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Background: Death among premature neonates contributes significantly to neonatal mortality which in turn represents approximately 40 % of paediatric mortality. Care for premature neonates is usually provided at the tertiary care level, and premature infants in rural areas often remain bereft of care. Here, we describe the characteristics and outcomes of premature neonates admitted to neonatal services in a district hospital in rural Burundi that also provided comprehensive emergency obstetric care. These services included a Neonatal Intensive Care Unit (NICU) and Kangaroo Mother Care (KMC) ward, and did not rely on high-tech interventions or specialist medical staff. Methods: A retrospective descriptive study, using routine programme data of neonates (born at <32 weeks and 32-36 weeks of gestation), admitted to the NICU and/or KMC at Kabezi District Hospital. Results: 437 premature babies were admitted to the neonatal services; of these, 134 (31 %) were born at <32 weeks, and 236 (54 %) at 32-36 weeks. There were 67 (15 %) with an unknown gestational age but with a clinical diagnosis of prematurity. Survival rates at hospital discharge were 62 % for the <32 weeks and 87 % for the 32-36 weeks groups; compared to respectively 30 and 50 % in the literature on neonates in low- and middle-income countries. Cause of death was categorised, non-specifically, as "Conditions associated with prematurity/low birth weight" for 90 % of the <32 weeks and 40 % of the 32-36 weeks of gestation groups. Conclusions: Our study shows for the first time that providing neonatal care for premature babies is feasible at a district level in a resource-limited setting in Africa. High survival rates were observed, even in the absence of high-tech equipment or specialist neonatal physician staff. We suggest that these results were achieved through staff training, standardised protocols, simple but essential equipment, provision of complementary NICU and KMC units, and integration of the neonatal services with emergency obstetric care. This approach has the potential to considerably reduce overall neonatal mortality.
This was a descriptive study involving a retrospective review of routinely collected hospital data. Burundi is a small, densely populated country of 8.6 million people, of whom 14 % are children under the age of 5 years [2, 8]. It is located in Central Africa, surrounded by Rwanda, Tanzania and the Democratic Republic of Congo. Government spending on health is approximately 21 US dollars per capita per year [8]. There are three tertiary care public hospitals and one private hospital in Burundi with NICUs, but district hospitals do not offer this kind of service because of lack of the necessary materials, adequate infrastructure and trained staff. Thus, access to NICU care for premature infants is very limited. Given the high rate of maternal and neonatal mortality in Burundi, and the humanitarian needs following armed conflicts that traumatized the country, MSF opened the EOC project in Kabezi district in 2006. The project has a catchment area of three districts (Kabezi, Isale and Rushubi) in the province of Rural Bujumbura, and represents approximately 186,000 habitants. The EOC project, part of Kabezi District Hospital and located 2 km from the hospital proper, was established as a referral centre for women with obstetrical complications in the district and does not providing primary obstetric and neonatal care (which is provided in Kabezi District Hospital itself). The details of the EOC component have been described elsewhere and include care for women with obstetric complications such as pre-eclampsia, prolonged or obstructed labour, uterine rupture, obstetric haemorrhage, and severe malaria [9]. Due to the referral pattern of cases, by 2008, the number of newborns who required special neonatal care had increased significantly, and an internal audit showed a high intra-hospital mortality rate. To address this need, a neonatal unit was set up in 2009 and integrated with the obstetric care programme. The neonatal service consists of two wards. One ward is the NICU, with 17 beds, staffed by skilled and trained non-specialist personnel (a generalist doctor, a general paediatrician who is shared with the obstetrics centre, two nurses and two lactation assistants), uses specially developed standardised treatment protocols (including on-site training on their use), and is equipped with relatively low-technology equipment such as heated mattresses, electric pumps to administer milk via nasogastric tubes, intravenous supplies, and oxygen concentrators. There are no ventilators. These measures are described in detail in a previous study done in 2013 [7]. The second ward is the Kangaroo Mother Care (KMC), which has five beds, providing skin-to-skin warming and is supervised by a neonatal nurse and one lactation assistant. The components of KMC are skin-to-skin contact and promotion of breastfeeding to aid mother-infant bonding and provide warmth after birth, particularly for premature babies [10–12]. Neonates with the following complications are admitted to the NICU ward: neonatal sepsis, birth asphyxia, respiratory distress not otherwise specified, congenital malformations, and conditions associated with low birth weight such as hypoglycaemia, hypothermia, respiratory distress or apnea linked to prematurity. Definitions of these diagnoses are discussed in detail in a previous publication—diagnoses were made clinically, as only limited laboratory tests were available [7]. Premature and low birth weight neonates, especially those under 2000 grams, who are not sick, but need support with feeding, control of blood sugar, or extra warmth, are admitted directly to the KMC ward. All neonates born at less than 37 weeks gestation and admitted to the NICU or KMC ward at Kabezi district hospital during 2011 and 2012 were included in the study. Data were single-entered from patient case files into a structured EpiData database (v3.1, EpiData Association, Odense, Denmark). This database was checked against the routine project database (Excel based). It was implemented in 2011 to record all project data, automatically calculate indicators set by the project and prepare various reports. Data collection was managed by the project data manager, who checked for missing information with the medical team. Validation of the data was done by the medical director, the medical coordinator and epidemiologist of the MSF mission. Gestational age was determined using the date of the last menstrual period. However, as most mothers could not accurately recollect the date of their last menstruation, ultrasound was routinely performed to confirm gestational age, in particular for mothers at risk of premature delivery, where accurate assessment the gestational age for e.g. lung maturation is of primordial importance. For patients who arrived with an imminent birth and for whom ultrasound was no longer possible, the age of the premature neonates was determined through clinical examination (Table 1). Criteria for rapid gestational assessment at delivery aThe breast nodule is not palpable before 33 weeks. Underweight full-term infants may have retarded breast development (Clinical significance of gestational age and objective measurement. Pediatr Clin North Am) Simple summary statistics were generated using EpiData Analysis software (v.2.2.1.178, EpiData Association). Neonates were classified as <32 weeks (very preterm neonates) or 32–36 completed weeks (moderately preterm) of gestation, since this cut-off has been shown to affect outcomes [1]. Neonate Apgar scores at 5 min were categorized as (0–6) or (7–10), as described in other studies [7, 13]. Proportions between the different gestational age groups were compared using Chi square test. This study was approved by the Burundi Ethics Review Committee and met the Médecins Sans Frontières’ (Geneva, Switzerland) Ethics Review Board-approved criteria for analysis of routinely-collected programme data. It also satisfied the requirements of the Ethics Advisory Group of the International Union against Tuberculosis and Lung Disease, Paris, France and met their approval. As an analysis of routinely-collected data, consent was not obtained from the participants. But it met the six criteria for studies of routinely-collected data from the MSF ERB.
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