A care bundle including antenatal corticosteroids reduces preterm infant mortality in Tanzania a low resource country

Augustine Massawe,Hege L Ersdal,Estomih Mduma,Jeffrey M Perlman,Robert Moshiro,Prisca Ringia,Aisa Shayo,Paschal Mdoe,Georgina Msemo,Edna Majaliwa,Mary Azayo,Flora Chacha,Hussein L Kidanto,Harald Ehrhardt

doi:10.1371/journal.pone.0193146

Abstract

BackgroundPreterm neonatal mortality (NM) has remained high and unchanged for many years in Tanzania, a resource-limited country. Major causes of mortality include birth asphyxia, respiratory insufficiency and infections. Antenatal corticosteroids (ACS) have been shown to significantly reduce mortality in developed countries. There is inconsistent use of ACS in Tanzania.ObjectiveTo determine whether implementation of a care bundle that includes ACS, maternal antibiotics (MA), neonatal antibiotics (NA) and avoidance of moderate hypothermia (temperature < 36°C) targeting infants of estimated gestational age (EGA) 28 to 34 6/7 weeks would reduce NM (< 7 days) by 35%.MethodsA Pre (September 2014 to May 2015) and Post (June 2015 to June 2017) Implementation strategy was used and introduced at three University-affiliated and one District Hospital. Dexamethasone, as the ACS, was added to the national formulary in May 2015, facilitating its free use down to the district level.FindingsNM was reduced 26% from 166 to 122/1000 livebirths (P = 0.005) and fresh stillbirths (FSB) 33% from 162/1000 to 111/1000 (p = 0.0002) Pre versus Post Implementation. Medications including combinations increased significantly at all sites (p<0.0001).By logistic regression, combinations of ACS, maternal and NA (odds ratio (OR) 0.33), ACS and NA (OR 0.30) versus no treatment were significantly associated with reduced NM. NM significantly decreased per 250g birthweight increase (OR 0.59), and per one week increase in EGA (OR 0.87). Moderate hypothermia declined pre versus post implementation (p<0.0001) and was two-fold more common in infants who died versus survivors.InterpretationA low-cost care bundle, ~$6 per patient, was associated with a significant reduction in NM and FSB rates. The former presumably by reducing respiratory morbidity with ACS and minimizing infections with antibiotics. If these findings can be replicated in other resource-limited settings, the potential for further reduction of <5 year mortality rates becomes enormous.

Highlights

One-week neonatal mortality still contributes significantly to the under-5-year mortality rates in Tanzania. [1, 2] Major contributing causes include birth asphyxia (BA), prematurity and infection
The principal finding of this pilot implementation initiative incorporating a care-package strategy, was significant for an overall 26% reduction in neonatal mortality (NM) 7 days, and an unanticipated 33% reduction in fresh stillbirths (FSB) rates in preterm infants 28 to 34 6/7 weeks estimated gestational age (EGA)
Neonatal characteristics associated with increased NM included lesser Birth weight (BW), lower Gestational age (GA) and outborn deliveries, in preterm infant 28 to 31 6/7 weeks

Summary

Introduction

One-week neonatal mortality still contributes significantly to the under-5-year mortality rates in Tanzania. [1, 2] Major contributing causes include birth asphyxia (BA), prematurity and infection. Antibiotics are only initiated when the preterm infant becomes symptomatic Given these limitations in care, we focused our attention towards a seemingly low-cost, evidence-based preventative approach, which is part of standard practice in resource-replete countries. These strategies include the administration of ACS to mothers in preterm labour, [5, 6] maternal antibiotics when in active labour, [7, 8] immediate stabilization/resuscitation of the newborn [9] including avoidance of moderate hypothermia (

Methods

Results

Conclusion