (42%) |
| Neutral | 2 (4%) | 1 (3%) |
| Unconfident | 1 (2%) | 2 (6%) |
| Very unconfident | 0 | 0 |
| How have you felt physically since your baby was born? | n: 49 | n: 31 |
| Very rested | 6 (12%) | 1 (3%) |
| Rested | 18 (37%) | 14 (45%) |
| Neutral | 10 (20%) | 7 (23%) |
| Tired | 14 (29%) | 5 (16%) |
| Very tired | 1 (2%) | 4 (13%) |
[i] * Due to the large percentage of missing data, we calculated parents reporting that they did not perform KMC in the numerator, and total responses in the denominator.
Table 6b
Additional Parent Post Warmer Survey Questions.
| PARENT POST WARMER SURVEY | N: 97 | ||||
|---|---|---|---|---|---|
| Very well | Well | Neutral | Poorly | Very poorly | |
| How did the Warmer work to keep your baby warm? (n: 97) | 50 (52%) | 39 (40%) | 4 (4%) | 4 (4%) | 0 |
| Strongly promotes | Promotes | Neutral | Discourages | Strongly Discourages | |
| What was the Warmer’s effect on: | |||||
| your ability to provide KMC (n: 96) | 39 (41%) | 31 (32%) | 22 (23%) | 4 (4%) | 0 |
| your ability breastfeeding (n: 96) | 34 (35%) | 38 (40%) | 20 (21%) | 4 (4%) | 0 |
| bonding with your baby (n: 97) | 43 (44%) | 28 (29%) | 19 (20%) | 7 (7%) | 0 |
| your sense of well-being (n: 97) | 40 (41%) | 40 (41%) | 16 (16%) | 1 (1%) | 0 |
| your physical recovery after childbirth (n: 87) | 50 (57%) | 29 (33%) | 8 (9%) | 0 | 0 |
| your confidence that your baby will survive and thrive (n: 84) | 52 (62%) | 21 (25%) | 11 (13%) | 0 | 0 |
| Yes | No | ||||
| Does the warmer look safe? (n: 81) | 80 (99%) | 1 (1%) | |||
| Does the warmer look well built? (n: 81) | 81 (100%) | 0 |
Table 6c
Post Warmer Parent Survey – Free Response.
| CATEGORY + ANSWER | N: 189 (100%) |
|---|---|
| What did you like? | n: 67 |
| Effectively warms/prevents hypothermia | 32 (42%) |
| Easy to use | 18 (27%) |
| Comfortable | 6 (22%) |
| Other | 11 (16%) |
| Helps mother: | 3 |
| Provide KMC | 1 |
| Bond with baby | 1 |
| Recover after childbirth | 1 |
| Portable | 7 |
| Shape and size | 1 |
| What did you dislike? | n: 64 |
| Prep time/ease of use | 17 (27%) |
| Heavy | 13 (20%) |
| Uncomfortable | 5 (8%) |
| Hard when cold | 3 (5%) |
| Other | 5 (8%) |
| Size | 2 |
| Doesn’t support KMC | 1 |
| Make it electric | 1 |
| Separates me from my baby | 1 |
| No dislikes | 21 (33%) |
| What would you change? | n: 58 |
| Design | 26 (45%) |
| Color | 9 |
| Smoother | 5 |
| Smaller | 4 |
| Resize (unspecified) | 4 |
| Longer | 3 |
| Lighter | 1 |
| Other | 12 (21%) |
| More Warmers in hospital | 3 |
| Be able to fully wrap the baby | 2 |
| More comfortable for KMC | 1 |
| Softer to allow breastfeeding while baby is on Warmer | 1 |
| Make a part that covers the head | 1 |
| Easier to prepare | 4 |
| No changes | 20 (34%) |
