Resuscitation of preterm infants in Nigeria - A national survey on practice

Preterm births constitute a major clinical problem associated with significant morbidity and mortality in the perinatal, neonatal, and childhood periods. Decisions around initiating and/or continuing resuscitation and treatment of preterm infants (PI) both at birth and afterwards need careful consideration. While the developed countries have published guidelines for the resuscitation and care of the PI, this is not the case in developing countries where availability of resources and the absence of a published guidelines impacts on practice. Our study was therefore carried out to access the practice and decision-making that surrounds the resuscitation of PIs by neonatologists and neonatal nurses working in neonatal intensive care units (NICU) across Nigeria.

We conducted an online national survey on neonatal care providers working in level 2 and level 3 neonatal units (NICU) across Nigeria. Around 190 participants were selected from the six geopolitical zones of the country and they were asked about current practices relating to resuscitation and stopping life-sustaining treatment as well as estimated survival rates at different gestational ages (GA).

In total, 138 clinicians responded to our survey. Of this, 73% completed the survey. Majority (83%) of the respondents worked in government-funded public hospitals while the remaining 17% worked in the private hospitals. 74% of the respondents' report having a guideline on the PI. Resuscitation practice varied amongst different neonatologists and neonatal nurses with 48% of the clinicians providing resuscitation at 23-26 weeks and the remainder providing resuscitation at a GA >26 weeks with a median GA threshold for initiating resuscitation at 27 weeks. From an institutional perspective, 75% of PIs <26 weeks were resuscitated in public hospitals while the remaining 25% were resuscitated in private hospital, however this is not statistically significant (P = 0.385). In situations when the GA is unknown, we found a median fetal weight of 700 g as the threshold for providing active treatment. We noticed wide variations in responses on the estimated survival rates of the PIs, however a common finding is the increased chances of survival with increasing GA. Also, PIs across all GAs had higher chances of survival in public hospitals than in private hospitals, however, this is not statistically significant (P = 0.385-0.956). The major factor influencing a clinicians' decision to limit resuscitation was the "risk of poor quality of life" (50%) and the prevalent way of palliating the newborn amongst respondents is by stopping life-sustaining treatment (34%).

Our survey revealed considerable variation in resuscitation practices amongst different neonatal care providers. Having a framework that will formulate and publish a national guideline based on factors like local survival rates, societal norms, and resources and ensuring that it is adopted by all NICUs will generate greater consistency of care.