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. 2025 May 1;8(5):e2510790.
doi: 10.1001/jamanetworkopen.2025.10790.

Adherence to Perinatal Asphyxia or Sepsis Management Guidelines in Low- and Middle-Income Countries

Afruna Rahman  1 , Meghna Ray  2 , Zachary J Madewell  3 , Kitiezo Aggrey Igunza  4 , Victor Akelo  5   6 , Dickens Onyango  7 , Florence Murila  8 , Winnie Mwebia  4 , Ikechukwu Udo Ogbuanu  2   9 , Julius Ojulong  9 , Dickens Kowuor  9 , Erick Kaluma  9 , Solomon Samura  10 , Shams El Arifeen  1 , Emily S Gurley  11 , Mohammad Zahid Hossain  1 , Kazi Munisul Islam  1 , Rajib Biswas  1 , Nega Assefa  12   13 , Temesgen Teferi  13 , Konjit Eshetu  13 , Lola Madrid  12 , Karen L Kotloff  14 , Milagritos D Tapia  14 , Adama Mamby Keita  15 , Elisio Xerinda  16 , Celisa Mendonça de Assis  17 , Milton Kincardett  16 , Inacio Mandomado  16 , Rosauro Varo  18 , Shabir A Madhi  19   20 , Ziyaad Dangor  19 , Vuyelwa Baba  21 , Sithembiso Velaphi  22 , Yasmin Adam  21 , Dianna M Blau  3 , Portia C Mutevedzi  6 , Quique Bassat  17   18   23   24 , Cynthia G Whitney  6 , Chris A Rees  25 ; Child Health and Mortality Prevention Surveillance (CHAMPS) Network
Collaborators, Affiliations

Adherence to Perinatal Asphyxia or Sepsis Management Guidelines in Low- and Middle-Income Countries

Afruna Rahman et al. JAMA Netw Open. .

Abstract

Importance: Most of the 2.3 million annual neonatal deaths occur in sub-Saharan Africa and South Asia, with perinatal asphyxia and neonatal sepsis being the leading causes of neonatal mortality. Most neonatal deaths are considered preventable through high-quality clinical care, which includes adherence to clinical care guidelines.

Objective: To assess adherence to World Health Organization clinical care guidelines for management of perinatal asphyxia and neonatal sepsis and to identify patient-level factors in adherence among neonates who died from these conditions.

Design, setting, and participants: This cross-sectional study obtained data from December 2015 through October 2023 from the Child Health and Mortality Prevention Surveillance (CHAMPS) catchment areas in 7 low- and middle-income countries in sub-Saharan Africa (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) and South Asia (Bangladesh). Participants were neonates who were born alive and were aged 0 to 28 days at the time of death and had either perinatal asphyxia or neonatal sepsis.

Exposure: Medical records of neonates who died from perinatal asphyxia or neonatal sepsis determined by postmortem diagnostics.

Main outcomes and measures: The main outcome was the proportion of deceased neonates who received guideline-adherent treatments before they died. Mixed-effect multivariable logistic regression analyses were performed to identify factors associated with administration of at least bag-valve-mask (BVM) ventilation for perinatal asphyxia.

Results: Of the 1194 neonates (median [IQR] age at the time of death, 2 [1-6] days; 692 males [58.0%]) who died and were enrolled in CHAMPS with available clinical data, 476 (39.9%) died from perinatal asphyxia, 562 (47.0%) died from neonatal sepsis, and 156 (13.1%) from both conditions. These neonates had a median (IQR) birth weight of 2130 (1266-2988) g. For cases with perinatal asphyxia, guideline adherence ranged from 12.2% (n = 77) for adrenaline administration to 85.4% (540) for supplemental oxygen administration. Only 4.4% of neonates (28) with perinatal asphyxia received all recommended treatments. Among cases with neonatal sepsis, antibiotics were administered to 86.8% (623), although the recommended treatment was administered to only 61.0% (438). In multivariable analyses, neonates in whom clinicians accurately identified perinatal asphyxia were more likely to receive BVM ventilation than those who had received discordant antemortem and postmortem diagnoses (adjusted odds ratio, 2.00; 95% CI, 1.29-3.12).

Conclusions and relevance: In this cross-sectional study, clinical care guideline adherence was suboptimal among neonates who died from perinatal asphyxia or neonatal sepsis. This finding underscores the critical need to increase adherence in regions with high rates of neonatal mortality and may inform strategies for strengthening health systems to support compliance with clinical care guidelines.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Murila reported receiving personal fees from The Bill & Melinda Gates Foundation during the conduct of the study. Prof El Arifeen reported receiving grants from Emory University during the conduct of the study. Prof Gurley reported receiving grants from Emory University and The Bill & Melinda Gates Foundation during the conduct of the study. Mr Biswas reported receiving grants from The Bill & Melinda Gates Foundation during the conduct of the study. Dr Tapia reported receiving grants from Emory University during the conduct of the study. Prof Madhi reported receiving institutional grants from The Bill & Melinda Gates Foundation Grant during the conduct of the study and institutional grants from Pfizer, Minervax, MSD, and EDCTP outside the submitted work. Dr Dangor reported receiving grants from The Bill & Melinda Gates Foundation during the conduct of the study. Dr Mutevedzi reported receiving grants from The Bill & Melinda Gates Foundation during the conduct of the study. Dr Whitney reported receiving grants from The Bill & Melinda Gates Foundation during the conduct of the study. Dr Rees reported receiving grants from the National Institutes of Health. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Adherence to World Health Organization Clinical Guidelines for Perinatal Asphyxia Stratified by Duration of Hospitalization (n = 617)
Error bars represent 95% CIs. IV indicates intravenous.
Figure 2.
Figure 2.. Adherence to World Health Organization Clinical Guidelines for Neonatal Sepsis Stratified by Duration of Hospitalization (N = 708)
Error bars represent 95% CIs.
See this image and copyright information in PMC

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