74 - Human and System Factors are Important Contributors to Neonatal Mortality (NM) and need to be Addressed if Sustainable Developmental Goal3(SDG) are be achieved by 2030: A Tanzanian Experience

Poster Number: 74
Publication Number: 74.449

Background: SDG3 aims to reduce NM to 12/1000 live births (LB) by 2030. We recently reported from Kilimanjaro Christian Medical Center (KCMC) (Shayo BMC 2022) that the early NM (ENM) < 7 days was 18/1000 LB with a rate of 8/1000 LB for newborns > 37 wks/2500 grams vs 83/1000 LB for newborn < 37 weeks/2500g birth weight (BW). Furthermore, for infants 1001-1500gm the rate was 189/1000 LB and 588/1000 LB for infants < 1000g BW. To explore insights into the causes of newborn deaths biweekly mortality reviews have been conducted.

Objective: To determine potential human and system factors that may contribute to ENM.

Design/Methods: Biweekly mortality conferences involving pediatric residents and consultants have been held since March 2023. Data reviewed included BW, gestational age (GA), inborn/outborn, initial temperature (TEMP), the severity of respiratory distress (RF) using the Silverman score, primary admitting diagnosis, and cause of death. The neonatal care unit is comprised of 16 beds and 8 bubble CPAP machines with blended O2; intubation is rare. Transfers are primarily via ambulance without isolettes and EMS staff are not trained in newborn care. Portable radiography and bedside ultrasound imaging are not available. The nurse-to-patient ratio is ~ 1 to 8.

Results: There were 61 neonates of BW 1850±982g and GA 33±4 weeks; 20 (33%) were inborn and 37(67%) outborn. BW distribution was < 1000g (n=12), 1001 to 1500g (n=15), 1501 to 2500g(n=12), and > 2500g (n=22). Admitting TEMP for inborn vs outborn infants was 36.2±0.6 vs 34.6 ± 2OC(p=0.0005) and < 1500g 36.2 ± 0.81 vs 33.9 ± 2.4 OC (p=0.0006). Putative causes of death included congenital abnormalities (n=8) i.e., gastroschisis (n=3), Trisomies (n=2), anencephaly (n=1), imperforate anus (n=1), midfacial microsomia (n=1); hypoxic-ischemic encephalopathy (HIE) (n=10)( outborn n=9);, severe progressive respiratory failure(RF) (n=15) all treated with CPAP, but rarely antenatal steroids (ANS); profound hypothermia ( < 32OC) (n=7) all outborn, presumed sepsis (n=7), extreme hyperbilirubinemia (n=2), unexplained hydrops (n-1), Extreme prematurity < 750g)(n=2); and unclear etiology (n=9).

Conclusion(s): ENM was associated with potentially preventable conditions I.e., severe RF without ANS, and profound hypothermia. The latter invariably reflected system failures with the transfer process i.e., maintaining TEMP due to no isolette or skin-to-skin care. The predominance of HIE in outborns highlights the need for educational outreach to obstetric providers. Meeting SDG goals will require a comprehensive package that addresses medical as well as human and system factors.