Respiratory support with Continuous Positive Airway Pressure in preterm neonates: an analysis of coverage and quality of care in 66 neonatal units in Kenya, Malawi, Nigeria and Tanzania implementing with the NEST360 Alliance

Background: Prematurity is the leading cause of child deaths worldwide, with the highest neonatal mortality in sub Saharan Africa. Respiratory distress syndrome (RDS) is the leading mortality pathway in preterm neonates, but continuous positive airway pressure (CPAP) has high impact. This analysis reports CPAP coverage and quality of care for preterm neonates admitted to 66 neonatal units in Kenya, Malawi, Nigeria and Tanzania. Methods: Analyses used individually linked neonatal inpatient data and cross-sectional health systems data. All admitted neonates were eligible for inclusion (January 2021 through December 2024). Service readiness for CPAP delivery and mean CPAP coverage were described for CPAP eligible newborns (weighing <1500g and symptomatic newborns >1500g). Quality of care cascades were constructed to illustrate key indicators. Survival among CPAP eligible neonates was analysed using regression models, stratified by clinical severity scores. Results: 375,255 newborn admissions were analysed in 66 neonatal units. Functional CPAP availability varied with median 16% of days (IQR: 4 to 47%) classified as high demand (>1.5 eligible newborns per CPAP). Of 64,761 CPAP eligible neonates, 22,006 (34%, 95% CI 33 to 34%) received CPAP. All countries showed improvement in CPAP coverage, with Tanzanian hospitals recording 63% increase in mean coverage (p-value=0.001) over time. Quality of care cascades showed treatment was initiated <24 hours after birth and continued for >1 day for 42% (95% CI 41 to 43%) of eligible neonates receiving CPAP. Only 10% of neonates <1500g started CPAP within the first hour of life. Among newborns on CPAP, 55% also received KMC (from 48% in Tanzania to 88% in Nigeria). Among newborns with high clinical severity, those treated with CPAP had a higher probability of survival (32%, 95% CI 29 to 36%) than those who were not (23%, 95% CI 21 to 26%). Odds of survival were higher for CPAP eligible newborns whose mothers received antenatal corticosteroids (aOR 1.07, p=0.001). Lower aOR of survival was associated with hypoglycaemia (aOR 0.71, p<0.001), respiratory distress (aOR 0.91, p<0.001), and outborn newborns (aOR 0.72, p<0.001). Conclusion: CPAP coverage and quality are critical for premature neonates. Clinical cascades highlight quality gaps, particularly in timely prophylactic CPAP initiation and appropriate duration. Improving comprehensive care quality for newborns on CPAP, including provision of co-interventions and maternal antenatal corticosteroids, can improve survival for preterm neonates.