Small newborns in post-conflict Northern Uganda: Burden and interventions for improved outcomes

Abstract

Introduction: A small newborn can be the result of either a low birthweight (LBW), or a preterm birth (PB), or both. LBW can be due to either a preterm appropriate-for gestational-age (preterm-AGA), or a term small-for-gestational age (term-SGA) or intrauterine growth restriction (IUGR). An IUGR is a limited in-utero foetal growth rates or foetal weight < 10th percentile. Small newborns have an increased risk of dying, particularly in low-resource settings. We set out to assess the burden, the modifiable risk factors and health outcomes of small newborns in the post-conflict Northern Ugandan district of Lira. In addition, we studied the use of video-debriefing when training health staff in Helping Babies Breathe.

Subjects and methods: In 2018-19, we conducted a community-based cohort study on 1556 mother-infant dyads, nested within a cluster randomized trial. In our cohort study, we estimated the incidence and risk factors for LBW and PB and the association of LBW with severe outcomes. We explored the prevalence of and factors associated with neonatal hypoglycaemia, as well as any association between neonatal death and hypoglycaemia. In addition, we conducted a cluster randomized trial to compare Helping Babies Breathe (HBB) training in combination with video debriefing to the traditional HBB training alone on the attainment and retention of health worker neonatal resuscitation competency.

Results: The incidence of LBW and PB in our cohort was lower than the global estimates, 7.3% and 5.0%, respectively. Intermittent preventive treatment for malaria was associated with a reduced risk of LBW. HIV infection was associated with an increased risk of both LBW and PB, while maternal formal education (schooling) of ≥7 years was associated with a reduced risk of LBW and PB.

The proportions of neonatal deaths were many-folds higher among LBW infants compared to their non-LBW counterparts. The proportion of neonatal deaths among LBW was 103/1000 live births compared to 5/1000 among the non-LBW.

The prevalence of neonatal hypoglycaemia in our cohort was 2.5%. LBW and PB each independently were associated with an increased risk of neonatal hypoglycaemia. Neonatal hypoglycaemia was associated with an increased risk of hospitalisation and severe outcomes.

We demonstrated that neonatal resuscitation training with video debriefing, improved competence attainment and retention among health workers, compared to traditional HBB training alone.

Conclusion: In northern Uganda, small infants still have a many-fold higher risk of dying compared to normal infants. In addition, small infants are also at more risk of neonatal hypoglycaemia compared to normal infants. Efforts are needed to secure essential newborn care, should we reach the target of Sustainable Development Goal number 3.2 of reducing infant mortality to less than 12/1000 live births by 2030.