title: Bubble CPAP to support preterm infants in rural Rwanda: a retrospective cohort study.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. evnahimana@gmail.com.|Department of Global Health and Social Medicine, Harvard Medical School, 02115, Boston, MA, USA. evnahimana@gmail.com.
authors.forename: Evrard
authors.initials: E
authors.lastname: Nahimana
authors.affiliation: Ministry of Health, Kigali, Rwanda. ngemasudi@gmail.com.
authors.forename: Masudi
authors.initials: M
authors.lastname: Ngendahayo
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. hema.magge@gmail.com.|Division of General Pediatrics, Boston Children's Hospital, Boston, USA. hema.magge@gmail.com.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA. hema.magge@gmail.com.
authors.forename: Hema
authors.initials: H
authors.lastname: Magge
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. ojacklineatieno@gmail.com.
authors.forename: Jackline
authors.initials: J
authors.lastname: Odhiambo
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. cheryl.amoroso@gmail.com.
authors.forename: Cheryl L
authors.initials: CL
authors.lastname: Amoroso
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. ernestinoy@gmail.com.
authors.forename: Ernest
authors.initials: E
authors.lastname: Muhirwa
authors.affiliation: Ministry of Health, Kigali, Rwanda. ujneposs@yahoo.fr.
authors.forename: Jean Nepo
authors.initials: JN
authors.lastname: Uwilingiyemungu
authors.affiliation: Ministry of Health, Kigali, Rwanda. fuldgence@gmail.com.
authors.forename: Fulgence
authors.initials: F
authors.lastname: Nkikabahizi
authors.affiliation: Ministry of Health, Kigali, Rwanda. habiregis@hotmail.fr.
authors.forename: Regis
authors.initials: R
authors.lastname: Habimana
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. bethhedt@gmail.com.|Department of Global Health and Social Medicine, Harvard Medical School, 02115, Boston, MA, USA. bethhedt@gmail.com.
authors.forename: Bethany L
authors.initials: BL
authors.lastname: Hedt-Gauthier
mesh_terms: D045422:Continuous Positive Airway Pressure / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D007234:Infant, Premature; D019102:Infant, Very Low Birth Weight; D008297:Male; D012127:Respiratory Distress Syndrome, Newborn / Q000453:epidemiology / Q000628:therapy*; D012189:Retrospective Studies; D012424:Rural Population; D012432:Rwanda / Q000453:epidemiology; D015996:Survival Rate / Q000639:trends