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doi:10.1111/jpc.12209

ORIGINAL ARTICLE

Three years of neonatal morbidity and mortality at the national

hospital in Dili, East Timor
Ingrid Kirsten Bucens,1 Alison Reid,4 Aniceto Cardoso Barreto,1 Vikas Dwivedi2,5 and Megan Counahan3
1
Department of Paediatrics, National Hospital Guido Valadares, 2TAIS, and 3World Health Organization, Dili, East Timor, 4Western Australian Institute for Medical
Research, University of Western Australia, Perth, Western Australia, Australia and 5JSI Research & Training Inc., Washington, DC, Washington, United States

Aim: The aim of this study was to undertake a retrospective review of admissions and discharges to the neonatal unit at the National Hospital
Guido Valadares, Dili, in order to gain insight into the epidemiology of hospitalised neonates in East Timor, as the information cannot be obtained
from the hospital health management information system.
Method: Data were sourced from unit registers for 3 years, 2008–2010 inclusive. Demographic characteristics and diagnoses were related to
the risk of dying using stepwise multivariate logistic regression and adjusting for potential confounders of age, sex and weight.
Results: Two thousand eighty-eight babies were admitted to the unit over the study period. Over a quarter of babies weighed <2.5 kg on
admission. Almost half were admitted from emergency or outpatient departments and only 27% were admitted within their first week of life. The
most common reasons for admission were sepsis and respiratory disease (38 and 22%, respectively). Overall mortality was 11.4%, mainly
attributed to prematurity (28%), infection (26%) and asphyxia (24%). Home birth, male gender, very low weight, young age and a short duration
of hospitalisation were independently associated with an increased risk of death. Half of all babies weighing <1.5 kg died. Two-thirds of deaths
occurred within 2 days of admission.
Conclusions: The study provides, for the first time, an insight into the admissions and outcomes of the largest neonatal unit in East Timor. It
is a baseline from which improvements to the quality of clinical care and data collection can be made.

Key words: East Timor; hospital; infant mortality; newborn.

What is already known on this topic What this paper adds

1 There are no published reports of neonatal morbidity and mor-
tality data from hospitals in Timor-Leste.
2 An epidemiological profile for hospitalised neonates in Timor-
Leste cannot be gained from health management information
system reports available from the Ministry of Health.
1 This study has provided the first comprehensive description of
morbidity and mortality profiles for sick babies in Timor-Leste.
2 For each year of the study, the most common reasons for admis-
sion were infection and respiratory disease (mainly cases of
pneumonia and meconium aspiration).
3 Almost one-third of the deaths were caused by prematurity, and
infection and asphyxia were each responsible for another
quarter.

Introduction natal mortality, although improving,4 are priority public health

Improving neonatal survival is a global health priority. The
Fourth Millennium Development Goal, to reduce under-five
mortality by two-thirds by 2015, can only be reached if the near
static rate of decline in neonatal mortality is addressed.1,2 The
Democratic Republic of Timor-Leste (East Timor (ET)) is a newly
independent developing country and its health indicators are
among the lowest in Southeast Asia.3 Child, infant and neo-
Correspondence: Dr Ingrid Kirsten Bucens, National Hospital Guido Vala-
dares (NHGV), Bidau, Dili, East Timor (Timor Leste). Email: ingbucens@
gmail.com
Competing Interests: The authors declare that none of them have commer-
cial affiliations and declare no other conflict of interest.
Accepted for publication 23 December 2012.
concerns,5 yet there are no published studies of neonatal health
from ET.
Information on neonatal health in ET is limited to two
national demographic health surveys (DHSs),4,6 quarterly Min-
istry of Health (MOH) reports and, largely qualitative, reports
from non-government organisations unpublished in main-
stream literature7,8 (CL Livermore, unpubl. report, 2003). The
latter focus on breastfeeding and cultural practices surrounding
childbirth and the post-partum period. The DHS reports on
neonatal mortality rate (NNMR) and perinatal mortality rate,
statistics related to birth place and attendants, birth size and
post-partum care. In 2009–2010, other immediate newborn
care practices and maternal knowledge of danger signs were
included.4 Birthweight data were surveyed; however, only a
quarter of respondents were able to supply the information,
making it difficult to interpret.

452 Journal of Paediatrics and Child Health 49 (2013) 452–457

© 2013 The Authors
Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
IK Bucens et al.
In 2009–2010, an overall NNMR of 22/1000 live births
(LBs) was reported, an impressive decline from 33/1000 LBs
reported in 2003.4,6 There is, however, wide variation between
districts. In Baucau, an urban area, the NNMR was 11/1000
LB compared with 44/1000 LB in Manufahi, a rural area.4 The
reasons for the overall decline and the regional variation are
likely multifactorial. Probable contributors are improved care
seeking and access to quality healthcare. The corresponding
increase in skilled birth attendance and post-partum checks
over this time supports this (from 18.4 to 30.0% and 11.5 to
32.2%, respectively).4,6
ET has six hospitals, five in the districts and one, the National
Hospital Guido Valadares (NHGV), in Dili. The NHGV is the
main hospital for residents in five of the country’s 13 districts
(the district of the capital Dili and the four adjacent districts) as
well as for referrals from district hospitals. The catchment area
population is approximately 500 000 or 46% of the country’s
population. The NHGV has around 4500 births per year and 30
neonatal inpatient beds, making it the busiest maternity and
neonatal facility in the country. The neonatal unit equates to a
‘level II’ facility9; oxygen and continuous positive airway pres-
sure are available though the latter was only introduced towards
the end of the study period.
The hospital health management information system (HMIS),
based on the International Classification of Diseases, Version
10,10 is managed and reported separately from all other health
data. The system centres on unstandardised ward admission
registers from which data are transferred to a centralised com-
puter system. An epidemiological profile for neonates however
cannot be gained from the hospital HMIS reports. Neonatal
health data are limited to numbers of admissions, deaths and
discharges. Morbidity and mortality data are not summarised
and, at national level, neonatal and infant diagnoses and statis-
tics are combined.
We undertook to improve the understanding of the epidemi-
ology of hospitalised neonates in ET by performing a retrospec-
tive review of 3 years of data at the NHGV.
Materials and Methods
Data source
Data were sourced from the neonatal unit patient registers for 3
consecutive years, 2008–2010. All non-identifying variables
were entered into STATA version X11 for analysis.
Variables of interest
Register entries were initially standardised for language and
diagnostic terminology. Then, based on a thematic analysis of
the commonly indicated diagnoses, one of only seven discharge
diagnoses were allocated by IKB to each child. These were
asphyxia, infection, jaundice, prematurity, congenital, respira-
tory disease and ‘other’. Admission diagnoses were used when
no discharge diagnosis was provided. A maximum of two diag-
noses were allocated per baby. The order diagnoses appeared in
the register were assumed to reflect priority unless a subsequent
diagnosis was described as ‘severe’. Prematurity was only allo-
cated when the baby’s weight was <1.5 kg and/or a clear com-
Journal of Paediatrics and Child Health 49 (2013) 452–457
© 2013 The Authors
Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Neonates Hospital East Timor
plication of prematurity was recorded (e.g. intraventricular
haemorrhage and necrotising enterocolitis).
Place of residence was categorised as Dili or ‘other’. Place of
birth was categorised as home, NHGV or other health facility.
Patient source was defined as external (emergency department/
outpatients) or internal (maternity ward/operating theatre/
postnatal ward). Admission weight was categorised as very low
(<1.5 kg), low (1.5–2.49 kg), normal (2.5–3.99 kg) and large
(ⱖ4 kg).
Age at admission, age at death and length of stay (LOS) were
calculated from the raw date data.
Statistical analysis
Non-normally distributed variables (age on admission and LOS)
were logged. Frequency of neonatal characteristics and demo-
graphic variables were compared between babies who were
discharged (‘survivors’) and those babies that died during their
stay using c2-tests. Babies who left against medical advice
(absconded) or who were transferred internationally were
excluded from the analysis as their baseline characteristics and
diagnostic profile differed significantly from survivors and their
outcome could not be determined. Neonatal characteristics were
related to the risk of dying using logistic regression and adjust-
ing for potential confounders of age, sex and weight. The level
of statistical significance was set at P < 0.05 and all statistical
analysis was undertaken on Stata X.
Ethical approval
Approval for the study was granted by MOH’s ethics and
research committee.
Results
Demographic profile
Two thousand two hundred eighty-eight babies were admitted
to the neonatal unit over the study period, accounting for 28%
(2288/8197) of all admissions to the paediatric department.
Neonatal admission numbers increased incrementally each year
(739, 755 and 794).
More than half of the babies were male (Table 1). Three
quarters were born to women who reside in Dili district and
72% of the others were from adjacent districts. Only 9% of
babies were born at home. Of the 47% of babies who were
admitted from home (Table 1), 50% were readmissions of
babies delivered at the NHGV. The median admission weight
was 2.8 kg (range 450 g–6.3 kg). More than a quarter of all
registered admission weights were below 2.5 kg, 6% were
below 1.5 kg and 7% were above 4 kg (Table 1).
Morbidity and mortality profile
Based on the primary diagnosis, the most common reason for
admission was infection, followed by respiratory disease,
asphyxia and prematurity (38, 22, 12 and 11%, respectively)
(Table 2). Of the infection cases, 38% were skin or soft tissue
infection (mastitis, omphalitis and abscess). Only one diagnosis
of meningitis, three of malaria and nine of tetanus were
recorded. Forty-nine were babies with a diagnosis of ‘risk of
453
Neonates Hospital East Timor IK Bucens et al.

most of whom were discharged (81%). The remainder died

Table 1 Baseline characteristics of the 2288 babies studied (11.4%, 260/2288), absconded (6.5%, 149/2288) or were
Variable Categories n % transferred internationally (0.6%, 13/2288). When analysed by
year, the proportions were stable with the exception of those
Gender Male 1278 55.8 who absconded, which increased significantly in 2010 (4.9, 5.8
Female 1005 43.9 and 8.9%, respectively; P 0.005).
Unknown 5 0.2 Most deaths were caused by prematurity (28.5%), infection
Parity Singletons 2226 97.3 (25.8%) and asphyxia (24.2%) (Table 2) and the majority
Twins 62 2.7
occurred within the first 2 days of admission (67%). Thirty-
Age on admission 0 1051 45.9
two per cent of deaths occurred in babies weighing <2.5 kg.
(days) 1–6 620 27.1
The condition with the highest case fatality rate was prema-
7–13 273 11.9
turity, followed by congenital problems and then asphyxia
ⱖ14 335 14.6
(Table 2).
Unknown 9 0.4
Weight on admission <1.5 126 5.5
In addition to diagnosis, having a very low admission weight,
(kg) 1.5–2.49 475 20.8 residing outside of Dili district, being male, younger at admis-
2.5–3.49 1343 58.7 sion, born at home and admitted from within the NHGV were
ⱖ4 161 7 associated with the risk of dying when included separately in
Unknown 183 8 the model (Table 3). However, when all variables were included
Residence Dili 1714 74.9 in a multivariable model in a stepwise manner, only being male,
Other district 568 24.8 of very young age, of very low weight, born at home and a short
Unknown 6 0.3 hospitalisation remained independently associated with an
Place of birth Home 272 11.9 increased risk of death (Table 3). Congenital malformations
Birth HNGV 1604 70.1 were associated with the highest risk of death, followed by
Other health facility 190 8.3 asphyxia and then prematurity and sepsis, equally, in the mul-
Unknown 222 9.7 tivariate model (Table 3).
Admitted from Emergency or outpatient 1066 46.6
department (‘external’)
Maternity department or 1211 52.9
Discussion
operating theatre (‘internal’) Our study describes the characteristics, morbidities and out-
Unknown 10 0.1
comes of over 2000 consecutive admissions to the neonatal unit
Length of stay 0–2 389 17.0
of the national hospital in ET. Reporting of this sort is accepted
(days) 3–7 1407 61.5
as a minimum standard in neonatal units around the world,
8–14 316 13.8
although it is less common in low-resource countries and this is
>14 175 7.7
the first of its kind from ET.
Unknown 1 0.0
Infection was the most common reason for admission fol-
NHGV, National Hospital Guido Valadares. lowed by respiratory disease, of which one-third of cases were
pneumonia, which, arguably, could be classified as infection.
The rate of infection in our study (38/100 admissions) is
towards the upper end of the range reported from hospital
studies in other middle- and low-income countries; however,
sepsis’. The cases of respiratory disease were mainly pneumonia our inclusion criteria were necessarily broader than many of
(39.4%) and meconium aspiration (36.0%). Hyaline membrane those.12 Our infection category included everything from septic
disease (HMD) was rarely recorded, but the generic term ‘res- shock and meningitis to skin infection, non-bacterial infections
piratory distress’ was allocated to 37 babies, possibly including and a small number of babies ‘at risk of sepsis’.
some cases of HMD. When primary diagnoses were analysed by Many studies on neonatal infection rates specify infections by
year, the ranking was remarkably similar. Infection and respi- site and/or by micro-organism. Such studies have documented
ratory disease were the top two conditions each year. There the different profiles of bacterial infections, particularly the pre-
were 109 babies with a primary diagnosis of congenital malfor- dominance of Klebsiella and Staphylococcal sepsis, found in low-
mations, ranging from cleft lip/palate to multiple major malfor- resource countries compared with developed countries.12,13 In
mations (data not shown). The single-most commonly reported our study, we were unable to reliably differentiate the majority
malformation was imperforate anus ⫾ fistulae, accounting for of infections by site; half of the cases were simply recorded as
25% of cases. ‘sepsis’ in the registers. Neither could we report bacterial aeti-
Only 362 babies (15%) had a second diagnosis, mostly infec- ology as microbiological culture was unavailable. However, skin
tion (28%), respiratory disease (26%) or jaundice (24%). The or soft tissue was the single-most commonly specified site in our
cases of infection were mainly skin and soft tissue or cases of study, probably mainly Staphylococcal disease.14
‘risk of sepsis’. Two-thirds of the respiratory cases were meco- Skin infections are common in the general population in
nium aspiration and one-third was pneumonia. ET,15 promoted by the ubiquitous poverty-related factors
The median LOS was 5 days and varied by condition (including a low level of hygiene and difficulties accessing
(Table 2). Outcome data were available for all but 12 babies, water), the tropical climate and overcrowded living

454 Journal of Paediatrics and Child Health 49 (2013) 452–457

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Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
IK Bucens et al. Neonates Hospital East Timor

Table 2 Morbidity and mortality of the study population

Primary diagnosis Cases Age on Length of stay Deaths Case fatality

admission† rate (CFR)

n % Geometric Geometric Median IQR n % %

mean‡§ mean‡ (days) (25%, 75%)
(days) (days) (days)

Infection 868 38 4.42 2.1 5 (3, 7) 67 25.8 7.7

Respiratory disease 499 22 1.56* 2.2 5 (3, 7) 23 8.9 4.6
Prematurity 242 11 0.14* 3.8 10 (3, 28) 74 28.5 30.6
Asphyxia 282 12 0.06* 1.8 4 (3, 6) 63 24.2 22.3
Jaundice 152 6.6 3.35* 1.9 4 (3, 6) 3 1.2 2
Congenital 109 4.8 1.48* 2.5 6 (3, 10) 28 10.8 25.7
Other 136 5.9 1.14* 1.8 3 (2, 6) 2 0.8 1.5
Total 2288 100 1.86 2.2 5 5 260 100 11.4

*P < 0.05. †Significance values refer to the comparison of proportions of the cases with infection vs. the other diagnostic categories. ‡Geometric means have
been presented in place of means for age of admission due to the skewed nature of the raw data. §Median data for age of admission were also meaningless
due to the skewed data and are not presented. CFR = number of deaths per 100 admissions with the specified diagnosis; IQR = inter-quartile range.

Table 3 Risk of mortality among neonatal inpatients (excluding babies who absconded or transferred from the neonatal unit)

Variable Subcategories Dead n Discharged n Unadjusted OR (95% CI) P Adjusted OR (95% CI) P

Overall 260 1854

Year admit 2008 73 609 1
2009 97 612 1.32 (0.96–1.83) 0.09 NA NA
2010 90 633 1.19 (0.85–1.65) 0.31
Gender Male 164 1017 1 0.60 (0.40–0.90)
Female 96 832 0.72 (0.55–0.94) 0.01 0.01
Age on admission (days) 0 171 792 1
1–6 59 503 0.54 (0.40–0.74) 0.00 0.51 (0.25–1.03) 0.06
7–13 11 251 0.20 (0.11–0.38) 0.00 0.40 (0.14–1.16) 0.09
ⱖ14 18 300 0.28 (0.17–0.46) 0.00 0.50 (0.20–1.28) 0.15
Admission weight (kg) Normal (2.5–3.49) 97 1159 1
Very low (<1.5) 61 52 14.02 (9.17–21.42) 0.00 41.44 (15.31–112.17) 0.00
Low (1.5–2.49) 77 356 2.58 (1.87–3.56) 0.00 3.65 (2.24–5.96) 0.00
High (>4) 5 143 0.42 (0.17–1.04) 0.00 0.22 (0.06–0.82) 0.02
Residence Dili 177 1422 1
Other 83 427 1.56 (1.18–2.07) 0.00 1.27 (0.79–2.02) 0.32
Place of birth Health facility 190 1466 1
Home 41 210 1.51 (1.04–2.17) 0.03 2.06 (1.11–3.81) 0.02
Admitted from Emergency/outpatients 103 910 1
Maternity/inpatient 157 934 1.48 (1.14–1.94) 0.00 1.52 (0.80–2.87) 0.20
Length of stay (days) 0–2 174 182 1
3–7 58 1258 0.05 (0.03–0.07) 0.00 0.04 (0.03–0.06) 0.00
8–14 16 271 0.06 (0.04–0.11) 0.00 0.02 (0.01–0.05) 0.00
>14 12 142 0.09 (0.05–0.16) 0.00 0.01 (0.00–0.02) 0.00
Primary diagnosis Infection 67 745 1
Asphyxia 63 189 3.71 (2.54–5.42) 0.00 2.44 (1.22–4.86) 0.01
Congenital problems 28 68 4.58 (2.76–7.60) 0.00 5.57 (2.55–12.19) 0.00
Jaundice 3 136 0.24 (0.08–0.79) 0.02 0.17 (0.04–0.77) 0.02
Respiratory disease 23 453 0.56 (0.35–0.92) 0.02 0.37 (0.18–0.80) 0.01
Prematurity 74 146 5.64 (3.87–8.20) 0.00 0.95 (0.39–2.29) 0.91
Other 2 117 0.19 (0.04–0.79) 0.02 0.07 (0.02–0.34) 0.00

CI, confidence interval; NA, not applicable; OR, odds ratio.

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Neonates Hospital East Timor
conditions.16,17 In the neonatal period, unclean birthing prac-
tices, including cord care, are additional risk factors for skin or
soft tissue infection as well as more severe forms of sepsis.18 In
home births in ET, the umbilical cord is often cut with
unsterile implements such as razors or bamboo.7 In addition,
there are entrenched post-partum practices aimed at providing
extra heat and preventing the mother and baby from being
exposed to cold or wind,7 which, intuitively, seem capable of
promoting infections. Specific examples include overwrapping
the baby and secluding the mother/baby in an unventilated
room heated with fire.
In our study, babies with infection were older on admission
than other babies and only one-third were admitted within
the first 3 days of life, implying a high proportion of ‘late
onset’ sepsis (Table 2). The term ‘late onset’ is usually applied
if neonatal sepsis presents beyond day 3 of life and, tradition-
ally, is considered to be community acquired.19 However, the
poor application of infection prevention standards in many
health facilities in low-resource contexts12,20 leads experts to
suggest that infections in any baby delivered in a hospital
setting in a resource poor setting should be considered to be
hospital acquired, whether early or late in onset.13 Our
assumption that many of our babies with infections had Sta-
phylococcal disease is further supported by the fact that Staphy-
lococcal infections typically present only 1–3 weeks after
discharge from hospital.21
In our study, infection, prematurity and asphyxia each
accounted for between one-quarter and one-third of deaths,
which is consistent with both health facility and community-
based studies from low-resource countries.2,22–25 The conditions
with the highest adjusted risk of dying however were congenital
abnormalities, then asphyxia, followed by prematurity and
infection with almost equal risk. This ranking is not surprising
given the limited curative and supportive care for severely
unwell babies or those with major malformations. In addition,
key preventative obstetric interventions frequently do not occur
(such as timely administration of antenatal steroids and
antibiotics).
Although the number of variables in the original data set was
limited, we were nonetheless able to identify several additional
risk factors for mortality. Admission weight was very significant.
Although overall mortality was 11.4%, half of all babies weigh-
ing less than 1.5 kg and 16% of babies weighing 1.5–2.49 kg
died. Extremely low weight babies (<1 kg), most of whom are
very premature, are expected to do poorly in low-resource
settings. Slightly bigger babies, in particular those 1.5–2.5 kg,
who are a mixed group of moderately preterm and growth
restricted babies, should not have significantly elevated mortal-
ity as the majority do not need sophisticated neonatal equip-
ment to survive.26 Improving care and survival of this subgroup
is a particular focus of the current movement to improve out-
comes of small babies.26
Additional mortality risks in our study included home births
(twice as likely to die as facility births) and being admitted from
outside, as compared with from within, the hospital. Both of
these points emphasise the well-established benefit of a skilled
birth attendant on neonatal outcome.27 The increased likelihood
of dying in babies who stayed in hospital for a shorter time
suggests that most deaths occurred because babies were very
456
Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
IK Bucens et al.
sick on admission and/or the resources needed for their care
were unavailable, inadequate or underutilised.
The major limitation of our study was its retrospective
design. The validity of our findings hinges on the quality of
the original data set and the sensitivity of our re-categorisation
of original diagnoses. Some of the problems have already been
outlined (e.g. no standardisation of diagnostic terminology and
diagnoses that were mostly based entirely on clinical assess-
ment) and discharge diagnoses were missing in one-third of
cases. The assessment of the burden of prematurity is likely to
have been underestimated as there was no systematic assess-
ment of gestation. We accept that misclassification may have
occurred during our reallocation of diagnoses, but, on balance,
this is unlikely because cross-checks such as the LOS analysis
and case fatality rate were as expected for the different
conditions.
Caution is needed before suggesting the results of this study
can be generalised to the rest of the country as the baseline
characteristics of our study population make them different
from others in ET. Previous work has shown that the population
of Dili differs in key indicators known to influence health out-
comes including income, level of education, access to health
services and health behaviours (assisted births and facility
births).4,6,17 However, a review of inpatient data for the same
period from Baucau hospital, the second largest hospital in ET,
found, although patient numbers were much smaller (561
babies in 3 years), that the inpatient mortality was identical,
11.4% (IKB, unpubl. work).
Conclusions and recommendations
This study has provided a comprehensive description of mor-
bidity and mortality profiles for sick babies in ET, an important
first step in a quality improvement process for hospital care for
babies in ET. The results clearly highlight priority areas for
service improvement and operational research, as well as
improved data collection.
Authors’ Contributions
IKB and ACB conceived the study and participated in its design
and logistics of implementation. IKB was responsible for data
collection and analysis and manuscript preparation. VD and AR
performed the statistical analysis and AR also assisted with
manuscript review. MC participated in manuscript preparation
and review. All authors read and approved the final manuscript.
Acknowledgements
The authors wish to thank Mrs Maria Ornai for her assistance
with review of the HMIS at the NHGV; Mrs Maria Olga do
Carmo, Mrs Cristina Santos da Silva, Mrs Armenia da Concei-
cao, Mrs Olimpia de Jesus, Ms Esther McCall, Dr Niola Leonard
Perez and Dr Daisy Joy Espejo-Torina for their assistance with
data entry and translation.
The work was supported by a small grant from the ET Cabinet
of Research and an additional grant from the Centre for Inter-
national Child Health, Melbourne, Australia.
Journal of Paediatrics and Child Health 49 (2013) 452–457
© 2013 The Authors
IK Bucens et al.
References
1 Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? where?
why? Lancet 2005; 365: 891–900.
2 Lawn JE, Kerber K, Enweronu-Laryea C, Massee Bateman O. Newborn
survival in low resource settings – are we delivering? BJOG 2009; 116
(Suppl. 1): 49–59.
3 UNICEF. The State of the World’s Children 2012. UNICEF, March 2012.
Available from: http://www.unicef.org/Sowc12/index_61804.html
[accessed September 2012].
4 Ministry of Health (MOH) [Timor-Leste], National Statistics Directorate
(NSD) [Timor-Leste], Ministry of Finance [Timor-Leste], and ICF Macro.
Timor-Leste Demographic and Health Survey 2009–10. Dili,
Timor-Leste: NSD [Timor-Leste] and ICF Macro. 2010. Available from:
http://www.measuredhs.com/pubs/pdf/fr235/fr235.pdf [accessed May
2012].
5 Ministry of Health (MOH) [Timor-Leste]. Timor-Leste Strategic
Development Plan 2011–2030. 2011. Available from:
http://timor-leste.gov.tl/wp-content/uploads/2011/07/Timor-Leste-
Strategic-Plan-2011-20301.pdf [accessed March 2013].
6 Ministry of Health (MOH) [Timor-Leste], National Statistics Directorate
http://timor-leste.gov.tl/wp-content/uploads/2011/07/Timor-Leste-
Strategic-Plan-2011-20301.pdf (NSD) [Timor-Leste], University of
Newcastle (UN), Australian National University (ANU), and ACIL
Australia. Timor-Leste 2003 Demographic and Health Survey.
Newcastle, Australia: University of Newcastle, 2004.
7 Health Alliance International (HAI). Cultural Practices and Beliefs
Relating to Pregnancy, Birth and the Post-Partum Period. Dili,
Timor-Leste: HAI, 2005.
8 Oxfam Australia. 2004. Results of Oecusse Baseline Nutrition
Assessment, April 2004.
9 American Academy of Pediatrics. Committee on Fetus and Newborn.
Levels of neonatal care. Pediatrics 2004; 114: 1341–7.
10 World Health Organisation. International Statistical Classification of
Diseases and Related Health Problems 10th Revision. 2010. Available
from: http://apps.who.int/classifications/icd10/browse/2010/en
[accessed September 2012].
11 Statacorp. Stata Statistical Software: release 10. 2007. College
Station, Texas.
12 Zaidi AKM, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, Goldmann DA.
Hospital-acquired neonatal infections in developing countries. Lancet
2005; 365: 1175–88.
13 Zaidi AK, Thaver D, Ali SA, Khan TA. Pathogens associated with sepsis
in newborns and young infants in developing countries. Pediatr.
Infect. Dis. J. 2009; 28 (1 Suppl.): S10–18.
14 Van Praag MC, Van Rooij RW, Folkers E, Spritzer R, Menke HE, Oranje
AP. Diagnosis and treatment of pustular disorders in the neonate.
Pediatr. Dermatol. 1997; 14: 131–43. Review.
Journal of Paediatrics and Child Health 49 (2013) 452–457
© 2013 The Authors
Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Neonates Hospital East Timor
15 dos Santos MM, Amaral S, Harmen SP, Joseph HM, Fernandes JL,
Counahan ML. The prevalence of common skin infections in four
districts in Timor-Leste: a cross sectional survey. BMC Infect. Dis.
2010; 10: 61.
16 World Health Organization. Epidemiology and Management of
Common Skin Diseases in Developing Countries. Geneva: World
Health Organization, 2005.
17 National Directorate of Statistics, Ministry of Finances Timor-Leste.
National Directorate of Statistics Ministry of Finances Timor-Leste
Survey of Living Standards. 2007. Available from: http://dne.mof.
gov.tl/TLSLS/Publication/finalstatisticalabstract.pdf [accessed
September 2012].
18 Blencowe H, Cousens S, Mullany LC et al. Clean birth and postnatal
care practices to reduce neonatal deaths from sepsis and tetanus: a
systematic review and Delphi estimation of mortality effect. BMC
Public Health 2011; 11 (Suppl. 3): S11. Available from: http://www.
biomedcentral.com/1471-2458/11/S3/S11 [accessed July 2012].
19 Harris J, Goldmann D. Infections acquired in the nursery;
epidemiology and control. In: Remington JS, Klein JO, eds. Infectious
Diseases of the Fetus, Newborn and Infants, 5th edn. Philadelphia:
WB Sanders, 2001; 1371–418.
20 Srivastava S, Shetty N. Healthcare-associated infections in neonatal
units: lessons from contrasting worlds. J. Hosp. Infect. 2007; 65:
292–306.
21 Shinefield HR, St Geme JW. Staphylococcal infections. In: Remington
JS, Klein JO, eds. Infectious Diseases of the Fetus, Newborn and
Infants, 5th edn. Philadelphia: WB Saunders, 2001; 1091–156.
22 Lawn JE, Wilczynska-Ketende K, Cousens SN. Estimating the causes of
4 million neonatal deaths in the year 2000. Int. J. Epidemiol. 2006; 35:
706–18.
23 Jimmy S, Kemiki AD, Vince JD. Neonatal outcome at Modilon Hospital,
Madang: a 5-year review. P. N. G. Med. J. 2003; 46: 8–15.
24 Okechukwu AA, Achonwa A. Morbidity and mortality patterns of
admissions into the Special Care Baby Unit of University of Abuja
Teaching Hospital, Gwagwalada, Nigeria. Niger. J. Med. 2009; 12:
389–94.
25 Islam MN, Siddika M, Hossain MA, Bhuiyan MK, Ali MA. Morbidity
pattern and mortality of neonates admitted in a tertiary level
teaching hospital in Bangladesh. Mymensingh Med. J. 2010; 19:
159–62.
26 March of Dimes, PMNCH, Save the Children, WHO. Born Too Soon:
The Global Action Report on Preterm Birth. Howson CP, Kinney MV,
Lawn JE, eds. World Health Organisation, Geneva, 2012. Available
from: http://whqlibdoc.who.int/publications/2012/9789241503433_
eng.pdf [accessed July 2012].
27 World Health Organisation. The World Health Report 2005. Make
Every Mother and Child Count. 2005. Available from: http://www.
who.int/whr/2005/whr2005_en.pdf [accessed April 2012].
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