Low-tech, high impact: Care for premature neonates in a district hospital in Burundi

Low-tech, high impact: Care for premature neonates in a

district hospital in Burundi

Brigitte Ndelema, Tony Reid, Rafael Van den Bergh, Marcel Manzi, Wilma van den Boogaard, Rose J. Kosgei, Isabel Zuniga, Manirampa Juvenal and Anthony D. Harries

Médecins Sans Frontières (MSF), Burundi, Brussels

Burundi - Context● Small landlocked

country in Central Africa

● ~ 10 million people

● Maternal mortality 200x higher than in Norway

● Neonatal mortality 20x higher than in Belgium

● 30% home deliveries

Burundi - MSF

MSF in Kabezi, Burundi:

- Emergency obstetrics

- Neonatal Intensive Care Unit

- Kangaroo Mother Care

Study rationale

Death among Prematures is a major contributor to neonatal mortality and overall under five mortality

Neonatal care is often restricted to centralised and tertiary level facilities

Decentralisation of care is recommended (‘Born Too Soon’ study group), but models of care have not been piloted nor described

Objective

To describe characteristics and treatment outcomes of premature neonates admitted to a

district hospital in rural Burundi.

Low technology - neonatal intensive care

Non-specialist staff (general practitioners and nurses) being trained in neonatology

Pulse –

Oxymeters

Low technology - neonatal intensive care

Low technology neonatal special care

Electronic IV pump

Oxygen concentrators for oxygen therapy

Low technology - neonatal intensive care

Kangaroo Mother Care

Breastfeeding Keeping warm

Admission criteria for prematures

Neonatal Intensive Care Unit Very preterm neonates (<32 weeks gestation) Moderately preterm neonates (32 to 36 weeks), if

together with pathology

Kangaroo Mother Care Moderately preterm neonates, if low birth weight

(< 2000 g) and no pathology

Methods

Design: Retrospective analysis of programme data

Period: January 2011 – December 2012

Setting: Kabezi District Hospital (rural)

Study population: All neonates born at less than 37 weeks and admitted

Ethics Approval: National Ethics Committee in Burundi and MSF Ethics Review Board.

Clinical conditions at birth

 Premature infants

< 32 weeks of gestationN=134 (%)

32-36 weeks of gestationN=236 (%)

Birth weight (g)     < 1000 17 (13) 1 (0.4)

1000-1499 61 (46) 33 (14)

1500-2499 47 (35) 181 (77) >2500 4 (3) 14 (6) Not recorded 5 (4) 7 (3)APGAR score at 5 minutes     0-6 54 (40) 71 (30) 7-10 74 (55) 151 (64) Not recorded 6 (5) 14 (6)Active birth resuscitation 107 (80) 151 (64)

Antenatal maternal complications    

Prolonged/obstructed labour 39 (29) 81 (34) Ante-partum haemorrhage 20 (15) 25 (11) Sepsis 7 (5) 8 (3) (Pre-)eclampsia 1 (1) 13 (6) Uterine rupture 0 1 (0.4) Other severe conditions 57 (43) 81 (34)

Length of Stay in days

Medians (Inter Quartile Ranges)

< 32 weeks of gestation: 11 (5 – 22) 32 – 36 weeks of gestation: 9 (4 – 16)

Discharge outcomes – stratified by gestational age

« Born too soon »

Discharge outcomes – stratified by birth weight

Discussion

Good outcomes achieved, even for very premature/very low birth weight babies. This compares well with the “Born too Soon” study group

Possible reasons: Strong focus on standardised protocols Training for non-specialised people (allowed task-sharing) Complete integration of maternal and neonatal services Integrated neonatal and Kangaroo care

Conclusions

It is feasible to provide intensive neonatal care for premature neonates at a district level in Africa

Extremely premature/extremely low birth weight babies should not be excluded

Good outcomes were achieved with low tech resources, suggesting that this model of neonatal care could be a way forward to reduce neonatal, and paediatric mortality in low-income settings

Acknowledgement

We thank all patients, the MSF Kabezi team, our partners and the Ministry of Health

This research was part of the Structured Operational Research and Training Initiative (SORT IT) in Africa - a global partnership of the WHO and led by the Operational Research Unit (LUXOR), Médecins Sans Frontières, OCB- Luxembourg; the Centre for Operational Research, The International Union Against TB and Lung Disease, the Centre for international health, University of Bergen, Norway and the Institute of tropical Medicine Antwerp