Provider Adherence to Clinical Care Recommendations for Neonates who Died from Neonatal Sepsis or Perinatal Asphyxia in Seven Low- and Middle-income Countries in the Child Health and Mortality Prevention Surveillance (CHAMPS) Network Open Access

Abstract

Background: In 2021, 2.3 million neonatal deaths occurred globally, and Sub-Saharan Africa and South Asia accounted for most of these deaths. Perinatal asphyxia and neonatal sepsis were the leading causes, comprising an estimated 23% and 35% of neonatal mortality, respectively. Most childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations.

Objectives: This study aimed to understand adherence to World Health Organization recommendations for managing perinatal asphyxia and neonatal sepsis and identify patient-level factors associated with guideline adherence.

Methods: We conducted a retrospective, descriptive study analyzing clinical data of hospitalized neonates aged 0 to 28 days who died within Child Health and Mortality Prevention Surveillance (CHAMPS) catchment areas in sub-Saharan Africa and Bangladesh from December 2015 to October 2023. We reviewed medical records of those who died from perinatal asphyxia and neonatal sepsis to assess the proportion who received recommended diagnostics and treatments. Mixed-effect multivariable logistic regression analyses were performed to identify factors associated with the administration of supplemental oxygen, bag-valve mask ventilation, and recommended antibiotics.

Results: A total of 3,479 neonates died in the CHAMPS catchment area during the study period. Of these, 1,494 neonates met the study requirements, with 803 dying from perinatal asphyxia and 691 dying from neonatal sepsis. The median age at the time of death was 2 days. For perinatal asphyxia, guideline adherence ranged from 9.6% for adrenaline administration to 67.5% for supplemental oxygen. Only 3.5% of neonates with perinatal asphyxia received all recommended treatments. In neonatal sepsis cases, antibiotics were administered to 70.8%, although the WHO-recommended treatment was administered to 49.8% of cases. In adjusted multivariate analyses, there was a statistically significant association between patient age and administration of recommended antibiotics, with older neonates having increased odds of receiving recommended antibiotics. No other associations were statistically significant in the adjusted multivariate models.

Conclusion: The low adherence to WHO guidelines for perinatal asphyxia and neonatal sepsis in this study underscores the critical need for efforts to increase adherence to clinical care guidelines in sites with high rates of neonatal and child mortality.

Table of Contents

CHAPTER 1: INTRODUCTION - 1

CHAPTER 2: LITERATURE REVIEW - 4

Leading Causes of Neonatal Mortality - 4

Previous Research on Reducing Neonatal Mortality - 5

Preventing Neonatal Deaths with High-Quality Clinical Care - 6

Clinical Care Guidelines - 6

WHO Pocket Book of Hospital Care for Children - 7

WHO Neonatal Sepsis & Perinatal Asphyxia Guidelines - 8

Clinical Care Guideline Adherence - 10

Gap in Literature - 11

Added Value of this Study - 12

CHAPTER 3: MANUSCRIPT - 13

Abstract - 13

Background - 14

Methods - 15

Study Design - 15

Study Setting - 15

Data Sources - 16

Inclusion & Exclusion Criteria - 16

Clinical Care Guidelines - 17

Variables - 18

Analyses - 18

Results - 19

Perinatal Asphyxia - 20

Neonatal Sepsis - 21

Discussion - 22

Public Health Recommendations - 25

Limitations - 25

Conclusion - 26

Figure 1. PRISMA flowchart of included cases of perinatal asphyxia and neonatal sepsis - 27

Figure 2. Adherence to WHO Pocketbook of Hospital Care for Children recommendations for perinatal asphyxia determined by postmortem diagnosis stratified by duration of hospitalization - 28

Figure 3. Adherence to WHO Pocketbook of Hospital Care for Children recommendations for neonatal sepsis determined by postmortem diagnosis stratified by length of hospitalization - 29

Table 1. Demographics of neonates who died from perinatal asphyxia and neonatal sepsis in the CHAMPS network - 30

Table 2. Adherence to WHO Pocketbook of Hospital Care for Children recommendations for perinatal asphyxia determined by postmortem diagnosis - 31

Table 3. Factors associated with any supplemental oxygen for birth asphyxia among neonates who had birth asphyxia in the causal chain of mortality - 32

Table 4. Adherence to WHO Pocketbook of Hospital Care for Children recommendations for neonatal sepsis, pneumonia, or congenital infection determined by postmortem diagnosis - 33

Table 5. Factors associated with the administration of any guideline-adherent antibiotics (ampicillin/penicillin and gentamicin OR cloxacillin and gentamicin) for neonatal sepsis among neonates who had neonatal sepsis in the causal chain of mortality - 34

CHAPTER 4: SUPPLEMENTAL MATERIALS - 35

Supplemental Table 1. Comparison of deceased neonates with MITS and DeCoDe in the CHAMPS network included and excluded in the analysis of clinical care recommendation adherence - 35

Supplementary Table 2. Factors associated with the administration of ventilation with bag-valve-mask for birth asphyxia among neonates who had birth asphyxia in the causal chain of mortality - 36

Supplemental Figure 1. Adherence to WHO Pocketbook of Hospital Care for Children recommendations for birth asphyxia determined by postmortem diagnosis by site - 36

Supplemental Figure 2. Pathogens implicated in sepsis, lower respiratory infections, or congenital infection in the causal chain - 36

Supplemental Figure 3. Adherence to WHO Pocket Book of Hospital Care for Children recommendations for neonatal sepsis determined by postmortem diagnosis by site - 36

REFERENCES - 40

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	Perinatal asphyxia Quality of care Neonate Mortality Guideline adherence Sepsis
Committee Chair / Thesis Advisor	Christopher Rees, Emory University Cynthia Whitney, Emory University
Partnering Agencies	International Non-governmental organization (e.g., CARE, Inc.)

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