Introduction

Globally, neonatal mortality rate has decreased from 36.6 deaths per 1000 live birth to 18.0 deaths per 1000 live birth between the year 1990 and 2017 [1]. The rate of decline in sub Saharan Africa needs to be accelerated to achieve the Sustainable Development Goals (SDG’s) by 2030 [1]. In Tanzania, the current neonatal mortality rate is estimated to be 25 deaths per 1000 live birth [2], with institutional deliveries of 76% according to District Health Information Software (DHIS2) of 2018. Considerable efforts have been emphasized on quality facility based care including investment in network of care to facilitate survival [3]. A large number of inter facility transfer is already happening and it is likely to increase.

Referral system challenges such as inadequate transportation, lack of communication, poor documentation and lack of monitoring have been established as factors impeding the stride towards reducing neonatal mortality in developing countries [4]. A well-established referral system is key to transfer neonates to a tertiary care facility [5–7].

Transportation of a neonate from one facility to another under ideal conditions is still a challenge in many developing countries, Tanzania included. Most of the neonates arrive in poor clinical conditions, which are mostly preventable. Previous studies have shown that hypothermia, hypoglycemia, poor perfusion and hypoxia are associated with increased mortality among transported neonates [8–12].

There is enough evidence to support that transport by a skilled organized team reduces neonatal morbidity and mortality [9, 13, 14]. The goal of all neonatal transport teams should be transporting a well-stabilized neonate. Pre transport stabilization is crucial; this entails securing the patency of the airway, breathing and circulation. Pre-transport procedures such as establishing an intravenous access should be carried out before arrival of the transport team [15, 16] and continuous monitoring is needed on the way to a higher facility.

Despite the effort to strengthen the referral system in the country and the improvement of health care delivery in terms of infrastructure and manpower, the outcome of referred neonates is still poor. According to raw data collected in 2020 from the tertiary facility, Muhimbili National Hospital (MNH), neonatal mortality among the out-borns is almost twice as high compared to the in-borns admitted at the same neonatal unit.

This study aimed at describing the transport characteristics (i.e. mode of transport, equipment, communication, accompanying personnel, pre referral care and monitoring enroute) for the referred neonates. Additionally, it sought to assess the clinical status at admission in terms of the presence of hypothermia, hypoxia, perfusion and hypoglycemia for the transported neonates to Muhimbili National Hospital (MNH). Furthermore, it determined 48 hours’ outcome and its associated factors in relation to the admission clinical status of referred neonates.

Materials and methods

Results

Baseline characteristics of the study participants

A total of 349 referred neonates were recruited during the study period, one was excluded from the study due to a congenital anomaly which was incompatible with life (anencephaly). Fig 1 shows the proportion of participants received at Muhimbili National Hospital (MNH), Upanga stratified by referring districts of Dar es Salaam, Tanzania. Out of the 348 neonates, 207 (59.5%) were term babies while 141 (40.5%) were preterm. Majority were male babies 197 (56.6%) with 258 (74.1%) neonates delivered by spontaneous vaginal delivery (SVD) while 85 (24.4%) were born via caesarean section. The median gestation age was 38 weeks (IQR; 32–39) with the mean birth weight of 2455 ± 938 g. The mean age at admission was 1.78 ± 0.757 days. Table 1 describes the socio- demographic and clinical characteristics of the study participants.

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Fig 1. Flow of the study participants referred from various districts of Dar es Salaam, Tanzania.

https://doi.org/10.1371/journal.pone.0269479.g001

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Table 1. Socio-demographic and clinical characteristics of study participants, N = 348.

https://doi.org/10.1371/journal.pone.0269479.t001

Ambulance characteristics

For those who came with an ambulance 308, 294 (95.5%) had an oxygen supply, but in 42.5% of those the oxygen delivery system was not functioning. Only 201 (65.3%) had resuscitation equipment such as Ambu bag packed in the ambulances. Resuscitation drugs such as adrenaline were included in 200 (64.9%). Monitoring equipment were not available in 104 (33.8%) ambulances. IV fluids were present in 237 (77.0) while only 184 (59.7%) had suction apparatus. No ambulance had an incubator.

Fig 2 summarizes coverage gap during the referral journey of a newborn in Dar es Salaam, Tanzania.

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Fig 2. Coverage gap during the referral journey of a newborn in Dar es Salaam, Tanzania.

https://doi.org/10.1371/journal.pone.0269479.g002

Admission clinical status and outcome at the receiving facility, MNH

Seventy-eight neonates (22.4%) died within 48 hours of admission. On arrival, the clinical status of the neonates were as follows; 115 (33%) hypothermic, 74 (21.3%) hypoxic, 30 (8.6%) with poor perfusion and 49 (14.1%) hypoglycemic. Those with hypothermia (< 36.5°C), were two times more likely to die compared to those who were normothermic (OR = 2.09, 95% CI (1.05–4.20), p = 0.037). Thirty-eight (50.7%) of those who had hypoxia (SPO2 < 90%) at arrival died compared to thirty-seven (49.3%) who survived (OR = 2.88, 95%CI (1.44–5.74), p = 0.003). Twenty-one (67.7%) neonates with prolonged capillary refill time (CRT) died compared to ten (32.3%) who survived (OR = 4.76, 95%CI (1.80–12.58), p = 0.002). Out of forty-nine neonates who arrived with hypoglycemia (RBG < 2.5mmol/l) twenty-one (42.9%) died in the first 48 hours (OR = 2.13, 95%CI (0.96–4.74), p = 0.064). Additionally, neonates who had hyperglycemia (RBG > 8.3mmol/l) on arrival were three times more likely to die compared to those who were euglycemic [(OR = 3.10, 95% CI (1.19–8.09) p = 0.021]. Table 2 summarizes the results of univariate and multivariable analysis of factors associated with mortality.

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Table 2. Univariate and Multivariate analysis of factors associated with mortality.

https://doi.org/10.1371/journal.pone.0269479.t002

The combined effect of poor clinical status on admission in terms of hypoglycemia, hyperglycemia, hypoxia, prolonged CRT and hypothermia were associated with increased mortality as shown in Fig 3.

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Fig 3. Combined effect of exposures on newborns mortality outcome at 48 hours post admission at Muhimbili National Hospital.

https://doi.org/10.1371/journal.pone.0269479.g003

Discussion

Despite its importance, neonatal transportation has often been overlooked in resource constrained and poor countries like Tanzania [16, 22, 23]. Due to lack of organized neonatal transportation system, most of these neonates arrive in poor clinical condition which influence their outcome negatively [5, 8]. This study assessed the gaps on pre referral care, neonatal transportation, admission clinical status and outcome of the referred neonates at MNH–Upanga, a tertiary facility in Dar es Salaam, Tanzania.

In our study, nineteen percent of the neonates were referred due to lack of a newborn unit in their facilities, seven percent had no equipment while almost half of others were referred for specialized medical or surgical care. Improving level of care in institutions including establishment of well-equipped neonatal units could reduce referrals and mortality of newborns. The ministry of health, Tanzania in collaboration with the Newborn Essential Solutions and Technologies (NEST360) program have been improving neonatal infrastructures, installing equipment and providing in service training to strengthen neonatal care in hospitals across three regions (Dar es Salaam, Mbeya and Moshi) since early 2020. The phase I implementation of NEST 360 program is focusing on regional and tertiary facilities in a stepped wedged approach. While it’s clear that the program is influencing the neonatal care, it’s too early and challenging to link the measurements due to lack of baseline data. Currently, all the three regional referral hospitals in Dar es Salaam have been upgraded to level 2 plus with ongoing quality improvement and mentorship within the region. The findings of this study may provide highlights on baseline data for future studies. Strengthening harmonized health services and investing in coordinated network of care is of paramount importance to ensure safe transfer and survival for those in need.

Pre transport care is pivotal before transfer to a higher facility and is generally agreeable that for a quality transport and desirable outcome, stabilization prior to transfer is mandatory [24]. A study by Narang et al. demonstrated an overall decrease in mortality among neonates in whom lifesaving interventions were done pre referral [25]. In our study, we focused on TOPS model and we noted that temperature was measured in more than half of the neonates prior to transfer. In more than half of the referred neonates neither oxygen saturation nor random blood glucose was measured or documented. Twenty percent of the neonates were transferred without a secured intravenous line which is vital for institution of drugs during resuscitation. In the majority, there was no documentation of what was done, for example to those who were found to be hypothermic. It is clear that poor pre transport care contributed to poor conditions at arrival with subsequent poor outcome. These findings have been documented in previous studies [26, 27]. Knowledge, skills and competence of health professionals is key to saving lives at first level referral facilities, this gap need further attention toward quality newborn care.

Three quarters of the referred neonates were brought in without any notification given to the neonatal unit that could give room for preparation and advice. This finding is similar to the study done by Abdulraheem et al. in Ibadan Nigeria which showed no communication or documented information regarding the clinical stability of any of the neonates prior to transfer [16]. In Tanzania, the referring institution is tasked with providing the escorting personnel and pre referral communication of the case. Our study has shown that in addition to lack of communication, most of the times staff who will render minimal interruption to the hospital running are utilized rather than competent nurses who can support a neonate in the ambulance. Quite a number of neonates were escorted by nurse attendants 73 (21.5%) who were not trained to provide that level of care. Furthermore, this study found more than half of the escorting health care personnel lacking training on essential newborn care. A study done in Jamaica reported one in three of the personnel accompanying the neonate were not skilled in neonatal resuscitation [15]. Transfer of neonates by trained personnel has shown to reduce morbidity and mortality [28]. Improvement in communication system and skills on emergency care is needed.

The preponderance of neonates who were referred to our facility came with hospital organized ambulances at 308 (88.5%) compared to other modes of transport. This is different from studies done in Ghana and Nigeria whereby majority of neonates were brought in by taxis and private vehicles at 36% and 43.9% respectively [16, 23]. The findings are consistent with the study done in the EThekwini health district of KwaZulu-Natal, South Africa whereby all the referrals were transported by ambulance [29]. In Tanzania, ambulance services are cost free in all government owned facilities this could explain why many neonates were brought in using ambulances. Nonetheless, it is worth noting that despite the availability of ambulance, inadequate equipment and functionality were observed. Lack of equipment such as patient monitors impedes actions that could be taken to reverse deterioration during transport. It is not surprising that many neonates arrived at the tertiary hospital in unsteady clinical conditions i.e poor perfusion, hypoxic, hypoglycemic and hypothermic.

Most ambulances had oxygen supply similar to a study done in Bangladesh [30], in our study only 57.5% of the oxygen delivery system were functional. This fact plus lack of monitoring during transport clearly could have contributed to a number of neonates arriving hypoxic at the facility. Similar to our findings, a study by Mehta et al. done in India using the TOPS model established that neonates who had hypoglycemia and prolonged capillary refill time on admission had an overall poor outcome compared to their counterparts [19]. Additionally, we found a number of neonates who were hyperglycemic, had significant higher odds of mortality. These could have been neonates whose blood sugar levels were not monitored and some were given continuous infusion of glucose without any blood glucose check. Monitoring during transportation is critical, ambulance services need to be coordinated.

Dar es Salaam has a tropical climate located 16m above sea level with an average annual temperature of 26.1°C. Despite this fact, one third of the neonates were hypothermic on admission which was associated with increased mortality. This finding is similar to studies done in low resource settings in Ghana and India where almost half of the neonates were found to be hypothermic [23, 25]. A study which was done on the same setting in 2003 by Manji et al. found a threefold increase in mortality and morbidity among hypothermic neonates [11]. Hypothermia in our study was contributed by lack of monitoring during transport and inferior means of maintaining warmth as more than two third of the referred neonates were covered by only light local clothes such as khanga and kitenge. Most facilities could not afford incubators in their ambulance, nevertheless the practice of KMC which has been shown to be cheap and effective in preventing hypothermia was observed in only 2% of the transferred neonates. In a study conducted by Rathod et al., in southern India, KMC practice was not observed at all [22].

The overall mortality of neonates 48 hours post admission was 22%. Furthermore, a correlation between poor clinical status on admission in terms of hypoxia, hypothermia, hyperglycemia and poor perfusion with increased risk of mortality 48 hours post admission has been demostarted in previous studies [9–12]. For example, persistent hypothermia in newborns can lead to complications such as infection, hypoglycemia, and metabolic acidosis, and increase the risk of late-onset sepsis [31, 32]. Managing hypothermia and maintaining a healthy temperature in neonates is essential to survival of the particularly vulnerable newborn [31, 33]. All these are preventable conditions, if tackled appropriately could increase survival of the newborns.

Overall, this study demonstrates inadequate pre transport care, documentation and lack of monitoring enroute contributing to poor clinical conditions of neonates at admission. Emphasis has to be placed on having coordinated ambulance services, strengthening referral system and pre referral care to neonatal transportation. Additionally, ensuring continuous training to health care workers on neonatal resuscitation and essential newborn care is key. Regional and national coordination is needed to strengthen the referral system network.

Our study may have been exposed to recall bias as some of the information relied on the escorting health personnel. Hawthorne effect can’t be ignored as the behaviors might have changed on the course of the study including improvement in the referral and transportation of neonates as they become aware they are being observed. Limitation in recording full data due to poor/incomplete documentation based on the referral forms, consequently contributed to the inadequate data of pre-referral care assessment, reasons for referral and monitoring enroute information. Despite the limitations, the findings reflect the gaps of referral system which need to be improved for quality care of newborns at the primary and secondary levels. Further studies are required to learn on barriers and facilitators of effective referral at all levels of care. All efforts should be done to ensure every small and sick newborn with condition(s) that cannot be managed effectively with available resources receive appropriate, timely referral through integrated newborn service pathways with continuity of quality care, including provisional of warmth using cost effective measures such as KMC during transportation.

Supporting information

Acknowledgments

The authors acknowledge all staff at Muhimbili National Hospital, all caregivers/guardians of neonates, escorting persons and nurses who made this study possible to accomplish what we have. We are particularly obliged to Dr. Robert Moshiro and all members of Peadiatrics and Child Health Department at MNH and MUHAS. We would like to dedicate this work to our mentor, neonatologist, a father and a neonatal champion in Tanzania, the Late Dr. Augustine Massawe. May his soul rest in peace, Amin.