Bubble CPAP to support preterm infants in rural Rwanda: A retrospective cohort study

Background: Complications from premature birth contribute to 35 % of neonatal deaths globally; therefore, efforts to improve clinical outcomes of preterm (PT) infants are imperative. Bubble continuous positive airway pressure (bCPAP) is a low-cost, effective way to improve the respiratory status of preterm and very low birth weight (VLBW) infants. However, bCPAP remains largely inaccessible in resource-limited settings, and information on the scale-up of this technology in rural health facilities is limited. This paper describes health providers' adherence to bCPAP protocols for PT/VLBW infants and clinical outcomes in rural Rwanda. Methods: This retrospective chart review included all newborns admitted to neonatal units in three rural hospitals in Rwanda between February 1st and October 31st, 2013. Analysis was restricted to PT/VLBW infants. bCPAP eligibility, identification of bCPAP eligibility and complications were assessed. Final outcome was assessed overall and by bCPAP initiation status. Results: There were 136 PT/VLBW infants. For the 135 whose bCPAP eligibility could be determined, 83 (61.5 %) were bCPAP-eligible. Of bCPAP-eligible infants, 49 (59.0 %) were correctly identified by health providers and 43 (51.8 %) were correctly initiated on bCPAP. For the 52 infants who were not bCPAP-eligible, 45 (86.5 %) were correctly identified as not bCPAP-eligible, and 46 (88.5 %) did not receive bCPAP. Overall, 90 (66.2 %) infants survived to discharge, 35 (25.7 %) died, 3 (2.2 %) were referred for tertiary care and 8 (5.9 %) had unknown outcomes. Among the bCPAP eligible infants, the survival rates were 41.8 % (18 of 43) for those in whom the procedure was initiated and 56.5 % (13 of 23) for those in whom it was not initiated. No complications of bCPAP were reported. Conclusion: While the use of bCPAP in this rural setting appears feasible, correct identification of eligible newborns was a challenge. Mentorship and refresher trainings may improve guideline adherence, particularly given high rates of staff turnover. Future research should explore implementation challenges and assess the impact of bCPAP on long-term outcomes.