Developmental Neurorehabilitation, June 2010; 13(3): 156–163

Perinatal profile of very low birthweight infants under a universal

newborn hearing screening programme in a developing country:
A case-control study

BOLAJOKO O. OLUSANYA

College of Medicine, University of Lagos, Maternal and Child Health Unit, Department of Community Health and
Primary Care, Idi-araba, Surulere, Lagos, Nigeria

(Received 3 November 2009; accepted 4 November 2009)

Abstract
Objective: To determine the perinatal profile and developmental risks of very low birth weight (VLBW) infants (1500 g)
under a universal hearing screening programme in a resource-poor country.
Methods: A case-control study of VLBW survivors matched by date of birth and sex with normal birth weight (2500 g)
infants delivered in an inner-city maternity hospital in Lagos, Nigeria. Hearing status was determined by two-stage
screening with transient evoked otoacoustic emissions (TEOAE) followed by automated auditory brainstem response
(AABR). Maternal and infant factors associated with VLBW were determined using unconditional and conditional
multivariable logistic regression analyses.
Results: All 45 VLBW singletons (mean weight 1.3  0.1 kg) during the study period were matched with 225 controls
(mean weight 3.4  0.5 kg). VLBW was associated with maternal occupation, lack of antenatal care, low 5-minute Apgar
score and hyperbilirubinemia based on unmatched and matched analyses. Additionally, VLBW infants were significantly
associated with failed or incomplete hearing screening outcomes. Four (10.5%) of the 38 infants tested with AABR failed,
but none returned for diagnostic evaluation and one child had previously passed TEOAE.
Conclusions: VLBW infants in resource-poor settings are associated with the risk of sensorineural hearing loss and other
perinatal outcomes that may potentially compromise their optimal development in early childhood.

Keywords: antenatal care, birth asphyxia, developmental deficits, hyperbilirubinemia, low birth weight, sensorineural hearing
loss, sub-Saharan Africa

Resumen
Objetivo: Determinar el perfil de riesgos perinatales y del desarrollo para infantes con muy bajo peso al nacer (VLBW)
(1500 g) dentro de un programa universal de tamizaje auditivo en un paı́s con recursos limitados.
Métodos: Un estudio caso-control de los supervivientes VLBW pareados por edad y sexo con infantes con pero normal al
nacer (2500 g) en un hospital de maternidad en el centro de la ciudad en Lagos, Nigeria. El estado de audición fue
determinado mediante un cribado de dos fases, utilizando emisiones otoacústicas transitorias (TEOAE) seguido por
respuestas auditivas de tallo cerebral automatizadas (AABR). Los factores de riesgo maternos e infantiles asociados con
VLBW fueron determinados utilizando análisis de logı́stica no condicional y condicional de regresión.
Resultados: Todos los 45 productos únicos (peso medio 1.3  0.1 kg) fueron pareados durante el estudio con 225 controles
(peso medio 3.4  0.5 kg). El muy bajo pero al nacer se asoció con la ocupación materna, la falta de atención prenatal, baja
calificación de Apgar a los 5 minutos y con hiperbilirrubinemia en un análisis de regresión multivariable ajustado y no
ajustado. Adicionalmente, los infantes VLBW se relacionaron con resultados fallidos o incompletos en el tamizaje auditivo.
Cuatro (10.5%) de los 38 infantes valorados con AABR fallaron, pero ninguno regresó para valoración diagnóstica y
únicamente uno de los niños habı́a pasado previamente TEOAE.
Conclusiones: Los infantes VLBW en un medio ambiente con pocos recursos, se asocian con riesgo de hipoacusia
neurosensorial y con otros resultados perinatales que potencialmente pueden comprometer su desarrollo óptimo durante la
infancia temprana.
Palabras clave: atención prenatal, asfixia al nacer, déficits del desarrollo, hiperbilirrubinemia, bajo peso al nacer, hipoacusia
neurosensorial, África subsahariana

Correspondence: Dr Bolajoko O. Olusanya, MBBS, FMCPaed, FRCPCH, PhD, College of Medicine, University of Lagos, Maternal and Child Health Unit,
Department of Community Health and Primary Care, Idi-araba, Surulere, Lagos, Nigeria. E-mail: boolusanya@aol.com
ISSN 1751–8423 print/ISSN 1751–8431 online/10/030156–8 ß 2010 Informa UK Ltd.
DOI: 10.3109/17518420903468472
 Very low birthweight infants in developing countries
Introduction
Newborns with very low birthweight (VLBW) 1500g
or less constitute a high proportion of the heteroge-
neous group of infants that are born pre-term with
low birth weight or restricted intrauterine growth or
both. They are associated with higher rates of
perinatal mortality (including stillbirths) and mor-
bidity worldwide [1, 2]. Improvements in obstetric
and neonatal care over the years particularly in
developed countries have resulted in increased sur-
vival rates for VLBW infants but not without a range
of short- and long-term risks [3, 4]. For example,
VLBW survivors are at an increased risk of adverse
short-term outcomes such as hypothermia, hypogly-
caemia, respiratory problems including birth
asphyxia, infections and hyperbilirubinemia as well
as neuro-sensory/developmental problems such
as cerebral palsy, visual and hearing impairments
[3, 4]. Such infants are also associated with
behavioural and emotional problems well into adult-
hood [5], with substantial long-term financial
burden to the family and society [6].
VLBW infants are perhaps most vulnerable in
resource-poor settings where the healthcare systems
are unable to effectively support all high-risk infants
due to the lack or shortage of requisite intensive
care facilities and services [7, 8]. Nonetheless, while
survival rates in developed countries are typically
over 75% [3], pre-discharge survival rates in excess
of 50% are not uncommon in many developing
countries [9–12], thus underscoring the need to
accurately establish essential baseline characteristics
of VLBW survivors to facilitate effective post-
discharge follow-up for such infants for optimal
growth and development [4]. For example, congen-
ital hearing impairment is a ‘hidden’ disability which
has the potential for exacerbating the overall
neurodevelopmental outcomes for VLBW infants
if not detected promptly due to the associated motor,
speech and language, cognitive and psycho-social
developmental deficits [13–15]. However, available
literature on the short-term outcomes of VLBW
in developing countries, particularly in Sub-Saharan
Africa, are limited in scope [9–12, 16] and rarely
report the risk of sensorineural hearing loss (SNHL)
for which effective intervention is restricted typically
within the first year of life [13–15]. Moreover, the
World Health Assembly of 193 Member States
has since 1995 adopted a resolution urging early
detection and intervention for all babies with hearing
impairment [17].
This study therefore set out to determine the
perinatal profile of VLBW survivors within the
context of a recently concluded pilot universal
newborn hearing screening (UNHS) programme to
157
provide typical baseline data for post-discharge
follow-up in a resource-poor country [18].
Methods
Study design and setting
This case-control study was conducted at the Island
Maternity Hospital in Lagos, Nigeria from May
2005 to December 2007. This inner-city govern-
ment hospital provides specialist services to several
private and public hospitals within and outside its
catchment area. At the time of this study, the
hospital had 180 beds for maternity services and a
15-bed special care baby unit (SCBU) equipped
with incubators, stand-alone resuscitation units,
suction machines, oxygen concentrators, infusion
sets for intravenous fluids (not parenteral nutrition)
and phototherapy units. Exogenous surfactant was
not available for VLBW newborns either as a
prophylactic or rescue treatment. Babies requiring
intensive care including exchange blood transfusion
were usually referred to a nearby children’s hospital
after a brief stay in the SCBU. Although the hospital
provided tertiary-level maternity services as an
accredited institution for residency training in anaes-
thesia, obstetrics and gynecology, it only offered
secondary-level neonatal services.
Study population
Participants were drawn from a sampling frame
of newborns under a UNHS programme at the
hospital as previously reported and for which ethical
approvals were obtained from Lagos State Health
Management Board, Nigeria and University College
London, UK [18]. Informed written consent was
obtained from mothers before enrolment. For this
study, every surviving VLBW singleton infant was
matched with five infants of normal birth weight
(2500 g or more) on the basis of sex and date of
birth. Multiple gestations were excluded to comply
with recommendations for international standard-
ization since they represent a special risk group for
adverse perinatal outcomes [19]. Birth weights were
obtained from the hospital records and correlated
with the anthropometric measurements of each
newborn obtained separately by a trained research
assistant at the point of enrolment into this study. All
newborns who died prior to or during enrolment
were excluded. Assuming a 25% exposure risk
among VLBW infants and 5% exposure risk among
full-term infants with an odds ratio of 6.33, a sample
size of 40 cases and 200 controls (ratio 1 : 5) will
have 90% power to detect a 20% difference in
exposure risk between the two groups at 95%
confidence interval. If the effect of case-control
158 B. O. Olusanya
matching were considered the required sample total
size would be lower than 240.
Study variables
Variables of interest included maternal factors such
as maternal age, marital status, education, occupa-
tion, parity, antenatal care, use of herbal drug
in pregnancy, hypertensive disorders (inclusive of
pre-eclampsia, eclampsia and pregnancy induced
hypertension), maternal HIV status and mode of
delivery as well as neonatal characteristics such as
mode of feeding, birth asphyxia (indexed by low
Apgar scores at 1 and 5 minutes), sepsis (used
collectively for septicemia, meningitis and pneumo-
nia), ototoxic medications (such as gentamicin) and
hyperbilirubinemia. Non-clinical information was
obtained predominantly from the mothers while
clinical data was obtained from the hospital records.
Clinical information on other relevant conditions
such as respiratory distress syndrome, retinopathy
of prematurity and necrotizing enterocolitis or use of
antenatal steroids was not available. Hearing screen-
ing status (pass, refer or inconclusive) was evaluated
based on a two-stage hearing screening protocol
consisting of a first-stage screening with transient
evoked otoacoustic emissions (TEOAE) followed
by a second-stage screening with automated audi-
tory brainstem response (AABR) test, as previously
reported [18]. TEOAE is a physiological test of the
integrity of the outer hair cells in the cochlea, while
AABR is an electro-physiological measure of the
function of the auditory pathway from the eighth
cranial nerve through the brainstem. In view of the
high risk of auditory neuropathy/dyssynchrony
(AN/AD) in VLBW infants, AABR was scheduled
for all cases regardless of their TEOAE outcome.
AN/AD is a type of hearing impairment in which
normal outer ear cell function of the cochlea
co-exists with abnormal or dyssynchronous auditory
brainstem response. All those who failed AABR
were scheduled for diagnostic evaluation with
tympanometry, auditory brainstem response (ABR)
and visual response audiometry.
Statistical analysis
Cross-tabulation of the factors among cases and
controls was done to provide a descriptive overview
of the study participants. Univariate association
between VLBW and maternal factors/perinatal out-
comes was explored with Pearson 2 or Fisher’s
exact tests as appropriate. Odds ratios (OR) and the
corresponding 95% confidence intervals (CI) were
estimated using both conditional and unconditional
logistic regression analyses to ascertain the robust-
ness of the results. The results from both analyses
were placed side-by-side for easy comparison.
Factors with p 5 0.10 from univariate analysis were
entered into multivariable logistic regression model
and factors that did not significantly ( p 4 0.05)
contribute to the models were eliminated by back-
ward stepwise method to derive adjusted OR for
variables in the final model. Statistical significance
in the logistic regression was based on the Wald
statistic and all tests were two-sided at a critical
level of p 5 0.05. Interaction effects between
variable-pairs of interest were assessed with the
likelihood ratio test. SPSS for Windows version
16.0 (SPSS Inc, Chicago, IL) was used for all
statistical analyses.
Results
A total of 66 VLBW infants were enlisted into the
UNHS programme over the study period, out of
which 13 infants died prior to discharge and eight
infants had multiple gestations. The mean (SD)
birth weight of the final 45 VLBW singletons
(16 males; 29 females) recruited as cases was 1.3
(0.1) kg (range 0.8–1.5 kg), while the mean (SD)
gestational age at birth was 31.2 (3.5) weeks (range
24–39 weeks). Only two infants were extremely
LBW (51.0 kg) and 11 (24.4%) infants were
small-for-gestational age. The 225 matched controls
had a mean (SD) birth weight of 3.4 (0.5) kg (range
2.6–5.6 kg) and a mean gestational age of 38.2 (1.7)
weeks (range 31–44 weeks). The controls were
chosen within a range of 3 days of the birth date
of each case at the time of enrolment.
The prevalence rates of the various factors
among cases and controls are presented in Table I.
Of the cases, over half (55.6%) were delivered by
multiparous mothers and almost two-thirds (64.4%)
had no antenatal care. Hypertensive disorders
(11.1%) and HIV (8.9%) were more prevalent
among the mothers of cases while antepartum
haemorrhage and premature rupture of membranes
were reported only in one mother for each obstetric
complication. Similarly, low 5-minute Apgar score
(52.3%), sepsis (11.1%) and hyperbilirubinemia
(20.0%) were more common among cases. No
congenital anomalies were found in both cases and
controls. Hearing screening outcomes among cases
compared with controls also showed higher rates of
referral (8.9% vs 3.1%) and incomplete/missed
screening (15.6% vs 2.7%). Details of hearing
screening outcomes among the cases are presented
in Figure 1. The median age at first-stage (TEOAE)
screening was 4.0 days (interquartile range: 2–7 days)
for cases and 1.0 day (interquartile range: 1–2 days)
for controls. One of the four who failed AABR and
were scheduled for diagnostic hearing tests passed
TEOAE. None returned for the tests, while one child
 Very low birthweight infants in developing countries 159

Table I. Perinatal profile of very low birthweight (1500g) infants under a universal newborn hearing screening programme in Lagos,
Nigeria.

Unadjusted odds ratios (95% CI) Adjusted§ odds ratios (95% CI)
Cases Controls
Profile (n ¼ 45) (n ¼ 225) Unmatched Matched Unmatchedy Matched

Maternal factors
Maternal age (years)
520 1 (2.2) 8 (3.6) 0.72 (0.08–5.06) 0.63 (0.08–5.00) — —
20–35 40 (88.9) 197 (87.6) Reference Reference
435 4 (8.9) 20 (8.9) 0.99 (0.32–3.04) 0.99 (0.33–3.01) — —
Marital status
Married 41 (91.1) 220 (97.8) Reference Reference
Unmarried 4 (8.9) 5 (2.2) 4.29 (1.11–16.67) 4.00 (1.07–14.90) — —
Education
None 0 (0.0) 6 (2.7) — —
Primary/Secondary 32 (71.1) 125 (55.6) 1.85 (0.92–3.72) 1.94 (0.94–4.01) — —
Post-secondary 13 (28.9) 94 (41.8) Reference —
Occupation
Informal or none 23 (51.1) 74 (32.9) Reference Reference Reference Reference
Formal employment 22 (48.9) 151 (67.1) 0.47 (0.25–0.90) 0.45 (0.23–0.89) 0.41 (0.19–0.88)* 0.42 (0.18–0.96)*
Parity
Primiparous 20 (44.4) 124 (55.1) Reference Reference
Multiparous 25 (55.6) 101 (44.9) 1.54 (0.81–2.92) 1.49 (0.80–2.79) — —
Antenatal care
Yes 16 (35.6) 149 (66.2) Reference Reference Reference Reference
None 29 (64.4) 76 (33.8) 3.55 (1.82–6.94) 3.44 (1.77–6.69) 4.11 (1.91–8.83)*** 4.36 (1.92–9.88)***
Herbal drug in pregnancy
None 38 (84.4) 180 (80.0) Reference Reference
Yes 7 (15.6) 45 (20.0) 0.74 (0.31–1.76) 0.73 (0.30–1.77) — —
Hypertensive disorders
None 40 (88.9) 216 (96.0) Reference Reference
Yes 5 (11.1) 9 (4.0) 3.00 (0.96–9.42) 2.78 (0.93–8.29) — —
HIV-positive
No 41 (91.1) 214 (95.1) Reference Reference
Yes 4 (8.9) 11 (4.9) 1.90 (0.58–6.25) 1.93 (0.58–6.45) — —
Mode of delivery
Vaginal 32 (71.1) 120 (53.3) Reference Reference
Caesarean 13 (28.9) 105 (46.7) 0.46 (0.23–0.93) 0.43 (0.21–0.90) — —
Infant factors
Mode of feeding
Breast only 36 (80.0) 186 (82.7) Reference Reference
Bottle/Mixed 9 (20.0) 39 (17.3) 1.19 (0.53–2.68) 1.28 (0.49–3.38) — —
1-min Apgar score (57)
No 1 (2.3) 20 (9.2) Reference Reference
Yes 43 (97.7) 198 (90.8) 4.34 (0.57–33.25) 4.20 (0.55–31.91) — —
5-min Apgar score (57)
No 21 (47.7) 168 (77.1) Reference Reference Reference Reference
Yes 23 (52.3) 50 (22.9) 3.68 (1.88–7.20) 3.35 (1.74–6.45) 3.88 (1.82–8.30)*** 3.61 (1.66–7.88)***
Sepsis
No 40 (88.9) 219 (97.3) Reference Reference
Yes 5 (11.1) 6 (2.7) 4.56 (1.33–15.67) 4.58 (1.31–16.00) — —
Hyperbilirubinemia
No 36 (80.0) 218 (96.9) Reference Reference Reference Reference
Yes 9 (20.0) 7 (3.1) 7.79 (2.73–22.22) 8.04 (2.67–24.23) 6.51 (1.90–22.35)** 5.47 (1.40–21.35)*
Ototoxic medications
No 36 (80.0) 212 (94.2) Reference Reference
Yes 9 (20.0) 13 (5.8) 4.08 (1.62–10.23) 3.91 (1.57–9.73) — —
Hearing screening outcome
Passed 34 (75.6) 212 (94.2) Reference Reference Reference Reference
Failed or incomplete 11 (24.4) 13 (5.8) 5.28 (2.19–12.73) 4.62 (1.99–10.73) 4.39 (1.54–12.51)** 3.67 (1.35–10.04)*

CI ¼ confidence interval; §Adjusted for marital status, hypertension, mode of delivery, sepsis and ototoxic medications.
*p 5 0.05; **p 5 0.01; ***p 5 0.001; Hosmer-Lemeshow test: yp ¼ 0.975.

was confirmed as dead when the parents were In both the unmatched and matched univariate
contacted. The default rates for the second-stage analyses, marital status, occupation, lack of antenatal
screening and diagnosis were 18.4% and 100%, care, hypertensive disorders, mode of delivery, low
respectively. 5-minute Apgar score, neonatal sepsis,
160 B. O. Olusanya

Very Low The final regression models were well calibrated

birthweight (Hosmer-Lemeshow test: 2 ¼ 1.25, df ¼ 6,
(≤1500g) p ¼ 0.975) and no evidence of any significant inter-
n = 45
action among variables entered into the final models
was observed.

First-stage Screen
[TEOAE]
Discussion
The neurodevelopmental status of VLBW infants
usually as from 12 months of age throughout early
childhood have been extensively reported in the
literature [3, 4, 16, 20]. However, this study is
Pass Refer Missed
perhaps the first from sub-Saharan Africa that
31 14 0
specifically examines the risk of sensorineural hearing
loss as part of the perinatal profile in a cohort of
VLBW infants and complements earlier reports on
Second-stage Screen the hearing status [18] and predictors of prematurity
[AABR]
in the general population of newborns from the same
region [21]. Similar studies from other developing
regions are rare. One such report from Brazil was
limited to a descriptive analysis of the hearing and
perinatal status of VLBW infants [22]. Most studies
Pass Refer Missed
34 4 7 have rather focused on all neonates in intensive care,
of which VLBW is a sub-set.
The findings on low 5-minute Apgar score
(a useful proxy for birth asphyxia in settings
lacking facilities for blood gases and pH analysis)
Diagnostic Tests and hyperbilirubinemia are not unexpected. These
conditions are leading causes of mortality, mor-
bidity and disability in developing countries.
Recommendations for their management are well
documented in the hospital guidelines for perinatal
Pass Fail Missed
0 0 4 care in resource-poor settings published by the
World Health Organization [23]. The management
of hyperbilirubinemia pre- and post-discharge would
Figure 1. Hearing screening outcomes in very low birthweight appear to be more challenging considering that
infants in Lagos, Nigeria. TEOAE ¼ transient evoked otoacoustic
emissions, AABR ¼ automated auditory brainstem response.
most hospitals lack functional laboratory facilities
for bilirubin estimation and monitoring. The severity
of the condition is more commonly based on visual
hyperbilirubinemia, ototoxic medications and failed estimation which is prone to errors in judgement
or incomplete hearing screening tests were signifi- depending on the skill and experience of the clinical
cantly associated with VLBW infants. However, after staff. Even where phototherapy units are available,
the multivariable logistic regression VLBW was their efficacy is usually compromised due to lack of
associated with lack of antenatal care, low regular maintenance or inadequate number of units
5-minute Apgar score, hyperbilirubinemia and unfa- to cater for all suspected cases of hyperbilirubinemia.
vourable hearing screening outcomes based on both It is therefore not surprising to find high rates
unmatched and matched analyses. Additionally, of hospital readmission usually for exchange blood
VLBW was significantly less likely to be associated transfusion in some countries. As may be the case
with mothers with full-time or part-time formal in many developing countries, the intervention
employment (matched OR: 0.42; 95% CI: 0.18– services available for VLBW infants in this study
0.96). With the exception of maternal occupation, location were basic, comprising incubator care,
VLBW was associated with more than 3-fold odds oxygen by face masks, resuscitation by Ambu bag,
for all the factors. VLBW infants were no more intravaneous infusion and nasogastric tube feeding.
associated with sepsis or ototoxic medications than Evidently, it is necessary for these infrastructural
their controls after adjusting for other confounders. constraints to be addressed in the current global
 Very low birthweight infants in developing countries
initiatives to improve health care systems in devel-
oping countries.
Another notable finding is that the four infants
who failed the second-stage AABR were significantly
at risk of SNHL based on the satisfactory efficiency
ratios associated with the two-stage screening pro-
tocol of an initial TEOAE test followed by AABR
in UNHS screening programmes worldwide
although these infants did not return for the
scheduled diagnostic evaluation [24, 25]. Typically,
this screening protocol has a sensitivity and specifi-
city of 90% or more, thus suggesting that up to
three of the four infants were likely to have been
confirmed with SNHL, which potentially translates
to a crude prevalence estimate of 6.6% (3/45),
assuming that all the seven infants who missed the
AABR screening had normal hearing. This finding
would be comparable to the 6.3% and 6.9%
reported from two studies from Brazil [22] and
Australia [26] and substantially lower than the 27%
reported from another UK study [27]. In contrast,
one study from Israel reported a prevalence of 0.3%,
even though 1.5% of the study cohort of 337 VLBW
infants with normal auditory thresholds had abnor-
mal prolongation of ABR waveform latency with
possible abnormal ascending brainstem pathways
[28]. The high risk of incomplete pre-discharge
screening among VLBW infants could be attributed
to mothers’ eagerness to leave the hospital as soon as
the baby was well enough and the general perception
of hearing loss as a condition that is not serious or
important in the presence of other obviously
life-threatening conditions.
The pathophysiology of SNHL in VLBW infants
has been extensively described in a recent review,
although the extent to which VLBW alone impacts
SNHL is still not fully understood [15]. However,
birth asphyxia and hyperbilirubinemia lie on the
causal pathways between VLBW and neurodevelop-
mental deficits including SNHL [29]. The evidence
from this study thus underscores the need to
incorporate objective hearing assessment in the
management of VLBW infants and establish the
neurodevelopmental profile of these infants from
birth towards ensuring that VLBW survivors in
developing countries are afforded every possible
opportunity to thrive and develop optimally. For
example, since the incidence of SNHL is likely to be
higher in VLBW infants compared with moderately
low birth weight (1500–2499 g) and normal birth
weight infants, it may be worthwhile to consider this
cohort for targeted hearing screening in settings
where UNHS is not immediately practicable. In fact,
low 5-minute Apgar scores and/or hyperbilirubine-
mia have been recommended as potential
pre-screening tools in resource-poor settings for
SNHL based on their satisfactory combination of
161
specificity (90.7%) and negative predictive values
(97.0%) [18].
Lack of antenatal care is associated with a
wide range of obstetric and adverse perinatal out-
comes, particularly in developing countries [1, 30].
Attendance at antenatal clinics from early pregnancy
has beneficial impact on the diagnosis and timely
treatment of obstetric complications and risk factors
for VLBW. The finding in this study also accords
with the observation from another comparable
study from Africa in which lack of antenatal care
was significantly associated with poor survival of
VLBW infants [11]. Lack of antenatal care is
perhaps the most modifiable risk factor for VLBW
in this study and merits special attention in reducing
the incidence and adverse perinatal outcomes, espe-
cially against the backdrop of the substantial eco-
nomic implications of providing effective short-term
and long-term care for affected infants [6–8].
For example, maternal work-related stress is an
established risk factor for adverse pregnancy out-
comes [1, 31]. Mothers without formal employment
in this population were likely to be engaged in
small trading which may demand working longer
hours than those in regular employment thus placing
them at increased odds of VLBW. The lack of
regular income to supplement the family income
in an expensive city like Lagos is in itself a potential
cause for concern for any expectant woman.
Such mothers can be targeted during attendance
at antenatal clinics to better appreciate the perinatal
risks associated with work-related stress.
Although VLBW infants in this study had a higher
incidence of neonatal sepsis and ototoxic medica-
tions compared to the controls consistent with
evidence in the literature, these factors were not
retained after adjusting for other confounders.
Similarly, marital status, hypertensive disorders and
mode of delivery were not independently associated
with VLBW in this population. The exclusion of
VLBW infants who died before or during enrolment
in this study may have understated the potential
contributions of these factors. In fact, it was difficult
to determine the survival rates in this hospital during
the study period as a retrospective study which
focused primarily on enlisting live births for a UNHS
programme and the incomplete hospital records for
the majority of infants who died prior to recruitment.
The lack of post-discharge follow-up was another
limitation in view of possible disconnection between
short-term and long-term outcomes, particularly due
to delayed-onset or progressive neuro-developmental
impairments. There was also no information on the
number of antenatal visits made by the mothers to
determine its relationship with VLBW. Nonetheless,
this study has identified short-term outcomes which
portend long-term developmental risks for VLBW
162 B. O. Olusanya
survivors, thus expanding the commonly reported
spectrum of perinatal care and on-going support
required by such infants in resource-poor settings.
Longitudinal studies of these outcomes are recom-
mended towards curtailing the associated burden
considering that primary prevention of all VLBW
incidences is not yet an attainable goal even in
developed countries.
Acknowledgements
The instruments for this study were provided by
Natus Medical Inc., USA, Otodynamics (UK) Ltd
and Oticon Foundation, Denmark. Hearing
International Nigeria (HING), a locally registered
charity, provided financial support for all the oper-
ational costs of the project. None of the sponsors was
involved in the study design, collection, analysis and
interpretation of data; the writing of the manuscript;
or the decision to submit these results for
publication.
Declaration of interest: The author reports no
conflicts of interest. The author alone is responsible
for the content and writing of the paper.
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