Mehretie et al.

BMC Pediatrics (2024) 24:80 BMC Pediatrics

https://doi.org/10.1186/s12887-024-04532-5

RESEARCH Open Access

Length of hospital stay and factors

associated with very‑low‑birth‑weight
preterm neonates surviving to discharge
a cross‑sectional study, 2022
Yimenu Mehretie1, Ashenafi Tazebew Amare1, Geta Bayu Getnet1 and Birhanu abie Mekonnen1*

Abstract
Background The length of hospital stay of very-low-birth-weight neonates (birth weight < 1500 g) depends on mul-
tiple factors. Numerous factors have been reported to influence the length of hospital stay (LOS). The objective
of this study was to identify the length of hospital stay and associated factors among very-low-birth-weight preterm
neonates.
Method A hospital-based, cross-sectional study was conducted. Data was collected using a pretested, structured
questionnaire from April 1 to November 30, 2022. The data was entered using Epidata and Stata version 15.1. The fre-
quencies, mean, median, and interquartile range were used to describe the study population about relevant variables.
A linear regression model was used to see the effect of independent variables on dependent variables.
Result About 110 very low-birth-weight preterm neonates who survived to discharge were included in the study.
The median birth weight was 1370 g, with an IQR of 1250–1430. The mean gestational age was 32.30 ± 1.79 weeks.
The median length of hospital stay was 24 days, with an IQR of 13.5–40. The gestational age, type of initial manage-
ment given, and presence of complications had a significant association with the length of hospital stay for VLBW
preterm neonates.
Conclusion The median hospital stay was 24 days. The gestational age, presence of complications, and type of initial
management given were associated with LOS for VLBW preterm neonates. The length of the hospital stay of the VLBW
preterm neonates can be reduced by applying the standards of care of very-low-birth-weight preterm neonates.
Keywords Hospital stay, Very low birth weight, Preterm neonates, Surviving, Discharge

Background
Low-birth-weight neonates are those who weigh less
than 2500 g, whereas a very-low-birth weight is one who
weighs less than 1500 g [1]. Around 17.3% of neonates
Yimenu Mehretie is principal author. in Ethiopia are born underweight. The factors that have
*Correspondence: been linked to very-low-birth-weight include maternal
Birhanu abie Mekonnen
age < 20 years, maternal age > 34 years, pre-eclampsia,
babie3085@gmail.com
1
Department of Pediatrics and Child Health, School of Medicine, College gestational DM, preterm, and gestational age < 37 weeks [2].
of Medicine and Health Science, University of Gondar, Po. Box 196,
Gondar, Ethiopia

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
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mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Mehretie et al. BMC Pediatrics (2024) 24:80 Page 2 of 8

The length of stay (LOS) of very low birth weights in specialized hospital (UoGCSH) neonatal intensive care
the hospital was influenced by their gestational age unit. UoGCSH is a referral, teaching, and research hos-
(GA) and any associated medical conditions, including pital in North Gondar, Ethiopia. The critical care unit,
bronchopulmonary dysplasia (BPD), repeated apneic oncology unit, neonatology unit, cardiac unit, well-child
episodes, or tube feeding [3]. There were relatively few care service, and outpatient department are among the
evidence-based, consensus-based criteria for when to pediatrics and child health department. The neona-
discharge a very preterm infant, despite the fact that tal intensive care unit is adjacent to the labor ward and
many therapies in this high-risk group adhered to stand- accepts referrals from various healthcare facilities in the
ardized recommendations in this regard. As a result, UoGCSH catchment area. The NICU ward has three dis-
the discharge time would be varied. Therefore, a VLBW tinct spaces: the term, preterm, and kangaroo mother
infant might be discharged home at various times in dif- care (KMC) rooms. The discharge criteria of very-low-
ferent settings, even though they have the same GA and birth-weight preterm neonates are weigh ≥ 1500 g, nor-
weight [4]. mal temperature, fed on breast milk on their own, and
A prolonged stay at the hospital lengthened exposure didn’t experience complications.
to risks associated with the hospital environment, includ-
ing nosocomial infections [5, 6]. Studies also showed that
the length of hospital stay of preterm neonates increased Inclusion and exclusion criteria
the hazard of death [7]. On the other hand, when a very The study included all preterm neonates with very low
low-birth-weight preterm neonate stayed less than the birth weights who were discharged alive. Preterm neo-
median length of hospital stay, there would be an associ- nates excluded were referral neonates from other facili-
ated increase in mortality [8]. In addition, the prolonged ties after the seventh day of postnatal age and transferred
stay of the neonate in the neonatal intensive care unit out of the hospital before meeting the discharge criteria.
(NICU) interfered with the development of relationships
between parents and their children [9]. From a health
system perspective, longer LOS reduced availability of Sample size determination and sampling procedure
beds and increased the health care cost [10–12]. The final sample size was 110, with a population percent-
The very-low-birth-weight preterm neonates had deli- age of 7.82%, a confidence interval of 95%, and a margin
cate, immature organs and required their own intensive of error of 5%. Due to a lack of data, the research included
care unit. Deciding the timing of discharge was challeng- all VLBW preterm neonates who were discharged alive
ing since there was no set protocol. There was a wide during the study period.
variation in discharge recommendations throughout the
world. It was the same in the setup where this research
held. The preterm neonates of the same birth weight had Operational definition
not discharged on the same day, which suggested the Neonate is an infant younger than 28 days of age.
presence of factors contributing to their respective hos- Preterm is neonate born before 37 completed weeks
pital stays. from the first day of their last menstrual period.
Prolonged hospital stay had a multifaceted effect on the Early/very preterm is preterm neonate born with
neonates with very low-birth-weight. It was necessary to 28-31 weeks of gestation from the first day of their last
identify the contributing factors to the additional days. The menstrual period.
expected median age of hospital stay for very low-birth- Moderate preterm is preterm neonate with 32–33 weeks
weight preterm neonates was not previously determined in of gestation the first day of their last menstrual period.
the setup where this research was done. In addition, know- Late preterm is preterm neonate with 34–36 weeks of
ing the contributing factors would be one of the solutions gestation the first day of their last menstrual period.
to the problem. The aim of this research was to determine Very low-birth-weight is neonate born with birth weight
the length of hospital stay and factors that were associated of < 1500 g.
with length of hospital stays in very low-birth-weight pre- Length of stay is length of time between the neonate’s
term neonates surviving to discharge. admission and survived discharge from the unit to home.
Maintenance fluid is fluid that is given via intravenous
Method line that contains fluid, glucose and electrolyte.
Study design and setting Mixed feeding is neonate who was taking both
A hospital-based cross-sectional study design was con- expressed breast milk and formula at any time during
ducted at the University of Gondar comprehensive his/her hospital stay.
Mehretie et al. BMC Pediatrics (2024) 24:80 Page 3 of 8

Data collection tools and procedure had no formal education. The mean gestational age
We employed a standardized, tested-in-advance English was 32.3 ± 1.79 weeks. The minimum and maximum
questionnaire. Under the guidance of the investigators, gestational ages were 29 and 36 weeks, respectively.
two medical interns were chosen to gather the data. Sec- The median birth weight was 1,370 g, with an IQR of
ondary data (maternal and neonate records) and in-per- 1,250.0–1,430.0. The maximum and minimum birth
son interviews with the mothers at the time of discharge weights were 1000 g and 1,495 g, respectively (Table 1).
were the sources of information. The mothers were
directly interviewed face-to-face, and the mothers’ basic
demographic information was collected. Weight, gesta- Clinical characteristics
tional age, complications, length of stay, post-menstrual Among mothers from rural areas, 19.5% gave birth at
age of the neonate, and mother sociodemographic vari- home. However, all urban mothers gave birth at health
ables were prioritized during data collection. institutions. The anthropometric measurements of
neonates revealed that 89 (80.91%) were appropriate
Data quality control for gestational age (AGA), and the remaining 21 neo-
Prior to the actual study period, a pretest using 5% of nates (19.09%) were small for gestational age (SGA).
the sample size was carried out to evaluate the validity There was no neonate large for gestational age (LGA).
and accuracy of the questionnaire. The data collectors Ninety-five percent of the SGA preterm neonates were
were trained on the purpose of the study, its applicabil- late-preterm.
ity, information confidentiality, respondents’ rights to The three most common admission diagnoses were
informed consent, and how to complete the question- respiratory distress syndrome (56.3%) and early-onset
naire. To verify the accuracy and consistency of the data neonatal sepsis (31.8%), followed by very low birth
collected, the primary investigator and the supervisor weight (4.5%). The very low-birth-weight preterm neo-
often reviewed the data gathering procedure. nates developed different complications at the hospital
(Table 2 and Fig. 1). The median postnatal age at the
Data processing and analysis initiation of feeding (expressed breast milk) was 43.5 h,
With dummy tables, the questionnaire was given the with an IQR of 24–72 h. However, seven neonates were
initial code. The data was then input using the statis- started on expressed breast milk (EBM) feeding at the
tical program Epidata version 4.6 and analyzed with first hour(h) of postnatal age, and just one neonate
Stata version 15.1. Data cleaning, accuracy and consist- began EBM at 240 h (10 days) of age.
ency, and missing values and variables were checked.
The frequency and percentage summaries of categorical
variables were used. The mean and median were used to Table 1 Sociodemographic characteristic of VLBW preterm
neonates and their mothers admitted to UOGCSH, 2022
characterize continuous variables. After performing all
assumptions of linear regression, we undertook multiple Variable Category Frequency Percentage
linear regression to determine factors associated with
Gestational age Early preterm 58 52.73
length of hospital stay. The outcome variable was trans-
Moderate preterm 22 20
formed with a square root to make it non-skewed. A
Late preterm 30 27.27
P-value of < 0.05 and a 95% confidence interval were used
Birth weight < 1370gm 54 49.1
to identify the statistically significant variables.
≥ 1370gm 56 50.9
Corrected GA < 36 weeks 67 60.9
Result ≥ 36 weeks 43 39.1
The socio‑demographic characteristics Sex Male 66 60
There were a total of 175 very low-birth-weight pre- Female 44 40
term neonates admitted over the study period. From Maternal age < 20 6 5.45
which, 110 were discharged alive with a 63% survival 20–35 57 51.82
rate. The male-to-female ratio of the study participants > 35 47 42.73
was 1.5:1. The median family income was 8,250 Ethio- Address Urban 28 25.45
pian birr (ETB), with an interquartile range (IQR) of Rural 82 74.55
5,000–12,250 ETB. The minimum and maximum fam- Level of education No formal education 19 17.27
ily income were 1100 and 25,000 ETB, respectively, Primary school 56 50.91
with 50% less than the median. Mothers who came Secondary school 29 26.36
from rural areas were 82 (74.55%); of these, 20.73% College and above 6 5.45
Mehretie et al. BMC Pediatrics (2024) 24:80 Page 4 of 8

Table 2 Clinical characteristics of VLBW preterm neonates and Length of hospital stay
their mothers admitted to UOGCSH, 2022 The median length of hospital stay of VLBW preterm
Variables Category Frequency Percentage neonates was 24 days, with an IQR of 13.25–40 days and
a range of 2–78 days. 48.18% of the study participants
Parity Primiparous 32 29.09 had hospital stays longer than the median. The mean
Multiparous 69 62.73 corrected gestational age (post-menstrual age (PMA)) at
Grand multiparous 9 8.18 discharge was approximately 36.2 ± 0.18 weeks (95% CI,
Place of delivery Inborn 78 70.91 35.82–36.52) but varied from 33 to 41 weeks. Six (5.5%)
Referral 20 18.18 of the study subjects were discharged at 33 weeks postna-
Home 12 10.91 tal age, while the rest discharged after 34 weeks. Among
Mode of delivery SVD 49 44.55 participant neonates, 32.7% discharged at a PMA of
Assisted 11 10.00 35 weeks. Around 43 (39.1%) of VLBW preterm neonates
C/S 50 45.45 discharged at ≥ 37 weeks of post-menstrual age.
ANC follow up Yes 94 85.45 Among the study participants discharged before
No 16 14.55 24 days (median), 22.72% had no complication, while
HIV status Positive 5 4.55 29% had complications. All study subjects (48.18%) who
Negative 105 95.45 stayed more than 24 days (median) had either of the
Age at the start < 49 h 75 68.18 complications (Fig. 2).
of EBM ≥ 49 h 35 32.82
Feeding type Expressed breast milk 86 78.18 Factors associated with length of hospital stay
Mixed 24 21.82 From the summary of the multiple linear regression
Type of Management CPAP 68 61.82 model analysis, length of hospital stay was explained by
Intravenous antibiot- 37 33.64 the independent variables by about 94%. We checked
ics each independent variable against the dependent vari-
MF fluid only 5 4.55 able, and complications, gestational age, time to reach
Complications Hospital acquired 25 22.72 maximum feeding, age at feeding initiation, management
sepsis
type, birth weight and address were associated with the
Necrotizing entero- 25 22.72
colitis dependent variable. Multiple linear regression was done
Jaundice 35 31.82 to identify the associated factors of length of hospital
No complications 25 22.72 stay. Accordingly, gestational age, type of management
given, and presence of complications were significantly
associated with length of hospital stay for very low-birth-
weight preterm neonates (Table 3).

Fig. 1 Distribution of complications across gestational age categories

Mehretie et al. BMC Pediatrics (2024) 24:80 Page 5 of 8

Fig. 2 Gestational versus length of hospital stay

Table 3 Multiple linear regression analysis of factors associated with length of hospital stay for very low birth weight preterm
neonates admitted to UoGCSH, 2022
Variable Category COR AOR P-value

Address Urban - - -
rural 0.52(0.23–1.15) 1.17(0.97- 1.42) 0.098*
Gestational age (in weeks) 0.44(0.39–0.496) 0.554(0.52—0.595) 0.000***
Management type CPAP 57.2(16.08–203.23) 1.79(1.11- 2.87) 0.017**
Antibiotics 5.824(1.58–21.46) 1.61(1.07–2.42) 0.024**
Maintenance fluid - - -
Age at feeding initiation( in hours) 1.03(1.02–1.04) 1.002(0.999—1.01) 0.26
Time to reach maximum feeding (in hours) 1.28(1.24–1.33) 1.01(0.98—1.04) 0.463
complication Hospital acquired sepsis 46.94(24.17–91.14) 1.566(1.12- 2.19) 0.009***
Jaundice 5.27(2.85–9.45) 1.41(1.11- 1.80) 0.006***
Necrotizing enterocolitis 27.88(14.36–54.15) 1.647(1.18- 2.296) 0.004***
No complication - - -
*-90% CI
**-95% CI
***-99% CI

There was a 45% decrease in the length of hospital 95% CI: 1.07–2.42) as compared with those managed
stay for every one-week gestational age in VLBW pre- with maintenance fluid only. The length of hospital stay
term neonates (AOR = 0.55, 95% CI (0.52–0.595)). The was increased by the odds of 1.57 for hospital-acquired
length of hospital stay of VLBW preterm neonates sepsis (HAS) (AOR = 1.57, 95% CI: 1.22–2.19), 1.65 for
managed with continuous positive airway pressure necrotizing enterocolitis (NEC) (AOR = 1.65, 95% CI:
(CPAP) was increased by a factor of 1.8 (AOR = 1.79, 1.18–2.296), and 1.41 for jaundice (AOR = 1.41, 95% CI:
95% CI: 1.11–1.87) and antibiotics by 1.6 (AOR = 1.61, 1.11–1.80) as compared to VLBW preterm neonates
with no complications.
Mehretie et al. BMC Pediatrics (2024) 24:80 Page 6 of 8

Discussion counterparts in research done at Kenyatta National

The findings of this study showed that the median length Hospital [4]. According to South African research, for
of hospital stay was 24 days. The hospital length of stay each one-week increase in gestational age, the length of
(LOS) of VLBW preterm neonates was significantly hospital stay of VLBW preterm neonates decreased by
associated with the gestational age, type of management 0.4 days [3].
given, and the presence of complications. The other factor associated with the length of hos-
The overall median LOS of VLBW preterm neonates pital stay was the type of management given to the
was found to be 24 days, with an IQR of 13.25–40 days. VLBW preterm neonates. Neonates managed with con-
This study was supported by a study conducted at Johan- tinuous positive airway pressure (CPAP) and antibiot-
nesburg’s Chris Hani Baragwanath Academic Hospital, ics were highly likely to stay longer than neonates only
which found that the median hospital stays of VLBW given supportive care (maintenance fluid). Research
neonates were 39 days [3]. In addition, research done in done in Ankara, Turkey, showed very low-birth-weight
King Fahad Medical City tertiary hospitals showed that neonates who were on ventilation (both invasive and
the median length of stay was 14.5 days, which was in line non-invasive) increased their length of stay as com-
with our study [13]. The other research that supported pared to those who did not get ventilation (respiratory
this result was done at the Loma Linda University (LLU) treatment) [17]. The rate of discharge of preterm neo-
Children’s Hospital, where the average length of hospital nates decreased by 45.7% with the development of RDS
stay was 24.01 days [14]. in research done on predictors of the length of stay for
However, the LOS for VLBW preterm newborns who preterm infants in Ethiopia [16].
survived to discharge was found to be 62 days in the Antibiotic intake was also another associated factor
research conducted at the National Cheng Kung Uni- for the length of hospital stay for very low-birth-weight
versity Hospital in Taiwan. In addition, research done in preterm neonates as compared to those receiving sup-
European countries on the duration and time trends in portive care only. This might be due to antibiotics given
hospital stay for very preterm infants across European to VLBW preterm neonates that had nosocomial infec-
regions showed the mean length of hospital stay was tion and necrotizing enterocolitis (NEC), which were
between 54 and 70 days [15]. Both the Taiwanese and identified as associated factors of the length of hospital
the European countries studies did not support the find- stay in this study.
ings of this study. The difference in the hospital length of Complication was one of the important associated
stay in Taiwan and Europe with this study was due to the factor for VLBW preterm neonates as compared to neo-
study participants, in which very preterm and very-low- nates without complication. Hospital acquired sepsis
birth weight (weight < 1000 gm) preterm neonates were increased the length hospital of stay by Complication
included in the Taiwan and European studies. So the was one of the associated factors for VLBW preterm
length of hospital stays in Taiwanese and European coun- neonates as compared to neonates without compli-
tries was longer than the current study. cations. Hospital-acquired sepsis (HAS) increased
Research done on the morbidity and mortality patterns the length of hospital stay by odds of 1.6 compared
of preterm low birthweight neonates admitted to referral to those without complications. This result was sup-
hospitals in the Amhara region and in the other five Ethi- ported by research conducted in Johannesburg’s Chris
opian hospitals showed the mean length of hospital stay Hani Baragwanath Academic Hospital, which showed
was 9.82 and 7 days, which was lower than this study [8, health care-associated infections increased the length
16]. This was because the study participant included in of hospital stay by odds of 31.9. The other research that
the study were low birth weight preterm neonates (birth supported the current study was done in AL Zahra Hos-
weight < 2500gm) and the sample size was also larger as pital, Tabriz, Iran. It showed that bacterial colonization
compared to the current study. These differences were and nosocomial infections were factors associated with
due to the study participants included low-birth weight prolonging hospital stays for very low-birth-weight
preterm neonates (birth weight < 2500 g), and the sample preterm infants [18]. Necrotizing enterocolitis and
size was larger as compared to the current study. nosocomial infection contributed to prolonged hospi-
Factors associated with the length of hospital stay of tal stays for very low-birth-weight preterm neonates
very low-birth-weight preterm neonates were gesta- [19, 20]. The main reason that complications were an
tional age, management type, and complications. For associated factor in hospital stays for VLBW neonates
every one week, regardless of the gestational age of the was that most complications happened at some point of
VLBW preterm neonates, the length of hospital stay admission and after the initiation of the initial manage-
decreased by 45%. The odds of prolonged hospital stay ment, and the new management for the complications
for preterm neonates were 2.8 compared to their term would take an additional period of time.
Mehretie et al. BMC Pediatrics (2024) 24:80 Page 7 of 8

Limitation of the study Funding

The study was not benefited from any funding.
The study has limitations in analyzing clinical condi-
tions like hypothermia, glucose level, anemia, and risk Availability of data and materials
factors for preterm delivery like PROM, gestational DM No datasets were generated or analysed during the current study.
and gestational hypertension, and maternal anthro-
pometry which might have association with LOS. Declarations
Ethics approval and consent to participants
The University of Gondar’s Institutional Review Board granted approval for the
Conclusion study’s ethical conduct. The participants were informed of the study’s signifi-
The median hospital stay for VLBW was 24 days. The cance and goal. After receiving complete informed and verbal consent, data
length of hospital stay was inversely related to the ges- was gathered. Information confidentiality was preserved by not mentioning
in the questionnaire. All the methods of the research respect the Declaration
tational age of neonates. The gestational age, presence of Helsinki.
of complications, and type of management given were
associated with the length of hospital stay for VLBW Consent for publication
Not applicable.
preterm neonates.
Competing interests
The authors declare no competing interests.
Recommendation
The length of the hospital stay of the VLBW preterm Received: 16 November 2023 Accepted: 2 January 2024
neonates can be reduced by applying the standards of
care for very-low-birth-weight preterm neonates. Fur-
ther research can be done in this area to identify other
determinants of the length of stay.
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