Predictors of Post- Special Care Unit Discharge Mortality among Low Birth Weight Neonates at Mulago National Referral Hospital.

Abstract

Introduction: Annually, more than 20 million infants are born with low birth weight (LBW) across the world, and majority of these are born in South Asia and sub-Saharan Africa (SSA). LBW can be due to prematurity or intrauterine growth restriction, or both. In Uganda, 10% of births with reported weight have LBW, and preterm birth which is commonly associated with LBW, accounts for 14% of all births. LBW infants are more likely to die compared to heavier infants, and preterm birth is the commonest cause of under-5 mortality worldwide. Objective: This study aimed to determine the post-Special Care Unit (SCU) discharge outcomes (poor weight gain, readmission and mortality) and predictors of post-SCU discharge mortality among LBW neonates at Mulago National Referral Hospital (NRH). Methods: This was a prospective study of 216 LBW neonates discharged from the SCU of Mulago NRH. These were followed up to 28 completed days of life or death, whichever occurred first. The primary outcome was mortality. Secondary outcomes were re-admissions within 28 days of life, or poor weight gain which was defined as average weight growth velocity less than 15grams per kilogramme per day. Independent variables were socio-economic and proximate factors (maternal, neonatal, delivery and post-delivery factors). Results: Of the 216 study participants, 54(25%) had birth weight of <1500g, and 162 (75%) had birth weight of 1500- 2499g. Thirty four (15.7%) had discharge weight <1200g, 49 (22.7%) had discharge weight 1200-1499g, 46 (21.3%) had discharge weight 1500-1799g, 45 (20.8%) had discharge weight 1800-1999g, and 42 (19.5%) had discharge weight ≥2000g. Out of the 191 participants with known gestational age at birth, 47 (24.6%) were very preterm (<32 weeks), 125 (65.4%) were moderate to late preterm (32-<37 weeks), and 19 (10% ) were term (≥37 weeks). During the study period, 14/216 neonates (6.5%) died. Mortality was highest (20.6%) among neonates with discharge weight <1200g. The predictors of mortality were discharge weight <1200g (adjusted hazard ratio [AHR]= 23.47, 95% CI: 4.34-126.8), 5-minute Apgar score <7 (AHR= 4.25, 95% CI: 1.31-13.8) and presence of other comorbidities during admission (AHR= 7.93, 95% CI: 1.67-37.6). Twenty eight (13%) (95% CI: 9-18%) of the 216 study participants were readmitted, and of these, 25 (89.3%) had possible neonatal sepsis whereas 3 (10.7%) had jaundice. Male gender was associated with increased risk of readmission (Risk Ratio= 2.48, 95% CI: 1.15.61). vi

Of the 130 participants at the first follow-up visit, 91 (70%) (95% CI: 61-77%) had poor weight gain, and 40/67 (60%) (95% CI: 47-71%) participants at the second follow-up visit had poor weight gain. Conclusions and Recommendations: One in fifteen LBW neonates die after discharge from the SCU at Mulago NRH. Discharge weight <1200g, 5-minute Apgar score <7, and suffering comorbidities such as neonatal sepsis during the initial admission are important predictors of postSCU discharge mortality among LBW neonates. One in seven LBW neonates are readmitted after discharge from the SCU at Mulago NRH, and neonatal sepsis is a major cause of post-SCU discharge mortality and morbidity (readmission). Majority of LBW neonates discharged from the SCU had poor weight gain. Identification and more intensive follow-up of LBW neonates at greator risk of mortality coupled with caregiver education about prevention of neonatal sepsis and when to seek for medical care are recommended. LBW neonates should be discharged with body weight >1200g