Study Area and Period
This study was carried out at NEMMCSH, which is located in Hossana town, Haddiya zone, from January to December 2022. Hossana Town, the capital of Central Ethiopia, is situated 230 kilometers from Addis Ababa, the capital of Ethiopia. In addition to providing general and specialty medical care, NEMMCSH is a public hospital that serves as a teaching hospital for medical and other health science students. The neonatal Intensive Care Unit (NICU) offers newborn care services to both inborn and out born term and preterm neonates. A hospital-based prospective follow-up study was carried out.
Treatment protocols in NICU.
The treatment protocol in a Neonatal Intensive Care Unit (NICU) varies depending on the specific medical conditions and needs of the newborn. NICUs are specialized units that provide intensive medical care for premature or ill newborns. Many premature infants have underdeveloped lungs and may require assistance with breathing. This can include mechanical ventilation and continuous positive airway pressure (CPAP). Premature babies often struggle to maintain their body temperature. Incubators or radiant warmers are used to keep the baby's temperature stable. Continuous monitoring of vital signs such as heart rate, respiratory rate, and oxygen saturation is crucial in the NICU. This helps healthcare providers promptly address any changes in the baby's condition. Neonates in the NICU are susceptible to infections, so strict infection control measures are implemented. This includes proper hand hygiene, aseptic techniques, and the judicious use of antibiotics. Many newborns experience jaundice, a yellowing of the skin and eyes due to elevated bilirubin levels. Phototherapy may be used to treat jaundice. NICUs often emphasize family-centered care, involving parents in the care of their newborns. This includes education on baby care, involvement in decision-making, and support for emotional well-being. Medications may be administered to address specific medical conditions or to support the baby's physiological functions (44).
Population
All preterm neonates admitted to the NICU of NEMMCSH were the source population whereas all preterm neonates admitted to the NICU at NEMMCSH from January to November 2022 comprised the study population.
Inclusion and exclusion criteria
Preterm neonates admitted to the NICU during the time of data collection were included in the study. Preterm neonates of mothers who are unable to speak and those with no immediate caregiver were excluded from the study.
Sample size determination and sampling technique
Using Stata version 14, the sample size was calculated with respect to a hazard ratio of 2.186 for gestational age, a standard deviation of 0.186, a 95% confidence interval, a 5% probability of type I error, 80% power, and a 29.31% probability of success (death). Taking into account the aforementioned criteria, a total of 197 preterm neonates were included in the study (45).
Data collection tool and technique
Until the required sample size was attained, the study participants were consecutively recruited into the study. The data collection tool and the follow-up data collection tool were adapted from different studies. Upon admission, the data collectors recruited study subjects and continued to follow them throughout their stay in the facility, documenting all clinical events until the neonates die or censored. Data collection was done by trained nurses and supervision was done by two public health experts. Interviews and a review of medical charts were used to collect data from mothers. Up until the neonatal death or censorship, newborn data were prospectively gathered from medical records. The neonates were followed for a maximum of 28 days from birth. To assure the quality of the data, the data collection tool was evaluated by pediatricians, and 1 day of training was given to the data collectors and supervisors about general research protocols. The Principal investigator reviewed the data before entering it to ensure it was consistent and complete.
Study Variables
Dependent Variable
Mortality of preterm neonates.
Independent variables
maternal age, place of residence, marital status, level of education, occupation, monthly income and sex of neonates, multiple pregnancy, parity, history of abortion and/or preterm birth, Birth interval, prolonged labour, ANC visits, human immunodeficiency virus (HIV) status, DM and place of delivery, mode of delivery, type of birth attendant, antenatal corticosteroid use, neonatal postnatal age at admission, anomalies, KMC, BMI, birth weight, 1 and 5-minute APGAR score and resuscitation history, gestational age, obstetric haemorrhage, eclampsia and preeclampsia, mal-presentation, feeding problem, asphyxia, neonatal sepsis, hypothermia, jaundice, HR, RR, SPO2, and hypoglycaemia.
Data analysis
Data were entered into Epi-data for Windows and analyzed using Stata version 14. Percentages and frequencies were used to summarize categorical variables. The results were presented in tables, texts, and graphs based on the nature of the variables. The distribution of the continuous variables was checked by a box plot. Mean with standard deviation and median with interquartile range were used to summarize normally and non-normally distributed continuous variables, respectively. The Kaplan-Meier Survival and failure curve was used to describe the proportion of deaths over time and to compare groups.
Multivariable Cox proportional hazards regression
The independent effects of covariates on the hazard of death were analyzed using the multivariable Cox proportional hazards model. Adjusted hazard ratios with their 95% confidence interval (CI) were estimated, and a p-value less than 0.05 was used to declare the presence of a significant association between predictors and preterm neonatal death.
Assessing model assumptions: the proportional hazard assumption states that the effect of the covariate is the same over time. It was tested using the global test running the estat phtest command in stata. The assumption was satisfied (p-value: 0.2042).
Operational Definitions:
Gestational age: from the LNMP to the date of delivery.
Event: Death
Discharged (Recovered): Those who left the hospital with clinical improvement confirmed by a physician.
Time to death: the time from admission to when the neonate died.
Time zero: the time when a neonate is being admitted to the NICU.
Censored: A neonate lost to follow-up, discharged, or alive until after 28 days.
The median time of death is the time when 50% of the neonates have died.