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 a neonatal ward, recording daily admissions and tracking outcomes over the course of hospitalization. During 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’s resources, 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 immediately after birth. Babies born elsewhere were more likely to come in at least one day after birth. Having availability to perform cesarean sections was also a factor; babies born vaginally had poorer survival, indicating an unmet need for surgical intervention. Over the course of 25 months, one in four neonates was taken home by their families before discharge. Three community health workers attempted to follow-up with these families, but were not able to make contact due to missing or incorrect contact information. Having a social worker and establishing a fund to assist families with food and lodging costs could have alleviated some of the financial stress that likely drove these families’ decisions to depart the hospital early.
The proportion of preterm babies and those born with 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 a lack of imaging and laboratory facilities. Hypoxia and infection represented a majority of the diagnoses made. Of note: perinatal hypoxia results from an insufficiency in the baby’s oxygen supply during the intrapartum and postpartum periods. A “hypoxia” diagnosis was given to babies that had “no cry at birth,” meconium aspiration, surfactant deficiency, fetal distress, and/or 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 HIC, indicating that the sickest babies were also those who were transferred right at birth, as opposed to babies born elsewhere who likely died before being brought in, thus contributing to potential selection bias in our sample. We did not record the 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 gestational age (31%) versus those that were 32–26-weeks gestational age [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 day-to-day ward operations, which showed us that, over the period of the study, there was considerable variability in the delivery of neonatal care. 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 also 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.
Another unexpected challenge was the lack of communication between the maternity and neonatal wards. Despite our 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 the maternity ward 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 to remedy. Communication between doctors and nurses was also stifled, and it was unclear to what extent nurses had the power to affect working conditions. Infrastructure was poor across the hospital, due to a piecemeal, project-by-project approach to building capacity that had left a 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 thus needs to account for the overall working conditions of the host institution.
There are a few notable strengths to this work. We critically examined hospital neonatal mortality in Haiti and discuss implications for future programming. We were able to collect data on relevant indicators, since the service was newly established in the hospital and we were able to create 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 on retrospective chart reviews. We were also able to identify and highlight ongoing data-quality issues for staff by performing periodic reviews of the service-delivery outcomes for the ward and field visits by the Dartmouth team. We benefitted from the tireless effort of the pediatricians to document each and every data point, and to alert us of any discrepancies with due notice. While we could not do anything about data that were missing all-together, we did trust that the data we collected were of the highest quality.
This study 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, i.e., including the 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 set 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 ultimately 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 were not able to 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 do not believe that neonatal mortality programs should run independent of maternal programs, whatever the cost.