Neonatal Transfer Situation Following Implementation of a Perinatal Network: An Analysis in Douala, Cameroon

Background: Postnatal transfer (PT) is interhospital transport of care-needing newborns. In 2016, a perinatal network was implemented to facilitate PT in the town of Douala, Cameroon. The network was supposed to improve PTrelated care standards. This study aimed at determining characteristics of PT five years following the implementation of this network. Methods: A crosssectional study was carried out from February to May 2021 at neonatology wards of six hospitals in Douala. Medical records of newborns transferred to the hospitals were scrutinized to document their characteristics. Parents were contacted to obtain information on PT route and itinerary. Data were analyzed using Epi Info software and summarized as percentages, mean and odds ratio. Results: In total, 234 of the 1159 newborns admitted were transferred, giving a PT prevalence of 20.2% (95% CI 17.9% 22.6%). Male-to-female ratio of the transferred newborns was 1.3. Neonatal infection (26.5%), prematurity (23.5%) and respiratory distress (15.4%) were the main reasons for transfer. Only 3% of the PT was medicalized while only 2% of the newborns were transferred through perinatal network. On admission, hypothermia and respiratory distress were found in 31% and 35% of the newborns, respectively. The mortality rate among babies was 20% and these had a two-fold risk of dying (95% CI 1.58 3.44, p < 0.0001). Conclusion: PT and the perinatal network are lowly organized and implemented in Douala. Sensitization of medical staff on in utero transfer, creating center for coordination of the How to cite this paper: Koum, D.K., Njinkui, D.N., Magnibou, M.C., Foko, L.P.K., Eposse, C., Mbono, R., Eboumbou, P.E. and Penda, C.I. (2022) Neonatal Transfer Situation Following Implementation of a Perinatal Network: An Analysis in Douala, Cameroon. Open Journal of Pediatrics, 12, 148161. https://doi.org/10.4236/ojped.2022.121016 Received: December 30, 2021 Accepted: February 27, 2022 Published: March 2, 2022 Copyright © 2022 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


Introduction
According to the World Health Organization (WHO), neonatal period goes from birth to 28 th day of life [1]. Postnatal transfer (PT) is greatly helpful for optimal management of newborns requiring to be transferred to health facilities with better quality healthcare services [2] [3]. Transfer relies on a gradation of care services and the main reasons for PT include prematurity, neonatal infections and surgical pathologies [3] [4]. Again, prematurity, neonatal infection and asphyxia account for the bulk of mortality cases in transferred babies, and are involved in 80% of neonatal deaths worldwide [5] [6].
In 2006, French Government released a circular on principles guiding the implementation of perinatal networks [7]. In Canada, ambulances allow newborns to be transported from local emergency medical services to intensive care units [8]. In 2019, prevalence of PT was 20% in Japan with perinatal network and medicalized transport used in 62% and 92 of the transfers, respectively [9]. In France, 20% of pre-term births were reported in health facilities (HF) with both no neonatology wards and requirement for PT [10].
In developing countries, PT patterns are contrasted. A study conducted in Tunisia reported prevalence of 6%, medicalized transport in 47% and mortality of 8% [11]. In Senegal, PT was performed using ambulances in 30% of the transferred newborns and mortality rate of 22% was found [12]. In The Democratic Republic of Congo, 13% of newborns were transported, among them 92% were transported through public transport means [13].
In 2016, it was reported that 53% of newborns underwent PT and 20% of them were deceased, in the town of Yaoundé, Cameroon [14]. In December 2016, a perinatal network was implemented in Yaoundé and Douala to improve PT conditions [15]. With the final aim to improve PT quality and perinatal network, we conducted a study to identify bottlenecks of PT and determine mortality risk of transferred newborns in the town of Douala.

Study Design and Sites
From 1 st February to 31 st May 2021, a cross-sectional study was conducted at neonatology wards of six Government reference HF in Douala, Littoral Region, Cameroon. Health system in the country is pyramidal and neonatology wards of various standards are included [16]. Reference hospitals included are described as follows: • Douala General Hospital (DGH) which is first category hospital endowed with neonatology unit offering resuscitation and intensive cares with 15 baby incubators, 6 cradles and 6 pediatricians; • Douala Gyneco-Obstetrics and Pediatrics hospital (DGOPH) is also a first category health facility whose neonatology unit has 12 incubators and 10 cradles with a staff composed of four pediatricians and one neonatologist; • Douala Laquintinie hospital (DLH) is a second category hospital with 8 baby incubators, 24 cradles and 4 pediatricians. These three HF receive most of transferred newborns in Douala as they have the best and well-equipped maternities and neonatology services allowing for management of newborns in critical state.
Three fourth category District hospitals with facilities to manage pathologies and disorders commonly seen in neonatology were also included. These hospitals are important as they help in unclogging first and second category hospitals. These include:

Study Population
The study was focused on newborns transferred and admitted at neonatology wards of the above mentioned hospitals. We excluded newborns not transferred during the investigation, deceased during transport and those whose parents refused to take part in the study. Newborns were selected randomly and enrolled consecutively to avoid selection and information bias. The Minimum sample size of 200 newborns was required for the study based on Lorentz's formula by using a PT prevalence of 15.4% reported earlier [17], n = Z 2 × p × (1-p)/d 2 , where n = the required sample size, Z = statistic for the desired confidence level (Z = 1.96 for 95% confidence level), p = assumed PT prevalence, and d = accepted margin of error (5%).

Data Collection
Authorization and Ethical clearance were issued respectively by the manager of the health facility and ethical committee of the University of Douala. Thereafter, research project was submitted to caregiving staff. Eligible newborns were identified based on reviewing of admission forms and then informed consent was obtained from parents. Medical records of the included babies were scrutinized.
Parents were asked on transport conditions and itinerary before admission at HF. Clinical examination of newborns was made on admission by a medical doctor to obtain data including: reason of transfer, temperature and respiratory distress signs. Whether perinatal network was used for PT was also sought. A summary of data collected for each newborn is presented in Table 1.

Perinatal Network in Douala
This network was created in December 2016 in the town of Douala. It comprises of 121 members including 2 administrators whose activities are voluntary. Members dedicated in management of mothers and newborns are recruited in public, private and confessional HFs. Communications are made day and night through the WhatsApp social media and thus each member is requested to own android phone and internet connection. This network lacks a coordination central unit and does not own proper transport means that can facilitate PT. The network aims at 1) giving information on availability of places at HF, 2) ensuring communication between HFs during PT, and 3) sharing helpful information for neonatal and maternal health.

Operational Definitions
• Medicalized transport: Newborn is accompanied with a caregiver and transported using an ambulance.
• Non-medicalized transport: utilization of taxi, motorcycles or personal vehicle to transport newborns even a caregiver is present.
• Initial contact: Notification of the HF through direct phone call or perinatal network for requirement of a PT. • Transferred/Referred: The newborn is transferred from one HF to another one.
• Therapeutic itinerary: Number of HF attended after initiating PT and before admission for hospitalization.

Ethical Approval
Authorizations were obtained from ethical committees of each HF. In addition, ethical clearance was issued by the institutional review board of the University of Douala (N˚ 2664). Data were collected in accordance with standards of medical research in Cameroon.

Statistical Analysis
Data were keyed and analyzed using the Epi Info 7 software. Qualitative variables were presented as percentage while quantitative variables were summarized as mean ± standard deviation (SD). Pearson's independence chi-square test was used to compare percentages. Mean were compared using unpaired t test.
The risk of death among transferred newborns was determined by computing relative risk (RR), odds ratio (OR) along with confidence interval at 95% (95% CI) and probability value. Level of statistical significance was set at p-value < 0.05.

Study Population
Out of the 1159 newborns admitted at the neonatology wards of study sites, 234 (20.2%) were transferred and thus included in the study (Figure 1).

Prevalence and Reasons of Postnatal Transfer
The overall prevalence of PT was 20.2% (95% CI 17.9% -22.6%) across all the study sites. A total of 11 pathologies and disorders were causes of PT with mainly neonatal infection (26.5%, n = 62), prematurity (23.5%, n = 55) and respiratory distress (15.1%, n = 36) (Figure 3).    were not announced before transfer to HFs. About 16.7% of the newborns overcome a detour to another health facility before admission at the study sites. Transport was not medicalized in 97.4% of the babies, and 29.9% were suffering from hypothermia on admission. More than one third (37.2%) of babies were suffering from respiratory distress on admission.

Utilization of the Perinatal Network
The perinatal network was lowly (2%) used and concerned DGOPH and DGH with rates of 8.7% and 2.3%, respectively ( Table 3). The perinatal network was not used at the DLH, BDH, DDH and NDH facilities.

Outcome, Mortality Rate and Mortality Risk
Of the 234 newborns referred to the study HFs, 46 (20%) are deceased. Evolution of these babies was depicted in Figure 4. Based on logistic regression analysis, the odds of mortality were 2.33 times higher in transferred newborns compared to their counterparts who didn't need transfer (95% CI 1.58 -3.11, p < 0.0001)     [19]. The last one has been conducted in the reference neonatology center in the town of Bamako (Mali), and this could explain the discrepancy between their results and ours.

Gender Distribution of the Transferred Newborns
More than half of transferred newborns were males. Faye and colleagues also reported a predominance of males among transferred babies in Senegal [13]. Newborns aged < 24 hours accounted for 29% of transfers, and this finding is lower than that reported by Salomé et al. in Jamaica (62%) and Daussac et al. in France (50%) [20] [21]. Late transfer in our context is the result of financial constraints that hinder initiation and coordination of PT. Additional reasons could include instability of newborns, absence of transport means and/or adequate HF. Again, these factors likely increase the risk of neonatal death, and this study we found 2% of newborns were arrived dead at the study HFs.

Reasons of the Transfer
Prematurity was found in 36% of transferred newborns and this is not in line with value (24%) reported in 2018 by Chioukh et al. in Tunisia [11]. In utero transfer is indicated for pre-term births when management of babies is not possible at birth place [22]. Furthermore, 24% of transferred newborns were born by caesarian. This point is crucial as neonatal risks should be carefully evaluated before making decisions for caesarian. To be noted, 37% of newborns had APGAR score < 7, and this poor adaption of newborns elicits a higher risk of death [23].
The predominance of neonatal infection among reasons for PT was also reported in Senegal where authors found neonatal infection was responsible for 35% of all PT causes. Neonatal infection is the main pathology encountered in clinical practice at neonatology wards, and the WHO estimated that it accounts for 20% of global neonatal mortality [24]. Prematurity (24%) and respiratory distress (15%) were the second and third reasons for PT in the study, and this is consistent with result found by Traoré et al. (2010) in Mali (29% and 14%), but lower than that found by Salomé et al. (2017) in Jamaica who reported > 50% of PT due to prematurity and respiratory distress [25] [26]. Jaundice was also a cause of PT with 12% and this is higher than value found in Nigeria (9%) and Jamaica (2%) [19] [20]. The lack of phototherapy facility could likely explain this high value in several low categories hospitals in our setting.

Utilization of the Perinatal Network
Only 5 of the 234 newborns were transferred through perinatal network, giving a utilization percentage of 2%. This finding is particularly worrisome as compared with other settings such as Japan where a study reported a utilization percentage of 62% [9]. In this country, perinatal network disposes a coordination center in each town which first receives calls from facilities requiring PT and then provides human resource and equipment for PT. Regarding transfer conditions, health facilities receiving transferred newborns had been contacted for 21% of them. This is consistent with that found in Senegal (27%) [12]. Whenever PT is decided, it is crucial to inform HF that supposed to receive newborns for a better management [27]. Transfer forms were missing for 44% of newborns. Such forms are important for better coordination between HFs and its utilization is recommended as a part of health norms and standards of the Ministry of Public Health in Cameroon [28].

Itinerary and Conditions of Neonatal Transfer
On analysis of itinerary, we noted that detours were made by 17% of newborns before their admission at the study facilities. Previous studies reported rate of 56% in the town of Yaoundé, Cameroon [14]. Newborns are managed by medical staff during transport in 92% of cases which is contrary to national guidelines [28]. Transport was medicalized in 3% of newborns included in the study and this is consistent with report in The Democratic Republic of Congo, but contrasting with higher values found in Senegal (30%) and Japan (96%) [9] [12] [13]. Transport of newborns to adequate emergency unit necessitates surveillance and high quality care to limit risk of death [9].
To be noted, hypothermia was found in 30% of newborns admitted at the health facilities. This supports result of Faye and colleagues who reported 34% in Senegalese babies [12]. Transport conditions could likely explain the presence of hypothermia. Indeed, most of transports were non-medicalized and done through public means especially taxi. This fact was also found by Faye and colleagues [12]. Such inadequate transport means could explain why respiratory distress was found in more than one-third of the newborns at their admission, thereby suggesting that these transports could be a cause of respiratory distress in them.  [14]. Mortality rate remained unchanged even after implementation of the perinatal network which was lowly used as above discussed. In addition, transport conditions were similar to those seen before the implementation of the network (i.e., non-medicalized transport, detour before admission and hypothermia on admission) [29]. The risk of death was doubled in transferred newborns compared to their non-transferred counterparts. This could explain severity of the PT-driving pathology as well as complication of the pathology due to poor transport conditions.

Limitations of the Study
Data were collected from Government HFs and this constitutes the main limitation of the study. However, we conducted the study in the HFs receiving the large proportion of newborns referred in Douala, thereby outlining findings re-Open Journal of Pediatrics ported here are representative of the global scenario in Douala.

Recommendations
A set of key recommendations may be given based on the findings of the present study: • The newborns were arrived at the HF with respiratory distress, and this should the need for information, education and communication campaigns, through seminars for instance, of the medical staff on in utero transfer; • The PT network was largely underused by the HF included in the study. It is utmost importance of updating members of the utilization of this network along with creation of a center for its coordination. Again, a better communication between both low-and high quality care HFs is crucial in order to improve the chances of survival of newborns when decision for transfer is made; • Finally, the Government of Cameroon should be allocated funds and transport means such as ambulances for improving the utilization of the postnatal network

Conclusion
This study outlined that newborns were transferred at late stage and main reasons of PT were neonatal infection, prematurity and respiratory distress. It also pinpointed the absence of medicalized transport in 9 of 10 newborns, the absence/lack of transfer form, the absence of notification of the HF receiving transferred newborns and the low utilization of the perinatal network. Based on these findings, it should be important to reduce neonatal mortality through sensitization of medical staff on in utero transfer, updating of the members of the perinatal network and creation of a center for coordination of this network.