Assessment of neonatal referral infrastructure and clinical characteristics of referred neonates in three first referral hospitals in Nairobi County, Kenya

Abstract

Background: One in five newborns in Nairobi County, Kenya, may require inpatient neonatal care. We sought to examine referrals to and from three busy first-level referral public hospitals in Nairobi and what infrastructure and systems are available to support neonatal transport from these first-referral level hospitals to the main tertiary care center.

Methods: Patient-level data of newborns over 12 months were retrospectively extracted from routinely collected patient data and examined to characterize those referred into and out of three newborn units in the study hospitals. Structural assessments using a checklist completed during hospital visits were used to describe hospitals' readiness to support newborn referral and transport.

Results: Five percent (398/7720) of the cohort studied were either referrals into study hospitals (68%, 272/398) or referrals out (32%, 126/398). Among 397 (99%) and 268 (67%) with sex and gestation documented respectively, 63% (251) were male and 44% (118) were preterm infants (<37 weeks). Among those referred in, 26% (69/272) died and 2.6% (7/272) were further referred to a tertiary-care newborn unit. Prematurity (39%) and birth asphyxia (29%) were the main in-referral reasons from 38 different health facilities, with specialist reviews (34%) predominant for out-referrals to a tertiary center. Diverse transport methods were used for referrals to study hospitals including private and public ambulances, vehicles, and guardian's arms while onward referrals to the tertiary center were done by hospital ambulances. Drugs and medical supplies required for stabilization were well available at the study sites, however, only oxygen nasal cannula, nasal prongs, and face masks were available in ambulance of hospital 3.

Conclusion: There is a need to develop, equip and maintain a high-quality referral and newborn transport system that can support the continuum of newborn care across referral care pathways into and from first-referral level hospitals.

Keywords: Kenya; Newborn; inpatient care; inter-facility; referral; transport.

Figure 1.. Schematic showing the relationship between the study sites, tertiary center, and lower level facilities, and the referral pathways.

Figure 2.. Shows reasons for referral in and out of study hospitals.

Other reasons for referrals in included chorioamnionitis, refusal to breastfeed, macrosomia, difficulty breathing, cyanosis, jaundice, maternal condition, etc. Other reasons for referrals out included Electrocardiography, congenital malformations, advanced airway support, etc.