1. National Surveillance on Birth Defects in Lebanon
2. Consanguinity Factor in the Genetics of Prematurity - by Qatar Neonatal Research Fund
3. Global Network on Maternal and Infant Health (GNMIH) March of Dimes Fundation
4. Regional networking in collaboration with WHO EMRO
National Surveillance on Birth Defects in Lebanon
Birth defects (BD) are among the main causes for neonatal morbidity and mortality. Lebanon, similar to many other developing countries, lacks surveillance systems for identifying birth defects. Whereas surveillance systems are essential for providing accurate information leading to the development of evidence-based approaches, the National Collaborative Perinatal Neonatal Network (NCPNN) in collaboration with the ministry of Public Health (MOPH) established in April 2012 a national BD registry in Lebanon. The project was launched through a decree issued by MOPH, mandating all hospitals to report BD. The surveillance included data from all Lebanese hospitals (N=131), and will be implemented over a period of 3 years.
The main two goals of this project are to establish a national surveillance for BD in Lebanon and to identify preventable BD and their complications resulting from modifiable risk factors. Three years were determined to achieve these goals.
Back to top
1- Abstraction form:
The NCPNN implemented BD collection forms in collaboration with the MOPH and the CDC based on the ICD-10 code. Variables includes socio demographic information, parental risk factors such as: maternal age, paternal age, parental consanguinity, substance exposure before and during pregnancy, body mass index, maternal chronic conditions, medications during pregnancy, family history of birth defects, data on the newborn, APGAR scores, congenital infections. Forms were distributed to all Lebanese hospitals during workshops, and are available online over the MOPH website.
Both passive and active ascertainments are deployed.
In the first year of the project, 7 workshops were organized to train personnel responsible for data collection; those were nurses and midwives from all Lebanese hospitals. The purpose of each workshop was to introduce the concept of surveillance, to familiarize the personnel with the different types of BD and to train them on the BD classification chosen for the purpose of this surveillance. The workshop training was given by a geneticist, a neonatologist or an epidemiologist.
Once the diagnosis of birth defect is made by the treating physician, the BD abstraction form is filled by the collectors of each hospital, irrespective of the newborn’s status at delivery (abort us, stillbirth, alive or dead). The data is then sent by fax to the MOPH representatives.
On a monthly basis, data is being collected by the NCPNN, and entered to the NCPNN software. Data is analyzed every 3 months and a report is sent to the MOPH.
Due to the manpower needed, active case ascertainment for birth defect cases reported from all hospitals in Lebanon was performed in 3 phases over the 3 years until all hospitals are included. Hospitals were selected for active case ascertainment based on their highest number of deliveries; governmental hospitals and underserved areas were prioritized. Prior to recruitment, healthcare providers (nurses, midwives, pediatricians and neonatologists) in these selected hospitals underwent an informative workshop in collaboration with the Ministry of Public Health (MOPH), to train on the recognition and proper diagnosis of BD; in addition they were given an illustrated BD manual that was previously developed by the NCPNN team. 51 hospitals were trained in the first year of the project, 29 new hospitals added in the second year.
To verify the quality of data collection and to ascertain the reported cases, trained research assistants (RA) from the NCPNN visit selected hospitals on a monthly basis. They retrieve the documented diagnosis, laboratory and radiology results from the infant’s and mother’s medical records. The information is then matched to the MOPH reported data; pending results were sought to confirm diagnosis. Furthermore, RA checks the presence of a clear medical report indicating the reported BD, whereby she checks the matching of the physician’s name signing the report with the physician’s signature on the abstraction form.
3- Birth Defects manual:
In collaboration with the center for disease control and prevention (CDC), NCPNN team updated the manual on birth defects, it was distributed to the 80 selected hospitals. This manual was developed in English, and translated to French and Arabic; it is available online here. The manual is divided into 9 chapters, each for an organ system. The diagnoses are listed based on the ICD-10 classification, with pictures or sketches of affected newborns along with a description of the defect or symptoms, diagnostic tests and associations with other malformations. This manual is intended to be distributed to all Lebanese hospitals gradually throughout the project. With the dissemination of this manual, it is expected that the surveillance and reporting of BD will improve which may lead to more accurate estimates of the true birth defect rates in Lebanon.
4- Statistical report:
A descriptive statistical report is developed and sent to the Ministry of Public Health (MOPH) every 3 months. It includes Birth Defects (BD) distribution among Lebanese provinces along with a presentation of all the reported cases. It also encloses socio-demographics data, maternal lifestyle, antenatal and general newborn characteristics. Data is analyzed using SPSS 20. Annual report will be established after a period of 10 to 12 months of data collection.
Back to top
1- School project:
In collaboration with the Lebanese Ministries of Education and Public Health and the March of Dimes Foundation, an awareness campaign was carried out in public and private Lebanese schools. The campaign’s aim was to increase awareness among adolescents of the preconception health components. The campaign consisted of a 20 minutes power point presentation to students at the grade 11 and 12 levels, tackling the following topics: importance of leading a healthy life style, risks related to obesity, toxoplasmosis, chronic conditions like diabetes, the use of certain medications, the importance of vaccinations, folic acid intake prior to pregnancy, the effects of smoking, alcohol and drugs during pregnancy, as well as risks of preterm birth and birth defects, fetal effect of smoking, obesity, alcohol consumption and certain medications during pregnancy; the importance of vaccinations and management of chronic diseases.
A knowledge assessment questionnaire addressing preconception health was collected from students prior to the intervention; the same questionnaire was administered 2 months after the intervention to assess knowledge retention rate.
2- Preconception brochures, pamphlets and posters:
Educational tools in the form of pamphlets and brochures were designed targeting women in reproductive age group. Different types of brochures were created, all addressing preconception care components as a mean to prevent birth defects. For instance, a pocket size booklet was designed and divided into 5 color coded pages each tackling a specific preconception care topic such as birth defects, rubella, toxoplasmosis, smoking, alcohol and folic acid. A monthly pregnancy planner was also designed that includes specific guidelines for women planning to become pregnant. In addition, a pamphlet was created and tailored for our population, more specifically for Lebanese moms to be addressing special messages on how to prevent birth defects from avoiding traditional dishes during pregnancy that might contain toxoplasmosis. A “did you know?” poster regarding all the steps to take to prevent birth defects was also designed. Those educational brochures were distributed during the international OBGYN congress. They are intended to be disseminated to obstetrician clinics in order to increase knowledge about preconception care and prevention of birth defects.
3- Health day campaign:
Health Day campaigns will be a nation-wide campaign targeting women in childbearing age from all Lebanese provinces. The overall objectives will be to raise awareness of the importance of preconception care and healthy behaviors for young women before and during their pregnancy. It will tackle proper nutrition and exercise; regular consumption of vitamins with folic acid; knowledge of family history; keeping up to date on vaccinations; avoidance of tobacco, alcohol, and abuse of other substances.
Back to top
Preconception care is defined as the care a woman receives before getting pregnant. It involves different interventions aiming to:
1- Identify problems that might affect the health of the pregnant woman and her baby.
2- Provide both males and females in the reproductive age with necessary information concerning preconception and pregnancy.
This health education when delivered to women during adolescence, before conception and between pregnancies may reduce health risks for the pregnant woman and her baby as well as reducing maternal mortality and morbidity, and neonatal complications such as birth defects, low birth weight and preterm delivery.
In Lebanon, preconception care and its services hold many limitations. It is highly recommended to target mothers and fathers to be with proper educational interventions, especially adolescents to increase their knowledge thus securing healthier pregnancy outcomes
The health intervention aims to increase awareness among adolescents concerning good health practices in preconception care to ensure safer pregnancies and healthier newborns.
In collaboration with the Lebanese Ministries of Education and Public Health, the National Collaborative Perinatal Neonatal Network (NCPNN) planned a health intervention for high school students namely grade10, grade 11 and grade 12 in both private and public schools for a period of three years. The Lebanese Ministry of Education selected a convenient sample of public schools from all six Lebanese provinces; approximately the same number of private schools was targeted by the NCPNN team.
The intervention was conducted during the academic years 2011, 2012 and 2013. It consists of a 20 minutes power point presentation on preconception care covering the following topics:
- Importance of leading a healthy life style
- Risks related to obesity
- Chronic conditions like diabetes, certain medications
- Importance of vaccinations
- Folic acid intake prior to pregnancy
- Effects of smoking, alcohol and drugs during pregnancy
- Risks of birth defects and preterm delivery
To evaluate this intervention, an anonymous questionnaire was administered to the students before the intervention to test their baseline knowledge. The same questionnaire was administered 2 months after the intervention to ascertain knowledge retention and benefit from the intervention. The questionnaire consists of short questions addressing the topics included in the presentation. The presentation was given by neonatologists, obstetricians and nurses from the NCPNN team and member hospitals.
Back to top
Consanguinity Factor in the Genetics of Prematurity - Qatar
In collaboration with University of IOWA and Pittsburg in the United States, Shafallah Medical Center in Qatar, and the Lebanese American University, the NCPNN is conducting a project to study the causes of preterm birth by identifying specific genes that may predispose to preterm birth.
Despite concerted efforts to reduce preterm delivery (PTD), its world-wide incidence remains high constituting a leading cause of childhood mortality and morbidity. Lebanon, a developing country with a four million population, has about (8.8%) incidence of preterm delivery. A wealth of studies has provided strong evidence that besides social and environmental influences, the genetic factor could be a main contributor to PTD. Prematurity and specifically infants born at less than 33 weeks appears to be genetically related and also is influenced by consanguinity and the environment.
This project aims at locating the maternal genes predisposing to preterm labor from a genetically homogeneous population.
This study will be based on collected data from the National Collaborative Perinatal Neonatal Network (NCPNN). Study patients (500) are mothers who have delivered prematurely at a gestational age (GA) less than 33 weeks with the following characteristics:
a) Live births
c) Without congenital anomalies.
Control cases (500) are mothers who have delivered at greater than 36 weeks at the same period of the study patients.
Intervention and procedures:
Participants will be recruited either prospectively at delivery or retrospectively by reporting to the hospital where they delivered or through a home visit by a member of the research team. After signing the consent forms, participants will be asked to donate 10 cc of blood and to respond to interview questions.
An improved understanding of the genetic factors that predispose to prematurity will help us in defining this complex mechanism and will offer hope for future solutions.
For more information, kindly visit Qatar National Research Fund website HERE .
Back to top
Global Network on Maternal and Infant Health (GNMIH) March of Dimes Fundation
A. Surveillance of preterm birth:
Preliminary data from the NCPNN database indicate a prematurity rate of 8.5% at 16 hospitals in Lebanon. The genetic homogeneity of the Lebanese population, the practice of consanguinity and the socioeconomic disparities that exist between communities make it a rich setup for studying risk factors of Preterm Birth (PTB) and for undergoing genetic investigations.
- To improve the surveillance of the causes and risk factors of preterm birth.
B. Health research capacity building – Training:
Development of a manual on Birth Defects:
As part of its goal to provide professional education and capacity building, the NCPNN developed a manual on BD with support from the March of Dimes Foundation to train personnel in improved diagnosis and reporting of BD. The manual includes color photos showing each of the abnormalities reported in the Network surveillance system, a description of the abnormality, and how to make a diagnosis and identify any associated birth defects.
This manual will be updated and used as an educational material in the above described workshops. Description of more malformations will be added (i.e. limb reduction malformations, minor defects and syndromes). For this purpose, the NCPNN team will follow the guidelines set by the National Birth Defects Prevention Network (NBDPN) and will add clear inclusion criteria for each defect and its code according to the ICD- 10 coding system set by the World Health Organization.
Back to top
Preterm Delivery in Lebanon
Preterm delivery (PTD) represents the occurrence of delivery before 37 weeks of gestation. It is one of the major causes of neonatal mortality and postnatal morbidity and accounts for the largest and increased proportion of, child health care expenditures in developed and developing countries.
Studies link many risk factors to PTD. These include: maternal demographic characteristics, history of previous PTD, the presence of PTD in a woman’s mother, full sister, maternal half-sisters or the woman’s own birth, cigarettes smoking and alcohol consumption, maternal medical disorders (diabetes, hypertension, vaginal bleeding), pregnancy history, present pregnancy characteristics (multiple gestations), psychological characteristics and social stress (working long hours and undertaking hard physical labor under stressful conditions), infections, uterine contractions and cervical length, and biological and genetic markers.
The main objective of this surveillance is to assess the determinants of PTD in Beirut
The "National Collaborative Perinatal Neonatal Network" (NCPNN) initiated surveillance for 2 years (2013 & 2014) in five member hospitals accounting for the highest numbers of deliveries in Beirut. The surveillance involves collection of data regarding determinants of PTD from delivering woman in the following member hospitals:
- American University of Beirut Medical Center (AUBMC)
- Hôtel Dieu de France- Centre Hospitalier de l’Université Saint Joseph de Beyrouth
- Sahel General Hospital
- Saint George hospital- University Medical Center
- University Medical Center Rizk Hospital
For this purpose, a two page questionnaire was added to the NCPNN original questionnaire and included various questions pertaining to the history of PTD, some of its risk factors along with clinical data on current and previous pregnancies. The relevant information is acquired through a face to face interview with the delivering mothers at the hospital in question. A well trained research assistant ascribed by the Network describes first the aim, objectives and methods of this surveillance through reading an oral consent form. After the delivering women grant oral approval, the research assistant proceed by filling in the questionnaire.
Data is collected, entered in the NCPNN database for later analysis to be performed on SPSS version 20.
Data collection at AUBMC started March 2013, once the Institutional Review Board of the American University of Beirut approved the conduction of the surveillance.
Official approval for the project in Sahel General Hospital was granted in June 2013.
As for the other 3 hospitals (Hôtel Dieu de France, Saint George hospital, University Medical Center Rizk Hospital), collection will begin once the approval of the administrative boards is secured.
Back to top
Central Line Associated Bloodstream Infection (CLABSI)
The Central Line Insertion and Maintenance Bundle Intervention is a quality improvement prospective and multi-center study.
The primary objective of this study is to reduce the Central Line Associated Bloodstream Infection (CLABSI) rates in the neonatal intensive care unit (NICU) by 50% over a period of 1 year.
Additionally, this study aims to increase and sustain staff hand hygiene compliance and to issue recommendation to standardize care among NICUs nationally. Two bundles were developed based on the “back to basics” strategy developed and tested by Dr. Peter Provonost; One bundle pertaining to the insertion of the catheter procedure and the other to its maintenance.
Daily data will be collected on insertion or maintenance of catheters performed on all neonates admitted for more than 24 hours to NICUs at the 3 participating referral hospitals. In addition, potential symptoms and morbidities occurring due to these procedures will be documented.
The participating hospitals are: The American University of Beirut Medical Center, Saint Georges Medical Hospital and Rafic Hariri Governmental hospital.
Once data collection is complete, CLABSI rate will be calculated and compared to baseline rates obtained from the infection control department in each of the recruited hospitals.
Back to top
WHO Regional Network
Due to the paucity of research and inequities between neighbouring countries in the Eastern Mediterranean Region (EMR), the National Collaborative Neonatal Network (NCPNN) has initiated the establishment of a regional collaboration similar to the NCPNN model that continues to grow in Lebanon.
This initiative has started with the network bi-annual meeting in November 2008 where medical centers in countries of the EMR were approached and a constitution and operation guidelines on building this regional collaboration have been issued by the network.
In November 2008,following the first regional meeting, training workshops were held in February and August 2009 on surveillance methods, techniques and indicators collected by the network targeting educators, nurses and midwifes from:
Outcomes of Training Workshops:
- Striking disparity in practice and knowledge in these countries ranging from high up-to-date quality to poor practice and knowledge.
- Usefulness of building collaboration in the region and the exchange of visits and knowledge sharing.
These outcomes suggest the immediate need for effective interventions and capacity building.
With other centers from the EMR expressing their willingness to be part of this collaboration, the NCPNN in collabortaion with WHO is preparing to conduct a regional training workshop in February of 2011 in collaboration with the World Health Organization.
Back to top