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

Additional file 1: of Midwives’ perceptions on using a fetoscope and Doppler for fetal heart rate assessments during labor: a qualitative study in rural Tanzania

The Focused Group Discussion guide. (DOCX 12 kb

Comparison of the 12-months observation period before and after full HBB implementation.

<p>*Pearson Chi-Square analysis, 2-sided.</p><p>ENM = Early neonatal mortality; BMV = Bag mask ventilation.</p

Total direct costs and cost factors of HBB training at HLH.

a<p>Travel expenses include transport,accommodation and per diems.</p>b<p>Administration includes as well refreshments during the course.</p>c<p>Courses took place during normal working hours and no extra staff was hired during the courses.</p><p>MHSW = Tanzanian Ministry of Health and Social Welfare; HLH = Haydom Lutheran Hospital; LDHF = Low-dose-high-frequency.</p

Sensitivity analysis.

<p>*All costs in USD.</p

Costs per life saved, life year gained and DALY averted.

<p>DALYs [r, K, β] = Disability adjusted life years [discounting rate, age weighting constant K, age weighting constant β].</p

Stepwise elimination process of the WHO near miss criteria.

<p><b>EXCL</b>: Excluded. <b>Bold:</b> Criteria that have an independent contribution to inclusion of cases. <b>Step 2:</b> Two inclusion criteria have n = 8. Cardiac arrest is excluded because it was the second most frequent used inclusion criterion from start. <b>Step 7:</b> Six cases are left with six corresponding, independently used inclusion criteria (oxygen saturation, respiratory rate >40 or <6/min, oliguria non responsive to fluids or diuretics, failure to form clots, jaundice in the presence of pre-eclampsia and transfusion of blood ≥5 units). They are excluded simultaneously for space reasons.</p

WHO near miss criteria adapted to the local context of HLH.

a<p>Shock is defined as a persistent severe hypotension, defined as a systolic blood pressure <90 mmHg for 60 min with a pulse rate of ≥120/min despite aggressive fluid replacement (>2L).</p>b<p>Oliguria is defined as an urinary output <30 ml/hour for 4 hours or <400 ml/24 hr.</p>c<p>Failure to form clots is defined as the absence of clotting from the IV site after 7–10 minutes.</p>d<p>Unconsciousness/coma lasting >12 hours is defined as a profound alteration of mental state that involves complete or near-complete lack of responsiveness to external stimuli or Glasgow Coma Scale <10.</p>e<p>Cardiac arrest is defined as loss of consciousness and absence of pulse or heart beat.</p>f<p>Stroke is defined as a neurological deficit of cerebrovascular cause that persists ≥24 hours, or is interrupted by death within 24 hours.</p>g<p>Uncontrollable fit is a condition in which the brain is in state of continuous seizure.</p>h<p>Pre-eclampsia: the presence of hypertension associated with proteinuria. Hypertension is defined as a blood pressure ≥140 mmHg (systolic) or ≥90 mmHg (diastolic). Proteinuria is defined as excretion of ≥300 mg protein/24 hr or 300 mg protein/litre urine or ≥1+ on a dipstick.</p>i<p>Eclampsia is defined as the presence of hypertension associated with proteinuria and fits. Hypertension is defined as a blood pressure ≥140 mmHg (systolic) or ≥90 mmHg (diastolic). Proteinuria is defined as excretion of ≥300 mg protein/24 hr or 300 mg protein/litre urine or ≥1+ on a dipstick.</p>j<p>Sepsis is defined as a clinical sign of infection and 3 of the following: temp>38°C or <36°C, respiration rate >20/min, pulse rate >90/min, WBC >12.</p>k<p>Uterine rupture is defined as the complete rupture of a uterus during labour.</p

Validity of the WHO and Haydom near miss criteria among all women.

<p><b>Validity WHO clinical criteria: Sensitivity:</b> 100%; 95%CI [91.1%–100%], <b>Specificity:</b> 99.5%; 95%CI [99.4%–99.7%], <b>Positive predictive value:</b> 41.6%; 95%CI [31.1%–52.8%], <b>Negative predictive value:</b> 100%; 95%CI [100%–100%].</p><p><b>Validity WHO near miss criteria: Sensitivity:</b> 100%; 95%CI [91.1%–100%], <b>Specificity:</b> 99.4%; 95%CI [99.2%–99.5%], <b>Positive predictive value:</b> 34.8%; 95%CI [25.6%–44.9%], <b>Negative predictive value:</b> 100%; 95%CI [100%–100%].</p><p><b>Validity Haydom near miss criteria: Sensitivity:</b> 100%; 95%CI [91.1%–100%], <b>Specificity:</b> 97.7%; 95%CI [97.4%–98.0%].</p><p><b>Positive predictive value:</b> 12.9%; 95%CI [9.2%–17.5%], <b>Negative predictive value:</b> 100%; 95%CI [99.9%–100%].</p

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

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