Care for Neonates in Haiti’s Health System – Outcomes and Lessons

Care for Neonates in Haiti’s Health System – Outcomes and Lessons | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Care for Neonates in Haiti’s Health System – Outcomes and Lessons Alka Dev, Michelucia Casseus, Wilhermine Jean Baptiste, Emma Le Winter, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-66799/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The rate of facility births in Haiti has doubled in the past two decades but this has not resulted in comparable reductions in maternal or neonatal mortality. To care for newborns requiring hospitalization in Haiti, we worked with the public health leadership in the Haitian department of the South ( Sud ) to establish a ward for compromised neonates in a large public hospital with over 3000 annual deliveries but no neonatal care capacity. Methods Significant investments were made in establishing basic neonatal services, train nurses, install and manage a supply chain, and strengthen infrastructure. We present outcomes for 1399 neonates admitted to the ward during the first two years of operation. Results Two-thirds of admissions were made from the hospital’s maternity ward at birth while the remaining babies were born at home or referring facilities. Inborn neonates had better rates of hospital survival than those born elsewhere. They were also more likely to be born via cesarean section and to be admitted right at birth. Babies born elsewhere were more likely to die during their hospital stay. There were no differences between the proportion of premature or low Conclusions birth weight babies born at the hospital or elsewhere. Nursing care proved to be a critical part of the care delivery system. We conclude that integrated, high frequency nursing training is necessary for both maternity and neonatal nurses to support maternal and newborn care. Resources are needed to address prematurity as an important outcome, especially as it is indicative of poor prenatal care, regardless of place of birth. Maternal & Fetal Medicine Neonatal mortality prematurity hypoxia sepsis Haiti newborn care neonatal morbidity facility-based care Figures Figure 1 Figure 2 Background Haiti has struggled with multiple development setbacks over the past decades, impeding its capacity to respond effectively to the health care needs of its people [ 1 ]. A majority of Haitians are vulnerable to natural disasters such as the 2010 earthquake in Port au Prince and Hurricane Matthew which battered southern Haiti in 2016. Economic instability is a major barrier to development with rapid currency depreciation and severe cuts in capital investments and social programs marking the end of 2019 [ 2 ]. The national health budget declined four-fold between 2004 and 2016, with greater reliance on international assistance and out-of-pocket payments even though poverty is a severe barrier to accessing medical care. Maintenance of the most basic of public health functions is challenging given the current financing and governance strucutres [ 3 ]. Understandably, Haiti lags far behind other countries in achieving public health targets. For example, with an increase in facility births in low income countries, the survival outcomes for neonates is expected to improve. In a systematic review of the effects of health facility delivery on neonatal mortality, Tura and colleagues showed that neonatal mortality was 29% lower in facility births than home births [ 4 ]. The rate of facility births in Haiti has doubled to 40% in the past two decades but this has not resulted in comparable reductions in maternal or neonatal mortality [ 5 ]. While global neonatal mortality rates have declined by 50% over the past three decades, the rate in Haiti has remained largely unchanged at 32 deaths per 1000 live births, well above the global target of 12 per 1000 by the year 2030 [ 6 – 8 ]. Lack of appropriate prenatal care, low quality of obstetric care, and high rates of eclampsia, obstructed labor, untreated infection, and preterm delivery are persistent factors behind the high rates of maternal and neonatal mortality in Haiti.[ 9 , 10 ] In a recent analysis, we reported that 2–5% of deliveries in hospitals in southern Haiti suffered from eclampsia, which was likely an underestimation due to poor diagnostic capacity and data quality [ 11 ]. An eclampsia rate of 23% was reported in another Haitian hospital with better electronic record keeping [ 12 ]. In low-resource settings, the major clinical contributors to the death of neonates include birth asphyxia, infection, and prematurity-related complications[ 13 ]. Essential newborn care services and ability to respond to emergent situations remain important gaps in most facilities in low and middle income countries, particularly in rural areas [ 14 , 15 ]. In addition to improving skilled care at birth, we need to generate evidence of the impact of providing skilled care to neonates requiring hospitalization in low-resource settings. Case management in neonatal care units can inform quality concerns for neonatal morbidity, mortality, and survival [ 16 ]. Rural hospitals in Haiti often lack the capacity to care for newborns after birth due to gaps in essential infrastructure, equipment, supplies, medicines, trained staff, and up to date protocols and guidelines [ 15 ]. Therefore, the challenges and triumphs of caring for neonates born and cared for in the facility setting in Haiti must be documented and built upon [ 17 , 18 ]. To care for newborns requiring hospitalization in Haiti, we worked with the public health leadership in the Haitian department of the South ( Sud ) to establish a ward for compromised neonates in a large public hospital with over 3000 annual deliveries but no neonatal care capacity. This paper presents the neonatal outcomes that occurred within the first two years of this effort. Methods Baseline Situation Program Setting Hopital Immaculae Conception (HIC) is the main public referral hospital, located in Les Cayes and serving the departmental population of 774,976 (Fig. 2 ). There are 18 communes in Sud of which Les Cayes is the largest with an approximate population of 140,327 people [ 19 ]. A commune is a sub-departmental administrative unit. The maternity ward has an annual volume of 3000–4000 deliveries [ 11 ]. At the time of our project, the maternity ward had two beds in the delivery room, staffed by a midwife or a nurse who attended deliveries and provided newborn resuscitation as needed. Obstetricians attended some of the complicated deliveries and performed caesarian sections. A warmer was available but hardly used. Normal procedures following a low-risk birth included weighing the baby and providing Vitamin K and ophthalmic tetracycline ointment. There was no oxygen in the delivery room; suction and/or resuscitation with bag valve mask was done as needed. Water and soap were available but hand sanitizer was more commonly used. Most women arrived at the maternity ward shortly before birth after laboring at home. Accurate estimates of gestational age were generally not available. Clinical assessment and the date of last menstrual period were used to establish the gestational age to determine prematurity. Before June 2017, there were no specific staff assigned for newborn care nor adequate space, equipment, or material for case management. The pediatric unit was located next to the maternity ward and received newborns, but those in need of critical care were referred to a hospital that was more than 2 hours away. Neonatal unit structure and function In June 2017, a team from Dartmouth and GHESKIO, with funding from the Children’ Prize and the WK Kellogg Foundation, established the first neonatal care unit at HIC. Two pediatricians were appointed to provide care on an 8-bed ward, later expanded to 13 beds due to high demand. The hospital administration hired eight nurses to staff the ward. Other support staff included a project coordinator, a data manager, a lab coordinator, three community health workers, and four cleaners. All staff were supported through project funding. Renovation and expansion of the space as well as provision of essential equipment, medications, oxygen, and supplies were done sequentially over the course of the first two years. Although nursing and administrative staff are now integrated into the hospital’s operating budget, the initial investment and technical oversight were provided by our team. However, all staff reported to supervisors within the hospital and were integrated into the hospital’s human resources structure. Staff training The two pediatricians (MC and WJB) received three months of supervised neonatal training at Dartmouth-Hitchcock Medical Center in the United States and at the Zanmi Lasante and St. Boniface hospitals in Haiti. This included a master training in Helping Babies Breathe (HBB) from Dr. George Little, one of the developers of the course.[ 20 ] Neonatal training for nurses was delivered at hiring and 18 months later, with frequent on-the-job training in between from visiting Dartmouth faculty. Nursing training focused on HBB and Essential Care for Every Baby [ 21 ] curricula, jaundice care, shift handoff, head-to-toe exams, and intake assessments. We also reviewed nursing charts and redesigned nursing forms to ease shift handoff, acknowledge doctors’ orders, reduce redundant note writing, and properly document medications. Study Design and Analysis Data Source and Outcome Patients were admitted to the ward from the maternity ward at HIC or brought by families from other facility and home births in the region. In a small number of cases, referring facilities transferred the newborn by ambulance. The admitting staff included both pediatricians and nurses. A daily electronic register documenting the date of birth, date of admission, place of birth, weight at admission, prematurity status, major health issue(s), length of stay, and final outcome for all infants admitted to the ward was maintained by the pediatricians in MS Excel©. Data was reviewed quarterly by the pediatricians and Dartmouth/GHESKIO team to track progress, review mortality cases, and identify major bottlenecks. The final database for this study was a compilation of all admissions to the ward between August 2017-August 2019. The outcome of interest was neonatal death on the ward. Diagnostic criteria Based on the assessment of the pediatricians, primary diagnoses were established based on the International Classification of Diseases and Related Health Problems (ICD-10) maintained by WHO [ 22 ]. Due to limited laboratory and diagnostic resources, the pediatricians were unable to confirm their diagnoses with more than minimal blood work. Microbiologic definitions, other than HIV and syphilis screening tests, were not available. Prematurity was defined as gestational age less than 37 weeks which was established using The Ballard Score Maturational Assessment of Gestational Age in Newly Born Infants [ 23 ]. Low birth weight (LBW) at admission was defined as weight less than 2500 g and very low birth weight (VLBW) as less than 1500 g. Exclusion Criteria A flow chart shows the derivation of the sample and reasons for exclusion (Fig. 2 ). Very small neonates weighing less than 1 kg (n = 12) and those who were more than 28 days of age (n = 11) were excluded from the dataset. We excluded very small neonates from the analysis due to their exceptionally poor survival prognosis although one infant weighing 400 g at birth did survive after a 2-month stay at the hospital. All neonates taken home against medical advice or transferred out were excluded from the multivariable analysis. Parents’ reasons for leaving early were numerous: having other children to care for at home; timing with major festivals; lack/cost of room and board for families; and political unrest and insecurity. We suspected that some parents also wanted the child to receive traditional medicine at home or were not confident that the baby could recover. Analyses Univariate analyses were completed to obtain crude measurements without adjustment using chi-squared t-tests. Neonates who were born at HIC were compared to those who were born elsewhere (at home or another facility) to identify any community referral patterns (Table 1). Next, we looked at univariate relationships between those who died and those who were discharged, excluding neonates whose parents took them home early against medical advice, to identify significant factors contributing to mortality on the ward (Table 2). Multivariate analysis was performed on the same dataset. Patient and Public Involvement As this study was based on retrospective data review, patients were not involved in choosing the methods and agreeing to plans for dissemination of the study results to participants and linked communities. Results Neonatal characteristics Half of the patients admitted to the neonatal ward at HIC came from Les Cayes , the commune in which the hospital is located (Fig. 1 ). The next biggest sending commune was Torbeck (10%), which has a birthing center with ambulance availability. The remaining cases came from the rest of Sud and communes in departments sharing a border with Sud . We did not ascertain why some of the neonates came from other departments but it is possible they had family relations near HIC. Table 1 presents the characteristics of all neonates admitted to the ward between August 2017–August 2019 by place of birth. In all, 1399 neonates who were 28 days of age or younger and weighed more than 1 kg at admission were admitted to the ward over the 25 months; 66% were “inborn” meaning born at HIC (922/1399) and the rest were “outborn” meaning born at home or another facility. There were few differences in the recorded baseline characteristics of patients by place of birth. The proportions of boy and girl neonates were similar for those born at HIC and elsewhere. Preterm birth complicated one fifth of all admissions regardless of place of birth. Less than 1 in 10 babies were from multiple gestation pregnancies. Differences in the neonate’s weight on admission and mother’s age were also insignificant by place of birth. Close to one third of neonates were low or very low birth weight regardless of place of birth. A majority of mothers were between 18 and 34 years of age and 62 were adolescents. What was significant by place of birth was survival status, the mode of delivery, and age at admission. Mortality was higher among outborn babies (14.5% mortality among babies arriving from outside of the hospital setting versus 11.1% among babies born in the HIC, p < 0.001). The mode of delivery was vaginal for most births, but more so for outborn babies which included home births (91.4% vaginal vs. 74.8% cesarean; p < .0001). If they were born outside, the majority were brought in within 1–6 days after birth (45.9%) compared to those born at HIC (29.4) where the majority were transferred at day of birth (62.7%). A majority of the admissions were made in the first week of life. A higher proportion of births at HIC were through cesarean section (25%) compared to those born elsewhere (9%). Table 1 Baseline characteristics of 1399 neonatal inpatients at Hopital Immaculae Conception, Les Cayes by place of birth (2017–2019) Outborn Inborn Total P-value n (%) 477 (34.1) 922 (65.9) 1399 (100.0) Sex Male 288 (60.4) 521 (56.5) 809 (57.8) Female 189 (39.6) 401 (43.5) 590 (42.2) 0.16 Age at admission Day of birth 128 (26.8) 578 (62.7) 706 (50.5) 1–6 days after birth 219 (45.9) 271 (29.4) 490 (35.0) 7–28 days after birth 130 (27.3) 73 (7.9) 203 (14.5) < 0.001 Timing of birth Term 386 (80.9) 741 (80.4) 1127 (80.6) Preterm 91 (19.1) 181 (19.6) 272 (19.4) 0.80 Outcome Died 69 (14.5) 102 (11.1) 171 (12.2) Discharged 274 (57.4) 643 (69.7) 917 (65.5) Left against Dr’s orders 123 (25.8) 168 (18.2) 291 (20.8) Transferred 11 (2.3) 9 (1.0) 20 (1.4) < 0.001 Multiple gestations Singleton 435 (91.2) 851 (92.3) 1286 (91.9) Twin or more 42 (8.8) 71 (7.7) 113 (8.1) 0.47 Birthweight categories 1.0-1.4 kg 35 (7.3) 52 (5.6) 87 (6.2) 1.5–2.4 kg 145 (30.4) 258 (28.0) 403 (28.8) 2.5 + kg 297 (62.3) 612 (66.4) 909 (65.0) 0.23 Type of Delivery Vaginal 436 (91.4) 690 (74.8) 1126 (80.5) Cesarean 41 (8.6) 232 (25.2) 273 (19.5) < 0.001 Age of mother 35 years 76 (15.9) 112 (12.1) 188 (13.4) Unknown 16 (3.4) 28 (3.0) 44 (3.1) 0.17 Neonates born at HIC but admitted the day after birth were either kept on the ward with the mother initially, or sent home and brought back by family members due to illness. Therefore, triage at birth to identify high risk babies was not well established. Although we do not show the data, home births were more likely to be admitted later than births from other facilities. We did not document whether births from other facilities were referred at birth or first taken home and later brought to the hospital by family members. Clinical characteristics Diagnostic capacity was limited by the lack of confirmatory testing and information on maternal risk factors. The most common health issues experienced by the neonates included suspected infection, hypoxia, and prematurity; neonates often suffered from more than one complication. (Fig. 4 ). Overall, 41% of neonates were suspected of having an infection which was treated empirically; 6% also shared a diagnosis of hypoxia in addition to the suspected infection. One in three neonates suffered hypoxia, with 14% also having complications from prematurity. The combined prematurity rate was 15% of all admissions (including hypoxia). Other health issues included: congenital malformations, obstetrical complications, jaundice, infections such as tetanus and meningitis, other pulmonary complications, seizures, cardiac conditions, and inappropriate feeding at home. Encephalitis was clinically diagnosed in 6% of cases. Neonatal mortality We compared neonates who died on the ward to those who were discharged, excluding those who were taken home early by parents (Table 2). Preterm birth, admission on day of birth, place of birth, mode of delivery, and weight at admission were significant risk factors for ward mortality in the univariate analysis. Half of all deaths (85/171) occurred in babies who were born preterm. Death was also more likely for babies born at home or at other facilities compared to those born at HIC (20.1% of babies born outside vs. 13.7% of babies born at HIC; p = .01). Vaginal birth (17.5% vs. 9.5% cesarean; p < .01) and being low or very low birth weight at admission (56.5% vs 22.8% normal birth weight; p 35; p < .01). Other demographic characteristics such as the neonate’s sex or being a twin or higher gestation birth were not correlated with mortality. Table 2 Risk factors for ward mortality among 1088 neonatal inpatients at Hopital Immaculae Conception, Les Cayes (2017–2019) Discharged Died Total P-value n (%) 917 (84.3) 171 (15.7) 1088 (100.0) Sex Male 521 (83.6) 102 (16.4) 623 (100.0) Female 396 (85.2) 69 (14.8) 465 (100.0) 0.49 Age at admission Day of birth 435 (78.5) 119 (21.5) 554 (100.0) 1–6 days after birth 336 (90.6) 35 (9.4) 371 (100.0) 7–28 days after birth 146 (89.6) 17 (10.4) 163 (100.0) < 0.001 Timing of birth Term 783 (90.1) 86 (9.9) 869 (100.0) Preterm 134 (61.2) 85 (38.8) 219 (100.0) < .001 Place of birth Outborn 274 (79.9) 69 (20.1) 343 (100.0) Inborn 643 (86.3) 102 (13.7) 745 (100.0) 0.001 Multiple gestation Singleton 841 (84.7) 152 (15.3) 993 (100.0) Twin or more 76 (80.0) 19 (20.0) 95 (100.0) 0.23 Birthweight 1.0–1.4 kg 30 (43.5) 39 (56.5) 69 (100.0) 1.5–2.4 kg 244 (77.2) 72 (22.8) 316 (100.0) 2.5 + kg 643 (91.5) 60 (8.5) 703 (100.0) < 0.001 Type of delivery Vaginal 712 (82.4) 152 (17.6) 864 (100.0) Cesarean 205 (91.5) 19 (8.5) 224 (100.0) < 0.001 Age of mother 35 years 124 (84.9) 22 (15.1) 146 (100.0) Unknown 22 (71.0) 9 (29.0) 31 (100.0) < 0.001 Regression models also showed higher risk of dying on the ward for neonates who were preterm (Table 3 ). After adjusting for birthweight, preterm neonates had over double the odds of dying as term babies (OR = 2.31; p = .001). As expected, babies who were very low birth weight (VLBW) and low birth weight (LBW) had higher odds of death on the ward when compared to normal weight babies (NBW); VLBW babies were five times as likely to die (p < .001) and LBW babies were almost twice as likely to pass away before discharge (p = .035). Babies admitted 1–6 days after birth (OR = 0.47; p = .001) or even a week after birth (Or = 0.44; p = .024) had less than half the odds of dying that babies admitted on the day of birth. Odds of dying were 1.68 times higher for babies referred to the hospital than those born at HIC (p = 0.015). Those born through cesarean section had a survival advantage (OR = 0.47; p = 0.014). Mothers who were less than 18 years of age had higher odds of losing their neonate – as were mothers whose age was not established, possibly indicating young age or a correlated risk factor. Table 3 Odds of death on the ward compared to discharge by risk categories Died Odds Ratio (95% confidence interval) P-value Timing of delivery Term reference Preterm 2.31 (1.36–3.93) 0.001 Birthweight VLBW 1.0–1.4 kg 5.03 (2.39–10.6) p < .001 LBW 1.5–2.4 kg 1.81 (1.12–2.95) 0.035 NBW 2.5 kg + reference Age at admission Day of birth reference 1–6 days 0.47 (0.30–0.75) 0.001 7 days or more 0.44 (0.24–0.81) 0.024 Place of birth Inborn reference Outborn 1.68 (1.26–2.87) 0.015 Type of delivery Vaginal Cesarean 0.47 (0.27–0.82) 0.014 Age of mother 35 years 1.26 (0.74–2.13) 0.41 Unknown 2.65 (1.08–6.50) 0.033 Discussion We had the unique opportunity to describe neonatal survival status for newborns receiving care at a large public health hospital in southern Haiti. We collected data over the first two years of operation of the neonatal ward, recording daily admissions and tracking outcomes over the course of hospitalization. In this period, we contributed to improvements in health service delivery through training, improvements to infrastructure, provision of essential equipment and medications, and improvements in operational systems. While working within the limited capacity of the facility conditions we found, we were able to care for more than 1400 babies. Hospital survival was better among neonates born at the hospital than those born elsewhere, indicating a survival advantage for referral right at birth. Babies born elsewhere were more likely to come in at least one day after birth. Availability of cesarean sections was a factor; babies born vaginally had poorer survival indicating an unmet need for surgical intervention. Over the course of the 25 months, one in four neonates was taken home by their families before discharge. Three community health workers attempted to follow-up of neonates after discharge but this proved to be challenging due to missing or incorrect addresses and phone numbers. Having a social worker and establishing a fund to assist families with food and lodging costs could have alleviated some of the financial stress. The proportion of preterm babies and those born low or very low birth weight were similar for inborn and outborn infants. Similar comparisons have been made in other settings [ 24 ]. This suggests that prenatal care plays a significant role in birth outcomes, regardless of place of birth. Diagnoses were mostly clinical due to lack of imaging and laboratory availability. Hypoxia and infection represented a great part of the diagnostic criteria. Perinatal hypoxia results from an insufficiency in the baby’s oxygen supply during the intrapartum and postpartum period. The diagnosis was made for babies with ‘no cry at birth’, meconium aspiration, surfactant deficiency, fetal distress, and secondary hypoxic injury such as hypoxic ischemic encephalopathy. We found that hypoxia was often complicated by other health issues such as infection or prematurity. In the sickest babies, manual resuscitation was often maintained by the pediatricians, which compromised their capacity to attend to other clinical duties. Pediatricians were also not available at night. Survival was higher among neonates born at HIC, likely due to the risks associated with home births or births at facilities without cesarean or other emergency obstetric capacity. Lower level facilities in Haiti have been found to be poorly equipped to provide obstetric care even if they do provide labor and delivery services.[ 25 ] We also found that the risk of dying was highest among babies admitted at birth from – indicating that the sickest babies were also those who were transferred right at birth from HIC as opposed to babies born elsewhere who likely died before being brought in, contributing to potential selection bias in our sample. We did not record length of stay in hours and it is possible that babies admitted from HIC were merely alive for a few hours before succumbing to their illnesses. While the standard practice is to separate community transfers or outborn babies from inborn babies due to risk of infection, we did not have the capacity to do so and there was likely transmission of infection from outborn to inborn neonates [ 26 ]. Deaths were highest among preterm neonates and those of low or very low birth weights. Half of premature neonates died, as has been noted in similar settings [ 27 ]. Among premature neonates in Burundi in 2011–2012, inpatient mortality was higher among those less than 32 weeks gestation (31%) than those among 32 − 26 weeks gestation [ 28 ]. Other published estimates of premature mortality are approximately 50% among neonates born at 34 weeks of gestation, and 70% among neonates born at < 32 weeks of gestation in low-income countries [ 29 , 30 ]. Weight categories provided a more nuanced representation of vulnerability as preterm birth was not disaggregated by gestational age. Beyond clinical outcomes, the most important lessons were learned during daily ward operations which showed us that over the period of the study, there was considerable variability in the delivery of neonatal care on the ward. This was driven in large part by the availability of antibiotics, laboratory testing, oxygen, and electricity. However, political instability, holidays, nursing schedules, and seasonal conditions contributed to the unpredictability of ward conditions. Hot summer temperatures in a crowded ward were dangerous for infection control and hurricane season rains often flooded the ward. Power outages were common at night and parents often slept on the floor of the ward by the neonatal beds. During renovations, the beds were moved to different parts of the pediatric ward which affected the time it took to walk the babies over from the maternity ward. Over time, we were able to improve many of these conditions by renovating the neonatal space, providing better quality furniture and equipment as well as air conditioning, and a steady supply of antibiotics and oxygen. However, conditions remained precarious due to the lack of adequate financial support from the health authorities that could be dedicated to ward operations. Another unexpected challenge was the lack of communication between the maternity and neonatal wards. Despite out best efforts to establish a referral system where critical maternal information about labor and delivery would be communicated to the neonatal team, securing any clinical information from maternity proved nearly impossible. We believe this was reflective of a broader lack of communication across the hospital and reflected entrenched hierarchies and systems that will require a significant cultural shift. Communication between doctors and nurses was also stifled and it was unclear what power nurses wielded in ensuring better working conditions. Infrastructure was poor across the hospital and a piecemeal, project by project approach to building capacity had left no long-term mark on the hospital’s operations. Programs that were better funded, such as HIV/AIDS prevention and treatment, were better staffed, equipped, and efficient. Any effort to establish a higher-level care delivery program needs to account for the overall working conditions of the host institution. Our work had some strengths. We critically examine hospital neonatal mortality in Haiti and discuss implications for future programming. We were able to collect data on relevant indicators as the service was new to the hospital and we created new medical charts with clearly identified data fields. This made it easier for the clinical team to collect relevant data in real time rather than rely solely on extensive chart reviews at a later date. We were also able to discuss ongoing data quality issues through periodic reviews of the service delivery outcomes for the ward, usually during field visits by the Dartmouth team. We benefitted from the tireless effort of the pediatricians to document each and every data point and alert us of any discrepancies with sufficient notice. While we could not do anything about data that were missing all together, we did trust that the data we collected were of high quality. We also had a number of limitations. Although improvements in infrastructure and service delivery capacity have been associated with improved neonatal survival in other settings, we could not meaningfully analyze the impact of improvements in our ward’s infrastructure and quality improvement efforts, including provision of free medications, as these improvements were made on an ongoing basis and often during unstable political conditions [ 24 ]. Additionally, there were too many changes in nurse staffing, electrical supply, and other service delivery parameters by the hospital that were beyond our control and that led to fluctuations in care. There was considerable unpredictability in the hospital’s supply chain which also led us to secure treatment through the private-sector. With less control of supply chain management, we could not standardize the treatment to established protocols. We also did not capture maternal risk factors including intrapartum complications despite our best efforts to work in tandem with the maternity team. For similar reasons, we did not collect maternal socioeconomic status or neonatal Apgar scores. We believe that with additional maternal health information, we would have been able to better understand neonatal prognosis at admission. Transfer of knowledge has to be an essential part of all neonatal mortality reduction efforts – we don’t believe that neonatal mortality programs should run independent of mothers, whatever the cost. Conclusion The potential to improve the quality of care in dedicated inpatient neonatal units in low and middle-income countries is great. There are many missed opportunities to provide effective interventions to mothers and babies, particularly those who seek facility-based care. In the short term, intrapartum-related neonatal deaths can be substantially reduced by improving the quality of services for all childbirths that occur in health facilities. An integrated nursing approach to reducing maternal and neonatal mortality is essential, especially for families who choose to deliver at a facility. In conclusion we offer the following recommendations: 1) a neonatal resuscitation program by itself cannot reduce neonatal deaths due to perinatal asphyxia. Resuscitation trainings should be delivered to both neonatal and maternity nursing staff, combined with a regular supply of clean bag masks and oxygen in the very least; 2) Coordinating communication between the maternity and neonatal wards is critical during complicated deliveries, transfer, and postpartum; 3) Neonatology should be co-located with obstetrics rather than pediatrics with nurses who care for both mothers and babies, and understand the etiology of poor outcomes for neonates due to poor quality intrapartum care; 4) Algorithms are needed for nurses to manage admission, vital signs, and suspected infection in the absence of a physician; and 5) Specialized care is needed for premature neonates. Declarations ETHICS Approval for the analysis of the data was obtained from The Haitian Committee for Protection of Human Subjects at GHESKIO and from the Institutional Review Board of Dartmouth-Hitchcock Medical Center (Study number 02000017). An exemption for minimal study risk was secured and informed consent was not required from study subjects as the data were extracted from patient charts after discharge or death. We paid careful attention to maintain and preserve anonymity of the subjects in any presentation of data. The results were made available for review by all the participating partners before submission for publication. CONSENT FOR PUBLICATION Not applicable. AVAILABILITY OF DATA The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. COMPETING INTERESTS Not applicable. FUNDING Funding for this project was provided by the W.K. Kellogg Foundation and The Children’s Prize. AUTHORS' CONTRIBUTIONS AD analyzed the data, wrote the first draft of the paper, and completed all editing after review. MC, WJB, EL, and KS reviewed the paper several times and provided comments. AW was instrumental in assessing the capacity of the maternity ward. PJ and PW served as project advisors and were the primary people in charge of overall project governance. They also reviewed the paper and provided comments. ACKNOWLEDGEMENTS Clinical staff in the maternity and pediatric wards at HIC were extremely helpful during implementation and included Dr. Jean Yves Domerçant (Medical Director); Dr. Lucien Gerard (Chief of Maternity); Dr. Edna Roberte (Chief of Pediatrics); Ms. Lucie Lafortune (Chief of Maternity Nursing); and Ms. Hyppolite (Chief of Pediatric Nursing). Our operational team in Haiti also provided significant operational assistance including Dr. Eli Francois (GHESKIO); Ms. Marie Shella Goda (GHESKIO); and Mr. Judner Mondelus (HIC). Finally we want to acknowledge the families who trusted us with their infants despite considerable challenges. Dr. Jean Pape and Ms. Penny Wright also provided valuable guidance as needed. References Labrador R. Haiti’s Troubled Path to Development. Counc Foreign Relat [Internet]. [cited 2020 Apr 21]; Available from: https://www.cfr.org/backgrounder/haitis-troubled-path-development . Cavagnero E, Cros M, Dunworth A, Sjoblom M. Better Spending. Better Care: A Look at Haiti’s Health Financing [Internet]. Washington, D.C: World Bank; 2017 Jun. Report No.: 11682. Available from: http://documents1.worldbank.org/curated/en/393291498246075986/pdf/116682-WP-v1-wb-Haiti-english-PUBLIC-summary.pdf . Lowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, Delsoins D. Public Health Progress in Haiti. Am J Trop Med Hyg. 2017;97:1–3. Tura G, Fantahun M, Worku A. The effect of health facility delivery on neonatal mortality: systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13:18. ICF. The DHS Program STATcompiler. Funded by USAID. http://www.statcompiler.com . 2015. Hug L, Alexander M, You D, Alkema L. National, regional, and global levels and trends in neonatal mortality between 1990 and 2017, with scenario-based projections to 2030: a systematic analysis. Lancet Glob Health. 2019;7:e710–20. Institut Haïtien de l’Enfance (IHE). ICF. Enquête Mortalité, Morbidité et Utilisation des Services (EMMUS -VI 2016–2017). Pétion -Ville, Haïti, et Rockville. Maryland: IHE et ICF; 2018. United Nations. Goal 3: Sustainable Development Knowledge Platform [Internet]. [cited 2020 Feb 10]. Available from: https://sustainabledevelopment.un.org/sdg3 . Jacobs LD, Judd TM, Bhutta ZA. Addressing the Child and Maternal Mortality Crisis in Haiti through a Central Referral Hospital Providing Countrywide Care. Perm J. 2016;20:59–70. Bridwell M, Handzel E, Hynes M, Jean-Louis R, Fitter D, Hogue C, et al. Hypertensive disorders in pregnancy and maternal and neonatal outcomes in Haiti: the importance of surveillance and data collection. BMC Pregnancy Childbirth BioMed Central. 2019;19:1–11. Dev A, O’Hern K, Domerçant JY, Lucien G, Lucie L, Grand-Pierre R, et al. A retrospective review of facility-level obstetric complications and stillbirths in southern Haiti, 2013–2016. Rev Panam Salud Pública. 2019;43:1. Raghuraman N, March MI, Hacker MR, Modest AM, Wenger J, Narcisse R, et al. Adverse maternal and fetal outcomes and deaths related to preeclampsia and eclampsia in Haiti. Pregnancy Hypertens. 2014;4:279–86. Goldenberg RL, McClure EM, Saleem S. Improving pregnancy outcomes in low- and middle-income countries. Reprod Health [Internet]. 2018 [cited 2019 Sep 18];15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6019988/ . Montagu D, Sudhinaraset M, Diamond-Smith N, Campbell O, Gabrysch S, Freedman L, et al. Where women go to deliver: understanding the changing landscape of childbirth in Africa and Asia. Health Policy Plan. 2017;32:1146–52. Winter R, Yourkavitch J, Wang W, Mallick L. Assessment of health facility capacity to provide newborn care in Bangladesh, Haiti, Malawi, Senegal, and Tanzania. J Glob Health [Internet]. [cited 2019 Apr 25];7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804038/ . Goyet S, Broch-Alvarez V, Becker C. Quality improvement in maternal and newborn healthcare: lessons from programmes supported by the German development organisation in Africa and Asia. BMJ Glob Health [Internet]. 2019 [cited 2019 Nov 26];4. Available from: https://gh.bmj.com/content/4/5/e001562 . Gabrysch S, Nesbitt RC, Schoeps A, Hurt L, Soremekun S, Edmond K, et al. Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials. Lancet Glob Health. 2019;7:e1074–87. Lohela TJ, Nesbitt RC, Pekkanen J, Gabrysch S. Comparing socioeconomic inequalities between early neonatal mortality and facility delivery: Cross-sectional data from 72 low- and middle-income countries. Sci Rep. 2019;9:1–11. Facebook Connectivity Lab, Center for International Earth Science Information Network - CIESIN - Columbia University. High Resolution Settlement Layer (HRSL). Source imagery for HRSL [Internet]. DigitalGlobe; 2016 [cited 2020 Apr 16]. Available from: https://data.humdata.org/dataset/haiti-high-resolution-population-density-maps-demographic-estimates . Breathe HB, Edition S. A Model for Strengthening Educational Programs to Increase Global Newborn Survival | Global Health: Science and Practice [Internet]. [cited 2020 Feb 10]. Available from: https://www.ghspjournal.org/content/6/3/538.short . American Academy of Pediatrics. Essential Care for Every Baby​. WHO. ICD-10 online versions [Internet]. WHO. World Health Organization; [cited 2020 Apr 16]. Available from: http://www.who.int/classifications/icd/icdonlineversions/en/ . Burstein R, Henry NJ, Collison ML, Marczak LB, Sligar A, Watson S, et al. Mapping 123 million neonatal, infant and child deaths between 2000 and 2017. Nature. 2019;574:353–8. Zonneveld R, Holband N, Bertolini A, Bardi F, Lissone NPA, Dijk PH, et al. Improved referral and survival of newborns after scaling up of intensive care in Suriname. BMC Pediatr. 2017;17:189. Wang W, Winner M, Burgert-Brucker CR. Limited Service Availability, Readiness, and Use of Facility-Based Delivery Care in Haiti: A Study Linking Health Facility Data and Population Data. Glob Health Sci Pract. 2017;5:244–60. Segal. The bacterial profile of neonatal sepsis and antibiotic use in the tertiary care NICU of Kosovo. J Pediatr Neonatal Care [Internet]. MedCrave Publishing; 2018 [cited 2020 Apr 21];Volume 8. Available from: https://medcraveonline.com/JPNC/JPNC-08-00319.pdf . Hedstrom A, Ryman T, Otai C, Nyonyintono J, McAdams RM, Lester D, et al. Demographics, clinical characteristics and neonatal outcomes in a rural Ugandan NICU. BMC Pregnancy Childbirth [Internet]. 2014 [cited 2020 Mar 11];14. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174605/ . Ndelema B, Van den Bergh R, Manzi M, van den Boogaard W, Kosgei RJ, Zuniga I, et al. Low-tech, high impact: care for premature neonates in a district hospital in Burundi. A way forward to decrease neonatal mortality. BMC Res Notes. 2016;9:28. Blencowe H, Cousens S, Chou D, Oestergaard M, Say L, Moller A-B, et al. Born Too Soon: The global epidemiology of 15 million preterm births. Reprod Health. 2013;10:2. Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C, GAPPS Review Group. Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy Childbirth. 2010;10(Suppl 1):1. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-66799","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":1982869,"identity":"7cc7c79f-0d85-4399-aec2-989f4a52dd5c","order_by":0,"name":"Alka Dev","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDACdjYgAcT8DAlQEQkg5sGnhRmqRbIBqOUASDXRWgwOEKuFv5kt8QNDmU3i5uPJzz5/zLFJ3C/dwPjgbRtuLRKH2Q5LMJxLS9x25pnxjIPb0hJ7ZA4wG87Fo4XhMHuDBGPbYWOzGwnGDAe3HU7skUhgk+bFo0X+MHvzD8a2/8bGM9I/w7Sw/8anxeAw2zGgLQfkDCRyELYw49NieJgtzSLhXLKcxJk3xQxnt6UZ99xIbJaccw63FrnjbcY3PpTZ8fC3p29mqNxmI9s+I/nghzdleLwPAgmoXMYGAupHwSgYBaNgFBACAFwdUbVHFMsaAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-1883-5324","institution":"The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, New Hampshire, USA 2.\tDartmouth-Hitchcock Medical Center, New Hampshire, USA","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Alka","middleName":"","lastName":"Dev","suffix":""},{"id":1982870,"identity":"43519299-b80a-4992-a85a-70edf3550ffc","order_by":1,"name":"Michelucia Casseus","email":"","orcid":"","institution":"Hopital Immaculae Conception","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michelucia","middleName":"","lastName":"Casseus","suffix":""},{"id":1982871,"identity":"cfb966c0-6be5-4103-b311-8931b7e769a9","order_by":2,"name":"Wilhermine Jean Baptiste","email":"","orcid":"","institution":"Hopital Immaculae Conception","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wilhermine","middleName":"Jean","lastName":"Baptiste","suffix":""},{"id":1982872,"identity":"9ffb40ed-cb1f-4ca6-8c1b-75b86149d583","order_by":3,"name":"Emma Le Winter","email":"","orcid":"","institution":"Dartmouth-Hitchcock Clinic: Dartmouth-Hitchcock Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Emma","middleName":"Le","lastName":"Winter","suffix":""},{"id":1982873,"identity":"89c156ab-c5f0-48d0-b9d7-4fc15bf516c9","order_by":4,"name":"Katie Simpher","email":"","orcid":"","institution":"Maternal and Newborn Health Advisor","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Katie","middleName":"","lastName":"Simpher","suffix":""},{"id":1982874,"identity":"31fe08af-d5d2-4ab9-9765-4ece243f5e57","order_by":5,"name":"Alice Werbel","email":"","orcid":"","institution":"Maternal and Newborn Health Advisor","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alice","middleName":"","lastName":"Werbel","suffix":""},{"id":1982875,"identity":"37a1cbbc-fecd-4527-b569-594facd32dd8","order_by":6,"name":"Patrice Joseph","email":"","orcid":"","institution":"GHESKIO","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Patrice","middleName":"","lastName":"Joseph","suffix":""},{"id":1982876,"identity":"e3ce53df-b7a0-4fdc-82ed-4d5eb227ed00","order_by":7,"name":"Peter Wright","email":"","orcid":"","institution":"Dartmouth-Hitchcock Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Wright","suffix":""}],"badges":[],"createdAt":"2020-08-27 10:39:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-66799/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-66799/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":2257194,"identity":"469dd885-0a27-42ee-8f89-1acd605d8e1e","added_by":"auto","created_at":"2020-09-04 21:15:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58771,"visible":true,"origin":"","legend":" Location of HIC and Sending Communes and Population Distribution [19]","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-66799/v1/Fig1.jpg"},{"id":2257195,"identity":"5a5fcc62-de59-4cd0-b092-9d80cb8967f5","added_by":"auto","created_at":"2020-09-04 21:15:22","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23542,"visible":true,"origin":"","legend":"Sample Calculation","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-66799/v1/Fig2.jpg"},{"id":13588203,"identity":"ee1c05c8-c2fc-415f-91e4-b088fa1ae1e2","added_by":"auto","created_at":"2021-09-17 04:54:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":434885,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-66799/v1/de014b9a-5372-4cbc-8fef-5a1236929275.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eCare for Neonates in Haiti’s Health System – Outcomes and Lessons\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eHaiti has struggled with multiple development setbacks over the past decades, impeding its capacity to respond effectively to the health care needs of its people [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A majority of Haitians are vulnerable to natural disasters such as the 2010 earthquake in Port au Prince and Hurricane Matthew which battered southern Haiti in 2016. Economic instability is a major barrier to development with rapid currency depreciation and severe cuts in capital investments and social programs marking the end of 2019 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The national health budget declined four-fold between 2004 and 2016, with greater reliance on international assistance and out-of-pocket payments even though poverty is a severe barrier to accessing medical care. Maintenance of the most basic of public health functions is challenging given the current financing and governance strucutres [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Understandably, Haiti lags far behind other countries in achieving public health targets. For example, with an increase in facility births in low income countries, the survival outcomes for neonates is expected to improve. In a systematic review of the effects of health facility delivery on neonatal mortality, Tura and colleagues showed that neonatal mortality was 29% lower in facility births than home births [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rate of facility births in Haiti has doubled to 40% in the past two decades but this has not resulted in comparable reductions in maternal or neonatal mortality [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While global neonatal mortality rates have declined by 50% over the past three decades, the rate in Haiti has remained largely unchanged at 32 deaths per 1000 live births, well above the global target of 12 per 1000 by the year 2030 [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Lack of appropriate prenatal care, low quality of obstetric care, and high rates of eclampsia, obstructed labor, untreated infection, and preterm delivery are persistent factors behind the high rates of maternal and neonatal mortality in Haiti.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] In a recent analysis, we reported that 2\u0026ndash;5% of deliveries in hospitals in southern Haiti suffered from eclampsia, which was likely an underestimation due to poor diagnostic capacity and data quality [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. An eclampsia rate of 23% was reported in another Haitian hospital with better electronic record keeping [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn low-resource settings, the major clinical contributors to the death of neonates include birth asphyxia, infection, and prematurity-related complications[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Essential newborn care services and ability to respond to emergent situations remain important gaps in most facilities in low and middle income countries, particularly in rural areas [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition to improving skilled care at birth, we need to generate evidence of the impact of providing skilled care to neonates requiring hospitalization in low-resource settings. Case management in neonatal care units can inform quality concerns for neonatal morbidity, mortality, and survival [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Rural hospitals in Haiti often lack the capacity to care for newborns after birth due to gaps in essential infrastructure, equipment, supplies, medicines, trained staff, and up to date protocols and guidelines [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, the challenges and triumphs of caring for neonates born and cared for in the facility setting in Haiti must be documented and built upon [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. To care for newborns requiring hospitalization in Haiti, we worked with the public health leadership in the Haitian department of the South (\u003cem\u003eSud\u003c/em\u003e) to establish a ward for compromised neonates in a large public hospital with over 3000 annual deliveries but no neonatal care capacity. This paper presents the neonatal outcomes that occurred within the first two years of this effort.\u003c/p\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Situation\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eProgram Setting\u003c/h2\u003e \u003cp\u003eHopital Immaculae Conception (HIC) is the main public referral hospital, located in \u003cem\u003eLes Cayes\u003c/em\u003e and serving the departmental population of 774,976 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There are 18 communes in \u003cem\u003eSud\u003c/em\u003e of which \u003cem\u003eLes Cayes\u003c/em\u003e is the largest with an approximate population of 140,327 people [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A commune is a sub-departmental administrative unit. The maternity ward has an annual volume of 3000\u0026ndash;4000 deliveries [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. At the time of our project, the maternity ward had two beds in the delivery room, staffed by a midwife or a nurse who attended deliveries and provided newborn resuscitation as needed. Obstetricians attended some of the complicated deliveries and performed caesarian sections. A warmer was available but hardly used. Normal procedures following a low-risk birth included weighing the baby and providing Vitamin K and ophthalmic tetracycline ointment. There was no oxygen in the delivery room; suction and/or resuscitation with bag valve mask was done as needed. Water and soap were available but hand sanitizer was more commonly used.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMost women arrived at the maternity ward shortly before birth after laboring at home. Accurate estimates of gestational age were generally not available. Clinical assessment and the date of last menstrual period were used to establish the gestational age to determine prematurity. Before June 2017, there were no specific staff assigned for newborn care nor adequate space, equipment, or material for case management. The pediatric unit was located next to the maternity ward and received newborns, but those in need of critical care were referred to a hospital that was more than 2 hours away.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eNeonatal unit structure and function\u003c/h2\u003e \u003cp\u003eIn June 2017, a team from Dartmouth and GHESKIO, with funding from the Children\u0026rsquo; Prize and the WK Kellogg Foundation, established the first neonatal care unit at HIC. Two pediatricians were appointed to provide care on an 8-bed ward, later expanded to 13 beds due to high demand. The hospital administration hired eight nurses to staff the ward. Other support staff included a project coordinator, a data manager, a lab coordinator, three community health workers, and four cleaners. All staff were supported through project funding.\u003c/p\u003e \u003cp\u003eRenovation and expansion of the space as well as provision of essential equipment, medications, oxygen, and supplies were done sequentially over the course of the first two years. Although nursing and administrative staff are now integrated into the hospital\u0026rsquo;s operating budget, the initial investment and technical oversight were provided by our team. However, all staff reported to supervisors within the hospital and were integrated into the hospital\u0026rsquo;s human resources structure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eStaff training\u003c/h2\u003e \u003cp\u003eThe two pediatricians (MC and WJB) received three months of supervised neonatal training at Dartmouth-Hitchcock Medical Center in the United States and at the Zanmi Lasante and St. Boniface hospitals in Haiti. This included a master training in \u003cem\u003eHelping Babies Breathe\u003c/em\u003e (HBB) from Dr. George Little, one of the developers of the course.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Neonatal training for nurses was delivered at hiring and 18 months later, with frequent on-the-job training in between from visiting Dartmouth faculty. Nursing training focused on HBB and \u003cem\u003eEssential Care for Every Baby\u003c/em\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] curricula, jaundice care, shift handoff, head-to-toe exams, and intake assessments. We also reviewed nursing charts and redesigned nursing forms to ease shift handoff, acknowledge doctors\u0026rsquo; orders, reduce redundant note writing, and properly document medications.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Analysis\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eData Source and Outcome\u003c/h2\u003e \u003cp\u003ePatients were admitted to the ward from the maternity ward at HIC or brought by families from other facility and home births in the region. In a small number of cases, referring facilities transferred the newborn by ambulance. The admitting staff included both pediatricians and nurses. A daily electronic register documenting the date of birth, date of admission, place of birth, weight at admission, prematurity status, major health issue(s), length of stay, and final outcome for all infants admitted to the ward was maintained by the pediatricians in MS Excel\u0026copy;. Data was reviewed quarterly by the pediatricians and Dartmouth/GHESKIO team to track progress, review mortality cases, and identify major bottlenecks. The final database for this study was a compilation of all admissions to the ward between August 2017-August 2019. The outcome of interest was neonatal death on the ward.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eDiagnostic criteria\u003c/h2\u003e \u003cp\u003eBased on the assessment of the pediatricians, primary diagnoses were established based on the International Classification of Diseases and Related Health Problems (ICD-10) maintained by WHO [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Due to limited laboratory and diagnostic resources, the pediatricians were unable to confirm their diagnoses with more than minimal blood work. Microbiologic definitions, other than HIV and syphilis screening tests, were not available. Prematurity was defined as gestational age less than 37 weeks which was established using The Ballard Score Maturational Assessment of Gestational Age in Newly Born Infants [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Low birth weight (LBW) at admission was defined as weight less than 2500\u0026nbsp;g and very low birth weight (VLBW) as less than 1500\u0026nbsp;g.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eExclusion Criteria\u003c/h2\u003e \u003cp\u003eA flow chart shows the derivation of the sample and reasons for exclusion (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Very small neonates weighing less than 1\u0026nbsp;kg (n\u0026thinsp;=\u0026thinsp;12) and those who were more than 28 days of age (n\u0026thinsp;=\u0026thinsp;11) were excluded from the dataset. We excluded very small neonates from the analysis due to their exceptionally poor survival prognosis although one infant weighing 400\u0026nbsp;g at birth did survive after a 2-month stay at the hospital. All neonates taken home against medical advice or transferred out were excluded from the multivariable analysis. Parents\u0026rsquo; reasons for leaving early were numerous: having other children to care for at home; timing with major festivals; lack/cost of room and board for families; and political unrest and insecurity. We suspected that some parents also wanted the child to receive traditional medicine at home or were not confident that the baby could recover.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eAnalyses\u003c/h2\u003e \u003cp\u003eUnivariate analyses were completed to obtain crude measurements without adjustment using chi-squared t-tests. Neonates who were born at HIC were compared to those who were born elsewhere (at home or another facility) to identify any community referral patterns (Table\u0026nbsp;1). Next, we looked at univariate relationships between those who died and those who were discharged, excluding neonates whose parents took them home early against medical advice, to identify significant factors contributing to mortality on the ward (Table\u0026nbsp;2). Multivariate analysis was performed on the same dataset.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003ePatient and Public Involvement\u003c/h2\u003e \u003cp\u003eAs this study was based on retrospective data review, patients were not involved in choosing the methods and agreeing to plans for dissemination of the study results to participants and linked communities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cdiv id=\"Sec14\" class=\"Section4\"\u003e \u003cdiv class=\"Heading\"\u003eNeonatal characteristics\u003c/div\u003e \u003cp\u003eHalf of the patients admitted to the neonatal ward at HIC came from \u003cem\u003eLes Cayes\u003c/em\u003e, the commune in which the hospital is located (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The next biggest sending commune was \u003cem\u003eTorbeck\u003c/em\u003e (10%), which has a birthing center with ambulance availability. The remaining cases came from the rest of \u003cem\u003eSud\u003c/em\u003e and communes in departments sharing a border with \u003cem\u003eSud\u003c/em\u003e. We did not ascertain why some of the neonates came from other departments but it is possible they had family relations near HIC.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;1 presents the characteristics of all neonates admitted to the ward between August 2017\u0026ndash;August 2019 by place of birth. In all, 1399 neonates who were 28\u0026nbsp;days of age or younger and weighed more than 1\u0026nbsp;kg at admission were admitted to the ward over the 25 months; 66% were \u0026ldquo;inborn\u0026rdquo; meaning born at HIC (922/1399) and the rest were \u0026ldquo;outborn\u0026rdquo; meaning born at home or another facility. There were few differences in the recorded baseline characteristics of patients by place of birth. The proportions of boy and girl neonates were similar for those born at HIC and elsewhere. Preterm birth complicated one fifth of all admissions regardless of place of birth. Less than 1 in 10 babies were from multiple gestation pregnancies. Differences in the neonate\u0026rsquo;s weight on admission and mother\u0026rsquo;s age were also insignificant by place of birth. Close to one third of neonates were low or very low birth weight regardless of place of birth. A majority of mothers were between 18 and 34\u0026nbsp;years of age and 62 were adolescents.\u003c/p\u003e \u003cp\u003eWhat was significant by place of birth was survival status, the mode of delivery, and age at admission. Mortality was higher among outborn babies (14.5% mortality among babies arriving from outside of the hospital setting versus 11.1% among babies born in the HIC, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mode of delivery was vaginal for most births, but more so for outborn babies which included home births (91.4% vaginal vs. 74.8% cesarean; p\u0026thinsp;\u0026lt;\u0026thinsp;.0001). If they were born outside, the majority were brought in within 1\u0026ndash;6 days after birth (45.9%) compared to those born at HIC (29.4) where the majority were transferred at day of birth (62.7%). A majority of the admissions were made in the first week of life. A higher proportion of births at HIC were through cesarean section (25%) compared to those born elsewhere (9%).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;1 Baseline characteristics of 1399 neonatal inpatients at Hopital Immaculae\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eConception, Les Cayes by place of birth (2017\u0026ndash;2019)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutborn\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInborn\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e477 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e922 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1399 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e288 (60.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e521 (56.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e809 (57.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189 (39.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e401 (43.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e590 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e578 (62.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e706 (50.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;6 days after birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e219 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e271 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e490 (35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;28 days after birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e203 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiming of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e386 (80.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e741 (80.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1127 (80.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreterm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e181 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e272 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e171 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e274 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e643 (69.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e917 (65.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft against Dr\u0026rsquo;s orders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123 (25.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e168 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e291 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransferred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple gestations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingleton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e435 (91.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e851 (92.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1286 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwin or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e113 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirthweight categories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.0-1.4\u0026nbsp;kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.5\u0026ndash;2.4\u0026nbsp;kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e145 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e258 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e403 (28.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.5\u0026thinsp;+\u0026thinsp;kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e297 (62.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e612 (66.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e909 (65.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e436 (91.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e690 (74.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1126 (80.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e232 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e273 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;18\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;35\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e368 (77.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e737 (79.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1105 (79.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;35\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e188 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNeonates born at HIC but admitted the day after birth were either kept on the ward with the mother initially, or sent home and brought back by family members due to illness. Therefore, triage at birth to identify high risk babies was not well established. Although we do not show the data, home births were more likely to be admitted later than births from other facilities. We did not document whether births from other facilities were referred at birth or first taken home and later brought to the hospital by family members.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003eClinical characteristics\u003c/div\u003e \u003cp\u003eDiagnostic capacity was limited by the lack of confirmatory testing and information on maternal risk factors. The most common health issues experienced by the neonates included suspected infection, hypoxia, and prematurity; neonates often suffered from more than one complication. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Overall, 41% of neonates were suspected of having an infection which was treated empirically; 6% also shared a diagnosis of hypoxia in addition to the suspected infection. One in three neonates suffered hypoxia, with 14% also having complications from prematurity. The combined prematurity rate was 15% of all admissions (including hypoxia). Other health issues included: congenital malformations, obstetrical complications, jaundice, infections such as tetanus and meningitis, other pulmonary complications, seizures, cardiac conditions, and inappropriate feeding at home. Encephalitis was clinically diagnosed in 6% of cases.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003eNeonatal mortality\u003c/div\u003e \u003cp\u003eWe compared neonates who died on the ward to those who were discharged, excluding those who were taken home early by parents (Table\u0026nbsp;2). Preterm birth, admission on day of birth, place of birth, mode of delivery, and weight at admission were significant risk factors for ward mortality in the univariate analysis. Half of all deaths (85/171) occurred in babies who were born preterm. Death was also more likely for babies born at home or at other facilities compared to those born at HIC (20.1% of babies born outside vs. 13.7% of babies born at HIC; p\u0026thinsp;=\u0026thinsp;.01). Vaginal birth (17.5% vs. 9.5% cesarean; p\u0026thinsp;\u0026lt;\u0026thinsp;.01) and being low or very low birth weight at admission (56.5% vs 22.8% normal birth weight; p\u0026thinsp;\u0026lt;\u0026thinsp;.01) were both risk factors for death. There was also indication that babies born to teenage mothers under 18 had higher mortality (31.8% vs. 14.5% 18\u0026ndash;35 \u0026amp; 15.1% \u0026gt;35; p\u0026thinsp;\u0026lt;\u0026thinsp;.01). Other demographic characteristics such as the neonate\u0026rsquo;s sex or being a twin or higher gestation birth were not correlated with mortality.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;2 Risk factors for ward mortality among 1088 neonatal inpatients at Hopital\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eImmaculae Conception, Les Cayes (2017\u0026ndash;2019)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDischarged\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDied\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e917 (84.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e171 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1088 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e521 (83.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e623 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e396 (85.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e465 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e435 (78.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e119 (21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e554 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;6 days after birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e336 (90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e371 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;28 days after birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146 (89.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e163 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiming of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e783 (90.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e869 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreterm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e134 (61.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85 (38.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e219 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutborn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e274 (79.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e343 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInborn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e643 (86.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e745 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingleton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e841 (84.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e152 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e993 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwin or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirthweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.0\u0026ndash;1.4\u0026nbsp;kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (43.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (56.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e69 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.5\u0026ndash;2.4\u0026nbsp;kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e244 (77.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72 (22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e316 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.5\u0026thinsp;+\u0026thinsp;kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e643 (91.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e703 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e712 (82.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e152 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e864 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e205 (91.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e224 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;18\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (68.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (31.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;35\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e741 (85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e126 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e867 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;35\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e124 (84.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e146 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (71.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegression models also showed higher risk of dying on the ward for neonates who were preterm (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After adjusting for birthweight, preterm neonates had over double the odds of dying as term babies (OR\u0026thinsp;=\u0026thinsp;2.31; p\u0026thinsp;=\u0026thinsp;.001). As expected, babies who were very low birth weight (VLBW) and low birth weight (LBW) had higher odds of death on the ward when compared to normal weight babies (NBW); VLBW babies were five times as likely to die (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and LBW babies were almost twice as likely to pass away before discharge (p\u0026thinsp;=\u0026thinsp;.035). Babies admitted 1\u0026ndash;6\u0026nbsp;days after birth (OR\u0026thinsp;=\u0026thinsp;0.47; p\u0026thinsp;=\u0026thinsp;.001) or even a week after birth (Or =\u0026thinsp;0.44; p\u0026thinsp;=\u0026thinsp;.024) had less than half the odds of dying that babies admitted on the day of birth. Odds of dying were 1.68 times higher for babies referred to the hospital than those born at HIC (p\u0026thinsp;=\u0026thinsp;0.015). Those born through cesarean section had a survival advantage (OR\u0026thinsp;=\u0026thinsp;0.47; p\u0026thinsp;=\u0026thinsp;0.014). Mothers who were less than 18\u0026nbsp;years of age had higher odds of losing their neonate \u0026ndash; as were mothers whose age was not established, possibly indicating young age or a correlated risk factor.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOdds of death on the ward compared to discharge by risk categories\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDied\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(95% confidence interval)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eTiming of delivery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ereference\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreterm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.36\u0026ndash;3.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eBirthweight\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVLBW 1.0\u0026ndash;1.4\u0026nbsp;kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.39\u0026ndash;10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLBW 1.5\u0026ndash;2.4\u0026nbsp;kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.12\u0026ndash;2.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNBW 2.5\u0026nbsp;kg +\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ereference\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAge at admission\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ereference\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;6 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.30\u0026ndash;0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7 days or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.24\u0026ndash;0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInborn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ereference\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutborn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.26\u0026ndash;2.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.27\u0026ndash;0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.35\u0026ndash;5.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;34\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ereference\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;35\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.74\u0026ndash;2.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.08\u0026ndash;6.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":" \u003cp\u003eWe had the unique opportunity to describe neonatal survival status for newborns receiving care at a large public health hospital in southern Haiti. We collected data over the first two years of operation of the neonatal ward, recording daily admissions and tracking outcomes over the course of hospitalization. In this period, we contributed to improvements in health service delivery through training, improvements to infrastructure, provision of essential equipment and medications, and improvements in operational systems. While working within the limited capacity of the facility conditions we found, we were able to care for more than 1400 babies. Hospital survival was better among neonates born at the hospital than those born elsewhere, indicating a survival advantage for referral right at birth. Babies born elsewhere were more likely to come in at least one day after birth. Availability of cesarean sections was a factor; babies born vaginally had poorer survival indicating an unmet need for surgical intervention. Over the course of the 25 months, one in four neonates was taken home by their families before discharge. Three community health workers attempted to follow-up of neonates after discharge but this proved to be challenging due to missing or incorrect addresses and phone numbers. Having a social worker and establishing a fund to assist families with food and lodging costs could have alleviated some of the financial stress.\u003c/p\u003e \u003cp\u003eThe proportion of preterm babies and those born low or very low birth weight were similar for inborn and outborn infants. Similar comparisons have been made in other settings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This suggests that prenatal care plays a significant role in birth outcomes, regardless of place of birth. Diagnoses were mostly clinical due to lack of imaging and laboratory availability. Hypoxia and infection represented a great part of the diagnostic criteria. Perinatal hypoxia results from an insufficiency in the baby\u0026rsquo;s oxygen supply during the intrapartum and postpartum period. The diagnosis was made for babies with \u0026lsquo;no cry at birth\u0026rsquo;, meconium aspiration, surfactant deficiency, fetal distress, and secondary hypoxic injury such as hypoxic ischemic encephalopathy. We found that hypoxia was often complicated by other health issues such as infection or prematurity. In the sickest babies, manual resuscitation was often maintained by the pediatricians, which compromised their capacity to attend to other clinical duties. Pediatricians were also not available at night.\u003c/p\u003e \u003cp\u003eSurvival was higher among neonates born at HIC, likely due to the risks associated with home births or births at facilities without cesarean or other emergency obstetric capacity. Lower level facilities in Haiti have been found to be poorly equipped to provide obstetric care even if they do provide labor and delivery services.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] We also found that the risk of dying was highest among babies admitted at birth from \u0026ndash; indicating that the sickest babies were also those who were transferred right at birth from HIC as opposed to babies born elsewhere who likely died before being brought in, contributing to potential selection bias in our sample. We did not record length of stay in hours and it is possible that babies admitted from HIC were merely alive for a few hours before succumbing to their illnesses. While the standard practice is to separate community transfers or outborn babies from inborn babies due to risk of infection, we did not have the capacity to do so and there was likely transmission of infection from outborn to inborn neonates [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDeaths were highest among preterm neonates and those of low or very low birth weights. Half of premature neonates died, as has been noted in similar settings [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Among premature neonates in Burundi in 2011\u0026ndash;2012, inpatient mortality was higher among those less than 32 weeks gestation (31%) than those among 32\u0026thinsp;\u0026minus;\u0026thinsp;26 weeks gestation [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Other published estimates of premature mortality are approximately 50% among neonates born at 34 weeks of gestation, and 70% among neonates born at \u0026lt;\u0026thinsp;32 weeks of gestation in low-income countries [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Weight categories provided a more nuanced representation of vulnerability as preterm birth was not disaggregated by gestational age.\u003c/p\u003e \u003cp\u003eBeyond clinical outcomes, the most important lessons were learned during daily ward operations which showed us that over the period of the study, there was considerable variability in the delivery of neonatal care on the ward. This was driven in large part by the availability of antibiotics, laboratory testing, oxygen, and electricity. However, political instability, holidays, nursing schedules, and seasonal conditions contributed to the unpredictability of ward conditions. Hot summer temperatures in a crowded ward were dangerous for infection control and hurricane season rains often flooded the ward. Power outages were common at night and parents often slept on the floor of the ward by the neonatal beds. During renovations, the beds were moved to different parts of the pediatric ward which affected the time it took to walk the babies over from the maternity ward. Over time, we were able to improve many of these conditions by renovating the neonatal space, providing better quality furniture and equipment as well as air conditioning, and a steady supply of antibiotics and oxygen. However, conditions remained precarious due to the lack of adequate financial support from the health authorities that could be dedicated to ward operations.\u003c/p\u003e \u003cp\u003eAnother unexpected challenge was the lack of communication between the maternity and neonatal wards. Despite out best efforts to establish a referral system where critical maternal information about labor and delivery would be communicated to the neonatal team, securing any clinical information from maternity proved nearly impossible. We believe this was reflective of a broader lack of communication across the hospital and reflected entrenched hierarchies and systems that will require a significant cultural shift. Communication between doctors and nurses was also stifled and it was unclear what power nurses wielded in ensuring better working conditions. Infrastructure was poor across the hospital and a piecemeal, project by project approach to building capacity had left no long-term mark on the hospital\u0026rsquo;s operations. Programs that were better funded, such as HIV/AIDS prevention and treatment, were better staffed, equipped, and efficient. Any effort to establish a higher-level care delivery program needs to account for the overall working conditions of the host institution.\u003c/p\u003e \u003cp\u003eOur work had some strengths. We critically examine hospital neonatal mortality in Haiti and discuss implications for future programming. We were able to collect data on relevant indicators as the service was new to the hospital and we created new medical charts with clearly identified data fields. This made it easier for the clinical team to collect relevant data in real time rather than rely solely on extensive chart reviews at a later date. We were also able to discuss ongoing data quality issues through periodic reviews of the service delivery outcomes for the ward, usually during field visits by the Dartmouth team. We benefitted from the tireless effort of the pediatricians to document each and every data point and alert us of any discrepancies with sufficient notice. While we could not do anything about data that were missing all together, we did trust that the data we collected were of high quality.\u003c/p\u003e \u003cp\u003eWe also had a number of limitations. Although improvements in infrastructure and service delivery capacity have been associated with improved neonatal survival in other settings, we could not meaningfully analyze the impact of improvements in our ward\u0026rsquo;s infrastructure and quality improvement efforts, including provision of free medications, as these improvements were made on an ongoing basis and often during unstable political conditions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, there were too many changes in nurse staffing, electrical supply, and other service delivery parameters by the hospital that were beyond our control and that led to fluctuations in care. There was considerable unpredictability in the hospital\u0026rsquo;s supply chain which also led us to secure treatment through the private-sector. With less control of supply chain management, we could not standardize the treatment to established protocols. We also did not capture maternal risk factors including intrapartum complications despite our best efforts to work in tandem with the maternity team. For similar reasons, we did not collect maternal socioeconomic status or neonatal Apgar scores. We believe that with additional maternal health information, we would have been able to better understand neonatal prognosis at admission. Transfer of knowledge has to be an essential part of all neonatal mortality reduction efforts \u0026ndash; we don\u0026rsquo;t believe that neonatal mortality programs should run independent of mothers, whatever the cost.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eThe potential to improve the quality of care in dedicated inpatient neonatal units in low and middle-income countries is great. There are many missed opportunities to provide effective interventions to mothers and babies, particularly those who seek facility-based care. In the short term, intrapartum-related neonatal deaths can be substantially reduced by improving the quality of services for all childbirths that occur in health facilities. An integrated nursing approach to reducing maternal and neonatal mortality is essential, especially for families who choose to deliver at a facility. In conclusion we offer the following recommendations: 1) a neonatal resuscitation program by itself cannot reduce neonatal deaths due to perinatal asphyxia. Resuscitation trainings should be delivered to both neonatal and maternity nursing staff, combined with a regular supply of clean bag masks and oxygen in the very least; 2) Coordinating communication between the maternity and neonatal wards is critical during complicated deliveries, transfer, and postpartum; 3) Neonatology should be co-located with obstetrics rather than pediatrics with nurses who care for both mothers and babies, and understand the etiology of poor outcomes for neonates due to poor quality intrapartum care; 4) Algorithms are needed for nurses to manage admission, vital signs, and suspected infection in the absence of a physician; and 5) Specialized care is needed for premature neonates.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval for the analysis of the data was obtained from The Haitian Committee for Protection of Human Subjects at GHESKIO and from the Institutional Review Board of Dartmouth-Hitchcock Medical Center (Study number 02000017). An exemption for minimal study risk was secured and informed consent was not required from study subjects as the data were extracted from patient charts after discharge or death. We paid careful attention to maintain and preserve anonymity of the subjects in any presentation of data. The results were made available for review by all the participating partners before submission for publication.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAVAILABILITY OF DATA\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCOMPETING INTERESTS\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this project was provided by the W.K. Kellogg Foundation and The Children\u0026rsquo;s Prize.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHORS' CONTRIBUTIONS \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAD analyzed the data, wrote the first draft of the paper, and completed all editing after review. MC, WJB, EL, and KS reviewed the paper several times and provided comments. AW was instrumental in assessing the capacity of the maternity ward. PJ and PW served as project advisors and were the primary people in charge of overall project governance. They also reviewed the paper and provided comments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical staff in the maternity and pediatric wards at HIC were extremely helpful during implementation and included Dr. Jean Yves Domer\u0026ccedil;ant (Medical Director); Dr. Lucien Gerard (Chief of Maternity); Dr. Edna Roberte (Chief of Pediatrics); Ms. Lucie Lafortune (Chief of Maternity Nursing); and Ms. Hyppolite (Chief of Pediatric Nursing). Our operational team in Haiti also provided significant operational assistance including Dr. Eli Francois (GHESKIO); Ms. Marie Shella Goda (GHESKIO); and Mr. Judner Mondelus (HIC). Finally we want to acknowledge the families who trusted us with their infants despite considerable challenges. Dr. Jean Pape and Ms. Penny Wright also provided valuable guidance as needed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e \u003cspan\u003eLabrador R. Haiti\u0026rsquo;s Troubled Path to Development. Counc Foreign Relat [Internet]. [cited 2020 Apr 21]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cfr.org/backgrounder/haitis-troubled-path-development\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eCavagnero E, Cros M, Dunworth A, Sjoblom M. Better Spending. Better Care: A Look at Haiti\u0026rsquo;s Health Financing [Internet]. Washington, D.C: World Bank; 2017 Jun. Report No.: 11682. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://documents1.worldbank.org/curated/en/393291498246075986/pdf/116682-WP-v1-wb-Haiti-english-PUBLIC-summary.pdf\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eLowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, Delsoins D. Public Health Progress in Haiti. 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Enqu\u0026ecirc;te Mortalit\u0026eacute;, Morbidit\u0026eacute; et Utilisation des Services (EMMUS -VI 2016\u0026ndash;2017). P\u0026eacute;tion -Ville, Ha\u0026iuml;ti, et Rockville. Maryland: IHE et ICF; 2018.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eUnited Nations. Goal 3: Sustainable Development Knowledge Platform [Internet]. [cited 2020 Feb 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sustainabledevelopment.un.org/sdg3\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eJacobs LD, Judd TM, Bhutta ZA. Addressing the Child and Maternal Mortality Crisis in Haiti through a Central Referral Hospital Providing Countrywide Care. Perm J. 2016;20:59\u0026ndash;70.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eBridwell M, Handzel E, Hynes M, Jean-Louis R, Fitter D, Hogue C, et al. 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BMC Pregnancy Childbirth. 2010;10(Suppl 1):1.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Neonatal mortality, prematurity, hypoxia, sepsis, Haiti, newborn care, neonatal morbidity, facility-based care","lastPublishedDoi":"10.21203/rs.3.rs-66799/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-66799/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\u003cp\u003eThe rate of facility births in Haiti has doubled in the past two decades but this has not resulted in comparable reductions in maternal or neonatal mortality. To care for newborns requiring hospitalization in Haiti, we worked with the public health leadership in the Haitian department of the South (\u003cem\u003eSud\u003c/em\u003e) to establish a ward for compromised neonates in a large public hospital with over 3000 annual deliveries but no neonatal care capacity. \u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e\u003cp\u003eSignificant investments were made in establishing basic neonatal services, train nurses, install and manage a supply chain, and strengthen infrastructure. We present outcomes for 1399 neonates admitted to the ward during the first two years of operation. \u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003eTwo-thirds of admissions were made from the hospital’s maternity ward at birth while the remaining babies were born at home or referring facilities. Inborn neonates had better rates of hospital survival than those born elsewhere. They were also more likely to be born via cesarean section and to be admitted right at birth. Babies born elsewhere were more likely to die during their hospital stay. There were no differences between the proportion of premature or low Conclusions\u003c/p\u003e\u003cp\u003ebirth weight babies born at the hospital or elsewhere. \u003c/p\u003e\u003cp\u003eNursing care proved to be a critical part of the care delivery system. We conclude that integrated, high frequency nursing training is necessary for both maternity and neonatal nurses to support maternal and newborn care. Resources are needed to address prematurity as an important outcome, especially as it is indicative of poor prenatal care, regardless of place of birth.\u003c/p\u003e","manuscriptTitle":"Care for Neonates in Haiti’s Health System – Outcomes and Lessons","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-09-04 21:15:20","doi":"10.21203/rs.3.rs-66799/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57c2ee04-5c44-4405-9dce-e735be0a6621","owner":[],"postedDate":"September 4th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":439825,"name":"Maternal \u0026 Fetal Medicine"}],"tags":[],"updatedAt":"2020-09-04T21:15:22+00:00","versionOfRecord":[],"versionCreatedAt":"2020-09-04 21:15:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-66799","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-66799","identity":"rs-66799","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}