Is facility based neonatal care in low resource setting keeping pace? A glance at Uganda's National Referral Hospital

Early Neonatal Mortality and Predictors in Newborns Admitted to the Neonatal Intensive Care Unit at Public Hospitals in Hadiya Zone, Central Ethiopia: A Retrospective Cohort Study

Background. Despite numerous life-saving measures, neonatal mortality remains high. This research aims to investigate the incidence and predictors of early neonatal mortality among newborns admitted to intensive care units in public hospitals in Hadiya Zone, Ethiopia. Methods. A retrospective cohort study was conducted on 689 neonates admitted to the neonatal intensive care unit. Cox proportional hazard regression by STATA was used. Results. This study followed for 3439 person-days found an incidence rate of 16.9 deaths per 1000 person-days. Birth weight [AHR = 4.4, 95% CI; 1.29, 14.94], APGAR score at the fifth minute 4 to 6 [AHR = 0.42, 95% CI; 0.2, 0.87], hypoglycemia [AHR = 8.1, 95% CI; 2.17, 30.43], no treated with oxygen [AHR = 2.6, 95% CI; 1.1, 5.9], and obstetric complications [AHR = 0.41, 95% CI; 0.18, 0.93] predicted early neonatal mortality. Conclusion. The study revealed a high neonatal mortality rate, necessitating increased focus on oxygen treatment for newborns and improved early diagnosis and treatment of obstetric complications.

Clinical profiles, incidence and predictors of early neonatal mortality at Mbarara Regional Referral Hospital, south-western Uganda

BACKGROUND

The current neonatal mortality rate in Uganda is high at 22 deaths per 1000 live births, while it had been stagnant at 27 deaths per 1000 live births in the past decade. This is still more than double the World Health Organization target of < 12 deaths per 1,000 live births. Three-quarters of new born deaths occur within the first week of life, which is a very vulnerable period and the causes reflect the quality of obstetric and neonatal care. At Mbarara Regional Referral Hospital (MRRH), the modifiable contributors and predictors of mortality remain undocumented, yet neonates make the bulk of admissions and contribute significantly to the overall infant mortality rate. We therefore examined the clinical profiles, incidence and predictors of early neonatal mortality of neonates admitted at MRRH in south-western Uganda.

METHODS

We conducted a prospective cohort study at the Neonatal Unit of MRRH between August - November, 2022 among neonates. We consecutively included all live neonates aged < 7 days admitted to neonatal unit and excluded those whose outcomes could not be ascertained at day 7 of life. We obtained baseline data including; maternal social-demographic and obstetric information, and performed neonatal physical examinations for clinical profiles. We followed up neonates at 24 and 72 h of life, and at 7 days of life for mortality. We summarized the clinical profiles and incidence of mortality as frequencies and percentages and performed modified Poisson regression analysis to identify the predictors of early neonatal mortality.

RESULTS

We enrolled 384 neonates. The majority of neonates were in-born (68.5%, n = 263) and were admitted within 24 h after birth (54.7%, n = 210). The most common clinical profiles at admission were prematurity (46%, n = 178), low birth weight (LBW) (44%, n = 170), sepsis (36%, n = 139), hypothermia (35%, n = 133), and birth asphyxia (32%, n = 124). The incidence of early neonatal mortality was at 12.0%, 46 out of the 384 neonates died. The predictors of early neonatal mortality were hypothermia, [adjusted Risk Ratio: 4.10; 95% C.I (1.15-14.56)], birth asphyxia, [adjusted Risk Ratio: 3.6; 95% C.I (1.23-10.73)] and delayed initiation of breastfeeding, [adjusted Risk Ratio: 7.20; 95% C.I (1.01-51.30)].

CONCLUSION

Prematurity, LBW, sepsis, birth asphyxia and hypothermia are the commonest admission diagnoses. The incidence of early neonatal mortality was high, 12.0%. We recommend targeted interventions by the clinical care team at MRRH to enable timely identification of neonates with or at risk of hypothermia to reduce incidence of adverse outcomes. Intrapartum care should be improved in order to mitigate the risk of birth asphyxia. Breastfeeding within the first hour of birth should be strengthened were possible, as this is associated with vast benefits for the baby and may reduce the incidence of complications like hypothermia.

Identifying neonates at risk for post-discharge mortality in Dar es Salaam, Tanzania, and Monrovia, Liberia: Derivation and internal validation of a novel risk assessment tool

INTRODUCTION

The immediate period after hospital discharge carries a large burden of childhood mortality in sub-Saharan Africa. Our objective was to derive and internally validate a risk assessment tool to identify neonates discharged from the neonatal ward at risk for 60-day post-discharge mortality.

METHODS

We conducted a prospective observational cohort study of neonates discharged from Muhimbili National Hospital in Dar es Salaam, Tanzania, and John F Kennedy Medical Centre in Monrovia, Liberia. Research staff called caregivers to ascertain vital status up to 60 days after discharge. We conducted multivariable logistic regression analyses with best subset selection to identify socioeconomic, demographic, clinical, and anthropometric factors associated with post-discharge mortality. We used adjusted log coefficients to assign points to each variable and internally validated our tool with bootstrap validation with 500 repetitions.

RESULTS

There were 2344 neonates discharged and 2310 (98.5%) had post-discharge outcomes available. The median (IQR) age at discharge was 8 (4, 15) days; 1238 (53.6%) were male. In total, 71 (3.1%) died during follow-up (26.8% within 7 days of discharge). Leaving against medical advice (adjusted OR [aOR] 5.62, 95% CI 2.40 to 12.10) and diagnosis of meconium aspiration (aOR 6.98, 95% CI 1.69 to 21.70) conferred the greatest risk for post-discharge mortality. The risk assessment tool included nine variables (total possible score=63) and had an optimism corrected area under the receiver operating characteristic curve of 0.77 (95% CI 0.75 to 0.80). A score of ≥6 was most optimal (sensitivity 68.3% [95% CI 64.8% to 71.5%], specificity 72.1% [95% CI 71.5% to 72.7%]).

CONCLUSIONS

A small number of factors predicted all-cause, 60-day mortality after discharge from neonatal wards in Tanzania and Liberia. After external validation, this risk assessment tool may facilitate clinical decision making for eligibility for discharge and the direction of resources to follow-up high risk neonates.

Infant mortality and its determinants in Uganda 2016: Using a geographically weighted regression approach

Infant mortality (IM) represents the overall health of a country or region as it relates to access to medicine, health care, and clean water in a population. IM remains understudied in many areas of Uganda, as many studies are from urban the capital (Kampala). The long-term goal of this research is the mitigation of IM and poor pregnancy outcomes in Uganda. Insights gained from geographic distribution of IM will allow adaptation of diagnosis, treatments, and interventions within the studied areas. Through using OLS and geographically weighted regression, this study has explored the significant factors and their heterogeneous and scaling effects in 2016 across Uganda. The empirical findings from this study include a significant association between IM and both being unmarried and preferring to speak Luganda when interviewed. Those unmarried may lack a social network to assist with income, childcare, and household chores representing decreased resources. Additionally, being interviewed in Luganda was associated over a large geographic area, which may represent not being comfortable in English, which is the language of education, commerce, and presumably health care, thus suggesting a disconnect with health care settings. These data suggest that strides can be made in Uganda by providing targeted resources to areas with high rates of unmarried mothers and those areas with high rates of Luganda as their language of choice.

Predictors of Neonatal Mortality: A Retrospective Cross-Sectional Study From the Special Newborn Care Unit of a Tertiary Care Hospital

Background In India, a significant number of newborns die each year, with Madhya Pradesh having the highest neonatal mortality rate. However, there is a lack of information on factors that can predict neonatal mortality. Objective This study aimed to examine the factors influencing neonatal mortality among neonates admitted to a tertiary care centre's special newborn care unit (SNCU). Methods This retrospective record-based observational study was done at a tertiary care centre, where data from the special newborn care unit (SNCU) from 1st January 2021 to 31st December 2021 was used. We included data of all newborns who were treated in SNCU during the said period and excluded those who got referred or left against medical advice. We abstracted data on age at admission, gender, category, maturity status, birth weight, place of delivery, mode of transport, type of admission, indication of admission, duration of stay and outcome. Qualitative variables were described using frequency and percentage. The chi-square test was used to find out the association of different variables with the outcome, while multivariate logistic regression was conducted to identify risk factors of neonatal mortality. A p-value of <0.05 was considered significant. Results We finalized data of 1052 neonates for analysis. Among them, 846 neonates were successfully discharged while 206 neonates were deceased. The major cause of admission was perinatal asphyxia followed by prematurity. The major cause of mortality in this study was sepsis followed by respiratory distress syndrome, birth asphyxia, and prematurity. Mortality of neonates was significantly associated with maturity status, birth weight, place of delivery, age during admission and duration of stay. Prematurity (OR=3.762, 95% CI:1.93-7.33), birth weight 1000-1499g (OR=4.78, 95% CI:2.21-10.32), birth weight <1000g (OR=25.11, 95% CI:5.71-110.24), age at admission <1-day (OR=2.312, 95% CI:1.03-5.19), duration of stay 1-3-days (OR=12.98, 95% CI:7.48-22.52) and <1-day (OR=1271.88, 95% CI:121.39-13325.69) were significant predictors of mortality in our study. Conclusion Our study emphasizes monitoring and addressing risk factors like maturity status, birth weight, and age at admission to reduce neonatal mortality, with a focus on early management of preterm births and low birth weight.

"My baby is fine, no need for more clinic visits." Facilitators and barriers for utilisation of follow-up services for children born preterm in low-resource setting: Parents' perceptions

OBJECTIVES

We sought to understand the facilitators and barriers impacting utilisation of follow-up services for children born preterm as perceived by parents in a low-resource setting.

METHODS

We conducted a qualitative study at Mulago Hospital, Uganda, with parents of children born preterm and aged 22-38 months at the time of the study. We collected data using five in-depth interviews and four focus group discussions. Data were analysed using thematic analysis informed by the social-ecological model.

RESULTS

Ten subthemes emerged that could be grouped into three main themes: (1) Individual: parents' knowledge, parenting skills, perception of follow-up and infant's condition; (2) Relationship: support for the mother and information sharing; (3) Institution: facility setup, cost of care, available personnel and distance from the facility. Parents of preterm infants perceived receiving timely information, better understanding of prematurity and its complications, support from spouses, availability of free services and encouragement from health workers as facilitators for utilisation of follow-up services. Limited male involvement, parents' negative perception of follow-up, stable condition of infant, health facility challenges especially congestion at the hospital, distance and care costs were key barriers.

CONCLUSION

An interplay of facilitators and barriers at individual, interpersonal and health system levels encourage or deter parents from taking their preterm children for follow-up services. Improving utilisation of services will require educating parents on the importance of follow-up even when children are not sick, eliciting maternal support from spouses and peers and addressing health system gaps that make follow-up unattractive and costly.

Born too soon in a resource-limited setting: A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border

Background

Preterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC).

Materials and methods

This sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care.

Results

From 2008-2017, mortality was reduced by 68% and 53% in very (EGA 28-32 weeks) and moderate (EGA 33-36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting.

Discussion

This study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs.

Cause and risk factors of early neonatal death in Ethiopia

Background

Globally, three fourth of neonatal deaths occur during the early neonatal period, this makes it a critical time to reduce the burden of neonatal death. The survival status of a newborn is determined by the individual (neonatal and maternal), and facility-level factors. Several studies were conducted in Ethiopia to assess early neonatal death; however, most of the studies had limited participants and did not well address the two main determinant factors covered in this study. In response to this gap, this study attempted to examine factors related to early neonatal death based on perinatal death surveillance data in consideration of all the possible determinants of early neonatal death.

Methods

The national perinatal death surveillance data were used for this study. A total of 3814 reviewed perinatal deaths were included in the study. Bayesian multilevel parametric survival analysis was employed to identify factors affecting the survival of newborns during the early neonatal period. Adjusted time ratio (ATR) with 95% Bayesian credible intervals (CrI) was reported and log-likelihood was used for model comparison. Statistical significance was declared based on the non-inclusion of 1.0 in the 95% CrI.

Result

More than half (52.4%) of early neonatal deaths occurred within the first two days of birth. Per the final model, as gestational age increases by a week the risk of dying during the early neonatal period is reduced by 6% [ATR = 0.94,95%CrI:(0.93–0.96)]. There was an increased risk of death during the early neonatal period among neonates deceased due to birth injury as compared to neonates who died due to infection [ATR = 2.05,95%CrI:(1.30–3.32)]; however, perinates who died due to complication of an intrapartum event had a lower risk of death than perinates who died due to infection [ATR = 0.87,95%CrI:(0.83–0.90)]. As the score of delay one and delay three increases by one unit, the newborn’s likelihood of surviving during the early neonatal period is reduced by 4% [ATR = 1.04,95%CrI:(1.01–1.07)] and 21% [ATR = 1.21,95%CrI:(1.15–1.27)] respectively. Neonates born from mothers living in a rural area had a higher risk of dying during the early neonatal period than their counterparts living in an urban area [ATR = 3.53,95%CrI:(3.34–3.69)]. As compared to neonates treated in a primary health facility, being treated in secondary [ATR = 1.14,95%CrI:(1.02–1.27)] and tertiary level of care [ATR = 1.15,95%CrI:(1.04–1.25)] results in a higher risk of death during the early neonatal period.

Conclusion

The survival of a newborn during the early neonatal period is determined by both individual (gestational age, cause of death, and delay one) and facility (residence, type of health facility and delay three) level factors. Thus, to have a positive early neonatal outcome, a tailored intervention is needed for the three major causes of death (i.e Infection, birth injury, and complications of the intrapartum period). Furthermore, promoting maternal health, improving the health-seeking behaviour of mothers, strengthening facility readiness, and narrowing down inequalities in service provision are recommended to improve the newborn’s outcomes during the early neonatal period.

Determinants of neonatal mortality among neonates admitted to neonatal intensive care unit of Dessie comprehensive and specialized hospital, Northeast Ethiopia; An unmatched case-control study

Background

According to the World health organization, neonatal mortality is defined as the death of babies within the first 28 days of their lives. The newborn period is the most vulnerable period for a child's survival, with the bulk of neonatal deaths occurring on the first day and week. According to a recent study, about a third of all newborn deaths occur within the first day of life, and nearly three-quarters occur within the first week. This study aimed to assess the determinants of neonatal mortality among neonates admitted to the neonatal intensive care unit in Dessie comprehensive and specialized hospital, northeast Ethiopia.

Methodology

Health institution-based unmatched case-control study was conducted among neonates admitted to Dessie comprehensive and specialized hospital, Ethiopia from February 01 up to March 30, 2020. After keeping cases and controls in separate frames, study participants were chosen using a simple random sampling procedure until the sample size was met. Epi data version 7.0 and SPSS version 25 were used for data entry and analysis respectively. P ≤ 0.05 was used as a cut point of statistical significance in multivariable binary logistic regression.

Results

A total of 698 (233 cases and 465 controls) participated in the study. Pregnancy induced hypertension (AOR = 3.02; 95% CI; 1.47-6.17), public hospital delivery (AOR = 3.44; 95% CI; 1.84-6.42), prematurity (AOR = 2.06; 95% CI; 1.43-2.96), being referred (AOR = 4.71; 95% CI; 3.01-7.39), and hypothermia (AOR = 2.44; 95% CI; 1.56-3.82) were determinant factors of neonatal mortality.

Conclusion

Pregnancy-induced hypertension, public hospital delivery, prematurity, referral, and hypothermia were found to be the determinant factors of neonatal mortality. It would be important to give due attention to neonates delivered from mothers with a history of hypertensive disorder. Besides better to give due attention to neonates delivered in public health institutions, prematurely delivered, referred, and hypothermic neonates. Lastly, further research should be conducted to investigate the additional determinants of neonatal mortality.

Risk factors for mortality in a hospitalised neonatal cohort in Botswana

OBJECTIVES

A disproportionate number of neonatal deaths occur in low/middle-income countries, with sepsis a leading contributor of mortality. In this study, we investigate risk factors for mortality in a cohort of high-risk hospitalised neonates in Botswana. Independent predictors for mortality for infants experiencing either a sepsis or a non-sepsis-related death are described.

METHODS

This is a prospective observational cohort study with infants enrolled from July to October 2018 at the neonatal unit (NNU) of Princess Marina Hospital (PMH) in Gaborone, Botswana. Data on demographic, clinical and unit-specific variables were obtained. Neonates were followed to death or discharge, including transfer to another hospital. Death was determined to be infectious versus non-infectious based on primary diagnosis listed on day of death by lead clinician on duty.

RESULTS

Our full cohort consisted of 229 patients. The overall death rate was 227 per 1000 live births, with cumulative proportion of deaths of 22.7% (n=47). Univariate analysis revealed that sepsis, extremely low birth weight (ELBW) status, hypoxic ischaemic encephalopathy, critical illness and infants born at home were associated with an increased risk of all-cause mortality. Our multivariate model revealed that critical illness (HR 3.07, 95% CI 1.56 to 6.03) and being born at home (HR 4.82, 95% CI 1.76 to 13.19) were independently associated with all-cause mortality. Low birth weight status was independently associated with a decreased risk of mortality (HR 0.24, 95% CI 0.11 to 0.53). There was a high burden of infection in the cohort with more than half of infants (140, 61.14%) diagnosed with sepsis at least once during their NNU admission. Approximately 20% (n=25) of infants with sepsis died before discharge. Our univariate subanalysis of the sepsis cohort revealed that ELBW and critical illness were associated with an increased risk of death. These findings persisted in the multivariate model with HR 3.60 (95% CI 1.11 to 11.71) and HR 2.39 (95% CI 1 to 5.77), respectively.

CONCLUSIONS

High rates of neonatal mortality were noted. Urgent interventions are needed to improve survival rates at PMH NNU and to prioritise care for critically ill infants at time of NNU admission, particularly those born at home and/or of ELBW.

Impact of secondary and tertiary neonatal interventions on neonatal mortality in a low- resource limited setting hospital in Uganda: a retrospective study

OBJECTIVE

To assess the impact of secondary and tertiary level neonatal interventions on neonatal mortality over a period of 11 years.

DESIGN

Interrupted time series analysis.

SETTING

Nsambya Hospital, Uganda.

INTERVENTIONS

Neonatal secondary interventions (phase I, 2007-2014) and tertiary level interventions (phase II, 2015-2020).

PARTICIPANTS

Neonates.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome: neonatal mortality.

SECONDARY OUTCOME

case fatality rate (CFR) for prematurity, neonatal sepsis and asphyxia.

RESULTS

During the study period, a total of 25 316 neonates were admitted, of which 1853 (7.3%) died. The average inpatient mortality reduced from 8.2% during phase I to 5.7% during phase II (p=0.001). The CFR for prematurity reduced from 16.2% to 9.2% (p=0.001). There was a trend in reduction for the CFR of perinatal asphyxia from 14.9% to 13.0% (p=0.34). The CFR for sepsis had a more than a twofold increase (3%-6.8% p=0.001) between phase I and phase II.

CONCLUSION

Implementation of secondary and tertiary neonatal care in resource-limited settings is feasible. This study shows that these interventions can significantly reduce the neonatal mortality, with the largest impact seen in the reduction of deaths from perinatal asphyxia and prematurity. An increase in sepsis related deaths was observed, suggesting emphasis on infection control is key.

Predictors of Survival Among Preterm Neonates Admitted to Felege Hiwot Comprehensive Specialized Hospital, Northwest Ethiopia

Background

Pre-maturity is the primary cause of neonatal mortality in the world. Although prematurity was the leading cause of neonatal mortality, the survival rate and its predictors may be varied from setting to setting and time to time due to different reasons. Therefore, this study aimed to assess the survival probability and predictors of mortality among preterm neonates at Felege Hiwot comprehensive specialized hospital.

Methods

This is a retrospective follow-up study that included 542 randomly selected preterm neonates admitted at Felege Hiwot comprehensive specialized hospital from the period of 2016-2020. Semi-parametric and parametric survival models were fitted to identify the survival probability of preterm neonates and its association with different predictors. The best fit model was selected using Akaike's information criteria, Bayesian information criteria and likelihood ratio criteria.

Results

The cumulative incidence and incidence rate of mortality among preterm neonates were 31 per 100 live births and 3.5 per 100 neonate days, respectively. From the adjusted cox-proportional-hazard model, predictors with higher preterm mortality risk include the presence of neonatal respiratory distress syndrome [AHR = 2.55, 95% CI: 1.23; 3.74], perinatal asphyxia [AHR = 4.26, 95% CI: 1.35; 6.79] and jaundice [AHR = 3.25, 95% CI: 2.14, 7.24]. However, admission weight of 1,500-2,499 g (AHR = 0.23, 95% CI: 0.11, 0.56) and ≥2,500 g (AHR = 0.12, 95% CI: 0.02; 0.32), early breastfeeding [AHR = 0.44, 95% CI: 0.36; 0.48] and kangaroo mother care [AHR = 0.11, 95% CI: 0.03; 0.15] were protective factors of preterm mortality.

Conclusion

The cumulative incidence of mortality among preterm neonates was consistent with the national incidence of preterm mortality. Factors such as respiratory distress syndrome, perinatal asphyxia, breastfeeding, kangaroo mother care, admission weight, and jaundice are significant predictors of survival. Therefore, considerable attention such as intensive phototherapy, optimal calorie feeding, oxygenation, and good thermal care should be given for admitted preterm neonates.

Incidence and predictors of preterm neonatal mortality at Mbarara Regional Referral Hospital in South Western Uganda

INTRODUCTION

Preterm neonatal mortality contributes substantially to the high neonatal mortality globally. In Uganda, preterm neonatal mortality accounts for 31% of all neonatal deaths. Previous studies have shown variability in mortality rates by healthcare setting. Also, different predictors influence the risk of neonatal mortality in different populations. Understanding the predictors of preterm neonatal mortality in the low-resource setting where we conducted our study could guide the development of interventions to improve outcomes for preterm neonates. We thus aimed to determine the incidence and predictors of mortality among preterm neonates born at Mbarara Regional Referral Hospital (MRRH) in South Western Uganda.

METHODS

We prospectively enrolled 538 live preterm neonates born at MRRH from October 2019 to September 2020. The neonates were followed up until death or 28 days, whichever occurred first. We used Kaplan Meier survival analysis to describe preterm neonatal mortality and Cox proportional hazards regression to assess predictors of preterm neonatal mortality over a maximum of 28 days of follow up.

RESULTS

The cumulative incidence of preterm neonatal mortality was 19.8% (95% C.I: 16.7-23.5) at 28 days from birth. Birth asphyxia (adjusted hazard ratio [aHR], 14.80; 95% CI: 5.21 to 42.02), not receiving kangaroo mother care (aHR, 9.50; 95% CI: 5.37 to 16.78), delayed initiation of breastfeeding (aHR, 9.49; 95% CI: 2.84 to 31.68), late antenatal care (ANC) booking (aHR, 1.81 to 2.52; 95% CI: 1.11 to 7.11) and no ANC attendance (aHR, 3.56; 95% CI: 1.51 to 8.43), vaginal breech delivery (aHR, 3.04; 95% CI: 1.37 to 5.18), very preterm births (aHR, 3.17; 95% CI: 1.24 to 8.13), respiratory distress syndrome (RDS) (aHR, 2.50; 95% CI: 1.11 to 5.64) and hypothermia at the time of admission to the neonatal unit (aHR, 1.98; 95% CI: 1.18 to 3.33) increased the risk of preterm neonatal mortality. Attending more than 4 ANC visits (aHR, 0.35; 95% CI: 0.12 to 0.96) reduced the risk of preterm neonatal mortality.

CONCLUSIONS

We observed a high cumulative incidence of mortality among preterm neonates born at a low-resource regional referral hospital in Uganda. The predictors of mortality among preterm neonates were largely modifiable factors occurring in the prenatal, natal and postnatal period (lack of ANC attendance, late ANC booking, vaginal breech delivery, birth asphyxia, respiratory distress syndrome, and hypothermia at the time of admission to the neonatal unit, not receiving kangaroo mother care and delayed initiation of breastfeeding). These findings suggest that investment in and enhancement of ANC attendance, intrapartum care, and the feasible essential newborn care interventions by providing the warm chain through kangaroo mother care, encouraging early initiation of breastfeeding, timely resuscitation for neonates when indicated and therapies reducing the incidence and severity of RDS could improve outcomes among preterm neonates in this setting.

"What are you carrying?" Experiences of mothers with preterm babies in low-resource setting neonatal intensive care unit: a qualitative study

INTRODUCTION

Babies born preterm often have challenges in feeding, temperature control and breathing difficulty and are prone to infection during the neonatal period. These usually necessitate admission to the neonatal intensive care unit (NICU). Admission to NICU disrupts the mother-baby bonding.

OBJECTIVE

This study explored the lived experiences of mothers with preterm babies admitted to NICU in a low-resource setting.

STUDY DESIGN

This was a qualitative study where 16 participants took part in indepth interviews and 35 in focus group discussions. We included mothers who delivered and were caring for preterm babies at the NICU of Mulago National Referral Hospital.

STUDY SETTING

Data were collected from a public hospital, which works as a district and national referral hospital located in the capital of Uganda.

PARTICIPANTS

Fifty-one mothers with preterm babies in the NICU were sampled and recruited after informed consent. Data were analysed using manual thematic analysis.

RESULTS

There were six themes on the experiences of mothers of preterm babies in NICU: constant worry and uncertainty about the survival of their babies, baby feeding challenges, worries of discharge, communication gaps between mothers and nurses, community acceptability and disdain for preterm babies, and financial challenges.

CONCLUSIONS AND RECOMMENDATIONS

Mothers of preterm babies admitted to NICU in a low-resource setting still need a lot of support other than the medical care given to their babies. Support groups in the hospital and community are recommended to help in dealing with these challenges.

Mortality, morbidity and clinical care in a referral neonatal intensive care unit in Haiti

Background

Neonatal mortality rates in Haiti are among the highest in the Western hemisphere. Few mothers deliver with a skilled birth attendant present, and there is a significant lack of pediatricians. The neonatal intensive care unit (NICU) at St. Damien Pediatric Hospital, a national referral center, is one of only five neonatology departments in Haiti. In order to target limited resources toward improving outcomes, this study seeks to describe clinical care in the St. Damien NICU.

Methods

A retrospective medical record review was performed on available medical records on all admissions to the NICU between April 2016 and April 2017.

Results

220 neonates were admitted to the NICU within the study epoch. The mortality rate was 14.5%. Death was associated with a maternal diagnosis of hypertension (p = 0.03) and neonatal diagnoses of lower gestational age (p<0.0001), lower birth weight (p<0.0001), prematurity (p = 0.002), RDS p = 0.01), sepsis (p<0.0001) and kernicterus (p = 0.04). The most common diagnoses were sepsis, chorioamnionitis, respiratory distress syndrome, jaundice, prematurity and perinatal asphyxia.

Conclusions

This study demonstrates that preterm birth, sepsis, RDS and kernicterus are key contributors to neonatal mortality in a Haitian national pediatric referral center NICU and as such are promising interventional targets for reducing the neonatal mortality rate in Haiti.

Preterm Neonatal Mortality and Its Determinants at a Tertiary Hospital in Western Uganda: A Prospective Cohort Study

Background

Prematurity contributes greatly to the neonatal mortality burden in sub-Saharan Africa. This study evaluated the proportion of preterm neonatal death, medical conditions at admission, and determinants of mortality of preterm neonates in the neonatal intensive care unit (NICU) of a tertiary hospital in Western Uganda.

Materials and Methods

A prospective cohort study of 351 consecutively enrolled preterm neonates was conducted from March to June 2019. Interviewer-administered questionnaires and physical assessment of neonates were used to obtain socio-demographic and clinical data for mothers and their preterm neonates. Descriptive statistics for participants’ characteristics were generated, while bivariate and multivariate logistic regression models were fitted so as to establish the determinants of mortality outcome. A p-value <0.05 was considered statistically significant.

Results

In-hospital neonatal mortality of 31.6% (95% CI: 26.9–36.7) was noted, with 65.8% of deaths occurring within 72 hours from admission. The most common medical conditions at admission were: hypothermia (67.2%), respiratory distress syndrome (43.0%), small for gestational age (15.7%), and perinatal asphyxia (14.5%). Under multivariate regression modelling, maternal age ≥35 years (AOR: 4.5; 95% CI: 1.35–15.31), no antenatal care (AOR: 4.7; 95% CI: 1.05–21.21), >4 ANC visits (AOR: 5.3; 95% CI: 1.88–15.21), neonatal resuscitation (AOR: 3.4; 95% CI: 1.66–6.82), outborn status (AOR: 2.3; 95% CI: 1.20–4.50), singleton pregnancy (AOR: 3.7; 95% CI: 1.74–7.89), <28 weeks’ gestation (AOR: 12.0; 95% CI: 2.24–64.27), and male sex (AOR: 2.0; 95% CI: 1.04–3.74), respiratory distress syndrome (AOR: 2.6; 95% CI: 1.22–5.70), apnea (AOR: 6.2; 95.5% CI: 1.09–35.38), hypothermia (AOR: 2.3; 95% CI: 1.09–4.92), and small for gestational age (AOR: 4.7; 95% CI: 2.06–10.74) were significantly associated with mortality.

Conclusion and Recommendations

In-hospital mortality of preterm neonates was high. We identified various maternal and neonatal risk factors, indicating a need for stakeholders to enhance efforts towards prevention of preterm-associated complications and optimize facility-based continuum of care.

Care of the Sick Newborn in a Cottage Hospital Level in a Developing Country

INTRODUCTION

Neonatal morbidity and mortality are high in Nigeria. The establishment of more centers that could offer adequate management of high-risk pregnancies and neonates is essential.

OBJECTIVES

This study seeks to describe sick newborn care at the cottage hospital level in Southern Nigeria with the aim of drawing lessons that may be useful to similar environments.

SUBJECTS AND METHODS

A description of facility upgrading and staff training in perinatal care at a public-private partnership cottage hospital with a robust community health insurance scheme in Nigeria is made. A retrospective descriptive study of the morbidity and outcomes of admitted neonates in the facility between March 2016 and February 2017 was made.

RESULTS

Out of 3630 babies born in the facility (302 per month), 189 were admitted, yielding an admission rate of 52.1/1000 live births. The main morbidities were neonatal hypoglycemia (32.4%), preterm low-birth weight (24.9%), neonatal sepsis (22.8%), and neonatal jaundice (12.7%). Sixteen of the 109 neonates died giving a mortality rate of 8.5%. The main causes of deaths were birth asphyxia (7 or 43.8%), meconium aspiration (6 or 37.5%), and congenital malformation (3 or 18.8%).

CONCLUSION AND RECOMMENDATIONS

The neonatal admission and mortality rates are quite low in this cottage hospital and similar to the situation even in developed environments. This salutary scenario is probably due to good antenatal and perinatal care, and a robust community health insurance scheme which enhances services uptake and public-private partnership which engenders infrastructure expansion and maintenance. This model is recommended for the hospitals in our region.

Determinants of neonatal mortality at neonatal intensive care unit in Northeast Ethiopia: unmatched case-control study

Background

Globally, in 2016, about 38% and 3% of all neonatal death were recorded in sub-Saharan Africa and Ethiopia, respectively. In the same year, 47 neonates out of 1000 live births were not surviving in the first 28 days of age in the Amhara region, Ethiopia. Despite the highest burden of neonatal death in the region, specific or the proximate determinants of neonatal death in the neonatal intensive care unit were not well identified.

Objective

This study aimed to identify the determinants of neonatal mortality at neonatal intensive care unit in Dessie Referral Hospital, Northeast Ethiopia.

Methods

An institution-based unmatched case-control study was conducted on neonates admitted to the neonatal intensive care unit of Dessie Referral Hospital, from January 1, 2016, to December 30, 2017. A total of 390 charts (130 cases and 260 controls) were selected by simple random sampling technique. The data were abstracted from the facility-based data abstraction form. A binary logistic regression analysis was fitted to identify the determinants of neonatal mortality.

Results

Pregnancy-induced hypertension (AOR = 4.57; 95% CI 1.45–14.43), prolonged rupture of membrane (AOR = 2.04; 95% CI 1.13–3.68), very low birth weight (AOR = 7.00; 95% CI 2.10–23.35), and low birth weight (AOR = 2.12; 95% CI 1.10–4.20) were identified factors. Moreover, respiratory distress syndrome (AOR = 3.61; 95% CI 1.10–12.04), perinatal asphyxia (AOR = 2.27; 95% CI 1.18–4.39), meconium aspiration syndrome (AOR = 2.35; 95% CI 1.12–4.97), and infection (AOR = 2.26; 95% CI 1.34–3.82) were also significantly associated with neonatal death.

Conclusions

Pregnancy-induced hypertension, prolonged rupture of membrane, low birth weight, respiratory distress syndrome, perinatal asphyxia, meconium aspiration syndrome, and infections were the major determinants of neonatal mortality. Therefore, special attention will be given to small and sick babies. Moreover, early anticipation of complications and management of mothers who had pregnancy-induced hypertension and prolonged rupture of the membrane would save neonates.

Decision-to-delivery interval of emergency cesarean section in Uganda: a retrospective cohort study

Background

In many low and medium human development index countries, the rate of maternal and neonatal morbidity and mortality is high. One factor which may influence this is the decision-to-delivery interval of emergency cesarean section. We aimed to investigate the maternal risk factors, indications and decision-to-delivery interval of emergency cesarean section in a large, under-resourced obstetric setting in Uganda.

Methods

Records of 344 singleton pregnancies delivered at ≥24 weeks throughout June 2017 at Mulago National Referral Hospital were analysed using Cox proportional hazards models and multivariate logistic regression models.

Results

An emergency cesarean section was performed every 104 min and the median decision-to-delivery interval was 5.5 h. Longer interval was associated with preeclampsia and premature rupture of membranes/oligohydramnios. Fetal distress was associated with a shorter interval (p < 0.001). There was no association between decision-to-delivery interval and adverse perinatal outcomes (p > 0.05). Mothers waited on average 6 h longer for deliveries between 00:00–08:00 compared to those between 12:00–20:00 (p < 0.01). The risk of perinatal death was higher in neonates where the decision to deliver was made between 20:00–02:00 compared to 08:00–12:00 (p < 0.01).

Conclusion

In this setting, the average decision-to-delivery interval is longer than targets adopted in high development index countries. Decision-to-delivery interval varies diurnally, with decisions and deliveries made at night carrying a higher risk of adverse perinatal outcomes. This suggests a need for targeting the improvement of service provision overnight.

Cause and predictors of neonatal mortality among neonates admitted to neonatal intensive care units of public hospitals in eastern Ethiopia: a facility-based prospective follow-up study

Background

The first month is the most crucial period for child survival. Neonatal mortality continues to remain high with little improvement over the years in Sub-Saharan Africa, including Ethiopia. This region shows the least progress in reducing neonatal mortality and continues to be a significant public health issue. In this study setting, the causes and predictors of neonatal death in the neonatal intensive care units are not well documented. Hence, this study aimed to determine the causes and predictors of neonatal mortality among infants admitted to neonatal intensive care units in eastern Ethiopia.

Methods

A facility-based in prospective follow-up study was conducted among neonates admitted to neonatal intensive care units of public hospitals of eastern Ethiopia from November 1 to December 30, 2018. Data were collected using a pre-tested structured questionnaire and a follow-up checklist. The main outcomes and causes of death were set by pediatricians and medical residents. EpiData 3.1 and Statistical Package for Social Sciences Version 25 software were used for data entry and analysis, respectively. Multivariable logistic regression was used to identify the predictors of facility-based neonatal mortality.

Results

The proportion of facility-based neonatal mortality was 20% (95% CI:16.7–23.8%). The causes of death were complications of preterm birth (28.58%), birth asphyxia (22.45%), neonatal infection (18.36%), meconium aspiration syndrome (9.18%), respiratory distress syndrome (7.14%), and congenital malformation (4.08%). Low birth weight, preterm births, length of stay of the neonatal intensive care unit, low 5 min APGAR score, hyperthermia, and initiation of feeding were predictors of neonatal death among infants admitted to the neonatal intensive care units of public hospitals in eastern Ethiopia.

Conclusions

The proportion of facility-based neonatal deaths was unacceptably high. The main causes of death were preventable and treatable. Hence, improving the timing and quality of antenatal care is essential for early detection, anticipating high-risk newborns, and timely interventions. Furthermore, early initiation of feeding and better referral linkage to tertiary health facilities could lead to a reduction in neonatal death in this setting.

Cause-specific neonatal morbidity and mortality in the Solomon Islands: An assessment of data from four hospitals over a three-year period

AIM

Data on stillbirths and neonatal morbidity and mortality in low-middle income Pacific Island Nations such as Solomon Islands is limited, partly due to weak health information systems. We describe the perinatal mortality and clinical factors associated with poor newborn outcomes at four hospitals in Solomon Islands.

METHODS

This was a registry based retrospective cohort study at three provincial hospitals and the National Referral Hospital (NRH) from 2014-2016 inclusive.

RESULTS

23 966 labour ward births and 3148 special care nursery (SCN) admissions were reviewed. Overall still birth rate was 29.2/1000 births and the perinatal mortality rate was 35.9/1000 births. PNMR were higher in provincial hospitals (46.2, 44.0 and 34.3/1000) than at NRH (33.3/1000). The commonest reasons for admission to SCN across the hospitals were sepsis, complications of prematurity and birth asphyxia. SCN mortality rates were higher in the 3 provincial hospitals than at NRH (15.9% (95/598) vs. 7.9% (202/2550), P value <0.01). At NRH, the conditions with the highest case fatality rates were birth asphyxia (21.3%), congenital abnormalities (17.7%), and prematurity (15.1%). Up to 11% of neonates did not have a diagnosis recorded.

CONCLUSIONS

The perinatal mortality rates are high and intrapartum complications, prematurity and sepsis are the main causes of morbidity and mortality for neonates at hospitals in Solomon Islands. Stillbirths account for 81% of perinatal deaths. These results are useful for planning for quality improvement at provincial level. Improved vital registration systems are required to better capture stillbirths and neonatal outcomes.

Mortality among very low birth weight infants after hospital discharge in a low resource setting

Background

Early discharge of very low birth weight infant (VLBW) in low resource settings is inevitable but to minimize mortality of these infants after discharge we need to identify the death attributes.

Method

A prospective cohort was conducted among 190 VLBW infants discharged from Mulago Special Care Baby Unit (SCBU) with discharge weight of < 1500 g over an 8 months period. These infants were followed up with the aims of determining the proportion dead 3 months after discharge, identifying factors associated and possible causes of death.

Relevant data were captured, transferred in to STATA and imported to SPSS 12.0.1 for analysis. To determine factors associated with mortality bi-variable and multivariable regressions were conducted. A p-value of < 0.05 was considered significant and 95% confidence interval was used.

Results

Of the enrolled infants 164 (86.3%) completed follow up. The median gestational age of study participants was 32 weeks (range 26-35 weeks), the mean discharge weight was 1119 g (range 760-1470 g), and 59.8% were small for gestational age (SGA). During follow up 32 (19.5%) infants died. Infants discharged with weight of < 1200 g accounted for 81.2% of the deaths. Majority of the deaths (68.7%) occurred in the first month after discharge. Factors independently associated with mortality were discharge weight < 1000 g (OR 3.10, p 0.015) and not being SGA (OR 3.54, p 0.019). The main causes of death were presumed sepsis 50.0% and suspected cot death (25.0%).

Conclusion

Mortality after hospital discharge among VLBW infants is high. Discharge at weight < 1200 g may not be a safe practice. Measures to prevent sepsis and suspected cot death should be addressed prior to considering early discharge of these infants.

Where technology does not go: specialised neonatal care in resource-poor and conflict-affected contexts

Setting: Although neonatal mortality is gradually decreasing worldwide, 98% of neonatal deaths occur in low- and middle-income countries, where hospital care for sick and premature neonates is often unavailable. Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) managed eight specialised neonatal care units (SNCUs) at district level in low-resource and conflict-affected settings in seven countries. Objective: To assess the performance of the MSF SNCU model across different settings in Africa and Southern Asia, and to describe the set-up of eight SNCUs, neonate characteristics and clinical outcomes among neonates from 2012 to 2015. Design: Multicentric descriptive study. Results: The MSF SNCU model was characterised by an absence of high-tech equipment and an emphasis on dedicated nursing and medical care. Focus was on the management of hypothermia, hypoglycaemia, feeding support and early identification/treatment of infection. Overall, 11 970 neonates were admitted, 41% of whom had low birthweight (<2500 g). The main diagnoses were low birthweight, asphyxia and neonatal infections. Overall mortality was 17%, with consistency across the sites. Chances of survival increased with higher birthweight. Conclusion: The standardised SNCU model was implemented across different contexts and showed in-patient outcomes within acceptable limits. Low-tech medical care for sick and premature neonates can and should be implemented at district hospital level in low-resource settings.