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Morbidity and mortality outcomes in neonates who were transferred from home and hospitals to the only neonatal intensive care unit in Guinea: a descriptive report using routinely collected health data a Faculty of Medicine Pharmacy and Odontostomatology, Gamal Abdel Nasser University of Conakry, BP 1147, Conakry, Guinea; bCentre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7FZ, UK *Corresponding author: Tel: +447340548405, +224666591112; E-mail: [email protected] Received 21 August 2018; revised 3 December 2018; editorial decision 2 January 2019; accepted 2 January 2019 Background: The Sustainable Development Goal (SDG) for neonatal mortality has identified its reduction as one of the main targets to be achieved by 2030. We provide a descriptive report on neonatal outcomes from the only neonatal intensive care unit (NICU) in Guinea. Methods: Data collection took place between November 2004 and May 2005 at the NICU of the Institute of Child Health in the capital, Conakry. A descriptive summary of the neonatal, maternal and intrapartum characteristics is reported. Results: A total of 294 neonates were admitted to the NICU incubators during the study period, transferred either from hospitals (48%) or directly from their homes (52%). The most common reasons for admission were foetal distress (37.1%) and maternal–foetal infections (35.4%). Among 270 neonates with known outcome, the overall mortality among the admitted children remained high at 20.7% (56/270),with a large proportion of the deaths (71.4%, 40/56) occurring within 7 d of their admission. The mortality rate was 23.7% (31/131) among the neonates who were admitted to our NICU after home birth and 17.9% (25/139) among those who were transferred from hospitals (OR: 1.41, 95% CI: 0.75–2.67). Conclusion: Almost one in every five neonates who were admitted to the NICU incubator died during the study period. More hospitals equipped with NICU facilities are urgently required if Guinea is to achieve the SDG target for neonatal mortality. Keywords: Guinea, neonatal ICU, neonatal mortality, neonates Introduction It is estimated that 2.6 million newborn babies die every year during the neonatal period, which is the first 28 d after birth.1,2 Global efforts which are currently underway to curb neonatal deaths have led to a steady decline in neonatal mortality (NNM) from 31 deaths per 1000 live births in 2000 to 19 deaths per 1000 live births in 2015.1,3 However, these figures are highly skewed as NNM still remains unacceptably high in many low and middle income countries in sub-Saharan Africa where it is estimated at 29 deaths per 1000 live births.3 The millennium development goal (MDG) for child survival (MDG-4) set in 2000 aimed to reduce mortality in children aged <5 y by two-thirds by 2015.4,5 This galvanized global efforts and led to a gradual decline in mortality among children aged 1–59 months in the next 15 y.2 However, the proportion of neonatal deaths contributing to the under 5 mortality has kept rising globally during this period (Figure 1). It is increasingly realized that the key to successfully reducing child mortality is highly dependent upon curbing neonatal deaths.6 The Sustainable Development Goal (SDG) 3.2 outlined in 2015 aims to reduce NNM to 12 per 1000 live births by 2030.7 In Guinea, the estimated NNM was 47.5 per 1000 live births in 2000 and 38.8 per 1000 live births in 2005, declining to 25.6 per 1000 live births in 2015.1 The Neonatal Intensive Care Unit (NICU) is a vital component of neonatal care and is increasingly important for reducing NNM.8,9 In Guinea, there is only one children’s hospital equipped with an NICU to date and we describe routinely collected © The Author(s) 2019. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected]. 455 Downloaded from https://academic.oup.com/inthealth/article/11/6/455/5308881 by guest on 27 October 2022 Mahamoud Sama Cherifa,b,*, Prabin Dahalb, Rashid Mansoorb, Facely Camaraa, Abdourahamane Baha, Alpha Konea, Fatoumata Cherifa, Dienaba Kassea, Mandiou Diakitea and Mamadou Pathe Dialloa ORIGINAL ARTICLE Int Health 2019; 11: 455–462 doi:10.1093/inthealth/ihz001 Advance Access publication 7 February 2019 M. S. Cherif et al. observational data from this hospital. The aim of this study was to describe maternal, neonatal and intrapartum characteristics from 294 Guinean neonates. Materials and methods Study design This is a retrospective study describing routinely collected observational data on the neonates and their mothers admitted to the NICU ward of the Institute of Child Health (INSE) of Guinea, Conakry, between November 2004 and May 2005. Hospital description The INSE is a public hospital under the administrative supervision of the Ministry of Health and Public Hygiene of Guinea and it is housed at the Donka national hospital in Conakry. As of now, it is the only neonatal hospital equipped with NICU facilities in Guinea. At the time when this study was conducted, the neonatology department included a physiotherapy unit, breastfeeding and counselling unit, a vaccination unit and an NICU. There were 41 cradles, 4 incubators and 7 beds for the neonates, and the department consisted of 1 neonatologist, 4 general practitioners and a team of 14 nurses. Neonatal resuscitation Neonates were resuscitated if the following symptoms were present: presence of generalized or localized cyanosis, rapid shallow breathing and Silverman Anderson retraction score of 0.13 The hospital was equipped to provide only basic resuscitation, and in those who were deemed to be needing resuscitation, the airway was first cleared using a suction aspirator with a controlled vacuum and a canister.10 Some of the neonates who started normal breathing upon suctioning using the aspirator were then transferred to the postresuscitation wards. If the breathing was still abnormal, ventilation using a bag-and-mask method was initiated. Heart rate and breathing rate were measured and skin colour evaluation was done after 30 s of ventilation support. If the breathing rate was <40 breaths per min and the heart rate was <100 beats per min (bpm), then oxygen was supplied using a nasal cannula in addition to positive pressure ventilation (PPV) support. If the neonates started breathing with a heart rate >100 bpm with signs of recovery from cyanosis, then postresuscitation care was initiated. If the heart rate was still <60 bpm with persistent cyanosis then epinephrine was administered along with continued PPV and chest compression.10,14 For the neonates who were judged as not requiring resuscitation, breast feeding was initiated. For the preterm neonates, after receiving initial care at the NICU, the kangaroo position (skin-to-skin contact onto the mother’s chest) was recommended to regulate and stabilize their body temperature. Neonatal care The standard of neonatal care consisted of following WHO 1998 guidelines.10 Umbilical cord care was given using antiseptics to avoid any infections and vitamin K was systematically administered to all neonates to avoid the risk of haemorrhagic diseases.11,12 456 Neonatal infection Since clinical symptoms and biological markers are neither sensitive nor specific, neonatal infection was defined as the Downloaded from https://academic.oup.com/inthealth/article/11/6/455/5308881 by guest on 27 October 2022 Figure 1. Median mortality in children aged <5 y and neonates globally and in Guinea; (left) mortality in children aged <5y accounted by neonatal deaths, globally and in Guinea; (right) the proportion of mortality in children aged <5 y accounted for by neonatal deaths was calculated as the ratio of neonatal mortality (NNM) per 1000 live births divided by mortality in children aged <5 y per 1000 livebirths. Data were taken from the United Nations Inter-agency Group for Child Mortality Estimation 2017.27 International Health presence of signs and symptoms of infection with or without accompanying bacteraemia. This included lethargy, refusal to suckle, vomiting, bleeding, seizure, pallor or cyanosis, rash tachypnoea, apnoea, hypothermia and fever. Neonatal sepsis was treated with a combination of ampicillin at 100 mg/kg and gentamycin at 5 mg/kg for at least 7 d.15 Data collection and definitions Statistical analyses Statistical analyses were carried out using Stata software, version 15.0 (StataCorp LP, College Station, TX, USA).19 A descriptive summary of the maternal, delivery and neonatal characteristics was presented. Continuous variables were summarized as median and IQR or as mean ± SD, and categorical variables were summarized as proportions. ORs were calculatued using the odds.ratio function in the questionr package in R software.20 The results were reported following the Reporting of studies Routinely collected Data Ethical clearance This retrospective study met the criteria for a waiver for ethical review as defined by the National Ethics Committee since it consisted of re-analysis of anonymized patient data collected during routine medical practice stored in a secured and confidential departmental database. Results Between November 2004 and May 2005, there were 294 newborns who were transferred from national and hospitals or directly from their homes to the NICU ward of the INSE hospital, Guinea. Of the 294 neonates admitted, 141 (47.9%) were transferred from hospitals, while the remaining 153 (52.1%) were admitted to our ward after home birth. The number of monthly admissions to the NICU during the study period is shown in Figure 2. The most common reasons for admission were intrapartum-related neonatal encephalopathy (37.1%), maternal–foetal infections (35.4%) and neonatal infections (21.4%) (Figure 3). Maternal characteristics The median maternal age was 24 y (IQR: 20–29 y; range: 14–50 y) with a fifth of the mothers (20.1%, 59/294) being teenagers. Information on the number of antenatal care (ANC) visits was missing for 54 women (18.4%). Of the remaining 227 mothers who visited the ANC unit at least once, more than half of the mothers (56.8%, 129/227) did not complete the four ANC visits during their pregnancy, 43.2% (98/227) had four or more ANC visits, while 5.7% (13/227) of mothers never attended an ANC clinic during pregnancy. Primigravida was reported by 38.7% (110/294) and primiparity by 38.0% (108/294) of mothers. Vaccination against tetanus was common, with 95.6% (234/294) of mothers receiving at least one dose. Further maternal characteristics are presented in Table 1. Delivery characteristics A total of 76 of the 294 babies (25.9%) were delivered by caesarean section (C-section), 197 (67.0%) had normal vaginal deliveries and the information on mode of birth was missing for 7.1% (21/294). The majority of the neonates (87.1%, 256/294) were singleton, 11.9% (35/294) were twins and 1% (3/294) were triplets. There were 116 mothers (40.8%) who reported being febrile (indicative of infection) during the delivery (Table 2). Neonatal characteristics The median neonatal age at admission was 1 d, with 46.2% (139/294) admitted to our ward within a few hours of birth. A total of 57 neonates (20.1%) were preterm and 30 (10.6%) were born after their due dates. The median weight at birth was 2700 g (IQR: 1920–3250; range: 1190–5000) among the 187 457 Downloaded from https://academic.oup.com/inthealth/article/11/6/455/5308881 by guest on 27 October 2022 At admission, all the neonates went through an assessment of primitive reflexes and skin colour evaluation. Measurements were taken of heart rate, breathing rate, body weight, height, temperature, cranial perimeter and signs of malformation or infection. In Guinea, every pregnant mother is assigned a mother–child booklet, which documents the details of antenatal care visits, and which is completed and signed off by a trained health professional (trained birth attendant [TBA]/doctor/nurse). The mother– child booklet was used for collecting further details on maternal, delivery and neonatal characteristics. These include information regarding the history of maternal pregnancies such as gravidity, parity, the number of antenatal consultations, tetanus vaccination status and delivery characteristics such as place and mode of childbirth. Further information on the neonates was collected by asking their mothers. All data were extracted from this booklet and then transferred to an access database. The status of home birth was derived using the information available from the mother–child booklet and by directly asking the mother. Information regarding whether the delivery was assisted by a TBA was obtained by directly asking the mother. Preterm birth was defined as gestational age <37 weeks and post-term birth was defined as gestational age >42 weeks. A very low birth weight (VLBW) was defined as birth weight <1500 g, and a birth weight <2500 g was defined as a low birth weight (LBW), following WHO guidelines.16–18 Illnesses at admission were grouped into three mutually nonexclusive categories: (1) possible severe bacterial infections defined as maternal–foetal infection and neonatal infection; (2) intrapartum-related neonatal encephalopathy and (3) preterm birth and LBW including intrauterine growth restriction. Intrapartum-related neonatal encephalopathy was defined based on the physician’s judgement, which was based on delivery history (obstructed labour or breech presentation). Respiratory depression was defined based on the Apgar score. In our resource-limited setting, the pH levels in blood samples from the cord could not be taken for confirming foetal acidosis and microbiology tests could not be carried out to identify severe bacterial infections. Conducted using Observational (RECORD) statement.21 M. S. Cherif et al. Figure 3. Distribution of admitted neonates according to the diagnosis on admission. The categories are mutually non-exclusive. neonates for whom information on birth weight was available. Using the WHO definition, a total of 72 (38.5%) were classified as having a LBW of <2500 g.16 Apgar scores at 5 min of birth were normal (i.e. a score of ≥7) in only 15 (10.3%) of 146 neonates for whom the information was recorded. The median body temperature on admission was 36.2°C with 46.9% (138/ 294) of neonates admitted with a low body temperature <36.5°C. Possible bacterial infections mainly consisting of maternal–foetal infections were reported in 35.4% (104/294), foetal distress in 37.1% (109/294), preterm birth in 19.4% (57/ 294), LBW in 38.5% (72/187) and intrauterine growth restriction in 20.4% (60/294). Neonatal resuscitation was carried out in 122 (38.1%) of 255 newborns for whom these data were available (Table 3). Neonatal outcomes Among the 294 neonates admitted to the NICU, almost onefifth died (19.0%, 56/294), just under three-quarters (72.9%, 458 214/294) were discharged after recovery, 6.1% (18/294) were withdrawn by their parents, and the outcome status was missing for 2% (6/294) (Table 3). A large proportion of the deaths (71.4%, 40/56) occurred within 7 d of admission to our ward. From the 270 neonates with available outcomes, the mortality rate was 23.7% (25/139) among the neonates who were admitted to our NICU after home birth, and 17.9% (31/131) among those who were transferred from hospitals (OR: 1.41, 95% CI: 0.75–2.67). Discussion We describe maternal, neonatal and intrapartum characteristics from 294 neonates admitted to the only NICU in Guinea between November 2004 and May 2005. We make several observations which we believe are of public health importance and highly relevant towards achieving the target outlined in SDG 3.2. Downloaded from https://academic.oup.com/inthealth/article/11/6/455/5308881 by guest on 27 October 2022 Figure 2. Monthly admission of neonates to the neonatal intensive care unit. International Health Table 1. Maternal characteristics Table 2. Delivery characteristics Frequency Percentage Characteristics Median mother age (IQR) y Maternal age group <20 y 21–34 y ≥35 y Not stated Profession Housewife Professional Student Not stated Tetanus vaccination dose 0 1 2 3 Not stated Antenatal hospital visits No visits 1–3 visits ≥4 visits Not stated Antenatal care started at first trimester No Yes Not stated Parity Primiparity ≥2 and more live births Gravida 1 2–4 ≥4 Not stated Residence Dixin Dubreka Kaloum Matam Matoto Ratoma Not stated History of hypertension No Yes Not stated 24 [20–29]a – 59 168 27 40 20.1 57.1 9.2 13.6 111 158 21 4 37.8 53.7 7.1 1.4 16 51 181 2 44 5.4 17.3 61.6 0.8 14.9 13 129 98 54 4.4 33.9 33.3 18.4 71 186 37 24.1 63.3 12.6 110 184 37.4 62.6 Mode of delivery Vaginal Caesarean section Not stated Apgar at 5 min of birth ≥7 <7 Not stated Maternal fever during delivery No Yes Not stated Did the water break at home? No Yes Not stated Gestational age (GA) Preterm (<37 weeks of GA) Normal (37–42 weeks of GA) Post-term (>42 weeks of GA) Median weight on admission [IQR]/g Pregnancy outcome Singleton Twins Triplets Not stated Resuscitation No Yes Not stated 110 140 34 10 37.4 47.6 11.6 3.4 44 2 16 30 88 101 13 14.9 0.7 5.4 10.2 29.9 34.4 4.4 197 6 91 67.0 2.1 30.9 ANC = antenatal care Median [IQR]; the rest of the figures are the number of observations a a Frequency Percentage 197 76 21 67.0 25.9 7.1 131 15 148 44.6 5.1 50.3 155 116 23 52.7 39.5 7.8 137 38 119 46.7 12.9 40.4 57 19.4 207 70.4 30 10.2 2700 [1920–3250] a 255 35 3 1 86.7 11.9 1.0 0.3 133 122 39 45.2 41.5 13.3 Median [IQR]; the rest of the figures are the number of observations First, a high proportion of the neonates (51.4%) admitted to our NICU were born at home in the absence of any skilled birth attendants. This observation is consistent with the fact that skilled attendance and institutional delivery rates are generally lower in low and middle income countries,22 and only a third of women deliver their baby in the presence of a skilled attendant. Neonates who were transferred from their homes were at a 1.41-fold (95% CI: 0.75–2.67) increased chance of death compared with those who were transferred from hospitals. This could possibly be related to a low level of care received at home births without any skilled attendants present during the labour and immediately after birth. This observation is concordant with the fact that NNM is inversely related to the skilled attendance at birth.22–24 Delays in recognizing problems and in transportation to reach appropriate care are among factors which affect 459 Downloaded from https://academic.oup.com/inthealth/article/11/6/455/5308881 by guest on 27 October 2022 Characteristics M. S. Cherif et al. Table 3. Newborn characteristics Frequency Median age on admission [IQR]/days Age category on admission 0–6 d ≥7 d Gender Female Male Median cranial perimeter [IQR]/cm Median height [IQR]/cm Median weight in [IQR]/g Low birth weight (LBW) status Very LBW (<1500 g) LBW (1500–2500 g) Normal (>2500 g) Not stated Median body temperature [IQR] Hypothermia (temperature <36.5°C) Normal (temperature between 36.5 and 37.5°C) Febrile (temperature> 37.5°C) Not stated Place of birth Home Hospital Intrauterine growth restriction No Yes Neonatal infection No Yes Maternal–foetal infection No Yes Foetal distress No Yes Neonatal anaemia No Yes Neonatal outcome Death Discharge Withdrawal from the hospital by parents Not stated 1[0–4]a Percentage 234 60 79.6 20.4 113 181 32.5 [31–34]a 50 [46–51]a 2510 [1820–3050]a 38.4 61.6 15 57 115 107 36.2 [35–38]a 138 33 112 11 5.1 19.4 39.1 36.4 153 141 52.0 48.0 234 60 79.5 20.4 231 63 78.6 21.4 190 104 64.6 35.4 185 109 62.9 37.1 289 5 98.3 1.7 56 214 18 6 19.0 72.9 6.1 2.0 46.9 11.2 38.1 3.7 LBW = low birth weight a Median [IQR]; the rest of the figures are the number of observations the survival of both mothers and newborns.25 Second, the case fatality among the neonates was very high (20.7%). Although direct comparison with other studies is not accurate, this is similar to 19.6% reported in neighbouring Guinea-Bissau,26 but much higher than what is observed in developed countries.27 460 Identifying factors associated with fatal outcomes would facilitate better understanding of the requirements for targeted interventions. Our observational study is susceptible to selection biases28 and was not appropriate for elucidation of any risk factors. The well-designed study from Guinea-Bissau has highlighted several Downloaded from https://academic.oup.com/inthealth/article/11/6/455/5308881 by guest on 27 October 2022 Characteristics International Health instance information regarding the times and causes of neonatal death, gestational age and maternal health outcomes. Fourth, our observational dataset is susceptible to confounding bias and we stress that the results presented in our report should be interpreted with this caveat taken into consideration. Despite these limitations, we believe our report provides highly valuable information regarding NNM in Guinea. Prospective and well-designed studies are urgently required to generate robust evidence and galvanize the national policy. Conclusion In conclusion, our study highlighted that NNM remained unacceptably high among those admitted to the only NICU in Guinea in 2005. Despite making strides in reducing mortality in those aged <5 y in the last 15 y, NNM has been very much overlooked in Guinea. Improved access to affordable obstetric care, universal health coverage and more neonatal hospitals equipped with NICUs are urgently required in an integrated approach if Guinea is to achieve the target presented in SDG 3.2. It will be a great human tragedy if we will be still reporting that globally 2.6 million neonates die every year, 7126 every day, 297 every hour and 5 every second in the year 2030. And all of these to largely preventable causes of neonatal death. Authors’ contributions: MSC, MPD, DK, AK and MD conceived and designed the observational study. MSC, FCam (Facely Camara) and AB collected and validated the data. MSC, FChe (as Fatoumata Cherif) and RM performed the statistical analysis. MSC and PD wrote the first draft of the manuscript. All authors read and approved the final version. Acknowledgements: We would like to thank Dr Makoto Saito for several helpful comments. We also thank the staff at the Institute of Child Health in Conakry and the Paediatrics chair of the Faculty of Medicine, Pharmacy and Odontostomatology of Gamal Abdel Nasser University. Funding: This work was not funded. Competing interests: The authors declare that there are no conflicts of interest. Ethical approval: This retrospective analysis met the criteria for a waiver for ethical review as defined by the Institute of Child Health in Conakry and the Paediatrics chair since it consisted of re-analysis of anonymized patient data collected during routine medical practice stored in a secured and confidential departmental database. The ultimate aim was to improve neonate management directly, and written informed consent was not applicable. Consent to publish: Approval was obtained from the administrative board of the Paediatrics chair and the Institute of Child Health in Conakry. Availability of data and materials: The datasets used and/or analysed during the current study are available from the Institute of Child Health in Conakry and the Paediatrics chair of the Faculty of Medicine, 461 Downloaded from https://academic.oup.com/inthealth/article/11/6/455/5308881 by guest on 27 October 2022 factors associated with neonatal deaths and we stress the need for a rigorous prospective study to corroborate whether the results from Guinea-Bissau are generalizable to our setting. Third, 38.5%(72/187) of the neonates who were admitted to our NICU were classified as having LBW (<2500 g), irrespective of the gestational age. This is concerning as it is estimated that LBW contributes to 60–80% of all neonatal deaths,22 and is considered to be one of the strongest predictors of NNM.29 The LBW observed in our dataset could be due to preterm birth (23/57) or to in utero growth restrictions (33/60). Identifying the measures for avoiding LBW should be a priority, and appropriate care units such as NICU incubators should be easily accessible to provide an appropriate level of care for these vulnerable neonates. The use of kangaroo mother care should be encouraged in those areas lacking incubator support. Fourth, presenting with maternal–foetal (104/294) infections, which represents a complex of mother and foetal infections, was a major reason for neonates being admitted to our hospital. There is an increased risk of rapid progression of illnesses among neonates which puts them at an increased risk of death.22 Controlling neonatal infections depends on improving maternal health during the pregnancy, preventing the vertical transmission of the infections and controlling nosocomial infections.29 To accomplish this, there is an urgent need for prospective evaluation and surveillance on the aetiology of neonatal and maternal infections. Finally, we report that this is the only hospital equipped with an NICU facility in Guinea as of today. This highlights that there is a large chasm in terms of health infrastructure and much more groundwork which needs to be done. In order to address some of these unmet needs, the Guinean government has introduced an integrated management of childhood illness which offers simple and effective methods to prevent and manage the leading causes of illnesses and mortality in young children.30 Despite this, NNM in Guinea remains around 25 per 1000 live births.31 However, it is important to realize the complex interplay of demographic,32 socio-economic33 and cultural factors34 from pregnancy through to childbirth which inevitably affect NNM.35 The distribution and relative contribution of various determinants of NNM are known to be highly region specific.22 Hence, it is vital to collect information regarding the antenatal, intrapartum and postnatal causes of NNM in a given setting in order to implement targeted and integrated packages.23 Timely availability of relevant information on the causes of NNM is thus crucial to inform the policy-makers and frontline health workers who deliver quality care. Our study has some noticeable limitations. First, we report data which were collected more than a decade ago when NNM was much higher in Guinea. Steady progress has been made since then as NNM has gradually declined (Figure 1). However, these improvements are far from satisfactory and well below the target set by SDG 3.2. Second, we assumed those who were transferred from home were delivered in the absence of a TBA. A home birth does not necessasirily preclude the possibility of a TBA assisted the delivery. From our local knowledge as practising paediatricians (MSC, FC and AB), and from the information derived from the mother–child booklet, we consider home birth in the presence of a TBA in our settings to be highly unlikely. Third, several critical variables were missing in our dataset, for M. S. Cherif et al. Pharmacy and Odonto stomatology of Gamal Abdel Nasser University on reasonable request. 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