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

1. 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 Juvenaland Anthony D. Harries Médecins Sans Frontières (MSF), Burundi, Brussels

2. 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 - Context

3. Burundi - MSF MSF inKabezi, Burundi: - Emergency obstetrics - Neonatal Intensive Care Unit - Kangaroo Mother Care

4. 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

5. Objective To describe characteristics and treatment outcomes of premature neonates admitted to a district hospital in rural Burundi.

6. Low technology - neonatal intensive care Non-specialist staff (general practitioners and nurses) beingtrained in neonatology

7. Low technology - neonatal intensive care Pulse – Oxymeters

8. Low technology neonatal special care Electronic IV pump

9. Low technology - neonatal intensive care Oxygen concentrators for oxygen therapy

10. Kangaroo Mother Care Breastfeeding Keeping warm

11. 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 Admission criteria for prematures

12. 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.

13. Clinical conditions at birth

14. Length of Stay in days • Medians (Inter Quartile Ranges) • < 32 weeks of gestation: 11 (5 – 22) • 32 – 36 weeks of gestation: 9 (4 – 16)

15. Discharge outcomes – stratified by gestational age « Born toosoon »

16. Discharge outcomes – stratified by birth weight

17. 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 standardisedprotocols • Training for non-specialised people (allowedtask-sharing) • Complete integration of maternal and neonatal services • Integratedneonatal and Kangaroo care

18. 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

19. 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