Evaluating Preterm Birth Patterns and Survival Rates in Ekiti State Tertiary Hospitals: A Six-Year Retrospective Study
DeborahTolulopeEsan1✉Emaildeborah.esan@bowen.edu.ng
AyodejiOlubunmiOgunmuyiwa2
WaliatOdunayoAyinde3
BlessedObemOyama4
CarlosGuillermoRamos5
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Faculty of Nursing Sciences, College of Health SciencesBowen University IwoNigeria2Nursing Services UnitLagos State University Teaching HospitalLagosNigeria
3Department of Nursing Science, College of Medicine and Health SciencesAfe Babalola UniversityAdo-EkitiNigeria
4Institute of Nursing ResearchOsogboNigeria
5Department of PediatricsUniversity of CaliforniaSan DiegoUSA
*Deborah Tolulope Esan1, Ayodeji Olubunmi Ogunmuyiwa2, Waliat Odunayo Ayinde3, Blessed Obem Oyama4, Carlos Guillermo Ramos5
1Faculty of Nursing Sciences, College of Health Sciences, Bowen University Iwo, Nigeria
2Nursing Services Unit, Lagos State University Teaching Hospital, Lagos, Nigeria
3Department of Nursing Science, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Nigeria
4Institute of Nursing Research, Osogbo, Nigeria
5Department of Pediatrics, University of California, San Diego, USA
Correspondence: deborah.esan@bowen.edu.ng. +2348062484864
Evaluating Preterm Birth Patterns and Survival Rates in Ekiti State Tertiary Hospitals: A Six-Year Retrospective Study
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Abstract
Background
Prematurity remains the leading cause of infant mortality, with stark global disparities in survival rates. According to World Health Organization (WHO) data, in high-income countries, survival rates exceed 90% for infants born at 28 weeks of gestation, with further improvements as gestational age increases. Whereas in low- and middle-income countries like Nigeria, only approximately 10% of infants born at 28 weeks of gestation survive, and half of infants born at 32 weeks of gestation and below do not survive due to inadequate and unaffordable care. This study aims to examine the patterns and survival rates of preterm births in the Neonatal Intensive Care Units (NICUs) of two tertiary hospitals in Ekiti State, Southwest Nigeria.
Method
Employing a descriptive cross-sectional design, this retrospective study analyzed NICU records from 2016 to 2021. Data were collected using an adapted checklist to monitor neonatal survival. Descriptive and inferential statistical analyses were conducted, with significance set at p < 0.05.
Results
During the six years, 759 preterm infants were recorded. Hospital A reported a survival rate of 20.1% (34 of 169), while Hospital B had a 73.3% survival rate (433 of 590),
resulting in an overall survival rate of 62.5%. A significant positive correlation was found between infant birth weight and survival in 2016 (r = 0.49, p < 0.001), 2018 (r = 0.49, p < 0.001), 2019 (r = 0.43, p < 0.001), and 2021 (r = 0.43, p < 0.001).
Conclusions
These findings highlight critical disparities in preterm birth outcomes between the two hospitals. There is an urgent need to enhance preterm infant survival through improved facilities, staff training, and adequate equipment provision.
Keywords:
Preterm birth
Neonatal Intensive Care Unit (NICU)
Survival rates
Low-resource settings
Tertiary hospitals
Southwest Nigeria
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Introduction
Preterm birth is a significant global health concern, affecting 5% to 18% of pregnancies worldwide (1). Defined as delivery before 37 weeks of gestation (2). Viability is generally considered to begin at around 22 to 24 weeks of gestation. Twenty-two weeks is often viewed as the earliest gestational age at which survival is possible, though survival rates are low and typically associated with significant morbidity. By Twenty-four (24) weeks, survival rates increase substantially with intensive neonatal care. In terms of birth weight, the threshold for viability is often placed at 500 grams. Infants weighing less than 500 g at birth are considered to have minimal chances of survival. At 500 g or more, the likelihood of survival improves with appropriate neonatal intensive care (3). Twenty-two (22) weeks’ gestation is considered the earliest gestational age at which resuscitation may be considered. Still, survival rates are low, and risks of severe morbidity are high (4). Between 23 and 24 weeks’ gestation, infants are more likely to be offered active resuscitation and admitted to the NICU. Survival improves with each week; about 25–33% at 23 weeks and 50–66% at 24 weeks in high-resource settings (5). For 25 Weeks and beyond, standard resuscitation and NICU admission are generally provided. Infants born at 25 weeks or later are typically viewed as viable, with survival rates exceeding 80% in well-resourced settings (6).
According to the World Health Organization (7), preterm birth accounts for approximately one million deaths annually, representing 40% of neonatal deaths (8). Preterm infants are particularly vulnerable to complications necessitating specialized care in NICUs (9). Tertiary hospitals with NICUs frequently report high incidences of prematurity-related adverse outcomes (10). Additionally, the hospitalization of preterm infants can be traumatic for mothers, causing emotional distress due to separation and uncertainty (11, 9). Despite medical advancements, preterm birth persists as the leading cause of death among children under five, with pronounced survival disparities between low- and high-income countries (10).
Sub-Saharan Africa and Southern Asia account for 79% of global neonatal deaths, with approximately 23 of every 1,000 live births in Sub-Saharan Africa resulting in death within the first week (12). Low- and middle-income countries struggle with inadequate maternal and newborn healthcare, contributing to higher disability rates among preterm survivors (10). The complex causes of preterm deaths involve both systemic healthcare challenges and maternal-child health factors (13, 9). Increasing preterm births have led to higher incidences of medical conditions (7). The financial strain of prematurity impacts both families and healthcare systems. While Nigeria's national health insurance system, through the NHIA and BHCPF, provides coverage for neonatal intensive care, the effectiveness of these programs in ensuring comprehensive and equitable access to NICU services is influenced by various systemic challenges such as limited enrollment, inadequate funding, and disparities in service delivery persist, affecting the accessibility and quality of neonatal intensive care services (15). Studies have highlighted that a significant portion of neonatal healthcare expenses is still borne out-of-pocket by families, indicating that full financial protection is not yet universally achieved (16).
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Nigeria ranks among the top four countries with the highest preterm death rates globally, with over 800,000 preterm births annually, many of which lack proper healthcare access (8). Addressing preterm birth is vital for achieving Sustainable Development Goals, particularly reducing neonatal deaths to fewer than 12 per 1,000 live births by 2030. Although global data suggest a declining trend in preterm birth burden since 2016 (8), localized data are crucial for targeted interventions. Therefore, this study evaluates preterm birth survival rates in Ekiti State's tertiary hospitals and proposes locally relevant strategies for improvement.Methods
Study Design
This retrospective study analyzed preterm neonates admitted to the NICUs of the Federal Teaching Hospital Ido-Ekiti (FETHI) and Ekiti State University Teaching Hospital (EKSUTH) from 2016 to 2021. FETHI, a suburban referral center with 280 beds and 24 departments, and EKSUTH, an urban referral hospital serving 3.5 million residents, both offer specialized neonatal care, including interventions such as continuous positive airway pressure (CPAP), phototherapy, exchange blood transfusion, and kangaroo mother care. None of these facilities have invasive ventilatory support.
Study Participants
All preterm neonates admitted to the NICUs of FETHI and EKSUTH within the study period (2016–2021) were included, identified through medical records and ward registers.
Inclusion and Exclusion Criteria
Infants with complete data on birth weight, gestational age, survival, and complications were included. Excluded were infants deceased upon NICU arrival or discharged against medical advice.
Data Collection
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A structured checklist, using the hospital record as a guide, was developed and utilized in conjunction with the WHO NICU standard to extract data on patient demographics, birth weight, gestational age, and survival status. Two trained personnel, supervised by the first author, collected and cross-verified the data. Data quality was ensured through review by the first and last authors.Data Analysis
Data analysis was conducted using SPSS version 25. Descriptive statistics were used to summarize frequencies and percentages. Inferential statistics (Correlation) were used to test the association between birthweight and survival rates across the years, with a significance level set at p < 0.05.
Ethical Considerations
Ethical approval
was obtained from both hospitals' ethics and research committees (Approval numbers: EKSUTH/A67/2022/02/003 and ERC/2021/10/29/657B). Data confidentiality was maintained through anonymization.
Results
A total of 759 preterm neonates were admitted to FETHI (169) and EKSUTH (590). FETHI reported the highest preterm births in 2020 (23.1%), while EKSUTH peaked in 2019 (18.8%). Overall survival was higher at EKSUTH (73.3%) compared to FETHI (20.1%) (Table 1). Positive correlations between birth weight and survival were observed in 2016, 2018, 2019, and 2021.
2016 | 2017 | 2018 | 2019 | 2020 | 2021 | Total | |
|---|---|---|---|---|---|---|---|
Hospital A (FETHI) | |||||||
Minimum per year | 0 | 0 | 0 | 0 | 0 | 0 | |
Maximum per year | 6 | 7 | 7 | 6 | 7 | 6 | |
Mean | 2.7 | 2.5 | 1.1 | 2.8 | 3.3 | 1.8 | |
Std. Deviation | 2.19 | 2.02 | 2.02 | 1.89 | 2.18 | 1.86 | |
Total per year (n) | 32 | 30 | 13 | 34 | 39 | 21 | 169 |
Total per year (%) | 18.9 | 17.8 | 7.7 | 20.1 | 23.1 | 12.4 | 100 |
Hospital B (EKSUTH) | |||||||
Minimum per year | 0 | 1 | 3 | 3 | 0 | 1 | |
Maximum per year | 25 | 16 | 13 | 15 | 13 | 16 | |
Mean | 8.5 | 7.9 | 7.2 | 9.3 | 9 | 7.3 | |
Std. Deviation | 6.61 | 4.23 | 3.1 | 3.52 | 3.91 | 4.49 | |
Total per year (n) | 102 | 95 | 86 | 111 | 108 | 88 | 590 |
Total per year (%) | 17.3 | 16.1 | 14.6 | 18.8 | 18.3 | 14.9 | 100 |
Grand total | 134 | 125 | 99 | 145 | 147 | 109 | 759 |
Figure 1 illustrates the survival and mortality rates of preterm neonates at FETHI throughout the study period. Of the 169 preterm births, 34 infants survived. The highest survival rates were recorded in 2016 (28.1%) and 2018 (30.8%), while the lowest survival rate occurred in 2021 (4.8%). A consistent decline in survival rates was observed at FETHI over the six years.
Fig. 1
Preterm Survival and Deaths from 2016 to 2021 (FETHI)
Figure 2 presents the survival and mortality rates of preterm neonates at EKSUTH, where 433 out of 590 preterm infants survived during the study period. The highest survival rate was recorded in 2020 (80.6%), and the lowest in 2017 (63.2%), reflecting an overall improvement in survival outcomes from 2017 to 2020.
Fig. 2
Preterm Survival and Deaths from 2016 to 2021 (EKSUTH)
Figure 3 compares the survival rates of preterm births at both hospitals from 2016 to 2021. Survival rates were calculated by dividing the number of surviving infants by the total number of preterm births for each year. The graph indicates consistently higher survival rates at EKSUTH compared to FETHI. A downward trend was noted between 2016 and 2017, followed by a brief improvement from 2017 to 2018. However, from 2018 onward, a significant disparity emerged, with FETHI experiencing a notable decline in survival rates. Over the six years, the survival rate at EKSUTH was 433 survivors (73.3%), whereas FETHI recorded a much lower rate of 34 survivors (20.1%), underscoring EKSUTH's superior overall performance in preterm infant survival.
Fig. 3
Line Graph showing Survival Rate of Preterm Births for both Hospitals between 2016 and 2021
Table 2 highlights the correlation between the frequency of preterm births and survival rates at both hospitals. At FETHI, strong positive correlations were observed in 2018 (r = 0.90, p < 0.001) and 2019 (r = 0.82, p = 0.001), with a moderate correlation in 2016 (r = 0.69, p = 0.013). These findings suggest that higher numbers of preterm births were associated with better survival outcomes during these years. No significant correlations were observed for 2017, 2020, and 2021. In contrast, EKSUTH demonstrated strong positive correlations across all study years, with the highest correlation in 2019 (r = 0.95, p < 0.001), followed by 2021 (r = 0.94, p < 0.001), 2020 (r = 0.91, p < 0.001), 2018 (r = 0.89, p < 0.001), 2017 (r = 0.88, p < 0.001), and 2016 (r = 0.83, p = 0.001). This consistent pattern indicates that increased occurrences of preterm births were positively linked to improved survival rates at EKSUTH.
FETHI | EKSUTH | |||
|---|---|---|---|---|
Year | r | p-value | r | p-value |
2016 | 0.69* | 0.013 | 0.83* | 0.001 |
2017 | -0.03 | 0.917 | 0.88* | < 0.001 |
2018 | 0.90* | < 0.001 | 0.89* | < 0.001 |
2019 | 0.82* | 0.001 | 0.95* | < 0.001 |
2020 | 0.04 | 0.902 | 0.91* | < 0.001 |
2021 | -0.3 | 0.351 | 0.94* | < 0.001 |
| * Correlation (r) is significant at the 0.05 level | ||||
Also, correlation analysis was done between the birth weights of preterm infants and their survival rates at EKSUTH from 2016 to 2021. Significant positive correlations were identified in 2016 (r = 0.49, p < 0.001), 2018 (r = 0.49, p < 0.001), 2019 (r = 0.43, p < 0.001), and 2021 (r = 0.43, p < 0.001), reinforcing the relationship between higher birth weights and better survival outcomes. However, no significant correlations were found in 2017 and 2020.
Discussion
The findings of this study provide critical insights into the patterns of preterm births and their survival rates in two tertiary hospitals in Ekiti State, Nigeria, over six years. Analysis of 759 preterm neonates revealed significant variations in both the incidence of preterm births and survival outcomes between the Federal Teaching Hospital Ido-Ekiti (FETHI) and the Ekiti State University Teaching Hospital (EKSUTH).
The data indicated that the highest proportion of preterm births occurred in 2020, particularly at FETHI, potentially reflecting broader trends in maternal health and healthcare access during that period. This increase in preterm births could be attributed to various factors, including socioeconomic challenges, limited healthcare accessibility, and the impact of the COVID-19 pandemic, which may have disrupted prenatal care and heightened stress among expectant mothers (12). This finding aligns with global evidence suggesting that external factors can significantly influence preterm birth rates (7).
Survival rates differed markedly between the two hospitals, with EKSUTH demonstrating a significantly higher survival rate (73.3%) compared to FETHI (20.1%). This disparity underscores the critical role of healthcare infrastructure and resource availability in determining neonatal outcomes. EKSUTH's urban setting and its ability to provide specialized care likely contribute to better survival rates, as urban hospitals typically have greater access to advanced medical technologies and highly trained personnel (8). Conversely, FETHI, located in a suburban area, may face challenges related to resource allocation, staff training, and the availability of essential neonatal care equipment (10).
A concerning decline in survival rates was noted at FETHI over the study period, particularly in 2021. This trend may reflect systemic issues such as inadequate staffing, insufficient training for healthcare providers, and a lack of necessary medical equipment (13). This finding was also consistent with a study conducted in Finland by Helenius et al. (17), which found that hospitals with higher preterm birth rates and better facility conditions had higher survival rates compared to their counterparts. In Finland, centralized level-3 centers exhibited markedly lower mortality rates compared to level-2 hospitals, with an odds ratio of 1.6–2.6 for death in lower-level centers. Addressing these challenges is essential to improving neonatal care and survival outcomes at FETHI.
In contrast, EKSUTH showed a significant improvement in survival rates from 2017 to 2020, suggesting that interventions aimed at enhancing neonatal care during this period were implemented and were effective. The strong positive correlations observed between the occurrence of preterm births and survival rates at EKSUTH further emphasize the importance of comprehensive care strategies that can adapt to the needs of preterm infants. Consistent positive correlations observed in this center indicate that as the incidence of preterm births rose, survival rates also increased. This finding was similar to the findings of Mocking et al. (10), who documented increased survival among preterm babies in Ghana. This trend may be attributed to enhanced care protocols and greater awareness among healthcare providers (7).
Moreover, the study identified significant positive correlations between birth weight and survival rates at EKSUTH, reaffirming the well-established understanding that higher birth weight is associated with better survival outcomes for preterm infants. This finding highlights the importance of monitoring and managing maternal health to optimize birth weight and implementing targeted interventions for low-birth-weight infants (18).
Overall, the results of this study underscore the urgent need for improvements in neonatal care, especially at FETHI, where survival rates remain alarmingly low. Enhancing the quality of care through facility upgrades, continuous staff training, and the provision of essential medical equipment is critical for improving preterm infant outcomes (10). Furthermore, local epidemiological data are vital for informing policy decisions and guiding resource allocation to address the specific needs of preterm infants across different healthcare settings.
Notably, data on the birth weights of preterm babies at FETHI were incomplete and, therefore, could not be reported in this study. This issue demands urgent attention and the need to improve documentation practices among nurses. A similarly low rate of medical record completeness was reported by Bayisa et al. (19), who emphasized that comprehensive medical records are essential for delivering high-quality care. Therefore, it is essential to implement measures that enhance the completeness of medical documentation.
Recommendations
The findings reveal significant disparities in preterm survival between urban (EKSUTH) and suburban (FETHI) settings. EKSUTH's higher survival rates may reflect superior infrastructure, staff training, and resource availability. FETHI's declining survival rates signal systemic issues requiring urgent intervention. Strategies should focus on improving healthcare infrastructure, staff training, and equipment provision.
Strengthen Healthcare Infrastructure at FETHI
Investments should be made in neonatal intensive care resources, including incubators, CPAP machines, and resuscitation equipment. Studies from Ghana and Malawi (10, 20) have demonstrated that low-cost technologies, such as bubble CPAP and thermal care, can significantly reduce neonatal mortality, particularly in resource-constrained settings. These technologies require modest investment and have high impact-to-cost ratios, especially when combined with proper training and maintenance.
Implement and Scale Up Kangaroo Mother Care (KMC)
KMC should be institutionalized as a standard practice at FETHI for all stable preterm and low birth weight babies. In Ethiopia and India, KMC implementation led to significant improvements in survival, weight gain, and bonding (21, 22). KMC is among the most cost-effective interventions, requiring no sophisticated technology and yielding significant benefits in terms of thermoregulation, breastfeeding, and survival.
Strengthening Capacity Through Continuous Staff Training
Implementation of ongoing, low-cost, on-site training for healthcare providers on Neonatal resuscitation (e.g., Helping Babies Breathe curriculum), Infection control, Kangaroo Mother Care (KMC)management of preterm complications. The Helping Babies Breathe program, validated in Tanzania and Nepal, reduced early neonatal mortality by up to 47% (23). Similarly, WHO-endorsed KMC has been proven to reduce neonatal deaths by up to 40% in preterm infants. These training programs and KMC require minimal financial resources, relying instead on knowledge transfer and basic equipment like wraps and training kits.
Establish Regional Neonatal Care Quality Improvement Collaboratives
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Facilitation of peer learning and mentorship between FETHI and EKSUTH through joint quality improvement initiatives, shared clinical audits, and standardized care protocols. Nigeria’s National Newborn Health Strategy and similar models in Uganda have demonstrated improved neonatal care through regional collaborations and protocol harmonization (24). These collaborative models leverage existing resources and expertise, with minimal added costs but potentially large system-wide benefits.Limitations
Reliance on medical records introduces potential data inconsistencies. Findings may not generalize beyond the two hospitals studied. Maternal health data, such as age, socioeconomic status, and prenatal care access, which could influence preterm birth rates and neonatal outcomes, were not included. There is also no mention of gestational age and birth weight on survival rates, given that these factors are critical to the survival of preterms. The presence of comorbidities, the timing of medical interventions, and other neonatal care were not explored.
Conclusion
This study highlights the disparities in neonatal care and survival rates across two tertiary hospitals in Ekiti State, Nigeria, one urban and another suburban. It calls for a concerted effort to strengthen healthcare infrastructure, enhance staff training, and allocate adequate resources to improve preterm infant survival, ultimately contributing to better maternal and child health outcomes in the region.
Declarations
Ethical Approval and Consent to Participate:
Ethical approval was obtained from the Ethics and Research Committees of both hospitals (Approval numbers: EKSUTH/A67/2022/02/003 and ERC/2021/10/29/657B). Data confidentiality was maintained through anonymization. The study was conducted in accordance with the principles of the Declaration of Helsinki, ensuring respect for participants' rights, welfare, and dignity.
Consent for Publication:
Not Applicable
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Data Availability
All datasets are available within the manuscript. Any additional information is available on request from the corresponding author.
Competing Interests:
The authors declare no competing interests.
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Funding:
This research received no external funding support.
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Author Contribution
DTE conceived and designed the study methodology, supervised the data collection and reviewed the initial draft of the manuscript. AOO analyzed the data and wrote the initial draft of the manuscript. WOA collected the data, analyzed the data and drafted the initial manuscript. BOO wrote the initial draft of the manuscript. CGR analyzed the data and critically revised the initial draft of the manuscript. All authors approved the final draft of the manuscript
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Acknowledgement
We appreciate the nurses who provided necessary support during data collection.
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