The Transport and Outcome of Sick Outborn Neonates Admitted to a Regional and District Hospital in the Upper West Region of Ghana: A Cross-Sectional Study

Neonatal transport practices and effectiveness of the use of low-cost interventions on outcomes of transported neonates in Sub-Saharan Africa: A systematic review and narrative synthesis

Background and Aims

Neonatal deaths contribute significantly to under-5 mortality worldwide with Sub-Saharan Africa (SSA) alone accounting for 43% of global newborn deaths. Significant challenges in the region's health systems evidenced by huge disparities in health facility deliveries and poor planning for preterm births are major contributors to the high neonatal mortality. Many neonates in the region are delivered in suboptimal conditions and require transportation to facilities equipped for specialized care. This review describes neonatal transport across the subregion, focusing on low-cost interventions employed.

Methods

We conducted a systematic review of studies on neonatal transport in SSA followed by a narrative synthesis. A search in the databases CINAHL, EMBASE, MEDLINE, Web of Science, African Index Medicus, and Google Scholar was performed from inception to March 2023. Two authors reviewed the full texts of relevant studies to determine eligibility for inclusion which was subsequently cross-checked by a third reviewer using a random 30% overlay. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool.

Results

A total of 20 studies were included in this review involving 11,895 neonates from 10 countries. All studies evaluated the transfer of neonates into referral centers from the peripheries. Most neonates were transferred by public transport (n = 12), mostly in the arms of caregivers with little communication between referring facilities. Studies reporting on ambulance transfers reported pervasive inadequacies in both human resources and transport equipment. No study reported on the use of Kangaroo mother care (KMC) in the transfer process.

Conclusions

The neonatal transport system across the SSA region is poorly planned, poorly resourced, and executed with little communication between facilities. Using cost-effective measures like KMC and improved training of community health workers may be key to improving the outcomes of transported neonates.

Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations

Neonatal sepsis causes significant global morbidity and mortality, with the highest burden in resource-limited settings where 99% of neonatal deaths occur. There are multiple challenges to achieving successful treatment of neonates in this setting. Firstly, reliable and low-cost strategies for risk identification are urgently needed to facilitate treatment as early as possible. Improved laboratory capacity to allow identification of causative organisms would support antimicrobial stewardship. Antibiotic treatment is still hampered by availability, but also increasingly by antimicrobial resistance - making surveillance of organisms and judicious antibiotic use a priority. Finally, supportive care is key in the management of the neonate with sepsis and has been underrecognized as a priority in resource-limited settings. This includes fluid balance and nutritional support in the acute phase, and follow-up care in order to mitigate complications and optimise long-term outcomes. There is much more work to be done in identifying the holistic needs of neonates and their families to provide effective family-integrated interventions and complete the package of neonatal sepsis management in resource-limited settings.

Trends in Neonatal Mortality at Princess Marie Louise Children's Hospital, Accra, and the Newborn Strategic Plan: Implications for Reducing Mortality in Hospital and the Community

BACKGROUND

In low and middle-income countries, close to half of the mortality in children under the age of five years occurs in neonates.

OBJECTIVES

We examined the trend, medical conditions and factors associated with newborn deaths at the Princess Marie Louise Children's Hospital (PML), Accra, from 2014 to 2017 (4 years).

METHODS

The study was a cross-sectional study. Data on age, sex, date of admission, date of discharge, cause of death and place of residence of these babies were obtained from the records department. This was transferred into an Access database and analyzed. Components of the Newborn Strategic Plan implemented at the hospital were described.

RESULTS

Neonatal sepsis, pneumonia and kernicterus were the major causes of death. Admissions increased and 5.4% of the neonates died, declining from 6.5% in 2014 to 4.2% in 2017 due to deliberate actions to reduce neonatal death. The highest mortality occurred in babies residing in an area more than 1 hour's drive away from the hospital.

CONCLUSION

Implementing the Newborn Strategic Plan was associated with a drop in mortality. A preponderance of community-acquired infections was observed. Thus, locality-specific interventions targeted at known determinants and implementing the newborn strategic plan are essential for reducing neonatal mortality.

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method

Background

Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh.

Methods

We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh.

Results

Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh.

Conclusions

This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

Referral challenges and outcomes of neonates received at Muhimbili National Hospital, Dar es Salaam, Tanzania

Background

Functional referral system including pre referral care, access to emergency transport and ensuring continuity of care between facilities is critical for improved newborn health outcome. The neonatal transport system is quite undervalued in many sub Saharan countries, Tanzania included. This study assessed the pre referral care, transport process, ambulance characteristics, admission clinical status and outcomes of referred neonates at Muhimbili National Hospital Upanga, a tertiary facility in Dar es Salaam, Tanzania.

Methods

A descriptive cross sectional study with a longitudinal follow up was conducted from September 2020 to February 2021 including neonates referred to Muhimbili National Hospital. A structured questionnaire was used to collect demographic characteristics and transport factors including pre referral care extracted from the referral documents and through interviewing caregivers or escorting person/nurse. Ambulances were directly observed using a structured checklist on presence, absence and functionality of supportive equipment. All enrolled neonates had a clinical assessment at admission and 48 hours post admission to determine admission clinical status and 48 hours’ clinical outcome as either survived/died.

Results

Out of the 348 neonates assessed during the study period, the median gestation age was 38 weeks (IQR 32, 39) with the mean birth weight of 2455 ± 938 g. Pre referral documentation showed that temperature was measured in 176 (57.1%), oxygen saturation and random blood glucose in only 143 (46.6%) and 116 (36.2%) neonates respectively. Ambulance was used as a means of transportation in 308 (88.5%) neonates. While no ambulance had an incubator only 7 (2.0%) neonates were kept on a Kangaroo Mother Care position. Monitoring enroute was done to only 94 (27%) of the transferred neonates with 169 (54.9%) of health care professionals escorting the neonates lacking training on essential newborn care. On arrival, 115 (33%) were hypothermic, 74 (21.3%) hypoxic, 30 (8.6%) with poor perfusion and 49 (14.1%) hypoglycemic. Hypothermic neonates had an increased chance of dying compared to those who were normothermic (OR = 2.09, 95% CI (1.05–4.20), p = 0.037). The chance of dying among those presenting with hypoxia was almost three times (OR = 2.88, 95%CI (1.44–5.74), p = 0.003) while those with poor perfusion was almost five times (OR = 4.76, 95%CI (1.80–12.58), p = 0.002). Additionally, neonates who had hyperglycemia (RBG > 8.3mmol/l) on arrival had a higher probability of dying compared to those who were euglycemic [(OR = 3.10, 95% CI (1.19–8.09) p = 0.021]. Overall mortality was 22.4% within 48 hours of admission and risk of dying increased as the presence of poor clinical status added on.

Conclusion

Neonatal transportation in Dar es Salaam, Tanzania was observed to be challenging. Pre transfer care and monitoring during transportation was inadequate and this contributed to poor clinical status on admission. Hypothermia, hypoglycemia, hyperglycemia, hypoxia and poor perfusion on admission were associated with increased mortality. Effective referral network is needed for improved neonatal health outcomes. Pre referral supportive care, training of health care professionals, transportation with improved monitoring, clear communication protocol and referral documentation should be invested and effectively utilized.

Incidence and predictors of mortality among neonates referred to comprehensive and specialized hospitals in Amhara regional state, North Ethiopia: a prospective follow-up study

Background

Neonatal mortality is a major global public health problem. Ethiopia is among seven countries that comprise 50 % of global neonatal mortality. Evidence on neonatal mortality in referred neonates is essential for intervention however, there is no enough information in the study area. Neonates who required referral frequently became unstable and were at a high risk of death. Therefore, this study aimed to assess the incidence and predictors of mortality among referred neonates.

Method

A prospective follow-up study was conducted among 436 referred neonates at comprehensive specialized hospitals in the Amhara regional state, North Ethiopia 2020. All neonates admitted to the selected hospitals that fulfilled the inclusion criteria were included. Face-to-face interviews, observations, and document reviews were used to collect data using a semi-structured questionnaire and checklists. Epi-data™ version 4.2 software for data entry and STATA™ 14 version for data cleaning and analysis were used. Variables with a p-value < 0.25 in the bi-variable logistic regression model were selected for multivariable analysis. Multivariable analyses with a 95% confidence level were performed. Variables with P < 0.05 were considered statistically significant.

Result

Over all incidence of death in this study was 30.6% with 95% confidence interval of (26.34–35.16) per 2 months observation. About 23 (17.83%) deaths were due to sepsis, 32 (24.80%) premature, 40 (31%) perinatal asphyxia, 3(2.33%) congenital malformation and 31(24.03%) deaths were due to other causes. Home delivery [AOR = 2.5, 95% CI (1.63–4.1)], admission weight < 1500 g [AOR =3.2, 95% CI (1.68–6.09)], travel distance ≥120 min [AOR = 3.8, 95% CI (1.65–9.14)], hypothermia [AOR = 2.7, 95% CI (1.44–5.13)], hypoglycemia [AOR = 1.8, 95% CI (1.11–3.00)], oxygen saturation < 90% [AOR = 1.9, 95% (1.34–3.53)] at admission time and neonate age ≤ 1 day at admission [AOR = 3.4, 95% CI (1.23–9.84) were predictors of neonatal death.

Conclusion

The incidence of death was high in this study. The acute complications arising during the transfer of referral neonates lead to an increased risk of deterioration of the newborn’s health and outcome. Preventing and managing complications during the transportation process is recommended to increase the survival of neonates.

Perspectives on Research Internships for Medical Students and Young Doctors in Ghana: An Opportunity to Replenish the Stock of Physician Investigators?

The corona virus pandemic undoubtedly demonstrates the growing need for research in medical science. However, with the decline in physician scientists world-wide, innovative ways are needed to engender interest in research among medical students and young doctors to replenish the stock of physician investigators. One way of doing this is to create compulsory and elective projects for them. We describe research internships created for medical students at the Noguchi Memorial Institute for Medical Research to expose them to the rudiments of biomedical research and proposal development. We also describe research internships for doctors waiting for house job postings or keen to do research who needed mentorship. Though the response has been positive, the full impact will be realized with time. The recognition that training should be backed with a supportive environment, mentorship and clear career paths for physician scientists is also mentioned.

The pattern of neonatal admissions and mortality at a regional and district hospital in the Upper West Region of Ghana; a cross sectional study

Background

High global neonatal deaths have triggered efforts to improve facility-based care. However, the outcomes achievable at different levels of care are unclear. This study compared morbidity and mortality patterns of newborns admitted to a regional and a district hospital in Ghana to determine outcome, risk and modifiable factors associated with mortality.

Objective

This study compared morbidity and mortality patterns of newborns admitted to a regional and a district hospital in Ghana to determine outcome, risk and modifiable factors associated with mortality

Methods

A cross-sectional study involving a records-review over one year at the Upper West Regional Hospital, and three years at St Joseph’s District Hospital, Jirapa was carried out. Age, sex, gestational age, weight, duration of admission, diagnosis, among others were examined. The data were analysed and statistical inference made.

Results

Altogether, 2004 newborns were examined, comprising 1,241(62%) from St Joseph’s District Hospital and 763(38%) from Upper West Regional Hospital. The proportion of neonatal deaths was similar, 8.94% (St Joseph’s District Hospital) and 8.91% (Upper West Regional Hospital). Prematurity, neonatal sepsis, birth asphyxia, low birth weight, neonatal jaundice and pneumonia contributed the most to mortality and suspected infections including malaria accounted for almost half (45.5%). Mortality was significantly associated with duration of stay of 48 hours, being premature, and being younger than 3 days.

Conclusion

Majority of the mortality among the neonates admitted was due to preventable causes. Better stabilization and further studies on the epidemiology of sepsis, prematurity, low birth weight, including the contribution of malaria to these and outcome of transferred neonates are needed.