by Bupe Mwamba | Lusaka, Zambia
Goal: Targeted midwifery education program on delayed cord clamping to reduce neonatal anemia in Zambia.
Twinning Association of Midwives Association of Zambia (MAZ), & American College of Nurse Midwives(ACNM)
Left to right: Lauren Arrington, CNM; Ruth Muzumala; Wreatha Carner, CNM; Rhoda Amafumba; Tina Johnson, CNM, MS, ACNM Director of Professional Practice & Health Policy; Sarah Ngama.
Prenatal interventions to decrease infant and maternal iron deficiency anemia, including iron supplementation and nutritional plus programs addressing malaria prevention and treatment, are slowly becoming more integrated into standards of practice. Research has shown that routine delayed clamping of the umbilical cord at birth can greatly reduce neonatal anemia during the critical first months of a child’s life. However, despite strong evidence on the many benefits for the newborn of delayed cord clamping, at present there exists a lag in change of practice as many Zambian midwives continue to clamp the cord immediately. In part, this lag is due to previous education about active management of the third stage of labor and fears about HIV transmission. In fact, in a small study performed in Zambia ninety percent of providers reported they believed the best time to cut the cord was immediately after delivery or within 1 minute (Vivio et al., 2010). Targeting midwifery education as a means to reducing neonatal anemia through delayed cord clamping presents a realistic intervention that has potential for widespread positive effects. Delayed cord clamping is defined as a delay in cutting the umbilical cord until 1-3 minutes after delivery of the baby. This allows for continued passage of blood from the placenta to the baby. The evidence from delayed cord clamping has been shown to increase the iron stores of young infants by over 50% at 6 months of age among babies born at full-term and reduce by 61% the rate of anemia requiring blood transfusion in newborns (WHO, 2013). Iron is a critical micro-nutrient in a child’s development, from immune function to neurological development. When mothers follow the recommendation to exclusively breastfeed for the first 6 months of life, their breast milk provides only a small amount of iron to the infant. To meet the high requirements for iron during this period of growth and development, the baby depends on their iron stores from birth. It is suggested that delayed cord clamping provides up to 75 mg of iron (a 3.5 month supply) in the infant’s first 6 months of life, and that the greatest benefit is seen in children born at term to iron-deficient mothers and babies with birth weights of less than 3,000 grams (Blouin et al., 2013) . This is particularly relevant in Zambia, where 12.9% of babies are born prematurely, and 35% of children under five and 30% of child-bearing aged women have iron-deficiency anemia (WHO, 2010). Iron deficiency anemia has been shown to have a direct negative impact on neurodevelopment in the critical first years of childhood. ?? Benefits that are specific for preterm infants include: a 62% reduction in the rate of necrotizing enterocolitis, a 29% reduction in the rate of neonatal sepsis, a 52% reduction in the rate of blood transfusions for low blood pressure, and a 59% reduction in the rate of intraventricular hemorrhage (Backes'et'al.,'2014).'As 12.9% of infants in Zambia are born prematurely, standardizing the process of delayed cord clamping has the potential to greatly decrease the personal, social, and economic burden of this high prematurity rate. Zambian midwives shared the three main concerns affecting their decision related to timing of umbilical cord clamping (Vivio et al., 2011): 1) Multiple changes in the management of the third stage of labor have resulted in confusion over the state of the science on the timing of cord clamping. Prior to 2006, immediate cord clamping was taught. This practice changed to reflect the state of the science at the time and was replaced with uterine massage after delivery of the placenta. 2) Although there is no scientific evidence that delayed cord clamping increases the possibility of HIV transmission from mother to newborn, midwives in this study expressed concern with mother-to-child transmission of HIV using delayed cord clamping. 3) Contrary to popular misconceptions, evidence shows that delayed cord clamping does not increase the risk of severe jaundice, or of associated polycythemia in the infant.