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Confidential: For Review Only Prospective cohort study of mortality risk factors of very low birth weight infants in the Eastern Cape Province, South Africa.

Journal: BMJ Paediatrics Open

Manuscript ID bmjpo-2020-000918

Article Type: Original research

Date Submitted by the 23-Oct-2020 Author:

Complete List of Authors: Michaelis, Isabel; Walter Sisulu University, Paediatrics Manyisane, Ncomeka; Walter Sisulu University, Paediatrics Krägeloh-Mann, Ingeborg; Eberhard Karls University Tübingen Faculty of Medicine, Children's Hospital, Neuropaediatrics, Developmental Neurology, Social Paediatrics Mazinu, Mikateko; South African Medical Research Council, Biostatistics unit Jordaan, Esme; South African Medical Research Council, Biostatistics unit http://bmjpaedsopen.bmj.com/ Keywords: Neonatology, Mortality

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the termsConfidential: applicable for US Federal Government For officers Review or employees actingOnly as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author unless you are acting as an employee on behalf of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34

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3 Title Page bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Mortality risk factors of Very Low Birth Weight infants at a tertiary hospital in the Eastern 8 Cape, South Africa. 9 10 11 Isabel Michaelis, MD, PhD, Walter Sisulu University, East London 12 Confidential: For Review Only 13 Ingeborg Krägeloh- Mann, Prof for Pediatrics, Eberhard Karls University of Tübingen, 14 Tübingen 15 Ncomeka Manyisane, McBCh, FcPaed, Walter Sisulu University, East London 16 17 Mikateko Mazinu, MSc Biomathematics , South African Medical Research Council, 18 Tygerberg 19 20 Esme Jordaan, MSc Statistics, African Medical Research Council, Tygerberg 21 22 23 24 Corresponding author: Isabel Michaelis, Private Bag 9047, Amalinda Main Road, 5200 East 25 London, Tel: +27 (43) 709 2077, Fax: +27 (43) 709 4065. [email protected] 26 27 28 29 Key words: neonatology, mortality risk factors, sub Saharan Africa, global health 30 Word count: 2512 words 31 32 33 34 Possible reviewer:

35 http://bmjpaedsopen.bmj.com/ 36 37 Natasha Rhoda ([email protected]) 38 39 Christian Gille: [email protected] 40 41 Dania Ballot: [email protected] 42 43 44

45 on September 27, 2021 by guest. Protected copyright. 46 I hereby confirm, that the submitted paper or any parts of it have not been published or 47 submitted anywhere else, nor been presented as an abstract or poster. 48 49 50 51 52 53 Dr Isabel Michaelis 54 55 56 57 58 59 60

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3 Prospective cohort study of mortality risk factors of VLBW infants in the Eastern Cape, South bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Africa. 6 7 Isabel Michaelis, MD, PhD, Walter Sisulu University, East London 8 Ingeborg Krägeloh-Mann, Prof for Pediatrics, Eberhard Karls University of Tübingen, Tübingen 9 10 Ncomeka Manyisane, McBCh, FcPaed, Walter Sisulu University, East London 11 12 Mikateko Mazinu,Confidential: MSc Biomathematics , South AfricanFor Medical Review Research Council, OnlyTygerberg 13 Esme Jordaan, MSc Statistics, African Medical Research Council, Tygerberg 14 15 16 17 Contact: [email protected] 18 19 20 I hereby confirm, that the submitted paper or any parts of it have not been published or 21 submitted anywhere else, nor been presented as an abstract or poster. 22 23 There is no conflict of interest. This work was supported by the South African Medical 24 Research Fund, grant number (086/2017). The sponsorship of the SAMRC Pilot Grant 25 serves to encourage clinicians in rural South Africa to engage in research. 26 27 28 29 Dr Isabel Michaelis contribution consisted of funding acquisition, study design, investigation, 30 data curation, supervision and drafting the initial manuscript. 31 32 Dr Ncomeka Mayisane contributed to study design, investigation, data curation and 33 reviewing the manuscript. 34

35 Prof Ingeborg Krägeloh-Mann contribution consisted of supervision and writing and http://bmjpaedsopen.bmj.com/ 36 reviewing the final manuscript. 37 38 Mrs Mikateko Mazinu contribution consisted of data curation and data analysis. 39 40 Mrs Esme Jordaan contribution consisted of data curation and data analysis. 41 42 43 What is known about this topic? 44 45 Neonatal mortality rate in South Africa is 32 % of the under five- year mortality rate. on September 27, 2021 by guest. Protected copyright. 46 47 Preterm and very low birth weight babies are most affected. 48 49 Studies about neonatal mortality have been done in the main cities in South Africa. 50 51 52 53 54 What does this study add? 55 56 To our knowledge this is the first prospective study about the mortality rate and mortality risk 57 factors of VLBW infants in the Eastern Cape of South Africa. 58 59 It shows that the chance of survival for those babies is lower than in other urban settings. 60

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3 Equipment, facilities, skills and staffing should be improved in those settings. bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 8 9 10 11 12 Confidential: For Review Only 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Background: 8 9 Neonatal mortality is worldwide a major contributor to the number of deaths in children under 10 5 years of age. The primary objective of this study was to assess the overall mortality rate of 11 12 babies withConfidential: a birth weight of less than 1501 For g in aReview neonatal unit at a Onlytertiary hospital in the 13 Eastern Cape Province, South Africa. Furthermore, different maternal and offspring related 14 15 risk factors for mortality were analysed. 16 17 Methods: 18 19 This is a prospective cohort study which included babies admitted to the neonatal wards of 20 21 the hospital within their first 24 hours of life and with a birth weight below 1501 g. 22 23 24 25 26 Results: 27 28 173 infants were admitted to the neonatal department with a birth weight below 1501g. The 29 overall survival rate to hospital discharge was 68%. Only 46.5% of babies born with a birth 30 31 weight below 1001 g survived their hospital stay. 32 33 Main predictors for survival were higher gestational age and higher birth weight. Need for 34

35 ventilator support and sepsis increased mortality risk significantly, as did maternal factors http://bmjpaedsopen.bmj.com/ 36 such as HIV infection or teenage age. Babies born to a mother with gestational hypertension 37 38 had a two-fold increased chance of survival. 39 40 41 42 Conclusion: 43 44

45 This is the first prospective study looking at survival of very low birth weight babies in the on September 27, 2021 by guest. Protected copyright. 46 underprivileged part of the Eastern Cape of South Africa. Compared to better resourced 47 48 public hospitals in the country the survival rate remains unacceptably low. More needs to be 49 done to prevent preterm and low birth weight births; the facilities caring for these most 50 51 vulnerable persons must be equipped and staffed accordingly. 52 53 54 55 56 57 58 59 60

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Introduction: 6 7 Despite improved survival rates of neonates worldwide, the survival of preterm and low birth 8 weight babies is still challenging, especially in middle and low-income countries (1–4). 9 10 11 In 2018 the WHO described a worldwide increase of babies born prematurely over the last 12 two decades.Confidential: The incidence has been estimated For betweenReview 5–18% (5,6). Only The rate of babies 13 14 born with a very low birth weight (VLBW) varied between different countries, for example it 15 has been found to be 3% in South Africa, while in the USA it is between 1.23 and 1.43% (7– 16 17 9). Furthermore, prematurity and low birth weight have been identified as the leading causes 18 19 of mortality in children less than five years of age (5,10–12). It is also well known that 20 neonatal mortality varies considerably amongst high and low-middle income countries for 21 22 example, a mortality rate of 15% in the United States, while India reports 24.6% for VLBW 23 infants (13,14). 24 25 26 In South Africa, neonatal mortality accounted for 32% of the under-5 mortality rate (4,15,16). 27 Kalimba and Ballot (17) studied the survival rate of extremely low birth weight (ELBW) 28 29 babies (babies weighing less than 1000g at birth) born between 2006 and 2010 in 30 Johannesburg and found that only 25.6% of babies born with a birth weight of less than 31 32 900g survived their hospital stay, with birth weight and gestational age being the strongest 33 predictors for survival. A newer retrospective cross sectional South African study found an 34

35 overall survival rate in VLBW babies (500g–1499 g) of 75.7% (18). http://bmjpaedsopen.bmj.com/ 36 37 However, there are other known contributory factors, which can be divided into offspring or 38 39 maternal related risk factors. Examples of baby related risk factors studied in the literature 40 are low Apgar scores, respiratory distress syndrome, intubation and mechanical ventilation, 41 42 sepsis and hemodynamic instability (Terzic and Heljic, 2012; Kabilan and Kumar, 2018). 43 44 Maternal or obstetric risk factors include eclampsia, alcohol consumption, smoking, low 45 socioeconomic status, scarce antenatal care and human immunodeficiency virus (HIV) on September 27, 2021 by guest. Protected copyright. 46 47 infection (17,21–23). Several studies suggest an increased risk for premature labour in 48 mothers taking antiretroviral treatment for HIV infection during pregnancy (24–27), while 49 50 others did not find a relationship (28). This is of note, as 30.8% of pregnant women in South 51 Africa in 2015 tested positive for HIV infection, and are put on treatment as soon as the 52 53 infection is diagnosed (Department of Health Republic of South Africa, 2017). 54 55 56 57 58 59 60

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3 Setting: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Frere Hospital is a public tertiary hospital in East London in the Eastern Cape Province in 6 7 South Africa, with a seven bed paediatric intensive care unit (PICU), which cares for 8 9 neonates, paediatric medical and surgical patients. Because of this very limited PICU 10 access, babies with a weight below 1000 g are not provided with invasive ventilatory 11 12 support.Confidential: These babies will receive surfactant For if needed Review and continuous Only positive airway 13 pressure (CPAP) ventilation is available for six infants in the high care neonatal unit. Stable 14 15 neonates with a weight >1000 g are referred to the general nursery ward, where they receive 16 17 kangaroo care (KMC) in the ward and, if necessary, intravenous fluids and/or antibiotics and 18 oxygen. Once clinically stable, off oxygen support, tolerating full enteral feeds and weighing 19 20 more than 1500 g, infants will be transferred to the KMC ward until mothers are competent in 21 caring for their baby and the weight has increased to at least 1700 g. 22 23 24 Frere Hospital is the tertiary neonatal and obstetric referral centre for obstetric units and for 25 surrounding district hospitals in the remote part of the Eastern Cape Province. These areas 26 27 were deprived from adequate infrastructure during the Apartheid regime and are still one of 28 most underprivileged parts of South Africa. 29 30 31 32 33 Materials and Methods: 34

35 This was a prospective cohort study. All babies born at, or admitted within the first 24 hours http://bmjpaedsopen.bmj.com/ 36 37 of life into the neonatal unit with a birth weight equal or below 1500 g and without any life- 38 threatening malformations were included (n=173). The recruitment period lasted from 39 40 December 2017 to November 2018. During this period 4207 babies were born at Frere 41 Hospital obstetric department. 42 43 44 After obtaining the approval of the institutional ethics committee (086/2017) and after

45 receiving written consent from the mother of the baby, data concerning mother and child on September 27, 2021 by guest. Protected copyright. 46 47 during the pre-, peri- and neonatal period were collected from the maternal and neonatal 48 case sheets, as well as from a questionnaire filled in with the mother (available as 49 50 supplements). The babies were followed up until discharge or death. All babies received 51 standard care during this period, as outlined above. 52 53 54 55 56 Patient and Public Involvement: 57 58 Infants born with a very low birth weight are followed up in a high risk clinic and often have to 59 60 be referred to a neurodevelopmental clinic for assessment. During these follow-up

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3 appointments the necessity for the check-ups is often questioned and if pathologies are bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 found the possible causes for those lye mostly in the perinatal and admission history. Being 6 able to answer those questions for our setting a study involving the postnatal admission stay 7 8 needed to be scrutinized. The patients, being mother-newborns pair, were not involved in the 9 10 study design. While doing the study and recruiting every new-born being admitted in our 11 wards with a birth weight below or equal to 1500g was assessed for inclusion in our study, 12 Confidential: For Review Only 13 no recruitment from there side was necessary. 14 15 The results of this study will be verbally communicated to the mothers during the follow-up 16 17 appointments. 18 19 Statistical analysis: 20 21 Demographic data is presented as frequencies (percentages) for categorical data, and as 22 23 means (SD) for numerical data. To test for association between the outcome variable 24 (mortality) and the predictor variables, a log binomial regression model was used. Multiple 25 26 regression analysis was performed for all significant variable from the baby and mother's 27 univariate analysis separately. A stepwise regression was used to exclude non-significant 28 29 variables one at a time. The standard for significance for all analyses was p<0.05. Data were 30 analysed using STATA version 15. 31 32 33 Offspring and Maternal multiple regression analysis: 34 These analyses include all variables with p value ≤ 0.1 from the baby univariate analysis 35 http://bmjpaedsopen.bmj.com/ 36 table. All variables with small cell number (n≤6) were excluded from the multiple regression 37 38 model. Apgar at 5 minutes was also excluded in the analysis due to colinear relationship 39 between Apgar 1 and Apgar 5. 40 41 42 43 44 Results:

45 on September 27, 2021 by guest. Protected copyright. 46 One hundred and sixty-one VLBW infants were recruited during the study period, of those 45 47 48 (28.0%) died before discharge and 116 (72.0%) were discharged home. All 116 babies 49 discharged home from Frere Hospital received a follow up date for the high-risk clinic (Figure 50 51 1). 52 53 54 55 Demographics: 56 57 Of the 161 babies included in the study, 96 were female (59.7%) and 65 were male (40.3%). 58 The mean birth weight was 1156 g (580 g – 1 500 g) with SD of 233 g. Almost three quarters 59 60 (73.4%) of the babies had a birth weight above 1000 g. The mean gestational age in weeks

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3 was 32.2 with SD of 2.6 weeks. About half were born at the gestational age of 26–32 weeks bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 (n=78; 49.1%). Most babies were delivered by normal vaginal delivery (n=97; 60.3%), to a 6 mother who was unemployed (n=135; 84.9%). More than a third of the babies (n=58; 36.0%) 7 8 were HIV exposed during pregnancy and birth. Almost all HIV exposed babies tested 9 10 negative for HIV infection at birth with a negative birth HIV-polymerase chain reaction (HIV- 11 PCR) (n=55; 94.8%). Three babies, who died a few hours after birth, did not receive an HIV- 12 Confidential: For Review Only 13 PCR at birth and their status is therefore unknown. 146 (91.8%) of the babies were 14 exclusively breastfed, nine were exclusively formula fed and four received mixed feeding. 15 16 17 The maternal age ranged between 14 and 46 years, with a mean maternal age of 27 years 18 (SD = 6.7). Eighteen percent of the mothers were teenagers (n=30). Only 13 (8.2%) of the 19 20 mothers were married, 78 (48.5%) were in a stable relationship and 67 (41.6%) mothers 21 were single. For 3 (1.9%) mothers, no such information was available. Less than half 22 23 (45.6%) of the mothers attended no or primary school only, while 54.4% went through 24 secondary or tertiary education. Almost 90% (89.9%) of the mothers lived in a house which 25 26 had electricity, but only 62.3% had running water on their property. Fifty-eight (36.0%) 27 28 mothers had HIV infection diagnosed before, during pregnancy, or at birth. Thirty-nine of 29 them (67.2%) had been on antiretroviral (ARV) treatment at delivery for more than 4 weeks. 30 31 Sixteen (27.6%) mothers had been on ARV treatment for less than 4 weeks or were not on 32 treatment at all when giving birth, and their babies were thus considered at high risk for HIV 33 34 transmission and treated accordingly.

35 http://bmjpaedsopen.bmj.com/ 36 The in-hospital survival rate for all babies born with a birth weight below 1500 g and admitted 37 to our neonatal wards was 118/173 (68.2%), and for the babies included in our study the 38 39 survival rate was 116/161 (72.0%). 40 41 42 43 44 Risk factors for in hospital mortality: 45 on September 27, 2021 by guest. Protected copyright. 46 Neonatal related risk factors: 47 48 Univariate regression analysis was used to examine the association between the outcome 49 50 death and individual risk factors. The significant risk factors were low gestational age 51 (p<0.0001; RR=4.2; 95% CI: 2.9–5.9), the need for resuscitation at birth (p< 0.0001; RR=4.5; 52 53 95% CI: 3.4–5.8) or during hospital stay (p=0.011; RR=12; 95% CI: 5.8–25.9), low 1 and/or 5 54 55 minute Apgar score (p≤0.0001; RR=2.5; 95% CI: 2.0–3.1 and p<0.0001; RR=2.4; 95% CI: 56 2.1–2.8), and sepsis (p<0.0001; RR=6.4; 95% CI: 3.8–10.9) were significantly associated 57 58 with death (table 1). Male gender was not associated with higher mortality risk (p=0.935; 59 RR=1.0; 95% CI: 0.7–1.5) (table 1). 60

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Table 1: Univariate analysis of risk factors associated with mortality in VLBW infants 6 7 8 n n* * ** ** 9 Description category % died %died SE P RR 95%CI 10 GA (weeks) 25-32 wks 78 49,06 36 46,2 3,28 11 33-37 wks 81 50,94 9 11,1 1,64 0,000 4,2 2,93 5,88 12 HIV exposedConfidential:no (0) 103 63,98For Review31 30,1 2,11 Only 1,2 1,00 1,56 13 14 yes (1) 58 36,02 14 24,1 2,42 0,053 15 birth weight >1000g (0) 118 73,29 22 18,6 2,31 2,9 2,08 3,96 16 <=1000g 17 (1) 43 26,71 23 53,5 3,73 0,000 18 Resuscitation at 19 birth no (0) 89 55,97 10 11,2 1,53 20 yes (1) 70 44,03 35 50 2,09 0,000 4,5 3,43 5,78 21 22 Apgar 1 min 7-10 (=0) 110 68,32 21 19,1 1,77 23 0-6 (=1) 51 31,68 24 47,1 2,23 0,000 2,5 1,99 3,05 24 Apgar 5 min. 7-10(=0) 144 89,44 35 24,3 1,66 25 0-6(=1) 17 10,56 10 58,8 0,000 2,4 2,12 2,77 26 27 HMD no (0) 85 52,8 16 18,8 1,50 28 yes (1) 76 47,2 29 38,2 3,03 0,000 2,0 1,72 2,38 29 Other no (0) 131 81,37 33 25,2 1,73 30 yes (1) 30 18,63 12 40 5,07 0,001 1,6 1,20 2,09 31 32 Oxygen support no (0) 50 31,06 2 4 0,63 33 yes (1) 111 68,94 43 38,7 2,42 0,000 9,7 7,39 12,68 34 Surfactant given no (0) 107 66,46 16 15 1,80 35 yes (1) 54 33,54 29 53,7 2,49 0,000 3,6 2,77 4,65 http://bmjpaedsopen.bmj.com/ 36 37 Weight gain no 85 64,89 6 7,1 1,12 38 yes 46 35,11 11 23,9 3,60 0,000 3,4 2,21 5,19 39 Sepsis no (0) 69 46,94 4 5,8 1,21 40 yes (1) 78 53,06 29 37,2 3,17 0,000 6,4 3,78 10,88 41 42 ICH no (0) 120 88,24 13 10,8 1,33 43 yes (1) 16 11,76 9 56,3 9,83 0,000 5,2 3,03 8,90 44 PDA no (0) 104 77,04 19 18,3 2,06 0,002 2,8 1,47 5,47

45 on September 27, 2021 by guest. Protected copyright. yes (1) 31 22,96 2 6,5 1,67 46 Resuscitation 47 during admission no (0) 112 74,17 7 6,3 2,45 48 49 yes (1) 39 25,83 30 76,9 2,12 0,011 12,3 5,85 25,88 50 Gender male (0) 65 40,37 18 27,7 3,74 51 female (1) 96 59,63 27 28,1 2.59 0,935 1,0 0,7 1,5 52 Born before 53 arrival no (0) 150 93,17 43 28,7 1,77 54 55 yes (1) 11 6,83 2 18,2 7,36 0,278 0,6 0,28 1,45 56 Mom not been to 57 ANC no (0) 136 84,47 37 27,2 1,97 58 yes (1) 25 15,53 8 32 3,40 0,218 1,2 0,91 1,52 59 *The number and percentage per risk factor category **The number and percentage of babies who died per risk factor category 60 SE standard error from the model

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3 RR relative risk with 95% confidence interval bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 GA: gestational age, HIV: human immunodeficiency virus, HMD: hyaline membrane disease, ICH: intracranial haemorrhage, 5 PDA: persistent ductus arteriosus, ANC: antenatal clinic. 6 Maternal risk factors for the univariate model: 7 8 The risk of dying while still in hospital was higher in babies of teenage mothers (p=0.004; 9 10 RR=1.2; 95% CI: 1.1–1.5) and if there was no refrigerator in the house the mother lived in 11 12 (p=0.038;Confidential: RR=1,2: CI: 1.01–1.48). Maternal For hypertension Review (RR=0,6; 95%Only CI: 0.5–0.8; 13 p=0.0001) and preeclampsia (RR=0,7: 95% CI: 0.6–0.8; p=0.0001) significantly decreased 14 15 the mortality risk in the babies. Education level of the mother and other socio-economic 16 status factors were not related to a higher mortality risk during admission in our study (table 17 18 2). 19 20 Table 2. The univariate associations between mortality and maternal related risk factors. 21 22 23 Description Codes n % n died %died P RR 95%CI 24 Age of mother 25 (years) <=20yrs 30 18,63 10 33,3 0,004 1,2 1,07 1,45 26 >20yrs 131 81,37 35 26,7 27 Marital status marr /stale rel 13 16,25 3 23,1 28 no partner 67 83,75 18 26,9 0,574 1,2 0,69 1,98 29 Substance 30 abuse no(0) 147 91,88 40 27,2 31 yes(1) 13 8,13 4 30,8 0,761 1,1 0,51 2,50 32 33 Hypertension no(0) 91 57,96 29 31,9 34 yes(1) 66 42,04 13 19,7 0,000 0,6 0,49 0,77

35 PROM no(0) 134 85,35 35 26,1 http://bmjpaedsopen.bmj.com/ 36 yes(1) 23 14,65 7 30,4 0,602 1,2 0,66 2,07 37 Pre-eclampsia no(0) 117 74,52 34 29,1 38 yes(1) 40 25,48 8 20 0,00 0,7 0,57 0,82 39 40 Other illnesses no(0) 125 79,11 31 24,8 41 yes(1) 33 20,89 11 33,3 0,023 1,3 1,04 1,74 42 Medication no(0) 130 81,25 40 30,8 43 yes(1) 30 18,75 4 13,3 0,004 0,4 0,25 0,77 44 Employment no(0) 135 84,91 39 28,9 45 on September 27, 2021 by guest. Protected copyright. yes(1) 24 15,09 5 20,8 0,055 0,7 0,52 1,01 46 47 Electricity no(0) 16 10,06 3 18,8 48 yes(1) 143 89,94 41 28,7 0,151 1,5 0,86 2,73 49 Running water no(0) 60 37,74 16 26,7 50 yes(1) 99 62,26 28 28,3 0,640 1,1 0,83 1,36 51 Refrigerator no(0) 50 31,45 12 24 52 yes(1) 109 68,55 32 29,4 0,038 1,2 1,01 1,48 53 54 Education Primary 72 45,57 22 30,6 0,119 1,3 0,94 1,66 55 secondary/tert 86 54,43 21 24,4 56 RVD infected no(0) 101 63,52 30 29,7 57 yes(1) 58 36,48 14 24,1 0,075 0,8 0,65 1,02 58 ARTs FTC 45 93,75 10 22,2 59 second line 2 4,17 0 0 60

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3 Other 1 2,08 0 0 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 PROM: premature rupture of membranes, RVD: retroviral disease, ARTs: anti-retroviral treatment 5 6 Offspring and maternal multiple regression analysis: 7 8 Significant independent statistical associations for many offspring-related variables could be 9 seen: Gestational age and birth weight with p<0.001: RR=1; 95% CI: 0.95–0.95 and 10 11 p=0.004: RR=1.2; 95% CI: 1.05–1.32 respectively. Exposure to an HIV-infected mother 12 Confidential: For Review Only 13 became significant: p<0.001: RR=2; 95% CI: 1.76–2.21. Resuscitation at birth (p<0.001; 14 RR=2.9; 95% CI: 2.25–3.69), HMD (p<0.001; RR=0.93; 95% CI: 0.93–0.93) and the 15 16 following necessity to give surfactant (p<0.001; RR=1.65; 95% CI:1.47–1.84) correlated with 17 an increased mortality risk. ICH was also found to be a significant risk factor for in-hospital 18 19 mortality with p<0.001; RR=2.01; 95% CI: 1.80–2.26. Unsurprisingly the need for 20 21 resuscitation during hospital stay correlated with an increased risk of dying (p=0.011; 22 RR=13.7; 95% CI: 7.17–26.19). 23 24 The multiple regression analysis of maternal risks showed, that being born to a mother with 25 26 hypertension was protective and decreased the risk of dying in hospital (p<0,001; RR=0.6; 27 28 95% CI: 0.51–0.77). The risk of mortality was 37% lower for the babies born to mothers with 29 hypertension compared to mothers without. All other maternal factors were non-significant in 30 31 the multivariate analysis. 32 33 34

35 http://bmjpaedsopen.bmj.com/ 36 37 Discussion: 38 39 40 The incidence of VLBW in our hospital was 41 in 1000 births for the year from December 41 2017 to November 2018 (95%CI: 35.0–47.7). The prevalence of VLBW in our hospital was 42 43 4,7%. This is a high prevalence of VLBW babies born compared to developed countries, 44 such as the USA with a prevalence of 1,4% (30), Europe between 0,8–1,2 (31) and China 45 on September 27, 2021 by guest. Protected copyright. 46 with 1,9% (32) but also compared to the prevalence found in Soweto, South Africa of 3% 47 48 and in Brazil of 0,9%–3% (1,7,33). However, it is within the prevalence of 3–7% reported 49 worldwide (3,13). 50 51 52 53 Survival of infants below 1000 g birth weight was 46.5% compared to 81.4% for those 54 55 weighing between 1000 g and below 1500 g at birth. The overall neonatal survival rates of 56 VLBW compare well with some other developing and developed countries in the last 15 57 58 years, with 63.1% in India (2), 70.9% in Iran (3), and 71.8% in South Korea (11) or 68% in 59 the Eastern Mediterranean Region (34). It is, though, lower than in other parts of South 60

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3 Africa where the survival rate was reported as 73.4%, 75% and 75.7% respectively bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 (18,35,36) and much lower than in most developed countries, where the survival rate was 6 found to be between 86.6% and 90.3% (12,23,31,32,37–42). This shows, that the Eastern 7 8 Cape Province lags behind other South African urban settings in the effort to improve the 9 10 survival of VLBW neonates. 11 12 Confidential: For Review Only 13 Consistent with other studies examining the causes of mortality in VLBW babies, birth weight 14 (specifically extremely low birth weight) and low gestational age were found to be major 15 16 predictors for neonatal mortality in our study population (17,20,23,31,35,43,44). 17 Complications of prematurity, such as the development of hyaline membrane disease and 18 19 the associated need for surfactant application was associated with a significant increased 20 21 risk of mortality. 22 23 Interestingly our study could not confirm the wide range of maternal factors increasing the 24 risk of death during admission found in other studies such as no antenatal care, premature 25 26 rupture of membranes, maternal primi-parity, mode or complication of delivery 27 28 (17,21,22,27,44,45). The only socio-economic factor showing in the univariate analysis as a 29 significant higher risk of baby dying during admission was when the mother was of teenage 30 31 age, and whether a refrigerator was present in the household the mother lived in. These 32 factors lost significance, however, when a multivariate analysis was used. Here exposure to 33 34 an HIV-infected mother became significant.

35 http://bmjpaedsopen.bmj.com/ 36 Infants born to mothers with hypertension had a better chance of survival than those born to 37 38 a mother who did not had hypertension. A multicentre prospective cohort study from Brazil 39 by de Alemida et al. found the same correlation (1). 40 41 42 Although a substantial percentage (36%) of the babies were born to HIV infected mothers, 43 all but three (who all died before HIV-PCR could be taken) were born with a negative HIV- 44

45 PCR infection. However, 17.2% (n=10) of the HIV infected mothers still had not received any on September 27, 2021 by guest. Protected copyright. 46 ART before giving birth. However, all mothers received prophylaxis in labour and their 47 48 babies were treated with nevirapine and zidovudine as high risk infants. 49 50 51 52 Conclusion: 53 54 55 Our study shows that the survival rate in VLBW babies is comparable to other developing 56 countries worldwide, but lower than in the urban hospitals of South Africa. Similar to the 57 58 findings of many other studies, gestational age and birth weight were the main baby-related 59 60

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3 predictors for survival, and HIV infection of the mother was the only maternal risk factor, bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 while pregnancy hypertension was found to be protective. 6 These findings indicate that the survival of VLBW and especially for ELBW babies are lower 7 8 in a setting with low resources. The Eastern Cape Province is known to be one of the most 9 10 disadvantaged areas in South Africa and this still has an impact on the survival of the most 11 vulnerable members of our society. 12 Confidential: For Review Only 13 14 15 16 17 18 19 20 21 22 23 24 25 Literature: 26 27 1. De Almeida MFB, Guinsburg R, Martinez FE et al. Fatores perinatais associados ao 28 óbito precoce em prematuros nascidos nos centros da Rede Brasileira de Pesquisas 29 30 Neonatais. J Pediatr (Rio J). 2008;84(4):300–7. 31 32 2. Basu S, Rathore P, Bhatia BD. Predictors of mortality in very low birth weight 33 34 neonates in India. Singapore Med J. 2008;49(7):556–60.

35 http://bmjpaedsopen.bmj.com/ 36 3. Afjeh SA, Sabzehei MK, Fallahi M et al. Outcome of very low birth weight infants over 37 38 3 years report from an iranian center. Iran J Pediatr. 2013; 23(5):579–587 39 40 4. Rhoda NR, Gebhardt GS, Kauchali S BP. Reducing neonatal deaths in South Africa. 41 42 S Afr Med J. 2018;3(1):S9–19. 43 44 5. World Health Organization. Newborns: reducing mortality. World Heal Organ 45 [Internet]. 2019;(September 2019):2018–21. Available from: on September 27, 2021 by guest. Protected copyright. 46 47 http://www.who.int/mediacentre/factsheets/fs178/en/ 48 49 6. Haas DM. Preterm birth. BMJ Clin Evid. 2011;2011(1):1–5. 50 51 7. Velaphi SC, Mokhachane M, Mphahlele RM, et al. Survival of very-low-birth-weight 52 53 infants according to birth weight and gestational age in a public hospital. South 54 55 African Med J. 2005; 95: 504-509. 56 57 8. Mackay CA, Ballot DE, Cooper PA. Growth of a cohort of very low birth weight infants 58 in Johannesburg, South Africa. BMC Pediatr. 2011;11:2–7. 59 60

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3 9. Martin JA, Hamilton BE, D P, Sutton PD, Ventura SJ, Menacker F, et al. National Vital bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Statistics Reports Births : Final Data for 2013. Statistics (Ber). 2015;64(1):1–104. 6 7 10. Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of under-5 8 9 mortality in 2000–15: an updated systematic analysis with implications for the 10 Sustainable Development Goals. Lancet. 2016;388(10063):3027–35. 11 12 Confidential: For Review Only 11. Hahn WH, Chang JY, Chang YS, et al. Recent trends in neonatal mortality in very low 13 14 birth weight korean infants: In comparison with Japan and the USA. J Korean Med 15 16 Sci. 2011;26(4):467–73. 17 18 12. Chung SH, Bae CW. Improvement in the survival rates of very low birth weight infants 19 after the establishment of the Korean neonatal network: Comparison between the 20 21 2000s and 2010s. J Korean Med Sci. 2017; 32(8):1228-1234 22 23 13. Fanaroff AA, Stoll BJ, Wright LL, et al. Trends in neonatal morbidity and mortality for 24 25 very low birthweight infants. Am J Obstet Gynecol. 2007; 196(2):147.e1-8 26 27 14. Bansal A. Comparison of outcome of very-low-birth-weight babies with developed 28 29 countries: A prospective longitudinal observational study. J Clin Neonatol. 30 2018;7(4):254. 31 32 15. Nannan N, Dorrington R, Laubscher R, et al. Under-5 mortaliy statistics in South 33 34 Africa: Shedding some light on the trend and causes 1997-2007. South African 35 http://bmjpaedsopen.bmj.com/ 36 Medical Research Council. 2012. 37 38 16. Bradshaw D, Dorrington R. Rapid Mortality Surveillance Report 2011. 2012. 39 40 17. Kalimba EM, Ballot DE. Survival of extremely low-birth-weight infants. SAJCH South 41 42 African J Child Heal. 2013;7(1):13–6. 43 44 18. Tshehla RM, Coetzee M, Becker PJ. Mortality and morbidity of very low-birthweight

45 on September 27, 2021 by guest. Protected copyright. 46 and extremely low-birthweight infants in a tertiary hospital in Tshwane. 2019;13(2). 47 SAJCH 2019; 13(2): 89-97. 48 49 19. Terzic S, Heljic S. Assessing mortality risk in very low birth weight infants. Med Arh. 50 51 2012;66(2):76–9. 52 53 20. Kabilan S, Kumar MS. Morbidity and mortality pattern of very low birth weight infants 54 55 admitted in SNCU in a South Asian tertiary care centre. Int J Contemp Pediatr. 56 2018;5(3):720–5. 57 58 59 21. Cupen K, Barran A, Singh V, etal. Risk Factors Associated with Preterm Neonatal 60 Mortality: A Case Study Using Data from Mt. Hope Women’s Hospital in Trinidad and

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3 Tobago. Children. 2017;4(12):108. bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 22. Vaahtera M, Kulmala T, Ashorn P, et al. Antenatal and perinatal predictors of infant 6 7 mortality in rural Malawi. Arch Dis Child Fetal Neonatal Ed. 2000;82(3):200–4. 8 9 23. Chen SD, Lin YC, Lu CL, et al. Changes in outcome and complication rates of very- 10 11 low-birth-weight infants in one tertiary center in southern Taiwan between 2003 and 12 Confidential: For Review Only 2010. Pediatr Neonatol [Internet]. 2014;55(4):291–6. Available from: 13 14 http://dx.doi.org/10.1016/j.pedneo.2013.10.010 15 16 24. Townsend CL, Schulte J, Thorne C, et al. Antiretroviral therapy and preterm delivery-a 17 18 pooled analysis of data from the United States and Europe. BJOG An Int J Obstet 19 Gynaecol. 2010;117(11):1399–410. 20 21 22 25. Van Der Merwe K, Hoffman R, Black V, et al. Birth outcomes in South African women 23 receiving highly active antiretroviral therapy: A retrospective observational study. J Int 24 25 AIDS Soc [Internet]. 2011;14(1):42. Available from: 26 http://www.jiasociety.org/content/14/1/42 27 28 29 26. Powis KM, Kitch D, Ogwu A, et al. Increased risk of preterm delivery among HIV- 30 infected women randomized to protease versus nucleoside reverse transcriptase 31 32 inhibitor-based HAART during pregnancy. J Infect Dis. 2011;204(4):506–14. 33 34 27. Uthman OA, Nachega JB, Anderson J, et al. Timing of initiation of antiretroviral 35 http://bmjpaedsopen.bmj.com/ 36 therapy and adverse pregnancy outcomes: a systematic review and meta-analysis. 37 Lancet HIV. 2017;4(1):e21–30. 38 39 28. González R, Rupérez M, Sevene E, et al. Effects of HIV infection on maternal and 40 41 neonatal health in southern Mozambique: A prospective cohort study after a decade 42 43 of antiretroviral drugs roll out. PLoS One. 2017;12(6):1–11. 44

45 29. Department of Health Republic of South Africa. National Antenatal Sentinel & Syphilis on September 27, 2021 by guest. Protected copyright. 46 Survey Report. Tech Reports. 2017; 47 48 49 30. Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2018. Natl Vital 50 Stat Reports. 2019; 51 52 53 31. Numerato D, Fattore G, Tediosi F, et al. Mortality and length of stay of very low birth 54 weight and very preterm infants: A EuroHOPE study. PLoS One. 2015;10(6):1–12. 55 56 32. Zhu JJ, Bao YY, Zhang GL, et al. No relationship between mode of delivery and 57 58 neonatal mortality and neurodevelopment in very low birth weight infants aged two 59 60 years. World J Pediatr. 2014;10(3):227–31.

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3 33. Victora JD, Silveira MF, Tonial CT, et al. Prevalence, mortality and risk factors bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 associated with very low birth weight preterm infants: an analysis of 33 years. J 6 Pediatr (Rio J). 2018; 96 (3): 327-332 7 8 9 34. Nayeri F, Emami Z, Mohammadzadeh Y, et al. Mortality and Morbidity Patterns of 10 Very Low Birth Weight Newborns in Eastern Mediterranean Region: A Meta-Analysis 11 12 Study.Confidential: J Pediatr Rev. 2018;7(2):67–76. For Review Only 13 14 35. Ballot DE, Chirwa T, Ramdin T, et al. Comparison of morbidity and mortality of very 15 16 low birth weight infants in a Central Hospital in Johannesburg between 2006/2007 and 17 2013. BMC Pediatr. 2015;15(1):1–11. 18 19 36. Gibbs L, Tooke L, Harrison MC. Short-term outcomes of inborn v . outborn very-low- 20 21 birth-weight neonates ( < 1 500 g ) in the neonatal nursery at Groote Schuur Hospital , 22 23 Cape Town , South Africa. S Afr Med J 2017;107(10):900-903. 24 25 37. Darlow BA, Cust AE, Donoghue DA. Improved outcomes for very low birthweight 26 infants: Evidence from New Zealand national population based data. Arch Dis Child 27 28 Fetal Neonatal Ed. 2003;88(1):23–8. 29 30 38. Moro M, Figueras-Aloy J, Fernández C, et al. Mortality for newborns of birthweight 31 32 less than 1500 g in Spanish Neonatal Units (2002-2005). Am J Perinatol. 2007; 33 26(5): 335-343 34

35 http://bmjpaedsopen.bmj.com/ 36 39. Tomé T, Guimarães H, Bettencourt A, et al. Neonatal morbi-mortality in very low birth 37 weight in Europe: The Portuguese experience. Journal of Maternal-Fetal and 38 39 Neonatal Medicine. 2009; 22(S3): 85–87. 40 41 40. Rüegger C, Hegglin M, Adams M, et al. Population based trends in mortality, 42 43 morbidity and treatment for very preterm- and very low birth weight infants over 12 44 years. BMC Pediatr [Internet]. 2012;12(1):17. Available from: 45 on September 27, 2021 by guest. Protected copyright. 46 http://www.biomedcentral.com/1471-2431/12/17 47 48 41. Horbar JD, Carpenter JH, Badger GJ, et al. Mortality and neonatal morbidity among 49 50 infants 501 to 1500 grams from 2000 to 2009. Pediatrics. 2012;129(6):1019–26. 51 52 42. Jeschke E, Biermann A, Günster C, et al. Mortality and major morbidity of very-low- 53 54 birth-weight infants in Germany 2008-2012: A report based on administrative data. 55 Front Pediatr. 2016;4(MAR):1–8. 56 57 43. Schindler T, Koller-Smith L, Lui K, et al. Causes of death in very preterm infants cared 58 59 for in neonatal intensive care units: A population-based retrospective cohort study. 60

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3 BMC Pediatr. 2017;17(1):1–9. bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 44. Zile I, Ebela I, Rozenfelde IR. Risk factors associated with neonatal deaths among 6 7 very low birth weight infants in Latvia. Curr Pediatr Res. 2017;21(1):64–8. 8 9 45. Yego F, D’Este C, Byles J, et al. A case-control study of risk factors for fetal and early 10 11 neonatal deaths in a tertiary hospital in Kenya. BMC Pregnancy Childbirth. 12 Confidential: For Review Only 2014;14(1):1–9. 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

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3 FNo: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Data of child at birth: 6 7 Date of birth: □ 8 9 Gender □ female □ male 10 11 12 GestationalConfidential: age: □ For Review Only 13 14 Mode of delivery: □ NVD □ Sectio □ Vacuum or forceps 15 16 HIV exposed: □ exposed □ unexposed 17 18 PMTCT □ yes □ no 19 20 Birth weight: gr 21 22 Length: cm 23 24 Head circumferences: cm 25 26 Resuscitation at birth: □ yes □ no 27 28 APGAR 1min 5 min 10 min 29 30 31 Diagnosis at birth: 32 33 Oxygen support □ yes □ no 34

35 Surfactant: □ yes □ no http://bmjpaedsopen.bmj.com/ 36 37 Ventilatory support: □ none □ CPAP □ Invasive ventilation 38 39 If yes, how long days 40 41 Maximum of oxygen needed: □ < 60% □ > 60% 42 43 Feeding option □ Breast □ formula □ mixed 44 45 Trend of weight gain: □ normal □ abnormal on September 27, 2021 by guest. Protected copyright. 46 47 Sepsis : □ yes □ no 48 49 PVL or IVH: □ yes □ no 50 51 52 PDA: □ yes □ no 53 54 Steroid use (postnatal): □ yes □ no 55 56 Resuscitation during hospital stay: □ yes □ no 57 58 59 60

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3 Mother’s Data: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Age of mother: 8 9 Number of pregnancy: □ 10 11 12 Children Confidential:alive: □ For Review Only 13 14 Marital status: □ married □ stable relationship □ single 15 16 During pregnancy: 17 18 Hypertension: □ yes □ no 19 20 PT rupture of membranes: □ yes □ no 21 22 Preeclampsia/ Eclampsia □ yes □ no 23 24 Any other problems (e.g. seizures, drug abuse, diabetes) 25 26 SES of mother: □ employed □ unemployed 27 28 Electricity at home: □ yes □ no 29 30 31 Running water at home: □ yes □ no 32 33 Fridge: □ yes □ no 34

35 Educational level: □ primary school □ matric □ tertiary education http://bmjpaedsopen.bmj.com/ 36 37 Mother’s HIV status: □ positive □ negative 38 39 If positive: 40 41 ARVs since when: weeks before birth 42 43 ARVS: □ FDC □ second line □ other 44 45 Disclosure to anyone: on September 27, 2021 by guest. Protected copyright. 46 47 Has partner been tested: 48 49 50 51 52 53 54 55 56 57 58 59 60

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Confidential: For Review Only Prospective cohort study of mortality in very low birth weight infants in a single centre in the Eastern Cape Province, South Africa

Journal: BMJ Paediatrics Open

Manuscript ID bmjpo-2020-000918.R1

Article Type: Original research

Date Submitted by the 23-Dec-2020 Author:

Complete List of Authors: Michaelis, Isabel; Walter Sisulu University, Paediatrics Manyisane, Ncomeka; Walter Sisulu University, Paediatrics Krägeloh-Mann, Ingeborg; Eberhard Karls University Tübingen Faculty of Medicine, Children's Hospital, Neuropaediatrics, Developmental Neurology, Social Paediatrics Mazinu, Mikateko; South African Medical Research Council, Biostatistics unit Jordaan, Esme; South African Medical Research Council, Biostatistics unit http://bmjpaedsopen.bmj.com/ Keywords: Neonatology, Mortality

on September 27, 2021 by guest. Protected copyright.

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the termsConfidential: applicable for US Federal Government For officers Review or employees actingOnly as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author unless you are acting as an employee on behalf of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34

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3 Title Page bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Prospective cohort study of mortality in very low birth weight infants in a single centre in the 8 Eastern Cape Province, South Africa 9 10 Isabel Michaelis, MD, PhD, Walter Sisulu University, East London 11 12 IngeborgConfidential: Krägeloh- Mann, Professor of Paediatrics,For Review Eberhard Karls UniversityOnly of Tübingen, 13 Tübingen 14 Ncomeka Manyisane, McBCh, FcPaed, Walter Sisulu University, East London 15 16 Mikateko Mazinu, MSc Biomathematics, South African Medical Research Council, Tygerberg 17 18 Esme Jordaan, MSc Statistics, South African Medical Research Council, Tygerberg and 19 20 Statistics and Population Studies Department, University of the Western Cape 21 22 23 24 25 Corresponding author: Isabel Michaelis, Private Bag 9047, Amalinda Main Road, 5200 East 26 London, Tel: +27 (43) 709 2077, Fax: +27 (43) 709 4065. [email protected] 27 28 29 30 Key words: neonatology, VLBW, infant mortality, sub Saharan Africa, global health 31 32 33 34

35 Word count: 2425 (without tables and abstract) http://bmjpaedsopen.bmj.com/ 36 37 38 39 Dr Isabel Michaelis 40 41 42 43 44

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3 Prospective cohort study of mortality in very low birth weight infants in a single centre bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 in the Eastern Cape Province, South Africa 6 7 8 Isabel Michaelis, MD, PhD, Walter Sisulu University, East London 9 10 Ingeborg Krägeloh-Mann, Professor of Paediatrics, Eberhard Karls University of Tübingen, Tübingen 11 Ncomeka Manyisane, McBCh, FcPaed, Walter Sisulu University, East London 12 Confidential: For Review Only 13 Mikateko Mazinu, MSc Biomathematics , South African Medical Research Council, Tygerberg 14 Esme Jordaan, MSc Statistics, African Medical Research Council, Tygerberg 15 16 17 18 Contact: [email protected] 19 20 21 I hereby confirm that neither the submitted paper nor any parts of it have been published or 22 submitted anywhere else. 23 24 There is no conflict of interest. This work was supported by the South African Medical 25 Research Council (SAMRC) Fund, grant number (086/2017). The sponsorship of the 26 27 SAMRC Pilot Grant serves to encourage clinicians in rural South Africa to engage in 28 research. 29 30 31 Dr Isabel Michaelis’ contribution consisted of funding acquisition, study design, investigation, 32 data curation, supervision and drafting the initial manuscript. 33 34 Dr Ncomeka Mayisane contributed to study design, investigation, data curation and 35 reviewing the manuscript. http://bmjpaedsopen.bmj.com/ 36 37 Prof Ingeborg Krägeloh-Mann contributed to supervision, writing and reviewing the final 38 manuscript. 39 40 Mrs Mikateko Mazinu contributed to data curation and data analysis. 41 42 Mrs Esme Jordaan contributes to data curation and data analysis and writing and reviewing 43 the final manuscript. 44

45 on September 27, 2021 by guest. Protected copyright. 46 47 What is known about this topic? 48 The perinatal mortality rate in sub-Saharan Africa is about 30 per 1000 live births. Preterm and 49 VLBW infants account for a large number of neonatal deaths. Although South Africa is 50 considered an upper-middle-income country by the World Bank, survival of VLBW varies greatly 51 dependent on resources. Survival of VLBW infants in studies from South Africa are about 75%. 52 53 54 55 What does this study add? 56 Survival of VLBW infants was 68% in our cohort. This shows that the chance of survival for 57 those babies in our setting is lower than in other South African urban settings. Causes for 58 59 this difference should be further explored. 60

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Background: 8 9 Neonatal mortality is a major contributor worldwide to the number of deaths in children under 10 5 years of age. The primary objective of this study was to assess the overall mortality rate of 11 12 babies withConfidential: a birth weight of less than 1500g For in a Reviewneonatal unit at a tertiaryOnly hospital in the 13 Eastern Cape Province, South Africa. Furthermore, different maternal and infant related 14 15 factors for higher mortality were analysed. 16 17 18 19 Methods: 20 21 22 This is a prospective cohort study which included infants admitted to the neonatal wards of 23 the hospital within their first 24 hours of life and with a birth weight equal to or below 1500g. 24 25 26 27 28 Results: 29 30 173 very low birth weight (VLBW) infants were admitted to the neonatal department between 31 32 November 2017 and December 2018. The overall mortality was 32%. More than half 33 (53.5%) of the infants with a birth weight below 1000g died during admission. 34 http://bmjpaedsopen.bmj.com/ 35 Main predictors for mortality were lower gestational age and lower birth weight. Need for 36 37 ventilator support and sepsis increased mortality risk significantly, as did maternal factors 38 39 such as HIV infection and age below 20 years. VLBW babies born to a mother with 40 gestational hypertension had a two-fold increased chance of survival, most likely due to 41 42 associated intrauterine growth restriction with higher gestational age at birth relative to 43 weight. 44

45 on September 27, 2021 by guest. Protected copyright. 46 47 48 Conclusion: 49 50 This prospective study looked at survival of very low birth weight babies in an 51 52 underprivileged part of the Eastern Cape of South Africa. Compared to other public urban 53 hospitals in the country the survival rate remains unacceptably low. Further research is 54 55 required to find the associated causes and appropriate ways to address these. 56 57 58 59 60

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Introduction: 6 7 Despite improved survival rates of neonates worldwide, the survival of preterm and low birth 8 weight babies is still a challenge, especially in middle- and low-income countries (1–4). 9 10 11 In 2018, the World Health Organisation (WHO) described a worldwide increase of babies 12 born prematurelyConfidential: over the last two decades. For The incidenceReview has been Only estimated between 5 to 13 14 18% of all life births (5,6). The prevalence of babies born with a very low birth weight 15 (VLBW) varies between different countries. For example, in one South African study the 16 17 prevalence was 3%, while in the USA it lies between 1.23 and 1.43% (7–9). Furthermore, 18 19 prematurity and low birth weight have been identified as the leading causes of mortality in 20 children less than five years of age (5,10–12). It is also well known that neonatal mortality for 21 22 VLBW infants varies considerably amongst high- and low-middle income countries: a 23 mortality rate of 15% is found in the United States (13), 20% by the Vermont Oxford network 24 25 (14), 29.1% in Iran (3), 28.2% in South Korea (11), 32% in the Eastern Mediterranean 26 Region (15), and 24.6% in India (16). Some single centres worldwide show a lower mortality 27 28 rate with 9.5%, 12.4%, 13.0% and 17.2% in single centres in Singapore, Taiwan, Hong- 29 30 Kong, Saudi-Arabia, respectively (14,17–19). 31 32 In South Africa, neonatal mortality accounted for 32% of the under-5 mortality rate (4,20,21). 33 A recent study illustrated survival rates of VLBW neonates between different hospitals in the 34

35 Western Cape Province of South Africa as characterized by unrestricted or restricted http://bmjpaedsopen.bmj.com/ 36 37 resources (22). The team found a significant difference with a survival rate of 84.4% and 38 70.4% respectively (22). Kalimba and Ballot (23) studied the survival rate of extremely low 39 40 birth weight (ELBW) babies (babies weighing less than 1000g at birth) born between 2006 41 and 2010 in Johannesburg and found that only 25.6% of babies born with a birth weight of 42 43 less than 900g survived their hospital stay, with birth weight and gestational age being the 44 strongest predictors for survival. A newer retrospective cross-sectional South African study 45 on September 27, 2021 by guest. Protected copyright. 46 found an overall survival rate in VLBW babies (500g–1499g) of 75.7% (24). 47 48 However, there are also other known contributory factors, which can be divided into infant-or 49 50 maternal-related risk factors. Examples of neonate-related risk factors studied in the 51 literature include low Apgar scores, hyaline membrane disease (HMD), intubation and 52 53 mechanical ventilation, sepsis, and hemodynamic instability (25,26). Maternal or obstetric 54 55 risk factors include eclampsia, alcohol consumption, smoking, low socioeconomic status, 56 scarce antenatal care and human immunodeficiency virus (HIV) infection (18,23,27,28). 57 58 Several studies suggest an increased risk of premature labour in mothers taking 59 antiretroviral treatment for HIV infection during pregnancy (29–32), while others did not find a 60

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3 relationship (33). This is noteworthy, as 30.8% of pregnant women in South Africa tested bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 positive for HIV in 2015, and are put on treatment as soon as the infection is diagnosed 6 (34,35). 7 8 9 The primary aim of this study was to research neonatal mortality of VLBW infants admitted to 10 the neonatal unit in a hospital in a mixed urban and rural setting in the Eastern Cape 11 12 ProvinceConfidential: of South Africa. Secondly, the associationFor Review between death andOnly different maternal 13 and neonatal factors were explored. 14 15 16 17 18 Setting: 19 20 Frere Hospital is a large (885 beds) public tertiary hospital in East London in the Eastern 21 22 Cape Province in South Africa, with a seven-bed paediatric intensive care unit (PICU), which 23 cares for neonates and paediatric medical and surgical patients. Because of this very limited 24 25 PICU access, babies with a weight below 1000g are not provided with invasive ventilatory 26 support due to poor survival. These babies will receive surfactant if needed and continuous 27 28 positive airway pressure (CPAP) ventilation is available for six infants in the high care 29 30 neonatal unit, which can cater for 12 infants altogether. This high care ward is constantly 31 above capacity, often having to care for up to 20 infants, when there is only adequate space 32 33 for the above-mentioned 12 neonates. Infants with a birth weight over 1000g will be taken to 34 PICU and receive invasive ventilation if needed and if space is available for them. Stable 35 http://bmjpaedsopen.bmj.com/ 36 neonates with a weight of more than 1000g are referred to the general nursery ward, where 37 they receive kangaroo care (KMC) in the ward and, if necessary, intravenous fluids and/or 38 39 antibiotics and oxygen. Once clinically stable, off oxygen support, tolerating full enteral feeds 40 41 and weighing more than 1500g, infants will be transferred to the KMC ward until mothers are 42 competent in caring for their baby and the weight has increased to at least 1700 g. Some 43 44 stable babies might be transferred to their regional hospital once their weight has reached 45 1500g. on September 27, 2021 by guest. Protected copyright. 46 47 48 Frere Hospital is the tertiary neonatal and obstetric referral centre for obstetric units and for 49 surrounding district hospitals in the middle part of the Eastern Cape Province. Some 50 51 referrals centres are more than 300 km away. These areas were deprived of adequate 52 infrastructure during the Apartheid regime and are still one of the most under-resourced and 53 54 insufficiently managed parts of South Africa. 55 56 Materials and Methods: 57 58 This was a prospective cohort study. All babies born at the hospital, or admitted within the 59 60 first 24 hours of life into the neonatal unit, with a birth weight equal or below 1500g and

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3 without any life-threatening malformations were included. Neonates who were admitted to bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 the neonatal ward or PICU beyond 24 hours of life were excluded as it was not possible to 6 get sufficient information on those mother-infant pairs. Mothers were then approached for 7 8 consent to include their data. The recruitment period lasted from December 2017 to 9 10 November 2018. 11 12 The studyConfidential: was approved by the institutional For ethics Review committee (086/2017) Only and, after receiving 13 written consent from the mothers, data concerning mother and child during the pre-, peri- 14 15 and neonatal period were collected from the maternal and neonatal case records, as well as 16 17 from a questionnaire filled in with the mother (see supplements). The babies were followed 18 up until discharge or death. All babies received standard care during this period, as outlined 19 20 above. 21 22 Gestational age was determined by either an early ultrasound or by applying the Ballard 23 24 gestational age scoring system. The different variables were defined as follows: a persistent 25 ductus arteriosus as identified by echocardiogram; hyaline membrane disease by the 26 27 presence respiratory distress; FiO2 requirement above 40% followed by a confirmatory blood 28 gas and typical X-ray signs; sepsis as clinical signs confirmed with a positive blood, urine or 29 30 cerebrospinal fluid culture and/or raised C-reactive protein (CRP) taken at least 24 hours 31 apart; normal weight gain was determined when weight loss after birth did not exceed more 32 33 than 10% and birth weight was regained within 10-14 days of life; intracranial haemorrhage 34

35 (ICH) was diagnosed with cranial ultrasound, which was only performed in clinically unstable http://bmjpaedsopen.bmj.com/ 36 infants with the clinical suspicion of ICH; resuscitation at birth included mask or invasive 37 38 ventilation with or without cardiac compressions and medication. 39 40 41 42 Patient and Public Involvement: 43 44 Mothers of VLBW and preterm babies often spend weeks in the neonatal wards with their 45 on September 27, 2021 by guest. Protected copyright. 46 very small and often very sick infant. As such, this is already an extremely stressful time, 47 48 heightened by the constant uncertainty concerning the baby’s survival. By informing our 49 knowledge of factors associated with mortality, this study will hopefully improve counselling 50 51 of mothers during admission and thus alleviate some anxiety. 52 53 The patients, being mother-newborn pairs, were not involved in the study design. Every 54 55 new-born admitted in our wards during the study period was assessed for inclusion in our 56 study, no recruitment from the patient’s side was necessary. The results of this study are 57 58 verbally communicated to the mothers and/or caretakers, during their high-risk baby follow- 59 up appointments. 60

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Statistical analysis: 6 7 8 Demographic data is presented as frequencies (percentages) for categorical data, and as 9 means (SD) for continuous data. To test for association between the outcome variable 10 11 (mortality) and the predictor variables, a log binomial regression model was used. In order to 12 Confidential: For Review Only investigate the relationship between hypertension and mortality in babies in more detail, a 13 14 multiple regression model was used, adjusting for IUGR and gestational age. The standard 15 16 for significance for all analyses was a p-value <0.05. Data were analysed using STATA 17 version 15. 18 19 Results: 20 21 22 During the study period 4 342 babies were born in the hospital, 4 210 of these were live 23 births and 231 (5.3%) were born with a birth weight between 500g and 1500g. Of those 231 24 25 VLBW infants, only 173 were admitted in our neonatal high care ward or to PICU. Of those, 26 55 died during admission, resulting in an overall mortality rate of 31.8% (95% CI: 25.2–39.2) 27 28 for VLBW infants admitted to our unit. One hundred and sixty-one of the 173 VLBW infants 29 30 were successfully recruited (caregivers gave informed consent) during the study period. 31 Forty-five (28.0%) of those babies died before discharge and 116 (72.0%) were discharged 32 33 home or referred to a peripheral hospital if they had reached a weight above 1500 g. For an 34 overview of recruitment and numbers of participants, see Figure 1. All 116 babies 35 http://bmjpaedsopen.bmj.com/ 36 discharged from hospital received a follow-up date for the high-risk clinic. 37 38 39 40 Demographics: 41 42 43 The maternal age ranged between 14 and 46 years. Fifty-eight (36.0%) mothers had HIV 44 infection diagnosed before or during pregnancy, or at birth. Thirty-nine of them (67.2%) had 45 on September 27, 2021 by guest. Protected copyright. 46 been on antiretroviral (ARV) treatment at delivery for more than 4 weeks. Sixteen (27.6%) 47 mothers had been on ARV treatment for less than 4 weeks or were not on treatment at all 48 49 when giving birth, and their babies were thus considered at high risk for HIV transmission 50 51 and treated accordingly. For other variables please see Table 1. 52 Of the 161 babies included in the study, 96 were female (59.7%). Almost all HIV exposed 53 54 babies (n=58) tested negative for HIV infection at birth with a negative birth HIV-polymerase 55 chain reaction (HIV-PCR) (n=55; 94.8%). Three babies, who died a few hours after birth, did 56 57 not receive an HIV-PCR at birth and their status is therefore unknown. For other variables 58 please see Table 2. 59 60

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Table 1: Maternal demographic variables 8 9 Overall* Mortality** 10 Variables Category n (%) n (%) 11 12 Age of motherConfidential: (years) ≤20 For30 (18.6) Review10 (33.3) Only 13 >20 131 (81.4) 35 (26.7) 14 Married/stable 15 Marital status relationship 91 (57.6) 24 (26.4) 16 No partner 67 (42.4) 18 (26.8) 17 18 Substance abuse Yes 13 (8.1) 4 (30.8) 19 No 147 (91.9) 40 (27.2) 20 Employment Yes 24 (15.1) 5 (20.8) 21 22 No 135 (84.9) 39 (28.9) 23 Electricity at home Yes 143 (89.9) 41 (28.7) 24 No 16 (10.1) 3 (18.8) 25 Running water at home Yes 99 (62.3) 28 (28.3) 26 27 No 60 (37.7) 16 (26.7) 28 Refrigerator at home Yes 109 (68.6) 32 (29.4) 29 No 50 (31.5) 12 (24.0) 30 31 Education level Primary 72 (45.6) 22 (30.6) 32 Secondary/tertiary 86 (54.4) 21 (24.4) 33 HIV-infection Yes 58 (36.5) 14 (24.1) 34

35 No 101 (63.5) 30 (29.7) http://bmjpaedsopen.bmj.com/ 36 ARTs FDC 45 (93.8) 10 (22.2) 37 Second line 2 (4.2) 0 (0.0) 38 Other 1 (2.1) 0 (0.0) 39 *The overall number and percentage per risk factor 40 **The number and percentage of babies who died per risk factor category. 41 HIV: human immunodeficiency virus, ART: antiretroviral treatment, FDC: fixed dose combination. 42 43 44 Table 2: Infant demographics variables

45 on September 27, 2021 by guest. Protected copyright. 46 Overall* Mortality** 47 Variables Category n (%) n (%) 48 Gender Female 96 (59.6) 27 (28.1) 49 Male 65 (40.4) 18 (27.7) 50 GA (weeks) 25-32 78 (49.1) 36 (46.2) 51 33-37 81 (50.9) 9 (11.1) 52 HIV exposed Yes 58 (36.0) 14 (24.1) 53 No 103 (64.0) 31 (30.1) 54 PMTCT Yes 44 (27.3) 11 (25.0) 55 No 117 (72.7) 34 (29.1) 56 57 Birth weight (g) ≤1000g 43 (26.7) 23 (53.5) 58 >1000g 118 (73.3) 22 (18.6) 59 Born before arrival Yes 11 (6.8) 2 (18.2) 60 No 150 (93.2) 43 (28.7)

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3 Mother not been to ANC Yes (no ANC) 25 (15.5) 8 (32.0) bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 No (ANC 5 attended) 136 (84.5) 37 (27.2) 6 IUGR Yes 111 (69.8) 23 (20.7) 7 No 48 (30.2) 21 (43.8) 8 *The overall number and percentage per risk factor 9 **The number and percentage of babies who died per risk factor category. 10 GA: gestational age, HIV: human immunodeficiency virus, PMTCT: prevention of mother to child transmission, IUGR: intrauterine 11 growth restriction. 12 Confidential: For Review Only 13 Factors associated with in hospital mortality: 14 15 Maternal associated factors for the univariate model: 16 17 Univariate regression analysis was used to examine the association between mortality and 18 19 associated individual factors. Associated factors of infants dying while still in hospital were 20 higher in babies of teenage mothers, mothers with illnesses and mothers on medication. 21 22 Maternal hypertension and preeclampsia were associated with decreased mortality in the 23 24 babies. Education level of the mother and other socio-economic status factors were not 25 significantly related to a higher mortality risk during admission in our study, with employment 26 27 status only showing a trend towards significance (Table 3). 28 29 Table 3: Significant univariate associations between VLBW infant mortality and maternal-related 30 factors. 31 32 33 34 Variables Category Risk Ratio (95% CI) P value

35 http://bmjpaedsopen.bmj.com/ 36 Age of mother (years) ≤20 vs >20 1.25 (1.07- 1.45) 0.004 37 38 Hypertension Yes vs no 0.62 (0.49 - 0.77) <0.0001 39 40 Pre-eclampsia Yes vs no 0.69 (0.57 - 0.82) <0.0001 41 Other illnesses Yes vs no 1.34 (1.04 - 1.74) 0.023 42 43 Medication Yes vs no 0.43 (0.25 - 0.77) 0.004 44

45 Employment Yes vs no 0.72 (0.52 - 1.01) 0.055 on September 27, 2021 by guest. Protected copyright. 46 47 Fridge Yes vs no 1.22 (1.01 - 1.48) 0.038 48 49 Other illnesses included malignancies, epilepsy, mental health disorders. Medication included all other medication besides 50 antiretroviral treatment. CI: confidence interval. Most maternal factors that were not significantly associated with mortality in the 51 regression analysis are not shown in this table. 52 53 54 55 Neonatal-associated factors: 56 57 There were many significant neonatal-associated factors related to infant mortality, such as 58 59 low gestational age (p<0.0001), low birth weight (p<00001), IUGR (p<0.0001), and the need 60

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3 for resuscitation at birth (p<0.0001) or during hospital stay (p=0.011). Male gender was not bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 associated with higher mortality risk (p=0.935; RR=1.0; 95% CI: 0.7–1.5) (Table 4). 6 7 8 9 10 11 12 Confidential: For Review Only 13 Table 4: Significant univariate associations between infant mortality and infant-related factors of 14 VLBW infants 15 16 17 Variables Category Risk Ratio (95% CI) P value 18 Gender Female vs Male 1.02 (0.70, 1.48) 0.935 19 GA (weeks) 25-32 vs 33-37 4.15 (2.93, 5.88) <0.0001 20 HIV exposed No vs yes 1.25 (1.00, 1.56) 0.053 21 Birth weight (g) ≤1000 vs >1000 2.87 (2.08, 3.96) <0.0001 22 IUGR Yes vs no 0.47 (0.35, 0.65) <0.0001 23 Resuscitation at birth Yes vs no 4.45 (3.43, 5.78) <0.0001 24 Apgar 1 min 0-6 vs 7-10 2.46 (1.99, 3.05) <0.0001 25 Apgar 5 min. 0-6 vs 7-10 2.42 (2.12, 2.77) <0.0001 26 HMD Yes vs no 2.03 (1.72, 2.38) <0.0001 27 Other Yes vs no 1.59 (1.20, 2.09) 0.001 28 Oxygen support Yes vs no 9.68 (7.39, 12.68) <0.0001 29 Days on oxygen 0-1 day vs >1 day 1.44 (0.94, 2.21) 0.091 30 31 Surfactant given Yes vs no 3.59 (2.77, 4.65) <0.0001 32 Weight gain Yes vs no 3.39 (2.21, 5.19) <0.0001 33 Sepsis Yes vs no 6.41 (3.78, 10.88) <0.0001 34 ICH Yes vs no 5.19 (3.03, 8.90) <0.0001

35 PDA No vs yes 2.83 (1.47, 5.47) 0.002 http://bmjpaedsopen.bmj.com/ 36 Resuscitation needed stay Yes vs no 12.31 (5.85, 25.88) 0.011 37 GA: gestational age, HIV: human immunodeficiency virus, IUGR: intrauterine growth restriction, HMD: hyaline membrane 38 disease, ICH: intracranial haemorrhage, PDA: persistent ductus arteriosus, ANC: antenatal clinic, Other: other problems like neonatal jaundice, hypoglycaemia, necrotizing enterocolitis, hypothermia. CI: confidence interval. Infant-related factors that 39 were not significantly associated with mortality in the univariate regression analysis are not shown in this table, besides gender. 40 41 42 43 Multiple regression analysis 44 As could be seen in the univariate analysis, maternal hypertension was associated with 45 on September 27, 2021 by guest. Protected copyright. 46 decreased mortality in the babies. However, when adjusting for IUGR and gestational age in 47 the multiple regression analysis, no significant association was found for maternal 48 49 hypertension (p=0.279; RR=0.88; 95% CI: 0.70-1.11), as shown in Table 5. 50 51 Table 5: Results of maternal and infant factors in multiple regression analysis 52 53 Variables Category Risk Ratio (95% CI) P value 54 Hypertension Yes vs No 0.88 (0.70, 1.11) 0.279 55 Yes vs No 0.032 56 IUGR 1.88 (1.68, 2.11) 57 GA (weeks) 25-32 vs 33-37 3.80 (2.43, 5.96) <0.0001 58 GA: gestational age, IUGR: intrauterine growth restriction. CI: confidence interval. 59 60

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3 Discussion: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 The prevalence of VLBW infants of all live birth in this single hospital study in the Eastern 6 7 Cape Province between December 2017 and November 2018 was 5.4%. This figure lies 8 9 within the prevalence of 3–7% reported worldwide (3,13), but is likely elevated due to the 10 referrals from obstetric units and surrounding district hospitals. 11 12 Confidential: For Review Only Almost 32% of all admitted VLBW neonates died before discharge. For infants with a birth 13 14 weight of 1000g or less this number rose to 60%, while the chance for survival of infants 15 16 weighing 1000g and up to 1500g at birth was higher, with a mortality rate of 18.5%. Thus, 17 the overall mortality rate is higher than the reported average of approximately 25% in major 18 19 cities in South Africa, (24,36,37) and much higher than in the hospitals with much greater 20 resources from the Western Cape Province (22). It is also much higher than in most 21 22 hospitals in high-income countries where mortality rates for VLBW infants are as low as 23 24 9.5% to 17.2% (14,17–19). The high mortality in our setting is most likely due to the scarcity 25 of skilled health care workers, limited infrastructures, as well as a patient overloaded, 26 27 resource-restricted system, as described (4). The data support that although South Africa is 28 considered an upper-middle-income country by the World Bank, survival of VLBW varies 29 30 greatly dependent on resources (22). 31 32 Consistent with other studies examining the causes of mortality in VLBW babies, birth weight 33 34 and low gestational age were predictors of neonatal mortality in our study population 35 (18,23,26,35). Complications of prematurity, such as the development of hyaline membrane http://bmjpaedsopen.bmj.com/ 36 37 disease (HMD) and the associated need for surfactant replacement therapy with ventilation 38 was associated with a significantly increased risk of mortality, as reported in previous 39 40 research (3,22,23,26). Other studies have shown that CPAP and/or surfactant replacement 41 42 therapy reduce mortality in VLBW and/or preterm neonates with hyaline membrane disease 43 (22,41). Unavailability of PICU beds and overcrowding in our high care unit with low nurse- 44

45 infants’ ratio could explain why we were unable to find this benefit in our cohort. on September 27, 2021 by guest. Protected copyright. 46 47 Interestingly, our study did not find that the wide range of maternal factors found in other 48 49 studies increased in-hospital mortality of infants, including lack of antenatal care, maternal 50 primi-parity, mode of delivery or complications thereof (23,27,28,32). 51 52 Although a substantial percentage (36%) of the babies were born to HIV infected mothers, 53 54 and 13.8% (n=8) of those had not received any ART before giving birth, all HIV-PCR done 55 56 were negative. This is encouraging, but further research is needed to investigate HIV 57 transmission rates in VLBW babies in low resource settings (34,35). 58 59 60

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3 There are several limitations to this study. Even though this was a prospective study, data bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 collection was not exhaustive and some prenatal variables could not be explored due to lack 6 of information. Also, due to staff shortage, ultrasound of the head was not performed 7 8 routinely, but only in clinically suspicious situations, and thus intracranial pathologies might 9 10 have been missed. Furthermore, this is a single, large hospital-based study, therefore the 11 number of VLBW cases is limited. 12 Confidential: For Review Only 13 14 15 16 Conclusion 17 Our cohort shows a higher in-hospital mortality of VLBW infants compared to some other 18 19 urban hospitals in South Africa. These findings indicate that the survival of VLBW and 20 especially ELBW babies are still unacceptably low in this resource restricted public hospital. 21 22 This is most likely caused by numerous factors, many of which have also been implicated in 23 24 similar studies, but need to be further investigated in future research and appropriately 25 addressed. 26 27 28 29 30 31 32 33 34

35 http://bmjpaedsopen.bmj.com/ 36 37 38 39 40 Literature: 41 42 43 1. De Almeida MFB, Guinsburg R, Martinez FE, Procianoy RS, Leone CR, Marba STM, 44 et al. Fatores perinatais associados ao óbito precoce em prematuros nascidos nos 45 on September 27, 2021 by guest. Protected copyright. 46 centros da Rede Brasileira de Pesquisas Neonatais. J Pediatr (Rio J). 47 2008;84(4):300–7. 48 49 50 2. Basu S, Rathore P, Bhatia BD. Predictors of mortality in very low birth weight 51 neonates in India. Singapore Med J. 2008;49(7):556–60. 52 53 3. Afjeh SA, Sabzehei MK, Fallahi M, Esmaili F. Outcome of very low birth weight infants 54 55 over 3 years report from an iranian center. Iran J Pediatr. 2013; 56 57 4. Rhoda NR, Gebhardt GS, Kauchali S BP. Reducing neonatal deaths in South Africa. 58 59 S Afr Med J. 2018;3(1):S9–19. 60

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3 5. World Health Organization. Newborns: reducing mortality. World Heal Organ bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 [Internet]. 2019;(September 2019):2018–21. Available from: 6 http://www.who.int/mediacentre/factsheets/fs178/en/ 7 8 9 6. Haas DM. Preterm birth. BMJ Clin Evid. 2011;2011(1):1–5. 10 11 7. Velaphi SC, Mokhachane M, Mphahlele RM, Beckh-Arnold E, Kuwanda ML, Cooper 12 Confidential: For Review Only PA. Survival of very-low-birth-weight infants according to birth weight and gestational 13 14 age in a public hospital. South African Med J. 2005; 15 16 8. Mackay CA, Ballot DE, Cooper PA. Growth of a cohort of very low birth weight infants 17 18 in Johannesburg, South Africa. BMC Pediatr. 2011;11:2–7. 19 20 9. Martin JA, Hamilton BE, D P, Sutton PD, Ventura SJ, Menacker F, et al. National Vital 21 22 Statistics Reports Births : Final Data for 2013. Statistics (Ber). 2015;64(1):1–104. 23 24 10. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national 25 26 causes of under-5 mortality in 2000–15: an updated systematic analysis with 27 implications for the Sustainable Development Goals. Lancet. 2016;388(10063):3027– 28 29 35. 30 31 11. Hahn WH, Chang JY, Chang YS, Shim KS, Bae CW. Recent trends in neonatal 32 mortality in very low birth weight korean infants: In comparison with Japan and the 33 34 USA. J Korean Med Sci. 2011;26(4):467–73. 35 http://bmjpaedsopen.bmj.com/ 36 12. Chung SH, Bae CW. Improvement in the survival rates of very low birth weight infants 37 38 after the establishment of the Korean neonatal network: Comparison between the 39 2000s and 2010s. J Korean Med Sci. 2017; 40 41 42 13. Fanaroff AA, Stoll BJ, Wright LL, Carlo WA, Ehrenkranz RA, Stark AR, et al. Trends in 43 neonatal morbidity and mortality for very low birthweight infants. Am J Obstet 44

45 Gynecol. 2007; on September 27, 2021 by guest. Protected copyright. 46 47 14. Chee YY, Wong MSC, Wong RMS, Wong KY. Neonatal outcomes of preterm or very- 48 49 low-birth-weight infants over a decade from queen mary hospital, Hong Kong: 50 Comparison with the vermont oxford network. Hong Kong Med J. 2017; 51 52 53 15. Nayeri F, Emami Z, Mohammadzadeh Y, Shariat M, Sagheb S, Sahebi L. Mortality 54 and Morbidity Patterns of Very Low Birth Weight Newborns in Eastern Mediterranean 55 56 Region: A Meta-Analysis Study. J Pediatr Rev. 2018;7(2):67–76. 57 58 16. Bansal A. Comparison of outcome of very-low-birth-weight babies with developed 59 60 countries: A prospective longitudinal observational study. J Clin Neonatol.

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3 2018;7(4):254. bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 17. Amudha Jayanthi Anand, Karthik Sabapathy, Bhavani Sriram, Victor Samuel 6 7 Rajadurai PKA. Single Center Outcome of Multiple Births in the Premature and Very 8 9 Low Birth Weight Cohort in Singapore. Am J Perinatol. 2020;Sep. 10 11 18. Chen SD, Lin YC, Lu CL, Chen SCC. Changes in outcome and complication rates of 12 Confidential: For Review Only very-low-birth-weight infants in one tertiary center in southern Taiwan between 2003 13 14 and 2010. Pediatr Neonatol [Internet]. 2014;55(4):291–6. Available from: 15 16 http://dx.doi.org/10.1016/j.pedneo.2013.10.010 17 18 19. Al Hazzani F, Al-Alaiyan S, Hassanein J, Khadawardi E. Short-term outcome of very 19 low-birth-weight infants in a tertiary care hospital in Saudi Arabia. Ann Saudi Med. 20 21 2011; 22 23 20. Nannan N, Dorrington R, Laubscher R, Zinyakatira N, Prinsloo M, Darikwa T, et al. 24 25 Under-5 mortaliy statistics in South Africa: Shedding some light on the trend and 26 causes 1997-2007. South African Medical Research Council. 2012. 27 28 29 21. Bradshaw D, Dorrington R. Rapid Mortality Surveillance Report 2011. 2012. 30 31 22. Van Wyk L, Tooke L, Dippenaar R, Rhoda N, Lloyd L, Holgate S, et al. Optimal 32 ventilation and surfactant therapy in very-low-birth-weight infants in resource- 33 34 restricted regions. Neonatology. 2020;117(2):217–24. 35 http://bmjpaedsopen.bmj.com/ 36 23. Kalimba EM, Ballot DE. Survival of extremely low-birth-weight infants. SAJCH South 37 38 African J Child Heal. 2013;7(1):13–6. 39 40 24. Tshehla RM, Chb MB, Sa DCH, Coetzee M, Chb MB, Sa DCH, et al. Mortality and 41 42 morbidity of very low-birthweight and extremely low-birthweight infants in a tertiary 43 hospital in Tshwane. 2019;13(2). 44

45 on September 27, 2021 by guest. Protected copyright. 46 25. Terzic S, Heljic S. Assessing mortality risk in very low birth weight infants. Med Arh. 47 2012;66(2):76–9. 48 49 26. S. K, Kumar MS. Morbidity and mortality pattern of very low birth weight infants 50 51 admitted in SNCU in a South Asian tertiary care centre. Int J Contemp Pediatr. 52 53 2018;5(3):720–5. 54 55 27. Cupen K, Barran A, Singh V, Dialsingh I. Risk Factors Associated with Preterm 56 Neonatal Mortality: A Case Study Using Data from Mt. Hope Women’s Hospital in 57 58 Trinidad and Tobago. Children. 2017;4(12):108. 59 60 28. Vaahtera M, Kulmala T, Ashorn P, Ndekha M, Cullinan T, Koivisto AM, et al.

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3 Antenatal and perinatal predictors of infant mortality in rural Malawi. Arch Dis Child bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Fetal Neonatal Ed. 2000;82(3):200–4. 6 7 29. Townsend CL, Schulte J, Thorne C, Dominguez KL, Tookey PA, Cortina-Borja M, et 8 9 al. Antiretroviral therapy and preterm delivery-a pooled analysis of data from the 10 United States and Europe. BJOG An Int J Obstet Gynaecol. 2010;117(11):1399–410. 11 12 Confidential: For Review Only 30. Van Der Merwe K, Hoffman R, Black V, Chersich M, Coovadia A, Rees H. Birth 13 14 outcomes in South African women receiving highly active antiretroviral therapy: A 15 16 retrospective observational study. J Int AIDS Soc [Internet]. 2011;14(1):42. Available 17 from: http://www.jiasociety.org/content/14/1/42 18 19 31. Powis KM, Kitch D, Ogwu A, Hughes MD, Lockman S, Leidner J, et al. Increased risk 20 21 of preterm delivery among HIV-infected women randomized to protease versus 22 23 nucleoside reverse transcriptase inhibitor-based HAART during pregnancy. J Infect 24 Dis. 2011;204(4):506–14. 25 26 32. Uthman OA, Nachega JB, Anderson J, Kanters S, Mills EJ, Renaud F, et al. Timing of 27 28 initiation of antiretroviral therapy and adverse pregnancy outcomes: a systematic 29 30 review and meta-analysis. Lancet HIV. 2017;4(1):e21–30. 31 32 33. González R, Rupérez M, Sevene E, Vala A, Maculuve S, Bulo H, et al. Effects of HIV 33 infection on maternal and neonatal health in southern Mozambique: A prospective 34

35 cohort study after a decade of antiretroviral drugs roll out. PLoS One. 2017;12(6):1– http://bmjpaedsopen.bmj.com/ 36 37 11. 38 39 34. John V, Harper K. HIV prevalence at birth in very low-birthweight infants. South 40 African J Child Heal. 2020;14(3):129–32. 41 42 43 35. Levin C, Le Roux DM, Harrison MC, Tooke L. HIV Transmission to Premature Very 44 Low Birth Weight Infants. Pediatr Infect Dis J. 2017; 45 on September 27, 2021 by guest. Protected copyright. 46 36. Ballot DE, Chirwa T, Ramdin T, Chirwa L, Mare I, Davies VA, et al. Comparison of 47 48 morbidity and mortality of very low birth weight infants in a Central Hospital in 49 50 Johannesburg between 2006/2007 and 2013. BMC Pediatr. 2015;15(1):1–11. 51 52 37. Gibbs L, Bch MB, Sa DCH, Paeds M, Sa F, Tooke L, et al. Short-term outcomes of 53 inborn v . outborn very-low- birth-weight neonates ( < 1 500 g ) in the neonatal nursery 54 55 at Groote Schuur Hospital , Cape Town , South Africa. 2017;107(10):900–3. 56 57 38. Schindler T, Koller-Smith L, Lui K, Bajuk B, Bolisetty S. Causes of death in very 58 59 preterm infants cared for in neonatal intensive care units: A population-based 60

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3 retrospective cohort study. BMC Pediatr. 2017;17(1):1–9. bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 39. Numerato D, Fattore G, Tediosi F, Zanini R, Peltola M, Banks H, et al. Mortality and 6 7 length of stay of very low birth weight and very preterm infants: A EuroHOPE study. 8 9 PLoS One. 2015;10(6):1–12. 10 11 40. Zile I, Ebela I, Rozenfelde IR. Risk factors associated with neonatal deaths among 12 Confidential: For Review Only very low birth weight infants in Latvia. Curr Pediatr Res. 2017;21(1):64–8. 13 14 15 41. Griffin JB, Jobe AH, Rouse D, McClure EM, Goldenberg RL, Kamath-Rayne BD. 16 Evaluating WHO-recommended interventions for preterm birth: A mathematical model 17 18 of the potential reduction of preterm mortality in sub-Saharan Africa. Glob Heal Sci 19 Pract. 2019; 20 21 22 42. Yego F, D’Este C, Byles J, Nyongesa P, Williams JS. A case-control study of risk 23 factors for fetal and early neonatal deaths in a tertiary hospital in Kenya. BMC 24 25 Pregnancy Childbirth. 2014;14(1):1–9. 26 27 28 29 30 31 32 33 34

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3 FNo: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Data of child at birth: 6 7 Date of birth: □ 8 9 Gender □ female □ male 10 11 12 GestationalConfidential: age: □ For Review Only 13 14 Mode of delivery: □ NVD □ Sectio □ Vacuum or forceps 15 16 HIV exposed: □ exposed □ unexposed 17 18 PMTCT □ yes □ no 19 20 Birth weight: gr 21 22 Length: cm 23 24 Head circumferences: cm 25 26 Resuscitation at birth: □ yes □ no 27 28 APGAR 1min 5 min 10 min 29 30 31 Diagnosis at birth: 32 33 Oxygen support □ yes □ no 34

35 Surfactant: □ yes □ no http://bmjpaedsopen.bmj.com/ 36 37 Ventilatory support: □ none □ CPAP □ Invasive ventilation 38 39 If yes, how long days 40 41 Maximum of oxygen needed: □ < 60% □ > 60% 42 43 Feeding option □ Breast □ formula □ mixed 44 45 Trend of weight gain: □ normal □ abnormal on September 27, 2021 by guest. Protected copyright. 46 47 Sepsis : □ yes □ no 48 49 PVL or IVH: □ yes □ no 50 51 52 PDA: □ yes □ no 53 54 Steroid use (postnatal): □ yes □ no 55 56 Resuscitation during hospital stay: □ yes □ no 57 58 59 60

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3 Mother’s Data: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Age of mother: 8 9 Number of pregnancy: □ 10 11 12 Children Confidential:alive: □ For Review Only 13 14 Marital status: □ married □ stable relationship □ single 15 16 During pregnancy: 17 18 Hypertension: □ yes □ no 19 20 PT rupture of membranes: □ yes □ no 21 22 Preeclampsia/ Eclampsia □ yes □ no 23 24 Any other problems (e.g. seizures, drug abuse, diabetes) 25 26 SES of mother: □ employed □ unemployed 27 28 Electricity at home: □ yes □ no 29 30 31 Running water at home: □ yes □ no 32 33 Fridge: □ yes □ no 34

35 Educational level: □ primary school □ matric □ tertiary education http://bmjpaedsopen.bmj.com/ 36 37 Mother’s HIV status: □ positive □ negative 38 39 If positive: 40 41 ARVs since when: weeks before birth 42 43 ARVS: □ FDC □ second line □ other 44 45 Disclosure to anyone: on September 27, 2021 by guest. Protected copyright. 46 47 Has partner been tested: 48 49 50 51 52 53 54 55 56 57 58 59 60

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Confidential: For Review Only Prospective cohort study of mortality in very low birth weight infants in a single centre in the Eastern Cape Province, South Africa

Journal: BMJ Paediatrics Open

Manuscript ID bmjpo-2020-000918.R2

Article Type: Original research

Date Submitted by the 27-Jan-2021 Author:

Complete List of Authors: Michaelis, Isabel; Walter Sisulu University, Paediatrics Manyisane, Ncomeka; Walter Sisulu University, Paediatrics Krägeloh-Mann, Ingeborg; Eberhard Karls University Tübingen Faculty of Medicine, Children's Hospital, Neuropaediatrics, Developmental Neurology, Social Paediatrics Mazinu, Mikateko; South African Medical Research Council, Biostatistics unit Jordaan, Esme; South African Medical Research Council, Biostatistics unit http://bmjpaedsopen.bmj.com/ Keywords: Neonatology, Mortality

on September 27, 2021 by guest. Protected copyright.

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the termsConfidential: applicable for US Federal Government For officers Review or employees actingOnly as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author unless you are acting as an employee on behalf of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34

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3 Title Page bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Prospective cohort study of mortality in very low birth weight infants in a single centre in the 8 Eastern Cape Province, South Africa 9 10 Isabel Michaelis, MD, PhD, Walter Sisulu University, East London 11 12 IngeborgConfidential: Krägeloh- Mann, Professor of Paediatrics,For Review Eberhard Karls UniversityOnly of Tübingen, 13 Tübingen 14 Ncomeka Manyisane, McBCh, FcPaed, Walter Sisulu University, East London 15 16 Mikateko Mazinu, MSc Biomathematics, South African Medical Research Council, Tygerberg 17 18 Esme Jordaan, MSc Statistics, South African Medical Research Council, Tygerberg and 19 20 Statistics and Population Studies Department, University of the Western Cape 21 22 23 24 25 Corresponding author: Isabel Michaelis, Private Bag 9047, Amalinda Main Road, 5200 East 26 London, Tel: +27 (43) 709 2077, Fax: +27 (43) 709 4065. [email protected] 27 28 29 30 Key words: neonatology, VLBW, infant mortality, sub Saharan Africa, global health 31 32 33 34

35 Word count: 2424 (without tables and abstract) http://bmjpaedsopen.bmj.com/ 36 37 38 39 Dr Isabel Michaelis 40 41 42 43 44

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3 Prospective cohort study of mortality in very low birth weight infants in a single centre bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 in the Eastern Cape Province, South Africa 6 7 8 Isabel Michaelis, MD, PhD, Walter Sisulu University, East London 9 10 Ingeborg Krägeloh-Mann, Professor of Paediatrics, Eberhard Karls University of Tübingen, Tübingen 11 Ncomeka Manyisane, McBCh, FcPaed, Walter Sisulu University, East London 12 Confidential: For Review Only 13 Mikateko Mazinu, MSc Biomathematics , South African Medical Research Council, Tygerberg 14 Esme Jordaan, MSc Statistics, African Medical Research Council, Tygerberg 15 16 17 18 Contact: [email protected] 19 20 21 I hereby confirm that neither the submitted paper nor any parts of it have been published or 22 submitted anywhere else. 23 24 There is no conflict of interest. This work was supported by the South African Medical 25 Research Council (SAMRC) Fund, grant number (086/2017). The sponsorship of the 26 27 SAMRC Pilot Grant serves to encourage clinicians in rural South Africa to engage in 28 research. 29 30 31 Dr Isabel Michaelis’ contribution consisted of funding acquisition, study design, investigation, 32 data curation, supervision and drafting the initial manuscript. 33 34 Dr Ncomeka Mayisane contributed to study design, investigation, data curation and 35 reviewing the manuscript. http://bmjpaedsopen.bmj.com/ 36 37 Prof Ingeborg Krägeloh-Mann contributed to supervision, writing and reviewing the final 38 manuscript. 39 40 Mrs Mikateko Mazinu contributed to data curation and data analysis. 41 42 Mrs Esme Jordaan contributes to data curation and data analysis and writing and reviewing 43 the final manuscript. 44

45 on September 27, 2021 by guest. Protected copyright. 46 47 What is known about this topic? 48 The perinatal mortality rate in sub-Saharan Africa is about 30 per 1000 live births. Preterm and 49 VLBW infants account for a large number of neonatal deaths. Although South Africa is 50 considered an upper-middle-income country by the World Bank, survival of VLBW varies greatly 51 dependent on resources. Survival of VLBW infants in studies from South Africa are about 75%. 52 53 54 55 What does this study add? 56 Survival of VLBW infants fulfilling inclusion criteria for the study was 68%. Survival for VLBW 57 babies in our setting is lower than in other South African urban settings. 58 59 60

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3 bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Background: 6 7 Neonatal mortality is a major contributor worldwide to the number of deaths in children under 8 5 years of age. The primary objective of this study was to assess the overall mortality rate of 9 10 babies with a birth weight equal or below 1500g in a neonatal unit at a tertiary hospital in the 11 12 Eastern Confidential:Cape Province, South Africa. Furthermore, For Review different maternal Only and infant related 13 factors for higher mortality were analysed. 14 15 16 17 18 Methods: 19 20 This is a prospective cohort study which included infants admitted to the neonatal wards of 21 the hospital within their first 24 hours of life and with a birth weight equal to or below 1500g. 22 23 Mothers who consented answered a questionnaire to identify factors for mortality. 24 25 26 27 28 Results: 29 30 173 very low birth weight (VLBW) infants were admitted to the neonatal department between 31 November 2017 and December 2018, of whom 55 died (overall mortality rate 32.0%). 32 33 Twenty-three of the 44 infants (53,5%) with a birth weight below 1000g died during 34

35 admission. One hundred and sixty-one mothers completed the questionnaire and 45 of their http://bmjpaedsopen.bmj.com/ 36 babies died. 37 38 Main factors associated with mortality were lower gestational age and lower birth weight. 39 40 Need for ventilator support and sepsis were associated with higher mortality, as were 41 42 maternal factors such as HIV infection and age below 20 years. 43 44

45 on September 27, 2021 by guest. Protected copyright. 46 Conclusion: 47 48 This prospective study looked at survival of very low birth weight babies in an 49 50 underprivileged part of the Eastern Cape of South Africa. Compared to other public urban 51 hospitals in the country the survival rate remains unacceptably low. Further research is 52 53 required to find the associated causes and appropriate ways to address these. 54 55 56 57 58 59 60

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3 Introduction: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Despite improved survival rates of neonates worldwide, the survival of preterm and low birth 6 7 weight babies is still a challenge, especially in middle- and low-income countries (1–4). 8 9 In 2018, the World Health Organisation (WHO) described a worldwide increase of babies 10 born prematurely over the last two decades. The incidence has been estimated between 5 to 11 12 18% of allConfidential: life births (5,6). The prevalence For of babies Review born with a very Only low birth weight 13 14 (VLBW) varies between different countries. For example, in one South African study the 15 prevalence was 3%, while in the USA it lies between 1.23 and 1.43% (7–9). Furthermore, 16 17 prematurity and low birth weight have been identified as the leading causes of mortality in 18 children less than five years of age (5,10–12). It is also well known that neonatal mortality for 19 20 VLBW infants varies considerably amongst high- and low-middle income countries: a 21 mortality rate of 15% is found in the United States (13), 20% by the Vermont Oxford network 22 23 (14), 29.1% in Iran (3), 28.2% in South Korea (11), 32% in the Eastern Mediterranean 24 25 Region (15), and 24.6% in India (16). Some single centres worldwide show a lower mortality 26 rate with 9.5%, 12.4%, 13.0% and 17.2% in single centres in Singapore, Taiwan, Hong- 27 28 Kong, Saudi-Arabia, respectively (14,17–19). 29 30 In South Africa, neonatal mortality accounted for 32% of the under-5 mortality rate (4,20,21). 31 32 A recent study illustrated survival rates of VLBW neonates between different hospitals in the 33 Western Cape Province of South Africa as characterized by unrestricted or restricted 34

35 resources (22). The team found a significant difference with a survival rate of 84.4% and http://bmjpaedsopen.bmj.com/ 36 70.4% respectively (22). Kalimba and Ballot (23) studied the survival rate of extremely low 37 38 birth weight (ELBW) babies (babies weighing less than 1000g at birth) born between 2006 39 40 and 2010 in Johannesburg and found that only 25.6% of babies born with a birth weight of 41 less than 900g survived their hospital stay, with birth weight and gestational age being the 42 43 strongest predictors for survival. A newer retrospective cross-sectional South African study 44 found an overall survival rate in VLBW babies (500g–1499g) of 75.7% (24). 45 on September 27, 2021 by guest. Protected copyright. 46 47 However, there are also other known contributory factors, which can be divided into infant-or 48 maternal-related risk factors. Examples of neonate-related risk factors studied in the 49 50 literature include low Apgar scores, hyaline membrane disease (HMD), intubation and 51 mechanical ventilation, sepsis, and hemodynamic instability (25,26). Maternal or obstetric 52 53 risk factors include eclampsia, alcohol consumption, smoking, low socioeconomic status, 54 scarce antenatal care and human immunodeficiency virus (HIV) infection (18,23,27,28). 55 56 Several studies suggest an increased risk of premature labour in mothers taking 57 58 antiretroviral treatment for HIV infection during pregnancy (29–32), while others did not find a 59 relationship (33). This is noteworthy, as 30.8% of pregnant women in South Africa tested 60

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3 positive for HIV in 2015, and are put on treatment as soon as the infection is diagnosed bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 (34,35). 6 7 The primary aim of this study was to research neonatal mortality of VLBW infants admitted to 8 9 the neonatal unit in a hospital in a mixed urban and rural setting in the Eastern Cape 10 Province of South Africa. Secondly, the association between death and different maternal 11 12 and neonatalConfidential: factors were explored. For Review Only 13 14 15 16 Setting: 17 18 19 Frere Hospital is a large (885 beds) public tertiary hospital in East London in the Eastern 20 Cape Province in South Africa, with a seven-bed paediatric intensive care unit (PICU), which 21 22 cares for neonates and paediatric medical and surgical patients. Because of this very limited 23 PICU access, babies with a weight below 1000g are not provided with invasive ventilatory 24 25 support due to poor survival. These babies will receive surfactant if needed and continuous 26 positive airway pressure (CPAP) ventilation is available for six infants in the high care 27 28 neonatal unit, which can cater for 12 infants altogether. This high care ward is constantly 29 30 above capacity, often having to care for up to 20 infants, when there is only adequate space 31 for the above-mentioned 12 neonates. Infants with a birth weight over 1000g will be taken to 32 33 PICU and receive invasive ventilation if needed and if space is available for them. Stable 34 neonates with a weight of more than 1000g are referred to the general nursery ward, where 35 http://bmjpaedsopen.bmj.com/ 36 they receive kangaroo care (KMC) in the ward and, if necessary, intravenous fluids and/or 37 antibiotics and oxygen. Once clinically stable, off oxygen support, tolerating full enteral feeds 38 39 and weighing more than 1500g, infants will be transferred to the KMC ward until mothers are 40 41 competent in caring for their baby and the weight has increased to at least 1700 g. Some 42 stable babies might be transferred to their regional hospital once their weight has reached 43 44 1500g.

45 on September 27, 2021 by guest. Protected copyright. 46 Frere Hospital is the tertiary neonatal and obstetric referral centre for obstetric units and for 47 48 surrounding district hospitals in the middle part of the Eastern Cape Province. Some 49 referrals centres are more than 300 km away. These areas were deprived of adequate 50 51 infrastructure during the Apartheid regime and are still one of the most under-resourced and 52 insufficiently managed parts of South Africa. 53 54 55 Materials and Methods: 56 57 This was a prospective cohort study. All babies born at the hospital, or admitted within the 58 first 24 hours of life into the neonatal unit, with a birth weight equal or below 1500g and 59 60 without any life-threatening malformations were included. Neonates who were admitted to

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3 the neonatal ward or PICU beyond 24 hours of life were excluded as it was not possible to bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 get sufficient information on those mother-infant pairs. Mothers were then approached for 6 consent to include their data. The recruitment period lasted from December 2017 to 7 8 November 2018. 9 10 The study was approved by the institutional ethics committee (086/2017) and, after receiving 11 12 written consentConfidential: from the mothers, data concerningFor Review mother and child Onlyduring the pre-, peri- 13 and neonatal period were collected from the maternal and neonatal case records, as well as 14 15 from a questionnaire filled in with the mother (see supplements). The babies were followed 16 17 up until discharge or death. All babies received standard care during this period, as outlined 18 above. 19 20 Gestational age was determined by either an early ultrasound or by applying the Ballard 21 22 gestational age scoring system. It is estimated that about 70% of the babies admitted to our 23 24 neonatal wards will have had their gestational age assessed by early ultrasound. The 25 different variables were defined as follows: a persistent ductus arteriosus as identified by 26 27 echocardiogram; hyaline membrane disease by the presence respiratory distress; FiO2 28 requirement above 40% followed by a confirmatory blood gas and typical X-ray signs; sepsis 29 30 as clinical signs confirmed with a positive blood, urine or cerebrospinal fluid culture and/or 31 raised C-reactive protein (CRP) taken at least 24 hours apart; normal weight gain was 32 33 determined when weight loss after birth did not exceed more than 10% and birth weight was 34

35 regained within 10-14 days of life; intracranial haemorrhage (ICH) was diagnosed with http://bmjpaedsopen.bmj.com/ 36 cranial ultrasound, which was only performed in clinically unstable infants with the clinical 37 38 suspicion of ICH; resuscitation at birth included mask or invasive ventilation with or without 39 cardiac compressions and medication. 40 41 42 43 44 Patient and Public Involvement:

45 on September 27, 2021 by guest. Protected copyright. 46 The patients, being mother-newborn pairs, were not involved in the study design. Every 47 48 new-born admitted in our wards during the study period was assessed for inclusion in our 49 study, no recruitment from the patient’s side was necessary. The results of this study are 50 51 verbally communicated to the mothers and/or caretakers. 52 53 54 55 Statistical analysis: 56 57 58 Demographic data is presented as frequencies (percentages) for categorical data, and as 59 means (SD) for continuous data. To test for association between the outcome variable 60

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3 (mortality) and the predictor variables, a log binomial regression model was used. In order to bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 investigate the relationship between hypertension and mortality in babies in more detail, a 6 multiple regression model was used, adjusting for IUGR and gestational age. The standard 7 8 for significance for all analyses was a p-value <0.05. Data were analysed using STATA 9 10 version 15. 11 12 ResultsConfidential:: For Review Only 13 14 During the study period 4 342 babies were born in the hospital, 4 210 of these were live 15 16 births and 231 (5.3%) were born with a birth weight between 500g and 1500g. Of those 231 17 VLBW infants, only 173 met the inclusion criteria for the study. Of those, 55 died during 18 19 admission, resulting in an overall mortality rate of 31.8% (95% CI: 25.2–39.2) for VLBW 20 infants admitted to our unit. 21 22 23 One hundred and sixty-one of the 173 VLBW infants were successfully recruited (caregivers 24 gave informed consent) during the study period. Forty-five (28.0%) of those babies died 25 26 before discharge and 116 (72.0%) were discharged home or referred to a peripheral hospital 27 if they had reached a weight above 1500 g. Forty-four of the 161 babies were born with a 28 29 birth weight below 1000g, of those 23 (53,5%) did not survive until discharge. For an 30 overview of recruitment and numbers of participants, see Figure 1. All 116 babies 31 32 discharged from hospital received a follow-up date for the high-risk clinic. 33 34

35 http://bmjpaedsopen.bmj.com/ 36 37 Demographics: 38 39 The maternal age ranged between 14 and 46 years. Fifty-eight (36.0%) mothers had HIV 40 infection diagnosed before or during pregnancy, or at birth. Thirty-nine of them (67.2%) had 41 42 been on antiretroviral (ARV) treatment at delivery for more than 4 weeks. Sixteen (27.6%) 43 44 mothers had been on ARV treatment for less than 4 weeks or were not on treatment at all

45 when giving birth, and their babies were thus considered at high risk for HIV transmission on September 27, 2021 by guest. Protected copyright. 46 47 and treated accordingly. For other variables please see Table 1. 48 Of the 161 babies included in the study, 96 were female (59.7%). Almost all HIV exposed 49 50 babies (n=58) tested negative for HIV infection at birth with a negative birth HIV-polymerase 51 chain reaction (HIV-PCR) (n=55; 94.8%). Three babies, who died a few hours after birth, did 52 53 not receive an HIV-PCR at birth and their status is therefore unknown. For other variables 54 55 please see Table 2. 56 57 58 59 60

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3 Table 1: Maternal demographic variables bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Neonates who 6 Overall* died ** 7 Variables Category n =161 (%) N=45 (%) 8 9 Age of mother (years) ≤20 30 (18.6) 10 (33.3) 10 >20 131 (81.4) 35 (26.7) 11 Married/stable 12 Marital statusConfidential:relationship For91 (57.6) Review24 (26.4) Only 13 No partner 67 (42.4) 18 (26.8) 14 15 Substance abuse Yes 13 (8.1) 4 (30.8) 16 No 147 (91.9) 40 (27.2) 17 Employment Yes 24 (15.1) 5 (20.8) 18 19 No 135 (84.9) 39 (28.9) 20 Electricity at home Yes 143 (89.9) 41 (28.7) 21 No 16 (10.1) 3 (18.8) 22 Running water at home Yes 99 (62.3) 28 (28.3) 23 24 No 60 (37.7) 16 (26.7) 25 Refrigerator at home Yes 109 (68.6) 32 (29.4) 26 No 50 (31.5) 12 (24.0) 27 28 Education level Primary 72 (45.6) 22 (30.6) 29 Secondary/tertiary 86 (54.4) 21 (24.4) 30 HIV-infection Yes 58 (36.5) 14 (24.1) 31 32 No 101 (63.5) 30 (29.7) 33 ARTs FDC 45 (93.8) 10 (22.2) 34 Second line 2 (4.2) 0 (0.0) 35 http://bmjpaedsopen.bmj.com/ Other 1 (2.1) 0 (0.0) 36 *The overall number and percentage per risk factor 37 **The number and percentage of babies who died per risk factor category. 38 HIV: human immunodeficiency virus, ART: antiretroviral treatment, FDC: fixed dose combination. 39 40 41 Table 2: Infant demographics variables 42 43 Neonates who died 44 Overall* ** 45 Variables Category n =161 (%) N=45 (%) on September 27, 2021 by guest. Protected copyright. 46 Gender Female 96 (59.6) 27 (28.1) 47 Male 65 (40.4) 18 (27.7) 48 GA (weeks) 25-32 78 (49.1) 36 (46.2) 49 33-37 81 (50.9) 9 (11.1) 50 51 HIV exposed Yes 58 (36.0) 14 (24.1) 52 No 103 (64.0) 31 (30.1) 53 PMTCT Yes 44 (27.3) 11 (25.0) 54 No 117 (72.7) 34 (29.1) 55 Birth weight (g) ≤1000g 43 (26.7) 23 (53.5) 56 >1000g 118 (73.3) 22 (18.6) 57 Born before arrival Yes 11 (6.8) 2 (18.2) 58 No 150 (93.2) 43 (28.7) 59 Mother not been to ANC Yes (no ANC) 25 (15.5) 8 (32.0) 60

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3 No (ANC bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 attended) 136 (84.5) 37 (27.2) 5 IUGR Yes 111 (69.8) 23 (20.7) 6 No 48 (30.2) 21 (43.8) 7 *The overall number and percentage per risk factor 8 **The number and percentage of babies who died per risk factor category. 9 GA: gestational age, HIV: human immunodeficiency virus, PMTCT: prevention of mother to child transmission, IUGR: intrauterine 10 growth restriction. 11 12 FactorsConfidential: associated with in hospital mortality: For Review Only 13 14 Maternal associated factors for the univariate model: 15 16 Univariate regression analysis was used to examine the association between mortality and 17 18 associated individual factors. Associated factors of infants dying while still in hospital were 19 higher in babies of teenage mothers, mothers with illnesses and mothers on medication. 20 21 Maternal hypertension and preeclampsia were associated with decreased mortality in the 22 23 babies. Education level of the mother and other socio-economic status factors were not 24 significantly related to a higher mortality risk during admission in our study, with employment 25 26 status only showing a trend towards significance (Table 3). 27 28 Table 3: Significant univariate associations between VLBW infant mortality and maternal-related 29 factors. 30 31 32 33 Variables Category Risk Ratio (95% CI) P value 34

35 Age of mother (years) ≤20 vs >20 1.25 (1.07- 1.45) <0.01 http://bmjpaedsopen.bmj.com/ 36 37 Hypertension Yes vs no 0.62 (0.49 - 0.77) <0.01 38 Pre-eclampsia Yes vs no 0.69 (0.57 - 0.82) <0.01 39 40 Other illnesses Yes vs no 1.34 (1.04 - 1.74) 0.02 41 42 Medication Yes vs no 0.43 (0.25 - 0.77) <0.01 43 44 Employment Yes vs no 0.72 (0.52 - 1.01) 0.06

45 on September 27, 2021 by guest. Protected copyright. 46 Fridge Yes vs no 1.22 (1.01 - 1.48) 0.04 47 48 Other illnesses included malignancies, epilepsy, mental health disorders. Medication included all other medication besides 49 antiretroviral treatment. CI: confidence interval. Most maternal factors that were not significantly associated with mortality in the 50 regression analysis are not shown in this table. 51 52 53 54 Neonatal-associated factors: 55 56 There were many significant neonatal-associated factors related to infant mortality, such as 57 58 low gestational age (p<0.01), low birth weight (p<0.01), IUGR (p<0.01), and the need for 59 60

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3 resuscitation at birth (p<0.01) or during hospital stay (p=0.01). Male gender was not bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 associated with higher mortality risk (p=0.94; RR=1.0; 95% CI: 0.7–1.5) (Table 4). 6 7 8 9 Table 4: Significant univariate associations between infant mortality and infant-related factors of 10 VLBW infants 11 12 Confidential: For Review Only 13 Variables Category Risk Ratio (95% CI) P value 14 Gender Female vs Male 1.02 (0.70, 1.48) 0.94 15 GA (weeks) 25-32 vs 33-37 4.15 (2.93, 5.88) <0.01 16 HIV exposed No vs yes 1.25 (1.00, 1.56) 0.05 17 Birth weight (g) ≤1000 vs >1000 2.87 (2.08, 3.96) <0.01 18 IUGR Yes vs no 0.47 (0.35, 0.65) <0.01 19 Resuscitation at birth Yes vs no 4.45 (3.43, 5.78) <0.01 20 Apgar 1 min 0-6 vs 7-10 2.46 (1.99, 3.05) <0.01 21 Apgar 5 min. 0-6 vs 7-10 2.42 (2.12, 2.77) <0.01 22 23 HMD Yes vs no 2.03 (1.72, 2.38) <0.01 24 Other Yes vs no 1.59 (1.20, 2.09) 0.01 25 Oxygen support Yes vs no 9.68 (7.39, 12.68) <0.01 26 Days on oxygen 0-1 day vs >1 day 1.44 (0.94, 2.21) 0.09 27 Surfactant given Yes vs no 3.59 (2.77, 4.65) <0.01 28 Weight gain Yes vs no 3.39 (2.21, 5.19) <0.01 29 Sepsis Yes vs no 6.41 (3.78, 10.88) <0.01 30 ICH Yes vs no 5.19 (3.03, 8.90) <0.01 31 PDA No vs yes 2.83 (1.47, 5.47) <0.01 32 Resuscitation needed stay Yes vs no 12.31 (5.85, 25.88) 0.01 33 GA: gestational age, HIV: human immunodeficiency virus, IUGR: intrauterine growth restriction, HMD: hyaline membrane 34 disease, ICH: intracranial haemorrhage, PDA: persistent ductus arteriosus, ANC: antenatal clinic, Other: other problems like

35 neonatal jaundice, hypoglycaemia, necrotizing enterocolitis, hypothermia. CI: confidence interval. Infant-related factors that http://bmjpaedsopen.bmj.com/ were not significantly associated with mortality in the univariate regression analysis are not shown in this table, besides gender. 36 37 38 39 Multiple regression analysis 40 41 As could be seen in the univariate analysis, maternal hypertension was associated with 42 decreased mortality in the babies. However, when adjusting for IUGR and gestational age in 43 44 the multiple regression analysis, no significant association was found for maternal 45 hypertension (p=0.28; RR=0.88; 95% CI: 0.70-1.11), as shown in Table 5. on September 27, 2021 by guest. Protected copyright. 46 47 48 Table 5: Results of maternal and infant factors in multiple regression analysis 49 Variables Category Risk Ratio (95% CI) P value 50 51 Hypertension Yes vs No 0.88 (0.70, 1.11) 0.28 52 IUGR Yes vs No 1.88 (1.68, 2.11) 0.03 53 GA (weeks) 25-32 vs 33-37 3.80 (2.43, 5.96) <0.01 54 GA: gestational age, IUGR: intrauterine growth restriction. CI: confidence interval. 55 56 57 58 59 60

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3 Discussion: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 The prevalence of VLBW infants of all live birth in this single hospital study in the Eastern 6 7 Cape Province between December 2017 and November 2018 was 5.4%. This figure lies 8 9 within the prevalence of 3–7% reported worldwide (3,13), but is likely elevated due to the 10 referrals from obstetric units and surrounding district hospitals. 11 12 Confidential: For Review Only Almost 32% of all admitted VLBW neonates died before discharge. For infants with a birth 13 14 weight of 1000g or less this number rose to 60%, while the chance for survival of infants 15 16 weighing 1000g and up to 1500g at birth was higher, with a mortality rate of 18.5%. Thus, 17 the overall mortality rate is higher than the reported average of approximately 25% in major 18 19 cities in South Africa, (24,36,37) and much higher than in the hospitals with much greater 20 resources from the Western Cape Province (22). It is also much higher than in most 21 22 hospitals in high-income countries where mortality rates for VLBW infants are as low as 23 24 9.5% to 17.2% (14,17–19,38,39). The high mortality in our setting is most likely due to the 25 scarcity of skilled health care workers, limited infrastructures, as well as a patient 26 27 overloaded, resource-restricted system, as described (4). The data supports that although 28 South Africa is considered an upper-middle-income country by the World Bank, survival of 29 30 VLBW varies greatly dependent on resources (22). 31 32 Consistent with other studies examining the causes of mortality in VLBW babies, birth weight 33 34 and low gestational age were predictors of neonatal mortality in our study population 35 (18,23,26,35). Complications of prematurity, such as the development of hyaline membrane http://bmjpaedsopen.bmj.com/ 36 37 disease (HMD) and the associated need for surfactant replacement therapy with ventilation 38 was associated with a significantly increased risk of mortality, as reported in previous 39 40 research (3,22,23,26). Other studies have shown that CPAP and/or surfactant replacement 41 42 therapy reduce mortality in VLBW and/or preterm neonates with hyaline membrane disease 43 (22,40). Unavailability of PICU beds and overcrowding in our high care unit with low nurse- 44

45 infants’ ratio could explain why we were unable to find this benefit in our cohort. on September 27, 2021 by guest. Protected copyright. 46 47 Interestingly, our study did not find that the wide range of maternal factors found in other 48 49 studies increasing in-hospital mortality of infants, including lack of antenatal care, maternal 50 primi-parity, mode of delivery or complications thereof (23,27,28,32). 51 52 Although a substantial percentage (36%) of the babies were born to HIV infected mothers, 53 54 and 13.8% (n=8) of those had not received any ART before giving birth, all HIV-PCR done 55 56 were negative. This is encouraging, but further research is needed to investigate HIV 57 transmission rates in VLBW babies in low resource settings (34,35). 58 59 60

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3 There are several limitations to this study. Even though this was a prospective study, data bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 collection was not exhaustive and some prenatal variables could not be explored due to lack 6 of information. Also, due to staff shortage, ultrasound of the head was not performed 7 8 routinely, but only in clinically suspicious situations, and thus intracranial pathologies might 9 10 have been missed. Furthermore, this is a single hospital-based study, therefore the number 11 of VLBW cases is limited. 12 Confidential: For Review Only 13 14 15 16 Conclusion 17 Our cohort shows a higher in-hospital mortality of VLBW infants compared to some other 18 19 urban hospitals in South Africa. These findings indicate that the survival of VLBW and 20 especially ELBW babies are still unacceptably low in this resource restricted public hospital. 21 22 This is most likely caused by numerous factors, many of which have also been implicated in 23 24 similar studies, but need to be further investigated in future research and appropriately 25 addressed. 26 27 28 29 30 31 32 33 34

35 http://bmjpaedsopen.bmj.com/ 36 37 38 Literature: 39 40 1. De Almeida MFB, Guinsburg R, Martinez FE, Procianoy RS, Leone CR, Marba STM, 41 42 et al. Fatores perinatais associados ao óbito precoce em prematuros nascidos nos 43 44 centros da Rede Brasileira de Pesquisas Neonatais. J Pediatr (Rio J).

45 2008;84(4):300–7. on September 27, 2021 by guest. Protected copyright. 46 47 2. Basu S, Rathore P, Bhatia BD. Predictors of mortality in very low birth weight 48 49 neonates in India. Singapore Med J. 2008;49(7):556–60. 50 51 3. Afjeh SA, Sabzehei MK, Fallahi M, Esmaili F. Outcome of very low birth weight infants 52 53 over 3 years report from an iranian center. Iran J Pediatr. 2013; 54 55 4. Rhoda NR, Gebhardt GS, Kauchali S BP. Reducing neonatal deaths in South Africa. 56 57 S Afr Med J. 2018;3(1):S9–19. 58 59 5. World Health Organization. Newborns: reducing mortality. World Heal Organ 60

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3 [Internet]. 2019;(September 2019):2018–21. Available from: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 http://www.who.int/mediacentre/factsheets/fs178/en/ 6 7 6. Haas DM. Preterm birth. BMJ Clin Evid. 2011;2011(1):1–5. 8 9 7. Velaphi SC, Mokhachane M, Mphahlele RM, Beckh-Arnold E, Kuwanda ML, Cooper 10 11 PA. Survival of very-low-birth-weight infants according to birth weight and gestational 12 Confidential: For Review Only age in a public hospital. South African Med J. 2005; 13 14 15 8. Mackay CA, Ballot DE, Cooper PA. Growth of a cohort of very low birth weight infants 16 in Johannesburg, South Africa. BMC Pediatr. 2011;11:2–7. 17 18 19 9. Martin JA, Hamilton BE, D P, Sutton PD, Ventura SJ, Menacker F, et al. National Vital 20 Statistics Reports Births : Final Data for 2013. Statistics (Ber). 2015;64(1):1–104. 21 22 10. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national 23 24 causes of under-5 mortality in 2000–15: an updated systematic analysis with 25 26 implications for the Sustainable Development Goals. Lancet. 2016;388(10063):3027– 27 35. 28 29 11. Hahn WH, Chang JY, Chang YS, Shim KS, Bae CW. Recent trends in neonatal 30 31 mortality in very low birth weight korean infants: In comparison with Japan and the 32 USA. J Korean Med Sci. 2011;26(4):467–73. 33 34

35 12. Chung SH, Bae CW. Improvement in the survival rates of very low birth weight infants http://bmjpaedsopen.bmj.com/ 36 after the establishment of the Korean neonatal network: Comparison between the 37 38 2000s and 2010s. J Korean Med Sci. 2017; 39 40 13. Fanaroff AA, Stoll BJ, Wright LL, Carlo WA, Ehrenkranz RA, Stark AR, et al. Trends in 41 42 neonatal morbidity and mortality for very low birthweight infants. Am J Obstet 43 Gynecol. 2007; 44

45 on September 27, 2021 by guest. Protected copyright. 46 14. Chee YY, Wong MSC, Wong RMS, Wong KY. Neonatal outcomes of preterm or very- 47 low-birth-weight infants over a decade from queen mary hospital, Hong Kong: 48 49 Comparison with the vermont oxford network. Hong Kong Med J. 2017; 50 51 15. Nayeri F, Emami Z, Mohammadzadeh Y, Shariat M, Sagheb S, Sahebi L. Mortality 52 53 and Morbidity Patterns of Very Low Birth Weight Newborns in Eastern Mediterranean 54 Region: A Meta-Analysis Study. J Pediatr Rev. 2018;7(2):67–76. 55 56 16. Bansal A. Comparison of outcome of very-low-birth-weight babies with developed 57 58 countries: A prospective longitudinal observational study. J Clin Neonatol. 59 60 2018;7(4):254.

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3 17. Amudha Jayanthi Anand, Karthik Sabapathy, Bhavani Sriram, Victor Samuel bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Rajadurai PKA. Single Center Outcome of Multiple Births in the Premature and Very 6 Low Birth Weight Cohort in Singapore. Am J Perinatol. 2020;Sep. 7 8 9 18. Chen SD, Lin YC, Lu CL, Chen SCC. Changes in outcome and complication rates of 10 very-low-birth-weight infants in one tertiary center in southern Taiwan between 2003 11 12 andConfidential: 2010. Pediatr Neonatol [Internet]. For 2014;55(4):291–6. Review Available Only from: 13 http://dx.doi.org/10.1016/j.pedneo.2013.10.010 14 15 16 19. Al Hazzani F, Al-Alaiyan S, Hassanein J, Khadawardi E. Short-term outcome of very 17 low-birth-weight infants in a tertiary care hospital in Saudi Arabia. Ann Saudi Med. 18 19 2011; 20 21 20. Nannan N, Dorrington R, Laubscher R, Zinyakatira N, Prinsloo M, Darikwa T, et al. 22 23 Under-5 mortaliy statistics in South Africa: Shedding some light on the trend and 24 causes 1997-2007. South African Medical Research Council. 2012. 25 26 21. Bradshaw D, Dorrington R. Rapid Mortality Surveillance Report 2011. 2012. 27 28 29 22. Van Wyk L, Tooke L, Dippenaar R, Rhoda N, Lloyd L, Holgate S, et al. Optimal 30 ventilation and surfactant therapy in very-low-birth-weight infants in resource- 31 32 restricted regions. Neonatology. 2020;117(2):217–24. 33 34 23. Kalimba EM, Ballot DE. Survival of extremely low-birth-weight infants. SAJCH South 35 http://bmjpaedsopen.bmj.com/ 36 African J Child Heal. 2013;7(1):13–6. 37 38 24. Tshehla RM, Chb MB, Sa DCH, Coetzee M, Chb MB, Sa DCH, et al. Mortality and 39 morbidity of very low-birthweight and extremely low-birthweight infants in a tertiary 40 41 hospital in Tshwane. 2019;13(2). 42 43 25. Terzic S, Heljic S. Assessing mortality risk in very low birth weight infants. Med Arh. 44

45 2012;66(2):76–9. on September 27, 2021 by guest. Protected copyright. 46 47 26. S. K, Kumar MS. Morbidity and mortality pattern of very low birth weight infants 48 49 admitted in SNCU in a South Asian tertiary care centre. Int J Contemp Pediatr. 50 2018;5(3):720–5. 51 52 53 27. Cupen K, Barran A, Singh V, Dialsingh I. Risk Factors Associated with Preterm 54 Neonatal Mortality: A Case Study Using Data from Mt. Hope Women’s Hospital in 55 56 Trinidad and Tobago. Children. 2017;4(12):108. 57 58 28. Vaahtera M, Kulmala T, Ashorn P, Ndekha M, Cullinan T, Koivisto AM, et al. 59 60 Antenatal and perinatal predictors of infant mortality in rural Malawi. Arch Dis Child

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3 Fetal Neonatal Ed. 2000;82(3):200–4. bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 29. Townsend CL, Schulte J, Thorne C, Dominguez KL, Tookey PA, Cortina-Borja M, et 6 7 al. Antiretroviral therapy and preterm delivery-a pooled analysis of data from the 8 9 United States and Europe. BJOG An Int J Obstet Gynaecol. 2010;117(11):1399–410. 10 11 30. Van Der Merwe K, Hoffman R, Black V, Chersich M, Coovadia A, Rees H. Birth 12 Confidential: For Review Only outcomes in South African women receiving highly active antiretroviral therapy: A 13 14 retrospective observational study. J Int AIDS Soc [Internet]. 2011;14(1):42. Available 15 16 from: http://www.jiasociety.org/content/14/1/42 17 18 31. Powis KM, Kitch D, Ogwu A, Hughes MD, Lockman S, Leidner J, et al. Increased risk 19 of preterm delivery among HIV-infected women randomized to protease versus 20 21 nucleoside reverse transcriptase inhibitor-based HAART during pregnancy. J Infect 22 23 Dis. 2011;204(4):506–14. 24 25 32. Uthman OA, Nachega JB, Anderson J, Kanters S, Mills EJ, Renaud F, et al. Timing of 26 initiation of antiretroviral therapy and adverse pregnancy outcomes: a systematic 27 28 review and meta-analysis. Lancet HIV. 2017;4(1):e21–30. 29 30 33. González R, Rupérez M, Sevene E, Vala A, Maculuve S, Bulo H, et al. Effects of HIV 31 32 infection on maternal and neonatal health in southern Mozambique: A prospective 33 cohort study after a decade of antiretroviral drugs roll out. PLoS One. 2017;12(6):1– 34

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45 36. Ballot DE, Chirwa T, Ramdin T, Chirwa L, Mare I, Davies VA, et al. Comparison of on September 27, 2021 by guest. Protected copyright. 46 morbidity and mortality of very low birth weight infants in a Central Hospital in 47 48 Johannesburg between 2006/2007 and 2013. BMC Pediatr. 2015;15(1):1–11. 49 50 37. Gibbs L, Bch MB, Sa DCH, Paeds M, Sa F, Tooke L, et al. Short-term outcomes of 51 52 inborn v . outborn very-low- birth-weight neonates ( < 1 500 g ) in the neonatal nursery 53 at Groote Schuur Hospital , Cape Town , South Africa. 2017;107(10):900–3. 54 55 56 38. Numerato D, Fattore G, Tediosi F, Zanini R, Peltola M, Banks H, et al. Mortality and 57 length of stay of very low birth weight and very preterm infants: A EuroHOPE study. 58 59 PLoS One. 2015;10(6):1–12. 60

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3 39. Zile I, Ebela I, Rozenfelde IR. Risk factors associated with neonatal deaths among bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 very low birth weight infants in Latvia. Curr Pediatr Res. 2017;21(1):64–8. 6 7 40. Griffin JB, Jobe AH, Rouse D, McClure EM, Goldenberg RL, Kamath-Rayne BD. 8 9 Evaluating WHO-recommended interventions for preterm birth: A mathematical model 10 of the potential reduction of preterm mortality in sub-Saharan Africa. Glob Heal Sci 11 12 Pract.Confidential: 2019; For Review Only 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

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3 FNo: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 Data of child at birth: 6 7 Date of birth: □ 8 9 Gender □ female □ male 10 11 12 GestationalConfidential: age: □ For Review Only 13 14 Mode of delivery: □ NVD □ Sectio □ Vacuum or forceps 15 16 HIV exposed: □ exposed □ unexposed 17 18 PMTCT □ yes □ no 19 20 Birth weight: gr 21 22 Length: cm 23 24 Head circumferences: cm 25 26 Resuscitation at birth: □ yes □ no 27 28 APGAR 1min 5 min 10 min 29 30 31 Diagnosis at birth: 32 33 Oxygen support □ yes □ no 34

35 Surfactant: □ yes □ no http://bmjpaedsopen.bmj.com/ 36 37 Ventilatory support: □ none □ CPAP □ Invasive ventilation 38 39 If yes, how long days 40 41 Maximum of oxygen needed: □ < 60% □ > 60% 42 43 Feeding option □ Breast □ formula □ mixed 44 45 Trend of weight gain: □ normal □ abnormal on September 27, 2021 by guest. Protected copyright. 46 47 Sepsis : □ yes □ no 48 49 PVL or IVH: □ yes □ no 50 51 52 PDA: □ yes □ no 53 54 Steroid use (postnatal): □ yes □ no 55 56 Resuscitation during hospital stay: □ yes □ no 57 58 59 60

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3 Mother’s Data: bmjpo: first published as 10.1136/bmjpo-2020-000918 on 17 February 2021. Downloaded from 4 5 6 7 Age of mother: 8 9 Number of pregnancy: □ 10 11 12 Children Confidential:alive: □ For Review Only 13 14 Marital status: □ married □ stable relationship □ single 15 16 During pregnancy: 17 18 Hypertension: □ yes □ no 19 20 PT rupture of membranes: □ yes □ no 21 22 Preeclampsia/ Eclampsia □ yes □ no 23 24 Any other problems (e.g. seizures, drug abuse, diabetes) 25 26 SES of mother: □ employed □ unemployed 27 28 Electricity at home: □ yes □ no 29 30 31 Running water at home: □ yes □ no 32 33 Fridge: □ yes □ no 34

35 Educational level: □ primary school □ matric □ tertiary education http://bmjpaedsopen.bmj.com/ 36 37 Mother’s HIV status: □ positive □ negative 38 39 If positive: 40 41 ARVs since when: weeks before birth 42 43 ARVS: □ FDC □ second line □ other 44 45 Disclosure to anyone: on September 27, 2021 by guest. Protected copyright. 46 47 Has partner been tested: 48 49 50 51 52 53 54 55 56 57 58 59 60

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