Improving SCBU Care for Preterm Babies

This study aims to describe the neonatal clinical outcome of preterm neonates (< 37+0 weeks of gestation) in terms of mortality and prematurity-related morbidity and the growth and neurodevelopment of preterm neonates (< 34+0 weeks of gestation) in the first year of life in order to optimize service delivery for preterm neonates in a resource-constraint setting. The study will consist of 3 parts as follows:

Part A: A retrospective chart review of preterm neonates born in one of the birthing SMRU unit between January 2008 and December 2017 and for whom a medical chart is available. In addition we propose to analyze the growth trajectory, the prevalence of anemia (Hct < 33%) and the level of neurodevelopment achieved in the first year of life reported in the clinical charts of preterm neonates born < 34+0 weeks of gestation.

Part B: Focus Group Discussion (FGD) of the medical staff working in the SCBU firstly on the benefits and difficulties in using existing guidelines for preterm care and secondly on the feasibility and acceptability of the revised guidelines 3-6 months after their implementation.

Part C: Interviews of mothers who delivered preterm neonates (< 37+0 weeks of gestation) to understand the challenges they faced while caring for their child.

This study was funded by Shoklo Malaria Research Unit Core funding (Wellcome Trust). Grant reference number is 220211.

Summary of Results:

Preterm birth is a major public health concern worldwide with the largest burden of morbidity and mortality falling upon the low- and middle-income countries. Evidence-based interventions for preterm neonatal care exist but often meet with barriers to implementation based on constraints in resource-poor settings.

This study summarizes clinical outcomes among preterm neonates born to mothers attending antenatal care at SMRU, regarding four main points of care: feeding, infections, thermal care, and respiratory care. In addition to these clinical outcomes, mixed methods were employed to highlight key implementation outcomes for SCBU care provision in this setting.

Between January 1, 2008, and December 31, 2017, a total of 2319 preterm births were documented, of which, 203 stillbirths were excluded from further analysis. There were 237 deaths documented over the study period, with the proportion of deaths decreasing significantly from 14.4% (144/999) during the early establishment period of SCBU (2008-2011) to 11.0% (66/603) during the expansion of SCBU care to all sites (2012-2014) and to 5.3% (27/514) while the continuum of care was performed more routinely at all sites (2015-2017) (p<0.001). Mortality reduction was observed in all categories of prematurity, with the largest reduction (68%) observed among very preterm neonates (EGA 28-32 weeks). Most deaths (184/237, 77.6%) occurred in the early neonatal period, of which half were within hours of birth (93/184).

Admission for surveillance and further care was routine. Very preterm neonates (EGA 28-32 weeks) remained under observation for nearly three weeks longer than moderate preterm neonates (EGA 33-36 weeks) with a median of 34 days (IQR 20, 49 days) compared to a median of 9 days (IQR 4, 14). Hypothermia (temperature < 36.5ºC) was the most common cause of abnormal body temperature on admission (402/480, 83.8%) independent of prematurity. Nearly one-third of neonates (394/1215, 32.4%) received intravenous antibiotics on admission to SCBU. Duration of oxygen therapy was longer for very preterm (median of 18 days [IQR 10, 32]) compared to moderate preterm neonates (2.5 days [IQR 2-6.5]).

Mothers of neonates (n=9) explained acceptability, satisfaction, and coverage outcomes related to SCBU care. Despite difficult circumstances around access and financial issues, many women realized the need for SCBU care for their newborns. The patient-centered care offset risks associated with both seeking care and the substantial toll that extended hospital stays took on women's personal lives. FGDs with medical staff (n=27) helped explain feasibility, fidelity, and effectiveness outcomes.

Conclusions:

SMRU provides a package of routine and specialized services for antenatal, intrapartum, delivery, postpartum, and newborn care that is facility-based. The package of care for preterm birth and small and sick newborns has evolved over the years and now includes the administration of steroids to women with preterm labor between 27-34 weeks of gestation, maternal antibiotic prophylaxis in case of prolonged rupture of membranes, and diagnosis and treatment of maternal infections The Special Baby Care Units for specialized care of preterm, small, or sick neonates has been equipped with equipment for optimizing respiratory support, phototherapy, feeding, and thermoregulation. The on-site medical staff has been trained in newborn resuscitation and participates in routine exercises based on the Basic Emergency Obstetric \& Newborn Care Life Support curriculum. And all these efforts have resulted in a reduction in mortality among all categories of neonates, mostly those very preterms (EGA 28-32 weeks).

However, despite this improvement in survival, interviews and FGDs findings highlighted the barriers in this resource-limited setting and their impact on the feasibility, fidelity, and effectiveness of evidence-based SCBU care. Financial burdens and social issues related to home life were often a pull away from the hospital, hampering the acceptability, appropriateness, and satisfaction mothers felt in accessing clinics or being admitted to the SCBU facility for long periods of time. Medical staff often adapted interventions to fit the financial and environmental constraints imposed by this setting. To further reduce neonatal mortality in preterm neonates there is an urgent need to consider the financial and social constraints on the mothers as well as support to the medical staff that goes beyond improving knowledge.

The final enrolment numbers: Part A: 2116 charts of preterm neonates born to mothers attending ANC at SMRU retrospectively analyzed; 27 participants to FGD and 9 interviews.