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Meta-Analysis
. 2025 Feb;13(2):e222-e231.
doi: 10.1016/S2214-109X(24)00469-8.

The prevalence of hypoxaemia in paediatric and adult patients in health-care facilities in low-income and middle-income countries: a systematic review and meta-analysis

Hamish R Graham  1 , Esrat Jahan  2 , Rami Subhi  3 , Farhia Azrin  2 , Jaclyn R Maher  3 , Jasmine L Miller  4 , Ahmed Ehsanur Rahman  2 , Felix Lam  4
Affiliations
Meta-Analysis

The prevalence of hypoxaemia in paediatric and adult patients in health-care facilities in low-income and middle-income countries: a systematic review and meta-analysis

Hamish R Graham et al. Lancet Glob Health. 2025 Feb.

Abstract

Background: Hypoxaemia (low oxygen saturation in blood) is a key predictor of in-hospital mortality, affecting people of all ages with many different conditions. Early detection and treatment of hypoxaemia are critical, but there are few data to quantify hypoxaemia burden outside the child pneumonia population. We aimed to estimate hypoxaemia prevalence for adults and children with acute illness attending health facilities in low-income and middle-income countries (LMICs).

Methods: We conducted a systematic review and meta-analysis, searching MEDLINE, PubMed, Embase, Cumulated Index in Nursing and Allied Health Literature, Index Medicus, and Google Scholar for studies reporting hypoxaemia prevalence among patients attending health facilities. We included articles with original data on peripheral blood oxygen saturation (SpO2), from an LMIC, published between Jan 1, 1998, and Jan 10, 2023. We included studies in acutely unwell people of any age and with any condition, but excluded those admitted to intensive care units, receiving perioperative care, or attending hospital for preventive or chronic care. We assessed study quality using Joanna Briggs Institute's Checklist for Prevalence Studies. Two reviewers independently conducted title and abstract screening, full-text review, data extraction, and quality assessment, requesting summary data from authors. We reported pooled prevalence of hypoxaemia (typically defined as SpO2 <90%) overall and by condition, using a random-effects meta-analysis model. This study is registered with PROSPERO, CRD42019136622.

Findings: We identified 9173 unique records from searches and included 213 in meta-analyses involving 601 757 participants. The majority of studies were from the World Bank regions of sub-Saharan Africa (108 [51%] of 213) or south Asia (58 [27%]). The pooled prevalence of hypoxaemia among admitted patients was 24·5% (95% CI 19·9-29·4) for neonates (aged 0-28 days), 12·1% (10·0-14·4) for children (aged 1 month-17 years), and 10·8% (4·9-18·7) for adults (aged ≥18 years). Hypoxaemia prevalence was highest in neonatal and primary respiratory conditions but still common in many other conditions. Hypoxaemia was associated with 4·84 (95% CI 4·11-5·69) times higher odds of death than no hypoxaemia.

Interpretation: Hypoxaemia is common across all age groups and a range of primary respiratory and other critical illnesses and is strongly associated with death. These estimates will inform oxygen-related strategies and programmes, and integration of pulse oximetry and oxygen into clinical guidelines, service structures, and strategies for maternal, neonatal, child, adolescent, and adult health.

Funding: Bill & Melinda Gates Foundation, the ELMA Foundation, and Unitaid.

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Conflict of interest statement

Declaration of interests HRG received general salary and grant support for child health research from the Royal Children's Hospital Foundation (Melbourne, VIC, Australia), the Australian National Health and Medical Research Council (ID 2009026), the Bill & Melinda Gates Foundation (INV 043011), and the Swedish Research Council, and has served as a trustee and adviser on oxygen-related projects with the Oxygen for Life Foundation, Lifebox Foundation, Unitaid, and Asian Development Bank. RS received general salary and grant support for child health research from the Murdoch Children's Research Institute and the Royal Australasian College of Physicians scholarship. AER received general salary and grant support for child health research from icddr,b, Global Affairs Canada, the US Agency for International Development (USAID), the UK Foreign, Commonwealth and Development Office, the Government of Bangladesh, WHO, UN Population Fund, the University of Edinburgh (Edinburgh, UK), the University of North Carolina (Chapel Hill, NC, USA), the University of Sheffield (Sheffield, UK), and Unitaid. FL and JLM worked for the Clinton Health Access Initiative, which has received grants related to oxygen service delivery from the Gates Foundation (INV 043011), ELMA Foundation (22-F0021), Unitaid, USAID, FHI 360, and GiveWell. All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Study selection CINAHL=Cumulated Index in Nursing and Allied Health Literature. LMIC=low-income or middle-income country. SpO2=peripheral blood oxygen saturation.
Figure 2
Figure 2
Distribution of the studies included in the meta-analysis by country
Figure 3
Figure 3
Hypoxaemia prevalence among hospitalised neonates, children, and adults, reporting random-effects pooled estimates across different subgroups Hypoxaemia was typically defined as peripheral blood oxygen saturation of less than 90%. Neonates were aged 0–28 days, children 1 month–17 years, and adults 18 years or older. Error bars show 95% CIs.
Figure 4
Figure 4
Scatterplot showing hypoxaemia prevalence among hospitalised neonates (A), children (B), and adults (C) at different altitude Neonates were aged 0–28 days, children 1 month–17 years, and adults 18 years or older. The linear line of best fit for neonates overall and children and adults with primary respiratory conditions is shown.
Figure 5
Figure 5
Relative odds of death comparing patients with hypoxaemia versus those without hypoxaemia Meta-estimates are presented for subgroups with three or more included studies. Hypoxaemia was typically defined as peripheral blood oxygen saturation of less than 90%, with odds of death compared with those with peripheral blood oxygen saturation of 90% or more. Neonates were aged 0–28 days, children 1 month–17 years, and adults 18 years or older. Error bars show 95% CIs.
See this image and copyright information in PMC

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