Neonatal oxygen therapy in low- and middle-income countries: a pragmatic review

Abstract

Background We assessed and summarized the peer-reviewed literature on the state of neonatal oxygen therapy in low and lower-middle income countries. Methods A literature search was performed in 3 online databases (Pub Med, EMBASE, CAB Global Health) and amongst USAID’s Service Provision Assessment (SPA) reports for publications pertaining to neonatal oxygen therapy in low and lower-middle income countries over the past 10 years (2007-2017). Results Our search yielded 474 records, of which 26 were relevant and included in the review. Maintenance and indirect costs associated with the procurement of oxygen may constitute barriers to oxygen supply. The quality of therapy provided to neonates was affected by factors including a lack of necessary equipment at neonatal healthcare facilities and high indirect costs associated with the procurement of oxygen. Pulse oximeters used for monitoring of oxygen therapy were available in healthcare facilities, but there is scant data on the frequency of that monitoring. There are some hospitals that deliver neonatal oxygen therapy without any necessary monitoring equipment. Prevalence of retinopathy of prematurity among neonates with risk factors ranged from 11.9-47.2%, which is notably higher than published rates in neonates of similar gestational age being treated in high-income countries. Conclusion There is a lack of data that provides direct estimates of availability of neonatal oxygen equipment and related clinical applications of oxygen therapy across health systems, particularly around the usage and availability of necessary monitoring equipment. Attention to the maintenance of oxygen and ancillary equipment for neonates and quality improvement initiatives to promote adherence to those guidelines can reduce the morbidity and mortality burden among neonates in low and lower-middle income countries.

The Male to Female Ratio in Treatment-Warranted Retinopathy of Prematurity

“…While there was a trend toward a greater ratio of male infants being treated in countries with lower income levels, the difference was not statistically significant (eFigure 2 in the Supplement). We hypothesize that high-income countries experiencing a survival of smaller and younger neonates is balanced by low-income countries having less advanced neonatal care and oxygenation protocols …”

Oxygen Blending is Urgently Needed in Resource-Limited Settings

“…Although data are scarce, reviews indicate that only a small minority of neonatal units in low-and middleincome countries have access to oxygen blenders. 24,25 In sub-Saharan Africa, for example, a recent study found that only 1% of neonatal units had the capacity to provide blended oxygen to neonates needing oxygen therapy. 26 Moreover, a 2012 survey of neonatologists and pediatricians practicing in metropolitan areas in Africa, Asia, and the Middle East found that although 91% of respondents supported the use of oxygen blending, only one-half reported blending capability, citing financial barriers as a key limiting factor.…”

“…In India, for example, the incidence of ROP is markedly higher than the incidence reported in high-income countries, and ROP has become the leading cause of avoidable blindness in children. 24,[37][38][39] Moreover, the coronavirus disease 2019 pandemic led to an unprecedented increase in oxygen availability globally. Hundreds of millions of dollars of investments from governments and philanthropic organizations (including the United States Agency for International Development, United Nations Children's Fund, and the World Bank, among others) are being made to rapidly expand oxygen supplies in lowresource settings.…”

Neonatal Respiratory Support Utilization in Low- and Middle-Income Countries: A Registry-Based Observational Study

“…In low-resource settings, the presence of respiratory disease does not guarantee receipt of or access to respiratory support [11, 12]. There are no population-based studies that evaluate the distribution of respiratory support between term and preterm infants in low- and middle-income countries (LMICs) [13]. Knowledge of the epidemiology of respiratory support receipt in low-resource settings will help address questions about access and use of respiratory support resources.…”