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

Background Preterm 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. Objective To determine whether implementation of a care bundle that includes ACS, maternal antibiotics (MA), neonatal antibiotics (NA) and avoidance of moderate hypothermia (temperature \u3c 36°C) targeting infants of estimated gestational age (EGA) 28 to 34 6/7 weeks would reduce NM (\u3c 7 days) by 35%. Methods A 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. Findings NM 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\u3c0.0001). 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 Interpretation A 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 ofenormou

Stepwise logistic regression analysis for estimating effects of administration of antenatal corticosteroids (ACS), maternal & neonatal antibiotics in combination or singularly for predicting death in p[reterm infants while controlling for BW, GA, source of admission, mode of delivery and gender for infants 28 to 30 6/7 weeks GA.

<p>Stepwise logistic regression analysis for estimating effects of administration of antenatal corticosteroids (ACS), maternal & neonatal antibiotics in combination or singularly for predicting death in p[reterm infants while controlling for BW, GA, source of admission, mode of delivery and gender for infants 28 to 30 6/7 weeks GA.</p

General characteristics of infants <35 weeks who survived versus died.

<p>General characteristics of infants <35 weeks who survived versus died.</p

Neonatal mortality and fresh stillbirths at the four hospitals, pre and post bundle of care implementation.

<p>Neonatal mortality and fresh stillbirths at the four hospitals, pre and post bundle of care implementation.</p

Stepwise logistic regression analysis for estimating effects of administration of antenatal corticosteroids (ACS), maternal & neonatal antibiotics in combination or singularly for predicting death in preterm infants while controlling for BW, GA, source of admission, mode of delivery and gender for infants 31 to 346/7 weeks.

<p>Stepwise logistic regression analysis for estimating effects of administration of antenatal corticosteroids (ACS), maternal & neonatal antibiotics in combination or singularly for predicting death in preterm infants while controlling for BW, GA, source of admission, mode of delivery and gender for infants 31 to 346/7 weeks.</p

General characteristics and medication use at the four hospitals pre/post implementation.

<p>General characteristics and medication use at the four hospitals pre/post implementation.</p

Outcome of preterm infants expected to 1/2 (partial) or 3/4 (complete) doses of dexamethasone versus no treatment.

<p>Outcome of preterm infants expected to 1/2 (partial) or 3/4 (complete) doses of dexamethasone versus no treatment.</p

Data collection sheet.

<p>Data collection sheet.</p

General characteristics of infants before and after implementation.

<p>General characteristics of infants before and after implementation.</p

The progressive decrease in mortality from September 2014 through June 2017.

<p>*Comparing years 2014 and 2017—Relative Risk Reduction (RR) and 95% Confidence Interval (CI) 0.658 (0.45–0.96) p = 0.031, ** Comparing years 2015–2017—RR 0.84 (0.73–0.97) p = 0.016. *** Comparing 2016 and 2017 RR 0.91 (0.78–1.06) p = 0.22.</p