Newborn babies in need of critical medical attention are normally admitted to the Neonatal Intensive Care Unit (NICU) [
Preterm birth is defined by the World Health Organization (WHO) as all births before 37 completed weeks of gestation or fewer than 259 days since the first day of a woman’s last menstrual period [
Being born preterm also increases a baby’s risk of dying due to other causes, especially from neonatal infections with preterm birth estimated to be a risk factor in at least 50% of all neonatal deaths [
More than 1 in 10 of the world’s babies born in 2010 were born prematurely [
The WHO classification categorizes preterm births into extreme preterm (<28 completed weeks), very preterm (28-<32 completed weeks), and moderate to late preterm (32-<37 completed weeks) [
The outcome of preterm babies is assessed as survival of the preterm baby and short- and long-term morbidity associated with preterm delivery. This is usually dependent on a number of factors such as biologic maturity and technological factors [
Neonatal survival varies with the quality of medical care [
Studies have found that primary causes of death for 78% of all non-malformation-related deaths in preterm babies were severe perinatal asphyxia, respiratory distress syndrome (RDS), and infection. Other causes of death were bronchopulmonary dysplasia (4%), necrotizing enterocolitis (2%), intraventricular hemorrhage (3%), and pneumothorax (2%) [
In Ghana, studies assessing the survival rate of premature babies and associated factors in the NICU are limited. Therefore, this study was designed to assess the survival rate of this group of neonates and associated factors in the Tamale Teaching Hospital (TTH) in the Northern Region of Ghana.
The TTH is a 450-bed capacity hospital which serves as the only teaching hospital in the northern part of Ghana. It is the main center for clinical training of medical students from the University for Development Studies (UDS), Tamale, Ghana. The hospital has a 40-incubator/crib capacity NICU with a 5-bed Kangaroo Mother Care (KMC) unit attached to it. The unit is able to provide respiratory support through a bubble Continuous Positive Airway Pressure (CPAP) setup. It is unable to provide invasive ventilation. With majority of its patients coming from the Tamale Metropolis, the approximate population of the catchment area is about 4 million.
This was a 7-month retrospective descriptive study conducted in the NICU of the TTH. It involved review of charts of all preterm babies admitted between 1 March 2017 and 30 September 2017.
A hospital record officer was assigned to retrieve case files of all preterm babies admitted to the NICU during the study period. The records retrieved were retrospectively reviewed for birth weight, gestational age, sex, mode of delivery, place of delivery, length of stay, and outcome of admission. Maternal information including age, parity (number of pregnancies carried to at least 24 weeks of gestational age), and illness in pregnancy was also retrieved.
All preterm babies admitted at the TTH NICU during the study period (1 March 2017 to 30 September 2017) were eligible for inclusion in the study. The participants included both inborn and outborn babies.
We excluded babies whose folders could not be retrieved from the records and low birth weight babies who were born at term.
The data were entered into Excel and exported into Stata (V12.1). The treatment outcome was categorized into discharged and died on admission while birth weight and gestational age at birth were categorized using WHO standards. The explanatory variables included gestational age at birth, comorbidities at presentation (RDS, hypothermia, hypoglycemia, neonatal jaundice, and sepsis), sex, mode of delivery, and birth weight. Gestational age was available for 187 participants while 161 participants had their birth weight data recorded. Therefore, analysis with respect to gestational age and birth weight was conducted on only 187 and 161 participants, respectively. The first part of the analysis dealt with descriptive statistics to ascertain the frequency of basic infant, maternal, and obstetric characteristics and to screen all the potential independent variables individually for their relationship with the dependent variable using a chi-squared test. In other words, the chi-squared test was used to establish if there was any association between basic infant, maternal, and obstetric characteristics and treatment outcome. Bonferroni’s correction was applied to correct for multiple testing. The chi-squared test is a nonparametric test that is appropriate for examining whether there is a significant relationship between nominal categorical variables. The test is based on the crosstabulation of the relevant variables and compares the observed frequencies in each cell of the crosstabulation to the frequencies expected if there were no relationship between the variables [
All independent variables with
Ethical clearance for this study was obtained from the TTH Ethical Review Committee with clearance no.: TTHERC/20/04/18/02.
A total of 192 preterm babies were included in the study. This translated to 19.2% (192/1000) of the total admissions to the unit during the study period.
Of the babies with a birth weight documented at admission, 13.04% have extremely low birth weight and 40.99% have very low birth weight while 45.34% have moderately low birth weight. About 10.7% of the babies were extreme preterm and 31.02% were very preterm while 58.29% were moderate to late preterm according to the WHO classifications. Out of the total records, 52.13% were female while 47.87% were males. Over 55% were born through spontaneous vaginal delivery (SVD) compared to about 44.8% who were born via cesarean section (C/S). Table
Baseline characteristics of preterm babies at presentation to the NICU.
Variable | Categories | |
---|---|---|
Birth weight (g) | <1000 | 21/161 (13.04) |
1000-1499 | 66/161 (40.99) | |
1500-2499 | 73/161 (45.34) | |
≥2500 | 1/161 (0.62) | |
Gestational age (weeks) | <28 | 20/187 (10.70) |
28-<32 | 58/187 (31.02) | |
32-37 | 109/187 (58.29) | |
Sex | Female | 98/188 (52.13) |
Male | 90/188 (47.87) | |
Mode of delivery | C/S | 82/189 (44.8) |
SVD | 105/189 (55.2) | |
Age on admission (days) | 1-3 | 144/181 (74.56) |
4-7 | 12/181 (6.63) | |
>7 | 25/181 (13.81) |
Table
Comorbidities of preterm babies at presentation to the NICU.
Variable | Categories | |
---|---|---|
Sepsis | Yes | 22/192 (11.46) |
No | 170/192 (88.54) | |
Hypothermia | Yes | 130/192 (67.71) |
No | 62/192 (32.29) | |
Hypoglycemia | Yes | 25/192 (13.02) |
No | 167/192 (86.98) | |
RDS | Yes | 83/192 (43.23) |
No | 109/192 (56.77) | |
Neonatal jaundice | Yes | 63/192 (32.81) |
No | 129/192 (67.19) |
The overall survival rate at discharge in this cohort was 60.73%. The survival rate was lowest in the extremely low birth weight group (14.3%) and highest in the moderately low birth weight group (82.2%). The survival rate was also the lowest among the extremely preterm babies (
Bivariate analysis of baseline maternal and neonatal characteristics at presentation.
Variable | Categories | Discharged | Died | |
---|---|---|---|---|
Birth weight (g) | <1000 | 3/21 (14.3) | 18/21 (85.7) | <0.0001 |
1000-1499 | 33/66 (50.0) | 33/66 (50.0) | ||
1500-2499 | 60/73 (82.2) | 13/73 (17.8) | ||
Gestational age (weeks) | <28 | 4/20 (20.0) | 16/20 (80.0) | <0.0001 |
28-<32 | 27/58 (46.55) | 31/58 (53.45) | ||
32-37 | 81/108 (75.0) | 27/108 (25.0) | ||
Sex | Male | 57/89 (64.0) | 32/89 (36.0) | 0.410 |
Female | 57/98 (58.2) | 41/98 (41.8) | ||
Age on admission (days) | 1-3 | 83/143 (58.04) | 60/143 (41.96) | 0.072 |
4-7 | 9/12 (75) | 3/12 (25) | ||
>7 | 20/25 (80) | 5/25 (20) | ||
Mode of delivery | C/S | 58/82 (70.7) | 24/82 (29.3) | 0.078 |
SVD | 57/101 (56.4) | 44/101 (43.6) | ||
Maternal age (years) | ≤20 | 14/17 (82.3) | 3/17 (17.7) | 0.168 |
21-30 | 59/94 (62.8) | 35/94 (37.2) | ||
≥31 | 26/46 (56.5) | 20/46 (43.48) |
Among the comorbidities identified at presentation, those presenting with hypothermia were more likely to die (50.0%) compared to those who were not (16.4%). Moreover, those presenting with RDS were also more likely to die (72.3%) compared to those without this diagnosis (13.9%). Further analysis of the data revealed that neonates who were hypothermic and at the same time hypoglycemic at the time of admission were also more likely to die (68.42%) compared to neonates who were either hypothermic or hypoglycemic (36.05%). Further, neonates who had both RDS and hypothermia were also more likely to die (73.08%) than those who had either RDS or hypothermia (33.94%). Table
Bivariate analysis of association between treatment outcome and comorbidities at presentation.
Variable | Categories | Discharged | Died | |
---|---|---|---|---|
Sepsis | Yes | 13/22 (59.1) | 9/22 (40.9) | 0.867 |
No | 103/169 (60.9) | 66/169 (39.1) | ||
Hypothermia | Yes | 65/130 (50.0) | 65/130 (50.0) | 0.001 |
No | 51/61 (83.6) | 10/61 (16.4) | ||
Hypoglycemia | Yes | 13/25 (52.0) | 12/25 (48.0) | 0.338 |
No | 103/166 (62.1) | 63/166 (37.9) | ||
RDS | Yes | 23/83 (27.7) | 60/83 (72.3) | 0.001 |
No | 93/108 (86.1) | 15/108 (13.9) | ||
Neonatal jaundice | Yes | 49/63 (77.8) | 14/63 (22.2) | 0.001 |
No | 67/128 (52.3) | 61/128 (47.7) | ||
Hypothermia & hypoglycemia | Yes | 6/19 (31.58) | 13/19 (68.42) | 0.006 |
No | 119/172 (63.95) | 62/172 (36.05) | ||
RDS & hypothermia | Yes | 7/26 (26.92) | 19/26 (73.08) | 0.001 |
No | 109/165 (66.06) | 56/165 (33.94) |
In the bivariate analysis, patients with hypothermia (
In the multiple logistic regression analysis (Table
Multiple logistic regression analysis of determinants of treatment success of preterm babies.
Variables | Variable categories | AOR (95% CI) | |
---|---|---|---|
Hypothermia | Yes | 7.2 (1.9-28.1) | 0.004 |
No | Reference | ||
RDS | Yes | 10.2 (3.7-27.9) | <0.0001 |
No | Reference | ||
Birth weight (g) | <1000 | 0.6 (0.04-8.1) | 0.668 |
1000-1499 | 0.4 (0.03-3.2) | 0.371 | |
1500-2499 | Reference | ||
Gestational age (weeks) | <28 | 1.5 (0.2-10.3) | 0.668 |
28-<32 | 0.8 (0.2-4.3) | 0.803 | |
32-37 | Reference | ||
Neonatal jaundice | Yes | 2.9 (1.0-8.5) | 0.045 |
No | Reference | ||
Mode of delivery | C/S | 1.6 (0.6-4.6) | 0.384 |
SVD | Reference | ||
Age on admission (days) | 1-3 | 6.0 (0.6-63.2) | 0.134 |
4-7 | 1.6 (0.1-33.4) | 0.763 | |
>7 | Reference |
Neonatal mortality attributable to preterm birth and complications remains a huge challenge globally and in low- and middle-income countries like Ghana. A few studies in Ghana have looked at predischarge mortality in this group of neonates [
Many of the patients in our cohort were born with extremely or very low birth weight and were in the gestational age ranges categorized by WHO as extremely or very preterm [
We documented an overall mortality rate of about 39% in this cohort prior to discharge from the NICU during the study period. Our mortality was comparable to the preterm-specific mortality rate reported in a study conducted at the NICU of the Korle BU Teaching Hospital in Accra, Ghana [
In another study conducted in the Mother-Baby Unit of the Komfo Anokye Teaching Hospital, Kumasi, Ghana [
Similarly, high preterm-specific mortality has been documented in countries across sub-Saharan Africa [
Among the neonatal factors we assessed, lower gestational age, lower birth weight, RDS, presence of jaundice, and hypothermia at presentation to the NICU were significantly associated with death in the bivariate analysis. Neonates who had more than one of these risk factors were more likely to die than those who have none or just one risk factor (Table
The association between lower gestational age and mortality was significant in bivariate analysis (
Low birth weight generally accompanies preterm births. In our cohort, >99% (Table
Compared to a previous study in Accra, Ghana, our weight-specific survival rate was similar for the extremely low birth weight group, but lower for the very low birth weight group [
Other studies in the African region have also found low survival rates for this group of preterm babies [
Hypothermia was common at presentation to our NICU (Table
Our study could not find a significant relationship between sepsis, mode of delivery, age at presentation, maternal age, and risk of death.
We did not do routine blood cultures for all babies admitted with prematurity. This could limit our ability to identify many of the babies with accompanying sepsis as signs and symptoms of sepsis may mimic many of the features of prematurity. We acknowledge this as one of the limitations of the study.
As a retrospective hospital-based study, our study had a number of limitations. One of them was the fact that our analysis was limited to the information found in the patient records we were able to retrieve. This could have introduced bias in the sampling. Our findings may also represent the profile of patients we admit and may not be generalizable to other units. We also mainly assessed neonatal risk factors, except the maternal age. The fact that our unit is unable to do routine blood cultures means our diagnosis of sepsis may be an underestimation of the problem. Despite this, our findings were similar to those from other studies on the same topic in similar settings, and we think it serves as a baseline for more comprehensive studies to be conducted in the future.
In conclusion, we found a high mortality rate in the preterm babies admitted to our unit and that mortality decreased with increasing gestational age and birth weight. We also found that a number of neonatal factors, either in isolation or in combination, were significantly associated with in-hospital mortality. The fact that there are much improved outcomes in more developed countries means that there is an opportunity to change the narrative for this vulnerable group by improving the quality of care provided during the antenatal and perinatal periods. In line with this high burden of hypothermia, we recommend routine feedback to all referring facilities and units, especially regarding maintenance of the warm chain during transport. Further studies are required to document the maternal risk factors associated with preterm birth and mortality in our hospital.
Adjusted odds ratio
Continuous Positive Airway Pressure
Cesarean section
Neonatal Intensive Care Unit
Respiratory distress syndrome
Spontaneous vaginal delivery
Tamale Teaching Hospital
World Health Organization.
The data supporting the conclusion of this paper are included within the manuscript. Upon reasonable request, the dataset could be obtained from the corresponding author.
The ethics review committee of the Tamale Teaching Hospital approved the study protocol.
The authors declared that they have no competing interest.
Alhassan Abdul-Mumin and Abdulai Abubakari conceived and designed the study; Sheila Agyeiwaa Owusu collected the data; and Abdulai Abubakari, Alhassan Abdul-Mumin, and Sheila Agyeiwaa Owusu analyzed the data and wrote the manuscript. All authors contributed to the data interpretation and critical revision of the manuscript and read and approved the final manuscript.
We thank all staff of the NICU, TTH, for their assistance during the data collection.