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 Juvenal and Anthony D. Harries Médecins Sans Frontières (MSF), Burundi, Brussels

2. Burundi - Context ● 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

3. Burundi - MSF MSF in Kabezi, 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) being trained in neonatology

7. Pulse – Oxymeters Low technology - neonatal intensive care

8. Low technology neonatal special care Electronic IV pump

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

10. Kangaroo Mother Care Breastfeeding Keeping warm

11. Admission criteria for prematures 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

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 Premature infants < 32 weeks of gestation N=134 (%) 32-36 weeks of gestation N=236 (%) Birth weight (g) < 100017 (13)1 (0.4) 1000-149961 (46)33 (14) 1500-249947 (35)181 (77) >25004 (3)14 (6) Not recorded5 (4)7 (3) APGAR score at 5 minutes 0-654 (40)71 (30) 7-1074 (55)151 (64) Not recorded6 (5)14 (6) Active birth resuscitation107 (80)151 (64) Antenatal maternal complications Prolonged/obstructed labour39 (29)81 (34) Ante-partum haemorrhage20 (15)25 (11) Sepsis7 (5)8 (3) (Pre-)eclampsia1 (1)13 (6) Uterine rupture01 (0.4) Other severe conditions57 (43)81 (34)

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 too soon »

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 standardised protocols  Training for non-specialised people (allowed task-sharing)  Complete integration of maternal and neonatal services  Integrated neonatal 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