Respiratory support with Continuous Positive Airway Pressure in preterm neonates: an analysis of coverage and quality of care in 66 neonatal units in Kenya, Malawi, Nigeria and Tanzania implementing with the NEST360 Alliance
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Background
Prematurity is the leading cause of child deaths worldwide, with the highest neonatal mortality in sub-Saharan Africa. Respiratory distress syndrome (RDS) is the leading mortality pathway in preterm neonates, but continuous positive airway pressure (CPAP) has high impact. This analysis reports CPAP coverage and quality-of-care for preterm neonates admitted to 66 neonatal units in Kenya, Malawi, Nigeria and Tanzania.
Methods
Analyses used individually-linked neonatal inpatient data and cross-sectional health systems data. All admitted neonates were eligible for inclusion (January 2021–December 2024). Service readiness for CPAP delivery and mean CPAP coverage were described for CPAP-eligible newborns (weighing <1500G and symptomatic newborns >1500g). Quality-of-care cascades were constructed to illustrate key indicators. Survival among CPAP-eligible neonates was analysed using regression models, stratified by clinical severity scores.
Results
375,255 newborn admissions were analysed in 66 neonatal units. Functional CPAP availability varied with median 16% of days (IQR: 4-47%) classified as high demand (>1.5 eligible newborns per CPAP). Of 64,761 CPAP-eligible neonates, 22,006 (34%, 95% CI 33-34%) received CPAP. All countries showed improvement in CPAP coverage, with Tanzania’s hospitals recording 63% increase in mean coverage (p-value=0.001) over time. Quality-of-care cascades showed treatment was initiated <24 hours after birth and continued for >1 day for 42% (95% CI 41-43%) of eligible neonates receiving CPAP. Only 10% of neonates <1500g started CPAP within the first hour of life. Among newborns on CPAP, 55% also received KMC (from 48% in Tanzania to 88% in Nigeria). Among newborns with high clinical severity, those treated with CPAP had a higher probability of survival (32%, 95% CI 29–36%) than those who were not (23%, 95% CI 21–26%). Odds of survival were higher for CPAP-eligible newborns whose mothers received antenatal corticosteroids (aOR 1.07, p=0.001). Lower aOR of survival was associated with hypoglycaemia (aOR 0.71, p<0.001), respiratory distress (aOR 0.91, p<0.001), and outborn newborns (aOR 0.72, p<0.001).
Conclusion
CPAP coverage and quality are critical for premature neonates. Clinical cascades highlight quality gaps, particularly in timely prophylactic CPAP initiation and appropriate duration. Improving comprehensive care quality for newborns on CPAP, including provision of co-interventions and maternal antenatal corticosteroids, can improve survival for preterm neonates.
KEY FINDINGS
WHAT WAS KNOWN?
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Respiratory distress syndrome (RDS) is the leading pathway to mortality in preterm neonates, but continuous positive airway pressure (CPAP) is a high-impact intervention and recommended by WHO.
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There are health systems barriers to CPAP implementation in low- and middle-income country (LMIC) settings. No current published reports analyse large-scale coverage of CPAP in neonatal units across sub–Saharan African contexts or report on quality of care.
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There is a gap in published clinical severity scores in LMICs which can be used in statistical analyses to predict survival.
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NEST360 Alliance is supporting governments to implement small and sick newborn care in hospitals in Malawi (national scale), Kenya, Tanzania, and Nigeria, with a focus on high-impact interventions such as CPAP.
WHAT WAS DONE THAT IS NEW?
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This multi-site analysis described service readiness, coverage, and care quality for over 370,000 inpatient neonates in 66 neonatal units, using individually-linked clinical data routinely collected from newborn admission records.
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Individual-level data were used to assess CPAP quality-of-care with novel quality-of-care cascades, enabling visualisation of quality at multiple steps in the care pathway during neonatal admissions.
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A clinical severity score predicting survival was developed to understand outcomes among CPAP-eligible neonates.
WHAT WAS FOUND?
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Limited CPAP equipment availability was demonstrated by nearly one-third (31%) of days having ≥1.5 eligible babies per device.
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CPAP coverage increased over time in all countries, with the largest increase in Tanzania from 25% to 88% over three years.
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CPAP quality-of-care cascades pooled across all sites showed 42% of eligible neonates who received CPAP were initiated within the first day of life and continued for at least one day. Among neonates under 1500g, only 10% started CPAP within the first hour of life.
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High clinical severity leads to death without CPAP (predicted probability of survival 23%, 95% CI 21–26%), but survival improves with CPAP (predicted probability of survival 32%, 95% CI 29–36%).
WHAT NEXT?
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Both CPAP coverage and quality are critical for premature neonates. Neonatal units in similar high-burden settings can apply clinical care cascades to improve care quality for the right babies at the right time.
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The respiratory care package also includes antenatal corticosteroids and prevention/ management of apnoea of prematurity. Stronger linkages between maternal and newborn care would improve this package. Future analyses could assess co-coverage with this more comprehensive respiratory care bundle.
