Neonatal References: Epidemiology and Prognosis in a Malian Context

Neonatal mortality remains a public health problem in Mali. The neonatal referral is a systemic factor determining the neonatal prognosis. This work was initiated to determine the frequency of neonatal referrals and to determine their prognosis. Patients and Methods: A cross-sectional study was carried out from November 1, 2019 to January 31, 2020 in the neonatology service of the pediatrics department of the Gabriel Toure University Hospital in Bamako. All newborns referred by another health structure in the country were included in this stud. All newborns referred by another health structure in the country were included in this study. To determine the risk factors related to the neonatal referral, we performed univariate and multivariate analyzes to determine the odds ratios and fitted with a significant p probability if p < 0.05 and the 95% confidence interval. Results: The frequency of referrals was 54.3%. Newborns came from basic structures in 19.3% of cases, from tertiary structures in 6.7%. The main reason for transfer was prematurity (40.2%) followed by perinatal anoxia (15.3%), malformations (15.3%), respiratory distress (15.2%) and infection neonatal (9.1%). The ambulance was the primary means of transfer in 71.3%. In 80% of cases the transfer had been made within the first 24 hours of life. On admission, a third of the newborns (31.1%) were less than 1500 g, hypothermic in 43.8% and febrile in 15.1%. The evolution was marked by 40.2% of deaths. The analysis of prognostic factors, allowed us to observe that the more the newborn is premature or of low weight the more risk of death was very high with respectively 18.5 times How to cite this paper: Diakité, F.L.F., Konaté, D., Traoré, N.L., Banou, N., Sidibé, L.N., Coulibaly, O., Maiga, B., Sacko, K., Traoré, F., Doumbia, A.K., Diall, H.G., Maiga, L., Ahamadou, I., Traoré, A., Koné, A., Dembélé, G., Ba-Sidibé, D., Togo, P., Dembélé, A., Cissé, El M., Diakité, A.A., Togo, B., Sylla, M. and Dicko-Traoré, F. (2021) Neonatal References: Epidemiology and Prognosis in a Malian Context. Open Journal of Pediatrics, 11, 479-489. https://doi.org/10.4236/ojped.2021.113045 Received: July 24, 2021 Accepted: September 12, 2021 Published: September 15, 2021 Copyright © 2021 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access F. L. F. Diakité et al. DOI: 10.4236/ojped.2021.113045 480 Open Journal of Pediatrics in the less than 28 weeks of amenorrhea (WA) (ORa = 18.5; CI = 1.9 180; p = 0.012) and 6.6 times in those less than 1000g (ORa = 6.6; CI = 1.4 29.7; p = 0.015). Likewise, any change in body temperature increased risk of death by 1.9 times compared to normothermia. Conclusion: The establishment of a neonatal referral system is necessary to reduce neonatal mortality in our context.


Introduction
Neonatal reference is the transfer of a newborn at a higher level for review and or care. It requires a rigorous organization by a prior call from the reception structure, a means of medical transport and competent medical and paramedical staff to ensure a referral in the best conditions [1] [2] [3]. In France, the organization of perinatal care, on the basis of a regional network, allows in utero transfer of the mother-fetus couple at an optimal level to ensure their complete care. This network organization has enabled a very significant reduction in the number of postnatal referrals [4] [5] [6]. In Mali, the reference system/evacuation of obstetric emergencies has been established since 1993 resulting in a positive impact in reducing maternal mortality [7] [8]. However, it was not until 2002 that the newborn was introduced into this system. Despite everything, neonatal mortality still remains high in our country [7] [8]. Because the system has remained in an embryonic state due to the fact that neonatal references are made without any prior organization and the means of transport are inadequate [7] [8] [9]. In setting up the referral/neonatal evacuation system, the optimal level of care expected must be defined by level of the health pyramid. The Gabriel Toure University Hospital Center is located at the top (tertiary level) of the health pyramid of Mali, which houses within it the country's reference neonatal service ensuring the activities of a neonatal service, neonatal intensive care and neonatal resuscitation [10]. Neonatal mortality remains very high from 28.5% to 36.8% [9] [10]. And referrals represent around 60% to 85% of our hospitalizations [9] [10] [11] [12]. We receive newborns from all health structures in Bamako and the different regions of the country. It is evident that improving the conditions of transport and transfer of the vitally distressed newborn is an essential factor in reducing neonatal mortality [13] [14]. Thus the reference constitutes a determining factor of the neonatal prognosis. It is with this vision that this work was initiated in order to determine the frequency of neonatal references and clarify their prognosis.

Patients and Methods
This study took place in the referral neonatal service in Mali, which was created in 1999. Until December 2007, it was a resuscitation service providing care for children in vital distress as well as newborns. With annual number of hospitalizations of 4000 infants, or 43% of hospitalizations of pediatric department and 23% of all Gabriel Toure University Hospital [11]. We carried out a cross-sectional study over a 3-month period from November 1, 2019 to January 31, 2020 in the neonatology service of the pediatrics department of the Gabriel Toure university hospital center. All newborns referred by another health structure in the country were included. We have excluded all referrals or transfers from the maternity the Gabriel Toure University Hospital, all births at home and newborns brought by their parents. We calculated a minimum sample size (n) by Schwartz's formula: and we took the prevalence p at 71% from the study carried out in the service in 2010 [9] and we found a minimum number of 360 newborns. The variables studied were: gender, residence, source structure, reference purposes, the means of transport used, the consultation period, gestational age (GA), weight, temperature and become immediate. Data collected retrospectively from newborn medical records and service registers. Analysis was done by Statistical Package for Social Sciences (SPSS) version 22. Descriptive analysis was done to determine the frequency of categorical variables. Univariate analysis and logistic regression were performed to determine the neonatal mortality determinants related to the reference. The binary logistic regression at various levels has been adjusted to identify significant neonatal mortality determinants associated with the reference of the newborn, adjusted odds ratio (OR a) with confidence interval (CI) of 95% and p < 0.05 demonstrated that the determinants were statistically significant.  (Figure 1).

Clinical Characteristics of the Patient
The average transfer time was 18 hours with 80% of referrals made in the first 24 hours, 67.6% of which were before the sixth hour of life. Regarding gestational age (GA) birth, the majority were born prematurely (50.7%) of which 6.4% before the 28th WA. For the admission weight, one third (31.1%) were less than 1500 g with 8.4% less than 1000 g. On arrival, 43.8% of the newborns were hypothermic (<36˚C) and 15 (Figure 2).

Prognostic Factors Influencing Mortality
By doing univariate analysis and logistic regression of certain prognostic factors,  we observed that the more the newborn was born prematurely the more the risk of death increased, so it was 18.5 times for children under 28th WA (ORa = 18.5; CI = 1.9 -180; p = 0.012) versus 2.3 times between 28 and 31 WA + 6 (OR = 2.3; CI = 1.4 -3.8; p = 0.001) compared to this born at term. The same observation for the weight less than 1000 g had 6.6 times risk of death (ORa = 6.6; CI = 1.4 -29.7; p = 0.015) against 2.2 times between 1000 g and 1499 g (OR = 2.2; CI = 1.3 -3.7; p = 0.003) relative to normal weight. Compared with normothermia, the risk was 1.9 times for hypothermia (OR = 1.96; CI = 1.3 -2.9; p = 0.002) than for fever (ORa = 1.9; CI = 1 -3.5; p = 0.042). Other factors did not influence mortality in our study. For the health structure of origin, we found that there was no statistically significant difference between the base structures (CHC), the reference health centers (RHC), tertiary structures (Hospitals) compared to private structures because the transfer conditions are practically identical. And there was no statistically significant difference between transport by ambulance and other means used (Table 1).

Characteristics of the Country's Reference System, Transfer Conditions, Patient Clinics
In developed countries, there are two types of transfer. Transfer in utero to a maternity unit with a neonatal intensive care unit gives better results (mortality, morbidity and long-term sequelae) than a postnatal transfer, especially in a premature newborn [15]. While for the full-term or near-term newborn, postnatal transfer is not always avoidable in cases of unforeseeable per-or postnatal pathology [3] [16]. Our neonatology service at Gabriel Toure University Hospital is the national reference in neonatal care, in recent years we have seen an increase in the number of referrals from 71% to 84% (2007 and 2008-2012) then Depending on the level of the system, each health facility should be capable of providing all the packets of minimum activities (PMA) [7] [8]. While the reality is different in our health centers, usually the building is not in the standards, lack of equipment, insufficient staff or otherwise lacks competence to practice birth, emergency neonatal care and continuity of care [20]. We found perinatal anoxia (15.3%) as a second reference reason, which shows the benefit of strengthening the skills of staff in neonatal emergency care. This is because childbirth care will have to be reoriented so that the interests of the newborn are duly taken into account [20]. It must start at the first level of the health system, to act on this important factor of neonatal survival which is the place of birth of the newborn [21]. In fact, the transfer of the newborn is indicated if its condition requires care, surveillance or investigations that cannot be carried out in their birth cen- in the ambulances (chains of hot, sugar, oxygen, asepsis and information) [9].
His has been demonstrated in our study that the conveyance was not a determining factor in our context because there was no statistically significant difference between the different means of transport used. Thus, to reduce the morbidity and mortality related to transportation, we must improve the conditions of this [21]. It is therefore urgent in Mali to put in place a means of transport adapted to the condition of the newborn and that our ambulances must be

Prognosis of Neonatal References
On the prognostic level, we found a mortality of 40.2%. This high mortality is found in all sub-Saharan countries [26]. Factors contributing to high mortality of neonatal references observed in our study were preterm, low weight, hypothermia and fever. We found a greater danger of death in newborns who were born more prematurely and or with a very low birth weight. The same observation was found in African studies [26]. The high risk of mortality in this population could be explained by their physical and physiological immaturity [27] [28] [29] [30]. Indeed, the poor transport conditions are very harmful to newborns, and the absence of a normthermal environment, ventilation source or a suitable sugar intake can cause irreversible damage in these infants fragile (premature and/or sick) [26] [27] [28] [29] [30]. In our study, we found that any changes in temperature (hypothermia or hyperthermia) would lead to a significant increase in the risk of death. Hypothermia is a real morbidity factor linked to transport found by Rao [29] [30] [31]. There is an urgent need to set up a neonatal referral system that meets all the conditions for secure transfer (the means of transport including all the chains, the appropriate equipment and the competent staff). Without respecting these measures, even in ultra-equipped intensive care units, the survival rate will decrease considerably [3]

Methodological Approach
We carried out a cross-sectional study. This type of study makes it possible to take stock of a given question in a given setting, during a given period, taking into account the realities in the field (the hospital). We used data from a survey we carried out in the neonatal ward. The data for this survey were collected retrospectively from a standardized survey form from the medical file and department records.

Difficulties Encountered
During our study, we were faced with problems of completeness some medical records of newborns in the first munites of life such as the Apgar score. Despite these limitations we were able to carry out our work.

Conclusion
The neonatal referral constitutes the major part of our hospitalizations, i.e. 54.3% of hospitalizations with still high mortality (40.2%). The top five reasons for neonatal reference were respectively prematurity, perinatal asphyxia, malformations, respiratory distress and neonatal infections. Thus, reducing this burden requires improving the practice of emergency neonatal care in our health facilities. The establishment of a neonatal reference system meets all the conditions of transfer (the means of transport including all the chains, the appropriate equipment and the competent staff) and is adapted to the clinical condition of the newborn.