Marked variability in institutional deliveries and neonatal outcomes during the COVID-19 lockdown in Nigeria.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and the interventions to mitigate its spread impacted access to healthcare, including hospital births and newborn care. This study evaluated the impact of COVID-19 lockdown measures on newborn service utilization in Nigeria. METHODS: The records of women who delivered in hospitals and babies admitted to neonatal wards were retrospectively reviewed before (March 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic lockdown in selected facilities in Nigeria. RESULTS: There was a nationwide reduction in institutional deliveries during the COVID-19 lockdown period in Nigeria, with 14 444 before and 11 723 during the lockdown-a decrease of 18.8%. The number of preterm admissions decreased during the lockdown period (30.6% during lockdown vs 32.6% pre-lockdown), but the percentage of outborn preterm admissions remained unchanged. Newborn admissions varied between zones with no consistent pattern. Although neonatal jaundice and prematurity remained the most common reasons for admission, severe perinatal asphyxia increased by nearly 50%. Neonatal mortality was significantly higher during the COVID-19 lockdown compared with pre-lockdown (110.6/1000 [11.1%] vs 91.4/1000 [9.1%], respectively; p=0.01). The odds of a newborn dying were about four times higher if delivered outside the facility during the lockdown (p<0.001). CONCLUSIONS: The COVID-19 lockdown had markedly deleterious effects on healthcare seeking for deliveries and neonatal care that varied between zones with no consistent pattern.

Cost implication of CPAP use in low resource settings, surmounting the oxygen administration challenge.

PURPOSE: Newborn respiratory support using Bubble Continuous positive airway pressure (bCPAP) has become acceptable in Nigeria as many centers are increasingly reporting its usefulness. There is increasing access to CPAP devices although the use of 100% oxygen for bCPAP administration is on the rise as oxygen/air blenders are not commonly available or insufficient. The cost of oxygen has become a significant contributor to hospital bills. The oxygen concentrator driven bCPAP device with blending capacity is expected to save lives and reduce cost of care. OBJECTIVE: To compare the cost saving benefit of the use of oxygen concentrator bCPAP devices for CPAP administration to oxygen based devices in a resource limited setting. METHODS: This prospective cross sectional study was done between February and December 2019. The oxygen use by CPAP devices-Improvised (IbCPAP), Fisher and Paykel and T-piece were quantified, costed, documented and compared with the same duration of use of concentrator CPAP-Diamedica. RESULTS: CPAP services was accessed by 357 babies, 154 males and 203 females of GA range from 22 to 42 weeks and Birthweights range from 264 to 4400 grams. The main indication for CPAP was respiratory distress syndrome 201(56.3%). Oxygen supply were by oxygen pipeline 250 (70%), cylinders 39 (10.9%), concentrator CPAP 44 (12.3%) mixed source 24 (6.7%). Mean duration on the CPAP devices was 5.4 days, mean cost ₦37,645 ($104) or ₦6,971 ($20)/day, highest with IbCPAP, non-existent with concentrator bCPAP. CONCLUSION: The high running cost implication of CPAP use in low resource settings could deter transitioning to quality devices hence the need for non-oxygen dependent devices.

The scope and extent of exogenous surfactant utilization in Nigerian health care facilities: benefits of its regular use to outcome of premature babies.

Background: Surfactant replacement therapy (SRT) is the standard of care in developed countries. Poor access to surfactant limits its use in low resource settings. The extent of its use and the effect of its regular use on the preterm in such settings is unknown.Objective: This study assessed the extent of exogenous surfactant utilization in Nigerian tertiary care facilities and the benefits of its regular use to the preterm population.Methods: A two-phase cross-sectional study design evaluated the response from a respondent administered structured questionnaire addressed to health care providers from 54 centers and a targeted assessment of the outcome of the regular use of exogenous surfactant in a tertiary care facility from January 2014 to December 2016.Results: SRT was available in 16.7% of 54 units evaluated nationally; three (33.3%) were located in south-south and south-west respectively, 2 (22.2%) in southeast and one (11.1%) in north-central regions of the country. Twenty-two percent of the units were private centers, 77.8% were public tertiary care facilities. Four (44.4%) units provide SRT as the standard of care while five (66.6%) provide the service on request. One thousand one hundred twenty babies were admitted to the audited tertiary facility with 550 (49%) as preterms. Only 2.72% received surfactant replacement therapy. Sixty-six percent of recipients survived whilst 33.3% died. Respiratory support positively enhanced outcome in recipients of surfactant therapy.Conclusion: There is a limited use of surfactant nationally. Its use seemed to have improved survival.

Newborn resuscitation practices and paucity of resuscitative devices in Nigeria; a call to action.

BACKGROUND: Neonatal resuscitation is a method of preventing morbidities & mortality from asphyxia. Up to 85% of facilities in sub-Saharan Africa lack supplies or skilled personnel for neonatal resuscitation. Relative to the place of birth and the skill of the birth attendant, a variety of resuscitative practice are employed to make babies cry instead of helping the baby breathe. Many painful procedures are applied when the baby is unable to cry after birth in the absence of a health care worker trained in bag-mask ventilation. OBJECTIVES: To ascertain the resuscitation practices in communities lacking bag-mask-valve devices. METHODS: Surveys on the resuscitation practices during NISONM annual community outreach and mENCC trainings for four consecutive years in different geopolitical zones of the country. RESULTS: Spanking of the baby usually in the upside down position (>90%), body massage with hot compress or salicylate containing balms, herbal concoctions, injection hydrocortisone or crystalline penicillin were used. CONCLUSION: There is an urgent need to address the issue of training on bag-mask ventilation and provision for frontline healthcare workers in Nigeria as a neonatal mortality reduction strategy.

A Multi-centre Survey of Acceptability of Newborn Screening for Sickle Cell Disease in Nigeria.

Background Sickle cell disease (SCD) is a major genetic disease that manifests early in life and may lead to significant morbidities. One of the health care services that have been effective in reducing the burden of SCD in developed countries is newborn screening (NBS) followed by pneumococcal vaccines, penicillin prophylaxis, and hydroxyurea treatment. Yet, in sub-Saharan African countries, where about 75% of annual affected babies worldwide are born, NBS programmes are largely unavailable. It is not clear whether this is due to technical challenges associated with setting up such programmes, or significant cultural and social barriers to its acceptance in such settings. Objective Our aim was to ascertain the attitudes to and acceptability of NBS in Nigeria among various socio-demographic groups including health professionals, undergraduate students, parents of children with SCD and SCD patients. Methods Data on socio-demographic characteristics, knowledge of SCD and attitude towards NBS were collected using a semi-structured pre-tested questionnaire from April to July 2014 across 15 health institutions and university campuses in Nigeria. Data were collected from 1,301 respondents across Nigeria. Results There was good knowledge of SCD as an inherited blood disorder. Although 86% of respondents (n = 1,119) supported NBS, there was a statistically significant relationship between support for NBS and age (p = 003), educational status (p = 000) and religion (p = 000). Conclusion This study suggests that there is a good acceptability of NBS across Nigeria. The main barriers to its use are likely to be financial and practical, rather than social or cultural.

Preliminary Evaluation of a Point-of-Care Testing Device (SickleSCAN™) in Screening for Sickle Cell Disease.

Sickle cell disease affects about 150,000 births annually in Nigeria. Early diagnosis is hampered by factors such as centralized and urban localization of laboratories, high cost of diagnostic equipment and inadequate skilled manpower to operate them. The need for a low-cost, portable, easy-to-use diagnostic test for sickle cell disease is critical, especially in resource-poor countries. In this study, we evaluated the performance characteristics of a novel point-of-care testing device (SickleSCAN™), and its acceptability and feasibility, as a possible screening tool for sickle cell disease. In the first phase, we assessed the performance characteristics of SickleSCAN™ by evaluating 57 subjects comprising both children and adults attending a primary health center, for Hb SS (ßS/ßS; HBB: c.20A>T), Hb SC (ßS/ßC; HBB: c.19G>A) and Hb AS (ßA/ßS) using SickleSCAN™, cellulose acetate electrophoresis (CAE) and high performance liquid chromatography (HPLC). Performance characteristics such as diagnostic sensitivity and specificity were compared to HPLC as a standard method. We subsequently undertook a second phase wherein the acceptability and feasibility of the device for sickle cell disease screening, was evaluated using semi-structured and structured questionnaires among 197 healthcare personnel and 221 subjects, respectively. Sickle cell disease was carried by 3.4% of the subjects. The diagnostic sensitivity, specificity and test efficiency of SickleSCAN™ for sickle cell disease (Hb SS and Hb SC), were 100.0, 98.2 and 98.2%, respectively. Findings from this study showed SickleSCAN™ to be a viable screening tool that can easily be applied in community-based screening for early diagnosis of sickle cell disease with little expertise and low cost.

Neonatal Jaundice in Low- and Middle-Income Countries: Lessons and Future Directions from the 2015 Don Ostrow Trieste Yellow Retreat.

Severe neonatal hyperbilirubinemia, defined as total serum bilirubin (TSB) ≥20 mg/dl, is associated with a higher risk of permanent neurological sequelae and death. Jaundice can and should be promptly diagnosed and treated. Reliable methods for TSB assay are not always readily available, particularly in low- and middle-income countries, making the true incidence of severe neonatal jaundice (NNJ) difficult to estimate. To gather a more comprehensive picture, a symposium addressing NNJ worldwide was organized during the 2015 Don Ostrow Trieste Yellow Retreat. Data collected by several researchers in different regions of the world were presented and differences/similarities discussed. This report points out the need for: (1) a coordinated worldwide effort to define the burden and the causes of severe NNJ and its consequences; (2) aggressive educational programs for families and health personnel to facilitate timely care-seeking, and (3) accurate diagnostics and effective phototherapy.

Neonatal hyperbilirubinemia and Rhesus disease of the newborn: incidence and impairment estimates for 2010 at regional and global levels.

BACKGROUND: Rhesus (Rh) disease and extreme hyperbilirubinemia (EHB) result in neonatal mortality and long-term neurodevelopmental impairment, yet there are no estimates of their burden. METHODS: Systematic reviews and meta-analyses were undertaken of national prevalence, mortality, and kernicterus due to Rh disease and EHB. We applied a compartmental model to estimate neonatal survivors and impairment cases for 2010. RESULTS: Twenty-four million (18% of 134 million live births ≥ 32 wk gestational age from 184 countries; uncertainty range: 23-26 million) were at risk for neonatal hyperbilirubinemia-related adverse outcomes. Of these, 480,700 (0.36%) had either Rh disease (373,300; uncertainty range: 271,800-477,500) or developed EHB from other causes (107,400; uncertainty range: 57,000-131,000), with a 24% risk for death (114,100; uncertainty range: 59,700-172,000), 13% for kernicterus (75,400), and 11% for stillbirths. Three-quarters of mortality occurred in sub-Saharan Africa and South Asia. Kernicterus with Rh disease ranged from 38, 28, 28, and 25/100,000 live births for Eastern Europe/Central Asian, sub-Saharan African, South Asian, and Latin American regions, respectively. More than 83% of survivors with kernicterus had one or more impairments. CONCLUSION: Failure to prevent Rh sensitization and manage neonatal hyperbilirubinemia results in 114,100 avoidable neonatal deaths and many children grow up with disabilities. Proven solutions remain underused, especially in low-income countries.

Thyroid profile of term appropriate for gestational age neonates in Nigeria: a forerunner to screening for congenital hypothyroidism.

Thyroid hormones in normal quantity are vital for physical growth and mental development during fetal and postnatal life. The available publications in Sub-Saharan Africa on the thyroid function of newborn infants was reported in babies delivered in moderate to severe goitre zones; utilizing the hormone levels from these studies may have a measure of bias. Newborn screening for congenital hypothyroidism (CH) in Sub-Saharan Africa is still a mirage, the technicality of the best timing for collection of blood samples need to be studied. Consequently, we report the serum levels of total thyroxine (T4), triiodothyronine (T3) and thyroid stimulating hormone (TSH) at birth and at 72 h after birth, and to ascertain if there is any significant difference between them. This was a prospective cross-sectional study (6 months period) between November and April 2005. One hundred and fourteen apparently healthy term AGA neonates had their thyroid function analyzed, the females (59) were slightly more in number than the (males 55). Most of them were between GA of 37-38 weeks at birth. The observed 72 h mean values of serum T3 and T4 (1.06 and 101.38 nmol l(-1)) compared with the cord values at birth (0.89 and 75.48 nmol l(-1)), was not statistically significant. The mean cord TSH levels (13.59 mU l(-1)) compared with 72 h serum TSH levels (10.25 mU l(-1)) was also insignificant p = 0.3. For Sub-Saharan Africa cord TSH analysis may be a reasonable choice for newborn screening for congenital hypothyroidism.

Adverse perinatal conditions in hearing-impaired children in a developing country.

Prevailing adverse perinatal conditions in developing countries have been associated with substantial mortality, but little evidence exists on their impact on permanent childhood disabilities and morbidity due to limitations in clinical investigations and medical records. This study aims to identify the possible association between parent-reported adverse perinatal conditions and permanent hearing loss, in order to establish service needs within current maternal and child health programmes. Structured questionnaires were administered to 363 parents of deaf children and 309 parents of normal-hearing children in an inner city area of Lagos, Nigeria. The parents were from all social classes. After a multivariable logistic regression analysis, birth asphyxia [OR 20.45; 95% CI 6.26, 66.85], difficult delivery [OR 8.09; 95% CI 2.76, 23.68], neonatal jaundice [OR 2.45; 95% CI 1.25, 4.79] and neonatal seizures [OR 2.30; 95% CI 1.09, 4.85] were associated with permanent hearing loss. Consanguineous marriages [OR 6.69; 95% CI 2.72, 16.46] and family history of deafness [OR 6.27; 95% CI 2.07, 18.97] also emerged as additional risk factors for permanent hearing loss. In addition, parents of children in state-owned schools for the deaf were significantly more likely to belong to higher social classes compared with normal-hearing children in mainstream state-owned schools. There is a need to incorporate services for the early detection of permanent hearing loss into current maternal and child healthcare programmes in developing countries.

Early hearing detection at immunization clinics in developing countries.

Early hearing detection has become a standard of neonatal care in most parts of the developed world. A growing number of developing countries are also currently exploring practical and culturally appropriate options for early hearing detection. Recent findings from on-going infant hearing screening programs in Nigeria and South Africa suggest that hearing screening programs are feasible if integrated into early childhood immunization programs in developing countries, especially where a significant number of births occur outside regular hospitals. A major challenge for a multi-stage screening protocol is how to minimize default rates for follow-up till diagnosis. However, this could be systematically addressed through improved parental education and appropriate support at various stages of the program.