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Survival Rate of Babies Born at 28 Weeks

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Outcomes of 28+1 to 32+0 Weeks Gestation Babies in the Land of Qatar: Finding Facility-Based Cost Effective Options for Improving the Survival of Preterm Neonates in Depression Income Countries

by i,2, one,ii,* , 1,ii, 1,2, 1,ii and 3

1

NICU Women's Hospital, Hamad Medical Corporation, Doha, Qatar

2

Section of Paediatrics, Weill Cornell Medical College, Doha, Qatar

3

Faculty of Sport, Health and Social Intendance, University of Gloucestershire, Gloucester, United kingdom

*

Writer to whom correspondence should be addressed.

Received: four May 2010 / Revised: 31 May 2010 / Accustomed: two June 2010 / Published: xi June 2010

Abstract

In this retrospective report nosotros did a comparative analysis of the result of 28+i to 32+0 weeks gestation babies between the State of Qatar and some high income countries with an objective of providing an evidence base for improving the survival of preterm neonates in depression income countries. Information covering a five twelvemonth period (2002–2006) was ascertained on a pre-designed Performa. A comparative analysis with the about recent information from VON, NICHD, Britain, French republic and Europe was undertaken. Qatar's 28+1 to 32+0 weeks Prematurity Rate (ix.23 per 1,000 births) was less than the United kingdom's (p < 0.0001). Of the 597 babies built-in at 28+1 to 32+0 weeks of gestation, 37.five% did not require any respiratory support, while 31.one% required only CPAP therapy. fourscore.12% of the MV and 96.28% of CPAP therapy was required for <96 hours. 86.1% of the mothers had received antenatal steroids. The 28+one to 32+0 weeks mortality charge per unit was 65.3/1,000 births with 30.77% deaths owing to a range of lethal congenital and chromosomal anomalies. The survival rate increased with increasing gestational historic period (p < 0.001) and was comparable to some high income countries. The incidence of in infirmary pre belch morbidities in Qatar (CLD 2.68%, IVH Course Iii 0.84%, IVH Grade IV 0.5%, Cystic PVL 0.5%) was less as compared to some high income countries except ROP ≥ Stage 3 (five.69%), which was higher in Qatar. The incidence of symptomatic PDA, NEC and severe ROP decreased with increasing gestational historic period (p < 0.05). We conclude that the mortality and in hospital pre belch morbidity issue of 28+ane to 32+0 weeks babies in Qatar are comparable with some high income countries. In two thirds of this group of preterm babies, the firsthand postnatal respiratory distress can be effectively managed by using two facility based cost constructive interventions; antenatal steroids and postnatal CPAP. This finding is very supportive to the efforts of international perinatal health care planners in designing facility-based cost effective options for low income countries.

1. Introduction

Very Preterm Babies (≤32 weeks of gestation) institute one–2% of all live births in high income countries, but account for at least one third of perinatal mortality, the majority of neonatal bloodshed [i–5], besides as both short-term [5] (pre discharge, in hospital) and long-term (at two years corrected age) morbidity [6–nine]. Although neonatal bloodshed and morbidity are known to worsen with decreasing gestational historic period and weight at nativity [1–9], the dramatic comeback in the intact survival of preterm babies has been one of the most remarkable features of neonatology in high income countries over the last 3 decades [ix]. Correspondingly, the question of how 'small is pocket-sized' has, over the last two decades, gradually decreased in terms of gestation period from 32 weeks to 28 weeks and so 24 weeks; and in terms of birth weight from i,500 g to 1,000 m, to 800 g and then 500 grand [10–15]. However, the long term outcomes, the cost of intendance of babies born ≤28 weeks (particularly ≤26 weeks) and/or nativity weight ≤i,000 one thousand (and particularly ≤750 g), and the futility of intervention at the edge of viability remains a hot debate, even among the most resource rich countries [10–15] and the care of extremely premature babies (≤28 weeks and ≤ 1,000 k at birth) is not an option for resources restricted developing countries. Instead these countries should focus on babies born ≥28 weeks gestation and ≥1,000 g at birth. Over the concluding decade the intact survival of this group of preterm babies has risen to a level which has put to rest any major controversy concerning cost effectiveness [ten]. In fact by the 1990s almost all NICUs in the high income countries had accomplished ≥ 90% survival of babies with a nascency weight of >1,000 g [10].

The world's nations are divided in providing disinterestedness in newborn care [xvi] and the global motion picture of newborn care and outcomes presents an unfortunate dissimilarity on both sides of the divide betwixt high income countries versus low income countries [16–19]. The scenario and challenges of neonatal survival are unique in depression income countries encumbered by very loftier neonatal mortality [16] and socioeconomic and political constraints [17]. Worldwide some 12.nine million babies are born preterm each year; of which ane.12 million die each yr (28% of iv million global neonatal deaths; 98% of which occur in low income countries) [18]. The very high cost and highly technology dependent intendance of extremely premature babies (<28 weeks and <1,000 grand at nativity) is neither a feasible nor a sustainable option for depression income countries. Therefore UNICEF'south Annual Global Child Survival Reports exclude babies <i,000 g from the mortality data published for depression income countries [19]. These countries might be better off investing their express resources in the care of full term and bigger preterm babies, the majority of which die of potentially preventable diseases [16]. Indeed some developing countries e.g., Sri Lanka, Indonesia, Moldova, Nicaragua, Vietnam and Honduras have, within their limited resources and without resorting to very expensive high tech intensive care facilities, successfully reduced their neonatal bloodshed rates [17].

Co-ordinate to the March of Dimes 2009 Global Study on Preterm Births [eighteen], at that place are huge gaps in the data with regards to preterm nascency, prevalence, bloodshed, acute morbidity and long term impairment in low income countries. Such deficiencies in the available data makes the much needed systematic scaling up of neonatal care [20] in these countries an extremely hard job. The nowadays study aims to bridge this gap. Nosotros collected, analyzed and compared the gestational age specific mortality and morbidity data from the State of Qatar which has accomplished excellent Neonatal mortality rates in recent years (4.37, 5.one, 4.four, and iv.0/1,000 births in 2006, 2007, 2008 and 2009 respectively) [nineteen,21,22] with the data from the developed countries. In addition, the current written report also explored the feasibility of facility based cost constructive options for saving babies at the lowest limits of viability (28+1 to 32+0 weeks) in low income countries.

1.1. Aim of the Study

The present written report analyzed the gestational age specific mortality and morbidity outcome of 28+i to 32+0 weeks gestation babies in the State of Qatar over a flow of v years (2002–2006), and compared the outcomes with recent data published in the well established international neonatal databases from some loftier income countries (VON [23] and NICHD [24]) and contempo studies published from United kingdom of great britain and northern ireland [1], France [2] and Europe [3,4]. The six specific objectives of our report were to:

  • Develop a Performa, using the international databases (VON and NICHD) as a template, in social club to collect the mortality and pre discharge in hospital morbidity of 28+one to 32+0 weeks gestation babies in the State of Qatar based on the private patient medical records;

  • Call back data on gestational historic period specific bloodshed and morbidity upshot of 28+1 to 32+0 weeks gestation babies in the Land of Qatar for the period (2002–2006); (N = 597 during the study period);

  • Double check the validity of the information collected via the Performa using parallel databases in our institution (Hamad Medical Corporation);

  • Appraise the Qatari mortality and pre belch in hospital morbidity information and compare the outcomes with similar information from VON, United states (NICHD), United kingdom of great britain and northern ireland, France and Europe;

  • Analyze the characteristics of respiratory support needed at each successive gestational week amid our sample (28+one to 32+0 weeks) and compare it with information from Vermont Oxford Network (2007) report; and,

  • Contribute towards finding evidence based toll effective neonatal care options for resource restricted developing countries which are struggling to reduce their burden of neonatal mortality.

ii. Methods

2.1. Procedures and Sample

This retrospective analytic report was canonical past the Institutional Research Lath of Hamad Medical Corporation (protocol No. 7004/07), and undertaken in the Neonatal Intensive Care Unit Women's Hospital in Doha (the simply third intendance maternity and neonatal unit in the Land of Qatar). The Hospital was accredited in 2006 and re-accredited in 2009 by the Joint Commission International (JCI) The states for its Standards and Quality of Care. About 99% of deliveries in Qatar take place in this hospital. All inborn and out built-in babies delivered ≤32 week gestation in the State are admitted to the Women's Hospital. Therefore the information with regards to ≤32 week gestation babies from our report not simply accurately represents Qatar'due south national data, for all practical purposes, it is equivalent to a population-based study.

2.2. Performa and Data Collection

A standard Performa based on established international neonatal databases like VON and NICHD likewise as some recently published preterm mortality and morbidity outcomes information from the loftier income countries [2–four,23,24] was adult past the authors. Using the standard Performa, data was collected by 2 of the authors (H.P, G.P.N) from private patient medical records using anonymous identification numbers. Due to the retrospective medical records based nature of the report, individual patient consent was not required past the Institutional Research Board. The Performa comprised data items that included a range of base line characteristics of antenatal intendance (Table 1); the employ of antenatal steroids, mode of commitment, condition at birth, and respiratory management in the neonatal period (Tabular array 2); mortality (Tabular array iii); and, in hospital pre belch morbidity in the survivors (Table 4). A Performa was completed for each of all 28+1 to 32+0 weeks gestation babies (N = 597) admitted during the study menstruation (1st January 2002–31st December 2006). Twenty seven individual patient medical records (4.5%) were incomplete. This deficiency was completed from other parallel data bases (e.g., admissions, belch and death registers of the neonatal unit). These parallel information sources were too used to double check the validity of the residuum of the data.

2.3. Outcome Measures

We employed three major categories of outcome measures: (1) 28+1 to 32+0 weeks gestation birth rates; (2) in infirmary pre-discharge bloodshed (total and gestational age specific); and, (three) in hospital pre-discharge morbidity (CLD, NEC, Symptomatic PDA, IVH Grade Three and Iv, Cystic PVL, ROP ≥ Phase iii). Chronic Lung Illness (CLD) was defined equally supplemental oxygen dependence or ventilation including CPAP at 36 weeks corrected postal service-menstrual historic period (PMA). Neurologic morbidity (IVH and PVL) were defined using the Papile Classification [25]. We also analyzed the characteristics of respiratory support (e.g., MV, surfactant therapy, CPAP therapy and total days on respiratory support) needed at each successive gestational week among our sample (28+i to 32+0 weeks). The comparative data for Vermont Oxford Network (VON) was ascertained from its 2007 report available in CD format and on its web site ( www.vtoxford.org) [23]. VON has two sections in its database:

  • Low birth weight database (babies 501–1,500 grams at nascence)

  • Expanded database (babies of all nascency weight and gestational ages)

The expanded database classifies babies both according to the nativity weight categories and gestational age categories. The gestational age category tables 19–32 of Expanded database in VON's 2007 study presents data co-ordinate to the following gestational age categories irrespective of their nativity weight; <27, 27–29, 30–32, 33–36, 37–41 and >41 weeks. Nosotros used the 30–32 weeks grouping from expanded database gestational age categories which is the best nearest to our data (28+1 to 32+0). VON'south 30–32 weeks group in the expanded database includes babies of all nascency weights (<1,500 g and >ane,500 chiliad). This makes the comparative groups very similar to ours. In VON database the outcomes are described as percentage (%) with 1st and 3rd network quartile without giving the actual numbers (n) in whatever category. VON gives the total and grouping specific number (N) of babies in the offset of each table. Nosotros calculated the n for each category of VON tables using the xix–32% and the total numbers (N) given in the beginning of each table.

ii.4. Statistical Analysis

The net based statistical package Vassar stat was employed for data analysis. The chi square (χ2) test was used to compare the Qatar data with that of VON and other high income countries. The significance level was set at p < 0.05.

three. Results

A full of 64,689 alive births were recorded during the study period with 597 of these babies being babies between 28+i to 32+0 weeks gestation, thus giving a prematurity rate of 9.23 per i,000 total births for the target gestational age category during the written report period. Our 28+one to 32+0 weeks gestation prematurity charge per unit was less than the rates for the same gestation grouping in the UK (p < 0.0001). Tabular array 1 highlights the patient characteristics of our sample in comparison to VON, which is an international database of more than 800 Neonatal ICU's; more than 95% of which are located in North America, Western Europe and Australia. 86.44% of our babies had birth weights between i,001 and 2,000 thousand and only three.9% were SGA every bit compared to 12% in VON database (p < 0.0001). Singleton babies comprised 81.91% of the sample. The gender distribution was equal, and well-nigh 45% of the babies were born to native Qatari families and 55% to expatriate families living and working in Qatar. This is in line with the general distribution of population in Qatar [25]. The rate of antenatal steroid administration in our sample (86.one%) was ameliorate (p < 0.0001) than VON (73%). The 28+1 to 32+0 weeks mortality rate in our sample was 65.3/ane,000, which was higher (p < 0.0001) than VON (29.9/1,000). 35.89% of deaths in our cohort were Early Neonatal Deaths (0–7 days of life) and 64.xi% Tardily Neonatal Deaths (8–28 days of life). Lethal Congenital and Chromosomal Anomalies accounted for 12 deaths (30.77%); Trisomy xviii (4 cases), Trisomy thirteen (one case), multiple congenital anomalies (ane case), and complex congenital heart disease (four cases including two with Down's syndrome).

Tabular array 2 shows the characteristics of the respiratory back up required by the 28+1 to 32+0 weeks gestation babies of our accomplice during their stay in the NICU. Slightly more than than one tertiary of our babies (37.52%, n = 224) did not require any respiratory support during their entire NICU stay. Of the remaining 373 babies (62.48%) who required respiratory support, 186 (31.iii% of total and 50% of babies requiring respiratory back up) needed CPAP alone. One hundred and lxxx seven (31.three% of total and 50% of babies requiring respiratory support) needed MV. Amid the babies requiring MV, 83 (thirteen.9% of total babies and 44.4% of babies requiring MV) needed post extubation CPAP support. Surfactant therapy was required only by one third (32.16%) of total babies. The need for respiratory support decreased (p < 0.001) with increasing gestational age (MV decreased from 88.71% at 29 weeks to thirteen.26% at 32 weeks; CPAP decreased from 66.xiii% at 29 weeks to 31.44% at 32 weeks; and surfactant replacement decreased from 88.71% at 29 weeks to 15.53% at 32 weeks). Most of the respiratory support (80.12% MV, 96.28% CPAP) was required for short duration (<96 hours).

Table 3 depicts the total and gestational age specific mortality and survival rates with a comparison with recent information from UK [ane]. Qatar's average Neonatal Mortality Rates for the study period 6.34/1,000 and 28+one to 32+0 weeks gestation mortality rate was 65.33/ane,000. Qatar'south 28+ane to 32+0 weeks gestation survival rate of 93.47% was significantly less (p < 0.0001) than the same gestational age survival rate in Great britain during 2006 [1]. Within our own cohort the gestational age specific survival rate increased significantly (p < 0.001) with every single week increase in gestational age (from 85.49% at 29 weeks to 96.66% at 32 weeks).

Tables 4 illustrates the total and gestational age specific in hospital pre discharge morbidity of 28+1 to 32+0 weeks gestation babies in Qatar with comparative figures for thirty–32 weeks gestation babies from the expanded data base in VON 2007 report [23].

Our incidence of CLD and symptomatic PDA was significantly less (p < 0.0001), while the incidences of NEC, IVH grade 3, IVH class IV and PVL were similar to VON. On the other mitt, our incidence of ROP was significantly higher (p < 0.0001) than VON. Inside our accomplice the incidence of symptomatic PDA, NEC and ROP (≥Stage 3) decreased with every single calendar week increase in gestational age (p < 0.05).

We constructed Table 5 using a subanalysis of our data restricted to babies with birth weight i,001–1,500 g (n = 282). This included 205 babies from our report, as shown in Table one, plus 77 babies who were <28 weeks gestation from another all the same unpublished study conducted for the same time period (2002–2006) past our group on extremely depression birth weight babies. This subanalysis made it more rational for us to compare our pre-discharge in hospital morbidity outcome with studies based on birth weight instead of gestational age. Table 5 depicts comparative data for i,001–1,500 g babies between Qatar and recent studies from the USA (NICHD) [24], Italy (Trento written report) [30] and UAE [31]. The incidence of pre-discharge respiratory and neurologic morbidity was very depression among our cohort equally compared to NICHD, but comparable to the Trento and UAE studies. Severe ROP (≥Phase 3) was high (five.69%) in our study as compared to all the other groups.

4. Discussion

Progress in neonatology is mostly portrayed as inexorable: doing ameliorate and better with smaller and smaller [ten]. However, this represents only one side of the challenge, reflecting the outcome of only 1% of global births which take identify in high income countries. Of the 130 million babies born every yr worldwide, 12.9 meg are born preterm. Iv 1000000 babies dice in the outset calendar month of life; and 99% of these deaths occur in low and centre income countries due to causes which are largely preventable [16]. Preterm bloodshed accounts for 28% of global neonatal deaths [16]; (near 1.12 million deaths per yr) [18]. This could perhaps even be an nether interpretation because a large number of preterm births in low income countries take place in the community and are never reported [sixteen]. Hence, low income countries are caught between the dilemma of limited man and economic resources and the reports of increasingly intact survival of very preterm babies particularly those born at >28 weeks gestation and >one,000 chiliad at nascence [10–xiv]. The rapid and widespread use of it has raised parental expectations all over the globe. The unfortunate fact is that the resource available are limited, peculiarly in developing countries, and rationing is imperative. Therefore where and how to invest in neonatal care in low income countries remains a very important question [27].

Among the low income countries, Sri Lanka stands out for having accomplished a significant decline in its neonatal bloodshed rates past sustained investment in primary health care facilities and without establishing many loftier tech expensive neonatal intensive care units [17]. However, any further reduction in neonatal bloodshed in low income countries, peculiarly among the preterm infants, will need some facility-based interventions. Some low cost interventions like regular use of antenatal steroids for preterm labor and the increasing use of not invasive respiratory support in the neonatal units has contributed significantly to the survival of extremely preterm babies in high income countries. The application of these depression cost interventions may increase the intact survival of preterm babies at the limit of viability in the low income countries (28+i to 32+0 weeks gestation) at an affordable price. In order to explore this proposition, we carried out this analytic and comparative written report of the consequence of 28+1 to 32+0 weeks gestation babies in the State of Qatar. The selection of Qatar is a model of report was based on ii rationale: kickoff, the Perinatal and Neonatal survival rates in Qatar accept significantly improved over the last thirty years to the extent that its current rates are comparable to many high income countries [19,21,22]; and 2nd, the population of Qatar displays great multifariousness in its genetic, cultural and social backgrounds. Almost lx% of the resident families are economic migrants, mostly from Middle East, South and South East Asia [26]. Since the Country of Qatar provides equal access to health intendance for its residents, both local and expatriate, the outcomes are fifty-fifty among a population with various origins [26]. In other words if a similar level of care is provided in the native countries of expatriate residents, the outcomes would be equally good.

We conducted the electric current report with half-dozen very clear objectives described in the methodology section. The kickoff three objectives were successfully met past developing a standard Performa based on international benchmarks [23,24] followed past its testing and validation using parallel information bases in our unit.

To run across the fourth objective of our study, we tabulated the characteristics of our patient population (Table 1) in comparison to similar characteristics employed in VON [23]. At that place was no difference in the sex activity distribution and plurality between our data and VON. The number of babies with intrauterine growth retardation (SGA) was very loftier (p < 0.0001) in VON (12%) equally compared to Qatar (3.9%). The example (p < 0.0001) for babies delivered by caesarean department (67% vs. 54.27%) was similar. Intrauterine growth retardation provides a respiratory advantage in the immediate postnatal period because the incidence and severity of surfactant deficiency lung disease is less in Small for Gestational Age (SGA) babies which comprise a significant proportion of the births in the depression income countries. According to our study, the birth charge per unit of 28+1 to 32+0 weeks gestation babies in Qatar is 9.23/1,000 which is significantly less (p < 0.0001) than the rate of similar gestation babies from UK (11.six/one,000) [one], but significantly higher (p < 0.0001) as compared to the rate of seven.6/1,000 in France [3,4]. The assisted reproductive unit of measurement in Qatar was established in the mid 1990s. Since then the number of preterm every bit well as multiple births have gradually increased in the Land. Approximately 97% of babies in our cohort were >1,000 yard at nascency; thus making it feasible to compare with some reports based on nascency weight rather than gestational historic period.

We assessed our data (Tables 2, 3 and 4) for the 3 result measures (bloodshed, morbidity and requirements for respiratory support in the immediate postnatal period) and compared the outcomes with similar data from, UK [1], Europe [two], France [three,4], USA [24], Italy [30] and UAE [31].

Mortality: Qatar's boilerplate NMR for the study period (2002–2006) was 6.34/k, which was significantly higher (p < 0.001) than U.k.'s NMR in 2006 (iii.4/1,000) [one]. All the same, year by year, Qatar's NMR decreased significantly from vii.49/1,000 in 2002 and 8.49/1,000 in 2003 to 4.37/1,000 in 2006. Qatar's 2006 NMR was comparable to Britain's 2006 NMR (p = 0.08). Qatar's boilerplate survival rate of 28+1 to 32+0 weeks gestation babies during the study period (2002 to 2006) was 93.47%, which is very close to the charge per unit in Europe (94.eight%) [2] and France (95.36%) [3,4] but significantly less (p < 0.0001) than the 2006 charge per unit in the Britain (97.6%) [ane]. Lethal congenital and chromosomal anomalies were the leading crusade (31%) of death in our Qatari cohort. This might not be very surprising, as according to the March of Dimes Birth Defects Foundation Report published in 2006 [28], Arab countries have the highest incidence of birth defects in the world. The incidence of nascency defects in Qatar is 73.4 per one yard live births [28] which is very similar to other Arabian Gulf countries. The overall consanguinity rate in the Arab world ranges between 40 and seventy% while Qatar's consanguinity rate is (54%) [29]. At the same time, Qatar has a very low elective antenatal termination rate due to socio cultural and religious reasons. Collectively these factors have resulted in a very high birth defects rate in Qatar. Among European countries the rate of elective terminations for congenital anomalies varies from 0.5% in Poland to 14.6% in Italy and 17.6% in France [3]. An improved antenatal termination rate may help in reducing neonatal deaths due to lethal built and chromosomal anomalies in Qatar. Qatar'southward 28+i to 32+0 weeks survival rate was very close to that of Europe (94.8%) [2] and France (95.3%) [three,4]. The French study [3,4] excluded congenital anomalies from outcome information. A head to head analysis between Qatar and France, after excluding built anomalies in both the data sets, reveals a better outcome of 28+1 to 32+0 weeks gestation babies in Qatar. The survival rate of 28+1 to 32+0 weeks gestation babies in our study increased (p < 0.001) with increasing gestational age (from 85.94% at 29 weeks to 96.66% at 32 weeks); a trend similar to the patterns witnessed in the UK [1] and France [3,4].

Morbidity: The incidence of in hospital pre discharge morbidity (Tabular array 4) of our cohort was better than VON [23] (symptomatic PDA iii.35% (p < 0.0001), NEC ii.51% (p = 0.057), IVH Grade Iii 0.84% (p = 0.086), Grade IV 0.5% (p = 0.032) and cystic PVL 0.5% (p = 0.032)). The incidence of CLD was significantly college (p < 0.0001) in VON as compared to Qatar (10% versus ii.68%). According to the 2007 report of VON [23], 40% of babies born at gestational age between xxx and 32 weeks required MV, 60.57% required CPAP, while 39% were given surfactant. It is possible that the high rate of utilize of antenatal steroids in Qatari cohort (86.1% vs. 73% in VON p < 0.0001) and the fact that 69% of babies in qatari cohort required either no respiratory support or only short term CPAP may have contributed toward a significantly low incidence of CLD amidst 28+1 to 32+0 weeks gestation babies Qatar. Qatar's higher bloodshed gestational age specific mortality rates during the report menses may have lowered the rates of morbidities. In this study we had also analyzed the week wise mortality for each individual year from 2002 to 2006. The gestational age specific mortality decreased significantly in each group betwixt 2002 and 2006. Qatar'due south 2006 gestational historic period specific mortality and morbidities remain comparable to most of the international benchmarks.

We undertook a sub assay for birth weight specific (ane,001 to i,500 grand) morbidity outcomes in our accomplice and compared our findings (Table 5) with the recently published NICHD information [24], the Trento Report from Italy [30] and a study from the United Arab Emirates [31]. Our rate of CLD was improve than NICHD [24], comparable to UAE [31] and more than Trento [xxx]. While our rates of IVH course Three, grade IV and PVL were similar to other studies, the rates of NEC and ROP (≥Stage 3) were much higher than these studies. This suggests the need for further enquiry into our very low birth weight feeding practices and oxygen saturation monitoring policies. Although 20 (3.35%) babies in Qatari cohort had hemodynamically pregnant PDA, only four babies (0.67%) required surgical ligation. Similarly, 34 (5.69%) babies in the Qatari accomplice had ROP (≥Stage 3) but merely six babies (i.0%) required laser therapy. The incidence of ROP decreased with increasing gestational age (11.74% at 29 weeks to 2.65% at 32 weeks). This decrease is in agreement with the pattern and intensity of respiratory back up and hence use of supplementary oxygen which decreased with increasing gestational historic period. A like design was likewise observed in a contempo study of low birth weight babies from UAE [31].

Patterns of Respiratory support: For the fifth objective, in add-on to analyzing the patterns of respiratory support nosotros also analyzed the implications of our findings for low income countries in terms of cost and feasibility. Respiratory back up, the immediate postnatal requirement of near preterm babies, has significantly changed its blueprint over the final decade with marked reduction in the requirement of mechanical ventilation [32]. The change, which is specially marked in babies ≥ 29 weeks gestation [32], may be a blessing for depression income countries because the number of care days required by the ventilated babies is a major expense in the NICU [x]. In our cohort of 28+1 to 32+0 weeks gestation babies in Qatar, slightly more than than ane third of the total babies (37.5%) did not crave any respiratory back up while another i third of the full babies (31.1%) required brusk term (<96 hours) non invasive respiratory support with CPAP. The number of babies requiring CPAP decreased sharply with increasing gestational age (p < 0.001) and increasing post natal age (p < 0.001). Of the babies who required CPAP in our cohort, 55% required CPAP for <24 hours while some other forty% required CPAP betwixt 24 and 96 hours of age. Over the concluding decade not only the knowledge and practice of using CPAP and its variants in NICUs has tremendously increased with significant reduction in the need of intubated respiratory support [32,33]; only also low cost CPAP modalities have been introduced for developing countries [34]. The recently published feel of using low price Bubble-CPAP in Fiji is very encouraging [34]. These changing patterns of respiratory back up and innovation in CPAP therapy makes it possible to save the majority of the 28+1 to 32+0 weeks gestation babies in low resource countries without restoring to high toll MV and surfactant replacement therapy. In our accomplice simply one 3rd of total babies (31%) required short term (<96 hours) MV and 32% of the total babies required surfactant replacement therapy. Some of the babies in our cohort were intubated, given surfactant and extubated to CPAP (INSURE therapy); hence the number of babies requiring surfactant is more than than the babies given MV. The requirement for MV, in our cohort, decreased sharply with increasing gestational age and postnatal historic period (p < 0.001). Antenatal steroids raise the foetal "lung maturation" by increasing the surfactant product and release; thus reducing the demand of respiratory back up in the immediate postnatal menstruation with improvement in survival of preterm infants [32]. Our very skillful charge per unit of antenatal steroid assistants (86.ane% equally compared to 73% in VON) and 100% surfactant replacement therapy in ventilated babies may have contributed significantly towards short term (<96 hours) gentle ventilation in the firsthand postnatal periods every bit well every bit to the low incidence of CLD (2.68%) in our cohort.

Our data is stratified co-ordinate to gestational age which is a better indicator of maturity, though most of the publications and some standard neonatal databases (eastward.chiliad., NICHD) are stratified co-ordinate to the birth weight [24]. VON data is stratified both according to the gestational age and birth weight [23]. Due to these different stratification methods, information technology was difficult for us to generate a caput to head comparison with other studies including VON in which the gestational historic period stratification group (30–32 weeks) was more closer to ours (28+1 to 32+0 weeks). Nonetheless, every bit shown in Tables 4 and v, the general patterns of bloodshed and incidence of in infirmary pre-belch morbidities are similar between these data bases and our study. The recently published nascence weight stratified data from Italian republic [30] and UAE [31] accept shown a lower incidence of in hospital pre belch morbidity as compared to VON. Our morbidity blueprint was similar to the study from Italy [xxx] and UAE [31]. A recent review of NICHD data base of operations has constitute a wide range of morbidity and mortality amongst network centres [24]. A similar variation was reported past the MOSAIC study data base from 10 dissimilar European regions [3,4]. This indicates that some all-time practices and currently bachelor therapies are awaiting a formal discovery [24] which may assistance modify the fate of millions of babies in the low income countries [35].

For the sixth objective, driven by Qatari data, we tried to observe evidence on how and where to invest in neonatal intendance in depression income countries to reduce the burden of four million total and 1.12 1000000 preterm neonatal deaths; a major challenge faced by Perinatal health care planners [17,27]. A point to annotation is that major reductions in neonatal mortality tin can exist accomplished, within resource restricted environments, by sustained input at the customs and master health care level which must stay as the highest priority. Sri Lanka, Vietnam, Republic of indonesia, Republic of honduras, Moldova and Nicaragua are low income countries with stories of success [17] in achieving significant reduction in neonatal mortality rates in resources restricted settings. For depression income countries, the lower limit of viability should stay at 28 weeks of gestation and ane,000 g birth weight as accustomed by the UNICEF [19]. The experience from Qatar, to which our written report is prove, demonstrates that excellent preterm survival rates with minimum morbidity, comparable to loftier income countries are achievable. With limited resource, the facility-based services required for the intendance of preterm babies will take to be scaled upward. Our report demonstrated that the vast majority of babies at the limit of viability for low income countries (28+1 to 32+0 weeks gestation) can be saved by using low toll techniques including extensive use of antenatal steroids and post natal CPAP therapy which, of grade will remain complementary to the basic needs of temperature maintenance, diet including breast feeding, and prevention and management of infection [20,35].

5. Conclusions

The State of Qatar has achieved an excellent rate of intact survival of 28+1 to 32+0 weeks gestation babies which is comparable to that of many loftier income countries. Qatar's data demonstrates that low cost techniques (antenatal steroids for preterm labor and post natal apply of CPAP therapy), can potentially save the majority of 28+i to 32+0 weeks gestation babies in low income countries with minimum in hospital pre belch morbidity. The cess of long term morbidities (at 2 years neurodevelopmental follow up) will exist the truthful determinant of the ultimate issue. Further, upwardly to date studies in this area will exist helpful for prioritizing health care investments in resource constrained countries.

Abbreviations:

CLD

Chronic Lung Disease
NEC

Necrotizing Enterocolitis
PDA

Patent Ductus Arteriosus
IVH

Intra Ventricular Hemorrhage
PVL

Periventricular Leukomalacia
ROP

Retinopathy of Prematurity
MV

Mechanical Ventilation
CPAP

Continuous Positive Airway Pressure
VON

Vermont Oxford Network
NICHD

National Institute of Child Health and Man Development

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Table 1. Comparison of patient characteristics between Qatar and Vermont Oxford Network (VON).

Tabular array one. Comparing of patient characteristics between Qatar and Vermont Oxford Network (VON).
Characteristic Qatari Sample N (%) VON* N (%) P –Value**
Birth Weight (grams)
  <1,000 19 (3.18) —
  1,001–ane,500 205 (34.34)
  i,501–2,000 311 (52.ane)
  >2,000 62 10. 38)
Gender
  Male person 295 (49.41) 6,222 (54)
  Female 302 (50. 59) five,301(46)
Ethnicity
  Qatari 269 (45.06) White vi,914(60)
  Not Qatari 328 (54. 94) NonWhite 4,609(40)
Plurality
  Singleton 489 (81. 91) 8,873 (77)
  Twins (39 × ii) 78 (thirteen.06) 1,613 (xiv)
  Triplets (10 × iii) 30 (5. 03) ane,037(ix)
Intrauterine Growth
  SGA 23(3. 9) one,383 (12) <0.0001
Antenatal Steroids
  Yes 514 (86.1) 8,412 (73) <0.0001
Caesarean Section
  Yes 324 (54. 27) 7,720 (67) <0.0001
Respiratory Support
  Yeah 373 (62.48) —
Surfactant Therapy
  Yes 192 (32.16) 4,312 (37.4)
Symptomatic PDA
  Total 20 (3.35) one,498 (13)
  Medical Treatment xvi (two.68) 461 (iv)
  Surgical Treatment 4 (0.67) 115 (1)
ROP ≥ Stage 3
  Total 34 (5.69) 115 (1)
  Surgical Treatment 6 (1.0) 0 (0)
Mortality Charge per unit/m
  Total 39 (65.3/1,000) 333 (29.9/one,000) <0.0001
  Early on (<7d) 14 (23.45/1,000)
  As % of Full Mortality 35. 89%
  Late (>7d) 25 (41.87/1,000)
  As % of Total Bloodshed 64.11%
Causes of Bloodshed
  Lethal Congenital & Chromosomal Anomalies 12 (30.77)
  Sepsis 11 (28.twenty) —
  Severe Nativity Asphyxia 6 (xv. xxx)
  NEC 4 (10. 25)
  Pulmonary Hemorrhage 3 (vii.69)
  Hydrops / Congenital Infection 3 (7.69)

Table 2. Characteristics of Respiratory Support in Qatar for 28+1 to 32+0 weeks gestation babies.

Table 2. Characteristics of Respiratory Support in Qatar for 28+i to 32+0 weeks gestation babies.
GA Weeks Northward RS north (%) Surf n (%) MV n (%) CPAP n (%)
29 62 58 (93.55) 55 (88.71) 55 (88.71) 41 (66.13)
thirty 116 95 (82.00) 42 (36.21) 48 (41.38) 63 (54.31)
31 155 110 (71.0) 49 (31.61) 49 (31.61) 82 (52.9)
32 264 110 (41.67) 41 (fifteen.53) 35 (13. 26) 83 (31.44)
Total 597 373 (62.48) 192 (32.16) 187 (31.32) 269 (45.06)*
p Value** <0.001 <0.001 <0.001 <0.001

Tabular array 3. Comparative analysis of total and gestational historic period specific mortality and survival rates: Qatar versus high income countries.

Table 3. Comparative analysis of full and gestational age specific mortality and survival rates: Qatar versus high income countries.
Parameter Qatar (2002–vi) UK (2006)a P Value
Total Births 64,689 669,465
Neonatal Mortalityb 410 (six.34/ane,000) ii,305(3.44/1,000) <0.0001
Neonatal Survival (%) 99.iv 99. 6
Premature Births 597 (29–32 weeks) seven,770* (29–32 weeks)
Prematurity Rate (/ane,000) 9.23 (29–32 weeks) 11.half dozen* (29–32 weeks) <0.0001
29–32 Weeks gestation
  Full 597 vii,770*
  Bloodshed n (/1,000) 39(65.33) 189(24.32) <0.0001
  Survival (%) 93.47 97. 6
29 Weeks gestation
  Total 62 one,243
  Mortality north (/i,000) 9(145.xvi) 61(49.07) <0.005
  Survival (%) 85.49 95.1
30 Weeks gestation
  Full 116 ane,569
  Mortality northward (/1,000) 15(129. 31) 52(33.xiv) <0.0001
  Survival (%) 87.07 96.7
31 Weeks gestation
  Total 155 2,066
  Mortality n (/1,000) 6(38.71) 43(xx.81) =0.24
  Survival (%) 96.13 97. nine
32 Weeks gestation
  Total 264 2,892
  Mortality due north (/1,000) nine(34. 09) 33(11.4) =0.005
  Survival (%) 96. 66 98. 9

Table iv. Full and gestational age specific in hospital pre discharge morbidity in Qatar compared with VON data (30–32 weeks).

Table four. Total and gestational historic period specific in hospital pre discharge morbidity in Qatar compared with VON data (30–32 weeks).
Gestation N CLD due north (%) PDA n (%) NEC n (%) IVH G-Iii due north (%) IVH Thousand-4 n (%) Cystic PVL n (%) ROP ≥Stage 3 due north (%)
  29 Weeks 62 five (viii.1) five(viii.06) two(three.22) three(4.81) 1 (1.61) 2(3.ii) 11(17.74)
  thirty Weeks 116 vii (6.0) 12(10.34) 7(6.03) 1 (0.86) one (0.86) one(0.86) 8(6.89)
  31 Weeks 155 3 (i.94) 3(ane.93) 4(ii.58) 1 (0.65) 0 0 8(five.sixteen)
  32 Weeks 264 i (0.38) 0 ii(0.75) 0 1(0.38) 0 seven(2.65)
Total 597 16 (two.68) 20(3.35) 15(2.51) 5(0.84) 3(0.5) 3(0.5) 34(five. 69)
VON* 1,1523 1,498(13%) one,498(thirteen%) 346(3%) 115(one%) 115(1%) 115(1%) 115(1%)
p-value** <0.0001 <0.0001 =0.57 =0.86 =0.32 =0.32 <0.0001

Table 5. Comparative Analysis of in hospital pre discharge Morbidity Rates for 1,001–one,500g nascence weight babies: Qatar versus NICHD, Trento and UAE.

Table 5. Comparative Analysis of in hospital pre discharge Morbidity Rates for 1,001–1,500g birth weight babies: Qatar versus NICHD, Trento and UAE.
Study N CLD n (%) PDA northward (%) NEC n (%) IVH G-3 n (%) IVH Thou-four n (%) Cystic PVL n (%) ROP ≥Stage 3 n (%)
NICHD24 ix,841 * (10) * (18) — * (5) * (2) * (ane.5) —
Trento 30 166 ii (ane.2) 16 (9. 6) i (0.six) 2 (1.2) 3 (ane.eight) four (ii.four) 0 (0)
UAE31 110 vi (5.five) — v (iv.5) one (1) 0 (0) 1 (1.1) 0 (0)
QATAR** 282 15 (five. 3) twenty (7.i) ten (three.five) 5 (1.viii) 4 (1.four) 3 (1.1) 7 (2.5)

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