Adherence to Perinatal Asphyxia or Sepsis Management Guidelines in Low- and Middle-Income Countries
Authors: Afruna Rahman, Meghna Ray, Zachary J. Madewell, Kitiezo Aggrey Igunza, Victor Akelo, Dickens Onyango, Florence Murila, Winnie Mwebia, Ikechukwu Udo Ogbuanu, Julius Ojulong, Dickens Kowuor, Erick Kaluma, Solomon Samura, Shams El Arifeen, Emily S. Gurley, Mohammad Zahid Hossain, Kazi Munisul Islam, Rajib Biswas, Nega Assefa, Temesgen Teferi, Konjit Eshetu, Lola Madrid, Karen L. Kotloff, Milagritos D. Tapia, Adama Mamby Keita, Elisio Xerinda, Celisa Mendonça de Assis, Milton Kincardett, Inacio Mandomado, Rosauro Varo, Shabir A. Madhi, Ziyaad Dangor, Vuyelwa Baba, Sithembiso Velaphi, Yasmin Adam, Dianna M. Blau, Portia C. Mutevedzi, Quique Bassat, Cynthia G. Whitney, Chris A. Rees, Sanwarul Bari, Shahana Parveen, Mohammed Kamal, A.S.M. Nawshad Uddin Ahmed, Mahbubul Hoque, Saria Tasnim, Ferdousi Islam, Farida Ariuman, Mohammad M Rahman, Ferdousi Begum, K. Zaman, Mustafizur Rahman, Dilruba Ahmed, Meerjady S Flora, Tahmina Shirin, Mahbubur Rahman, Joseph Oundo, Alexander M Ibrahim, Fikremelekot Temesgen, Tadesse Gure, Addisu Alemu, Melisachew M Yeshi, Mahlet A Gizaw, Stian MS Orlien, Solomon Ali, Peter Otieno, Peter N Onyango, Janet Agaya, Richard Oliech, Joyce A Were, Dickson Gethi, George Aol, Thomas Misore, Harun Owuor, Christopher Muga, Bernard Oluoch, Christine Ochola, Sharon M Tennant, Carol L Greene, Ashka Mehta, J. Kristie Johnson, Brigitte Gaume, Rima Koka, Karen D Fairchild, Diakaridia Kone, Diakaridia Sidibe, Doh Sanogo, Uma U Onwuchekwa, Nana Kourouma, Seydou Sissoko, Cheick B Traore, Jane Juma, Kounandji Diarra, Awa Traore, Tiéman Diarra, Kiranpreet Chawla, Khátia Munguambe, Ariel Nhacolo, Maria Maixenchs, Kyu H Lee, Shailesh Nair, Lucy Liu, Courtney Bursuc, Kristin LaHatte, Sarah Raymer, John Blevins, Solveig Argeseanu, Kurt Vyas, Manu Bhandari, Mischka Garel, Navit T Salzberg, Jeffrey P Koplan, Jana Ritter, Tais Wilson, Jonas Winchell, Jakob Witherbee, Andrew Moseray, Fatmata B Tarawally, Martin Seppeh, Ronald Mash, Babatunde Duduyemi, James Bunn, Alim Swaray-Deen, Joseph Bangura, Amara Jambai, Margaret Mannah, Okokon Ita, Cornell Chukwuegbo, Sulaiman Sannoh, Princewill Nwajiobi, Oluseyi Balogun, Carrie J Cain, Samuel Pratt, Francis Moses, Tom Sesay, James Squire, Joseph K Sesay, Osman Kaykay, Binyam Halu, Hailemariam Legesse, Francis Smart, Sartie Kenneh, Soter Ameh, Fatima Solomon, Gillian Sorour, Hennie Lombaard, Jeannette Wadula, Karen Petersen, Martin Hale, Nelesh P Govender, Peter J Swart, Sanjay G Lala, Richard Chawana, Amy Wise, Nellie Myburgh
Journal: JAMA Network Open (2025)

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.