Reducing preterm mortality in eastern Uganda: the impact of introducing low-cost bubble CPAP on neonates <1500 g

Abstract

Background Complications of prematurity are the leading cause of deaths in children under the age of five. The predominant reason for these preterm deaths is respiratory distress syndrome (RDS). In low-income countries (LICs) there are limited treatment options for RDS. Due to their simplicity and affordability, low-cost bubble continuous positive airway pressure (bCPAP) devices have been introduced in neonatal units in LICs to treat RDS. This study is the first observational study from a LIC to compare outcomes of very-low-birth-weight (VLBW) neonates in pre- and post-CPAP periods. Methods This was a retrospective study of VLBW neonates (weight < 1500 g) in Mbale Regional Referral Hospital Neonatal Unit (MRRH-NNU), a government hospital in eastern Uganda. It aimed to measure the outcome of VLBW neonates in two distinct study periods: A 14-month period beginning at the opening of MRRH-NNU and covering the period until bCPAP was introduced (pre-bCPAP) and an 18-month period following the introduction of bCPAP (post-bCPAP). After the introduction of bCPAP, it was applied to preterm neonates with RDS when clinically indicated and if a device was available. Clinical features and outcomes of all neonates < 1500 g were compared before and after the introduction of bCPAP. Results The admission records of 377 VLBW neonates < 1500 g were obtained. One hundred fifty-eight were admitted in the pre-bCPAP period and 219 in the post-bCPAP period. The mortality rate in the pre- bCPAP period was 39.2% (62/158) compared with 26.5% (58/219, P = 0.012) in the post-bCPAP period. Overall, there was a 44% reduction in mortality (OR 0.56, 95%CI 0.36–0.86, P = 0.01). There were no differences in birthweight, sex, presence of signs of respiratory distress or apnoea between the two groups. Conclusion Specialized and resource-appropriate neonatal care, that appropriately addresses the challenges of healthcare provision in LICs, has the potential to reduce neonatal deaths. The use of a low-cost bCPAP to treat RDS in VLBW neonates resulted in a significant improvement in their survival in a neonatal unit in eastern Uganda. Since RDS is one of the leading causes of neonatal mortality, it is possible that this relatively simple and affordable intervention could have a huge impact on global neonatal mortality.

Enhancing early breast milk for sick and preterm neonates admitted at regional referral hospitals in Dar es Salaam, Tanzania

“…A birth weight of ≤ 1200 g and Thompson HIE score of ≥ 15 were independent predictors of mortality among neonates with very low birth weight and perinatal asphyxia respectively. The high mortality rate for high risk neonates in our study corresponds well to results from other low income countries, where neonatal intensive care facilities are not yet available [26,30,31].…”

Enhancing early initiation of breast milk for sick and preterm neonates admitted at regional referral hospitals in Dar es Salaam, Tanzania

“…Early initiation of breast milk feeding signi cantly reduced the duration of regaining birth weight more than three days in the intervention group when compared to the controls. This nding demonstrates the bene t of early enteral feeding in the prevention of postnatal growth failure and is consistent with studies from Uganda [13], Iran [26] and India [12,30]. However, this did not correspond with a shortened hospital stay as shown in previous studies [12,26] and may be explained by other factors such as neonatal sepsis which may impact on the early stabilization of the neonates.…”

Intraventricular haemorrhage in a Ugandan cohort of low birth weight neonates: The IVHU study

“…MRRH-NNU saw signi cant reduction in preterm mortality following implementation of a two-tiered hospital-based neonatal care package (3). Further reduction in preterm mortality was achieved with the introduction of bubble CPAP (bCPAP) (19) . The Ugandan National Guidelines recommend antenatal steroids are given to all women in threatened preterm or preterm labour and intrapartum antibiotics are given to women with signs of sepsis, chorioamnionitis or preterm premature rupture of membranes (PPROM) but the practice is not ubiquitous (20) .…”

“…There is little evidence on survival after IVH in LICs, but in this cohort there was a much lower mortality in neonates with IVH than in Nigerian neonates with IVH weighing <1500g (41.7% vs 66.7%) (9) . This is likely due to the relatively high standard of care at our centre, resulting in decreased preterm mortality, following implementation of a two-tiered hospital-based neonatal care package and bCPAP (19) .…”