Department of Neonatology, Sint Antonius Hospital, Nieuwegein, The Netherlands.
Department of Neonatology, Wilhelmina Children's Hospital University Medical Center Utrecht, Utrecht, The Netherlands.
BMJ Glob Health. 2021 Feb;6(2). doi: 10.1136/bmjgh-2020-003618.
Preterm birth is the leading cause of under-five-mortality worldwide, with the highest burden in low-income and middle-income countries (LMICs). The aim of this study was to synthesise evidence-based interventions for preterm and low birthweight (LBW) neonates in LMICs, their associated neonatal mortality rate (NMR), and barriers and facilitators to their implementation. This study updates all existing evidence on this topic and reviews evidence on interventions that have not been previously considered in current WHO recommendations.
Six electronic databases were searched until 3 March 2020 for randomised controlled trials reporting NMR of preterm and/or LBW newborns following any intervention in LMICs. Risk ratios for mortality outcomes were pooled where appropriate using a random effects model (PROSPERO registration number: CRD42019139267).
1236 studies were identified, of which 49 were narratively synthesised and 9 contributed to the meta-analysis. The studies included 39 interventions in 21 countries with 46 993 participants. High-quality evidence suggested significant reduction of NMR following antenatal corticosteroids (Pakistan risk ratio (RR) 0.89; 95% CI 0.80 to 0.99|Guatemala 0.74; 0.68 to 0.81), single cord (0.65; 0.50 to 0.86) and skin cleansing with chlorhexidine (0.72; 0.55 to 0.95), early BCG vaccine (0.64; 0.48 to 0.86; I 0%), community kangaroo mother care (OR 0.73; 0.55 to 0.97; I 0%) and home-based newborn care (preterm 0.25; 0.14 to 0.48|LBW 0.42; 0.27 to 0.65). No effects on perinatal (essential newborn care 1.02; 0.91 to 1.14|neonatal resuscitation 0.95; 0.84 to 1.07) or 7-day NMR (essential newborn care 1.03; 0.83 to 1.27|neonatal resuscitation 0.92; 0.77 to 1.09) were observed after training birth attendants.
The findings of this study encourage the implementation of additional, evidence-based interventions in the current (WHO) guidelines and to be selective in usage of antenatal corticosteroids, to reduce mortality among preterm and LBW neonates in LMICs. Given the global commitment to end all preventable neonatal deaths by 2030, continuous evaluation and improvement of the current guidelines should be a priority on the agenda.
早产是全球五岁以下儿童死亡的主要原因，在低收入和中等收入国家（LMICs）负担最重。本研究旨在综合早产儿和低出生体重（LBW）新生儿在 LMICs 中基于证据的干预措施，及其与新生儿死亡率（NMR）的关联，以及实施这些干预措施的障碍和促进因素。本研究更新了该主题的所有现有证据，并回顾了目前世卫组织建议中尚未考虑的干预措施的证据。
为了确定早产儿和/或 LBW 新生儿在 LMICs 中接受任何干预后的 NMR，我们检索了截至 2020 年 3 月 3 日的六个电子数据库中的随机对照试验。在适当的情况下，使用随机效应模型汇总死亡率结局的风险比（PROSPERO 注册号：CRD42019139267）。
共确定了 1236 项研究，其中 49 项进行了叙述性综合，9 项纳入了荟萃分析。这些研究包括 21 个国家的 39 项干预措施，涉及 46993 名参与者。高质量证据表明，产前皮质激素（巴基斯坦 RR 0.89；95%CI 0.80 至 0.99|危地马拉 0.74；0.68 至 0.81）、单脐带（0.65；0.50 至 0.86）和氯己定皮肤清洁（0.72；0.55 至 0.95）、早期卡介苗疫苗（0.64；0.48 至 0.86；I 0%）、社区袋鼠式护理（OR 0.73；0.55 至 0.97；I 0%）和家庭新生儿护理（早产 0.25；0.14 至 0.48|LBW 0.42；0.27 至 0.65）可显著降低 NMR。在培训分娩护理人员后，未观察到围产期（基本新生儿护理 1.02；91%至 1.14|新生儿复苏 0.95；84%至 1.07）或 7 天 NMR（基本新生儿护理 1.03；83%至 1.27|新生儿复苏 0.92；77%至 0.99）的效果。
本研究的结果鼓励在当前（世卫组织）指南中实施更多基于证据的干预措施，并在使用产前皮质激素时具有选择性，以降低 LMICs 中早产儿和 LBW 新生儿的死亡率。鉴于全球致力于到 2030 年消除所有可预防的新生儿死亡，当前指南的持续评估和改进应成为议程上的优先事项。
