Sultan Qaboos University Med J, August 2015, Vol. 15, Iss. 3, pp. e351–356, Epub. 24 Aug 15. doi: 10.18295/squmj.2015.15.03.008.
Submitted 29 Jun 14
Revisions Req. 13 Oct 14 & 17 Mar 15; Revisions Recd. 19 Feb & 1 Apr 15
Accepted 9 Apr 15

Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
*Corresponding Author e-mail: asad99khan@yahoo.com

تغري معدل البقاء للرضع املواليد قبل األسبوع 26 من احلمل
دراسة مركز واحد

اأ�سد رحمن، حممد عبدالطيف، �رسيف وعد اهلل �رسيف، حممد ف�سل اهلل، خلفان ال�سنيدي، اأ�سفاق اأحمد خان، �سعود اأحمد، ماثيو كريبايل،
مازن اأبو عنزة، ما فلورديلزا بتكالن

abstract: Objectives: This study aimed to evaluate the changing survival rate and morbidities among infants
born before 26 gestational weeks at the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman. Methods:
This retrospective study assessed the mortality and morbidities of all premature infants born alive at 23–26
gestational weeks at SQUH between June 2006 and May 2013. Infants referred to SQUH within 72 hours of birth
during this period were also included. Electronic records were reviewed for gestational age, gender, birth weight,
maternal age, mode and place of delivery, antenatal steroid administration, morbidity and outcome. The survival
rate was calculated and findings were then compared with those of a previous study conducted in the same hospital
from 1991 to 1998. Rates of major morbidities were also calculated. Results: A total of 81 infants between 23–26
gestational weeks were admitted to the neonatal unit during the study period. Of these, 58.0% were male and 42.0%
were female. Median gestational age was 25 weeks and mean birth weight was 770 ± 150 g. Of the 81 infants, 49
survived. The overall survival rate was 60.5% compared to 41% reported in the previous study. Respiratory distress
syndrome (100.0%), retinopathy of prematurity (51.9%), bronchopulmonary dysplasia (34.6%), intraventricular
haemorrhage (30.9%) and patent ductus arteriosus (28.4%) were the most common morbidities. Conclusion:
The overall survival rate of infants between 23–26 gestational weeks during the study period had significantly
improved in comparison to that found at the same hospital from 1991 to 1998. There is a need for the long-term
neurodevelopmental follow-up of premature infants.

Keywords: Extremely Premature Infants; Neonates; Survival Rate; Morbidity; Oman.

جامعة م�ست�سفى يف احلمل من الأ�سبوع 26 قبل املواليد الر�سع يف املرا�سة و البقاء معدل يف التغري تقييم اإىل الدرا�سة هذة تهدف الهدف: امللخ�ص:
ال�سلطان قابو�س مب�سقط، �سلطنة عمان. الطريقة: قيمت هذة الدرا�سة اال�ستعادية معدل الوفيات و املرا�سة جلميع املواليد اخلدج الأحياء يف الأ�سابيع 23-26
للحمل من يونيو 2006 اإىل مايو 2013. املواليد املحولون مل�ست�سفى جامعة ال�سلطان قابو�س خالل 72 �ساعة من الولدة يف نف�س الفرتة مت اأي�سا اإدراجهم
يف الدرا�سة. امللفات الإلكرتونية متت مراجعتها و�سملت عمر احلمل، اجلن�س، الوزن عند الولدة، عمر الأمومة، طريقة ومكان الولدة، اإعطاء ال�ستريويد اأثناء
معدلت ح�ساب اأي�سا مت .1998 اإىل 1991 من بامل�ست�سفى �سابقة درا�سة نتائج مع النتائج ومقارنة البقاء معدل ح�ساب مت والنتائج. املرا�سة احلمل،
الوفيات الرئي�سية. النتائج: جمموع 81 ر�سيعا من 26-23 اأ�سبوع حمل مت إدخالهم اإىل وحدة املواليد خالل فرتة الدرا�سة. منهم %58.0 ذكورا و 42.0%
اإناثا. متو�سط عمر احلمل كان 25 أ�سبوعا و متو�سط الوزن عند الولدة كان150 ± 770 جم. من اأ�سل 81 ر�سيعا، 49 بقوا على قيد احلياة. معدل البقاء
الكلي كان %60.5 مقارنة بـ %41 يف درا�سة �سابقة. كان اأكرث الأمرا�س �سيوعا متالزمة ال�سائقة التنف�سية )%100(، اعتالل ال�سبكية للخدج )51.9%(،
خلل التن�سج الق�سبي الرئوي )%34.6(، نزف داخل البطني )%30.9(، القناة ال�رسيانية ال�سالكة )%28.4(. اخلال�صة: اإجمايل معدل البقاء ملواليد 23-26
اأ�سبوع حمل خالل فرتة الدرا�سة حت�سنت ب�سكل ملحوظ مقارنة مع النتائج املتوفرة من نف�س امل�ست�سفى من 1991 اإىل 1998. هناك حاجة ملتابعة طويلة

املدى للنمو الع�سبي يف املواليد اخلدج.
مفتاح الكلمات: الر�سع �سديدى اخلدج؛ املواليد؛ معدل البقاء؛ املرا�سة؛ عمان.

Changing Survival Rate of Infants Born
Before 26 Gestational Weeks

Single-centre study
*Asad Rahman, Mohamed Abdellatif, Sharef W. Sharef, Muhammad Fazalullah, Khalfan Al-Senaidi, Ashfaq A. Khan,

Masood Ahmad, Mathew Kripail, Mazen Abuanza, Flordeliza Bataclan

Advances in Knowledge
- The survival rate of extremely premature infants in a tertiary care centre in Oman was calculated over a seven-year period.
- Improvement in the overall survival rate of premature infants, potentially due to advances in neonatal care, was noted in comparison

to a similar study at the same hospital conducted a decade previously.
- Common short-term complications arising among infants admitted to a neonatal intensive care unit are illustrated.

Application to Patient Care
- Knowledge of survival rates can advise patient care decision-making and determine whether active resuscitation and management of

infants with extremely low birth weight is justified.
- The results of this study may aid in the establishment of guidelines for the care of infants born at the limits of viability.

clinical & basic research

Changing Survival Rate of Infants Born Before 26 Gestational Weeks
Single-centre study

e352 | SQU Medical Journal, August 2015, Volume 15, Issue 3

The survival of extremely premature infants has improved significantly over the last several decades.1–5 The reasons for
this improvement are multifactorial—technological
advances, use of antenatal steroids, surfactant therapy,
improvement in neonatal resuscitation and standard
antenatal and postnatal care are major contributing
factors. The survival rate of extremely premature
infants is much higher in developed countries than
in developing countries.6–8 However, there is limited
information about the survival and long-term outcome
of extremely preterm infants in Oman.9–11

Survival and short- and long-term morbidity
rates are needed to determine if active perinatal
management is rational for preterm infants born at
or before 26 gestational weeks.3 The limits of viability
and the gestational age at which a neonate can be
resuscitated and supported are still a challenge in
the Eastern Mediterranean region. Given the limited
resources and infrastructure for supporting disabled
children, it is very important to know the outcomes
of extremely preterm infants in Oman. Sultan Qaboos
University Hospital (SQUH) in Muscat, Oman, is
a tertiary care centre with an obstetrics unit which
accepts high-risk delivery cases from other health
institutes in the country. The newborn service operates
as a referral neonatal intensive care unit (NICU). A
previous study from SQUH indicated much lower
survival rates of extremely preterm infants born
between 1991 to 1998 compared with other reports
from developed countries.9

The aim of this study was to determine and evaluate
the survival rate and morbidities of preterm infants at
23–26 gestational weeks at SQUH. These were then
compared with the results of the study conducted in
the same unit approximately a decade previously to
ascertain the change in survival rate.9 Additionally,
survival rates and common morbidities among the
infants from the current study were compared with
international data.12,13

Methods

All premature infants born between 23–26 gestational
weeks and admitted to the NICU at SQUH between
June 2006 and May 2013 were included in the study.
Infants referred to SQUH 72 hours or later after birth
were excluded. Data were collected retrospectively
from hospital electronic records, including mater-
nal data, mode and place of delivery, antenatal
complications, course of treatment during NICU stay
and patient outcome (discharge or death). Standard
definitions from the literature were used to define

chorioamnoitis, morbidities and complications.14–17
Gestational age was determined from early ultrasound
scans or calculated from the date of the last maternal
menstrual period.

Data were analysed using the Statistical Package
for the Social Sciences (SPSS), Version 20 (IBM Corp.,
Chicago, Illinois, USA). Descriptive statistics and
the incidence of neonatal mortality during the study
period and among each gestational age group were
calculated. For categorical variables, frequencies and
percentages were reported. For numerical variables,
the mean ± standard deviation or median and ranges
were reported according to a normal distribution. A
comparison of categorical data was performed using
Chi-squared or Fisher’s exact tests as appropriate.
Numerical variables were compared using the Student’s
t-test for continuous data and the Mann-Whitney U test
for non-continuous data. An a priori two-tailed value
(P value) of ≤0.05 was considered significant.

Ethical approval for this study was obtained
from the Medical Research & Ethics Committee of
the College of Medicine & Health Sciences at Sultan
Qaboos University (MREC#898).

Table 1: Maternal demographic characteristics,
complications and mode of delivery of infants born
before 26 gestational weeks (N = 81)

Characteristic n (%)

Demographic variables

Age in years, mean ± SD 27 ± 5

Gravidity, median (IQR) 2 (1–3)

Parity, median (IQR) 0 (0–2)

Admission 36 (44.4)

Steroid administration 43 (53.1)

Complication

Hypertension 1 (1.2)

Diabetes mellitus 5 (6.2)

Cervical cerclage 7 (8.6)

Antepartum haemorrhage 18 (22.2)

Abruptio placenta 10 (12.3)

Ruptured membrane >18 hours 21 (25.9)

Chorioamnionitis 8 (9.9)

Mode of delivery

Vaginal 55 (67.9)

Caesarean section 26 (32.1)

SD = standard deviation; IQR = interquartile range.

Asad Rahman, Mohamed Abdellatif, Sharef W. Sharef, Muhammad Fazalullah, Khalfan Al-Senaidi, Ashfaq A. Khan,
Masood Ahmad, Mathew Kripail, Mazen Abuanza and Flordeliza Bataclan

Clinical and Basic Research | e353

Results

Between June 2006 and May 2013, a total of 81 extremely
preterm infants were admitted to the NICU at SQUH.
Only 44% of mothers were admitted to SQUH and
received antenatal follow-up. A total of 14 mothers
(17.3%) received one dose of antenatal steroids, 29
(35.8%) received two doses of antenatal steroids, 21
(25.9%) had prolonged rupture of the membranes (>18
hours) and eight (9.9%) had chorioamnionitis [Table 1].
Table 2 shows the demographic characteristics of

preterm infants admitted to the NICU during the study
period. Out of the 81 neonates, 47 were male (58.0%)
and 34 were female (42.0%). The median gestational age
was 25 weeks and the mean birth weight was 770 g.

The infants were assessed for common morbidities
[Table 3]. All of the infants were diagnosed with
respiratory distress syndrome on the basis of clinical
and radiological findings. A total of 37 infants (45.7%)
received one dose of surfactant and 39 (48.1%)
received two doses or more; five (6.2%) did not receive
surfactant treatment. A total of 62 infants (76.5%)
were screened for intraventricular haemorrhage
(IVH) using cranial ultrasonography. Of these, 25
developed various degrees of IVH (seven neonates
with grade I, five with grade II, four with grade III
and nine with grade IV). A total of 10 infants (12.3%)
developed necrotising enterocolitis while 17 (21.0%)
and 11 (13.6%) infants developed moderate and severe

Table 2: Demographic characteristics of infants born
before 26 gestational weeks (N = 81)

Characteristic

Birth weight in g, mean ± SD 770 ± 150

Gestational age in weeks, median (range) 25 (23–26)

Male, n (%) 47 (58.0)

Female, n (%) 34 (42.0)

Apgar score at 1 minute, mean ± SD 4 ± 2

Apgar score at 5 minutes, mean ± SD 7 ± 2

SD = standard deviation.

Table 3: Morbidities of infants born before 26
gestational weeks (N = 81)

Morbidity or treatment n (%)

Respiratory distress syndrome 81 (100.0)

Surfactant therapy

One dose 37 (45.7)

Two or more doses 39 (48.1)

Patent ductus arteriosus 23 (28.4)

Intraventricular haemorrhage

Grade I 7 (8.6)

Grade II 5 (6.2)

Grade III 4 (4.9)

Grade IV 9 (11.1)

Pneumothorax 3 (3.7)

Pulmonary haemorrhage 7 (8.6)

Bronchopulmonary dysplasia

Moderate 17 (21.0)

Severe 11 (13.6)

Retinopathy of prematurity

Any stage 42 (51.9)

Stage 3 4 (4.9)

Necrotising enterocolitis 10 (12.3)

Table 4: Comparison of demographic and clinical
characteristics of infants born before 26 gestational
weeks by patient outcome (N = 81)

Characteristic Outcome, n (%) P value

Died
(n = 32)

Survived
(n = 49)

Admission 11 (34.4) 25 (51.0) 0.119

Received antenatal
steroids

10 (31.3) 33 (67.3) 0.001

Born outside the
delivery room

5 (15.6) 1 (2.0) 0.016

Antepartum
haemorrhage

5 (15.6) 13 (26.5) 0.229

Ruptured
membrane >18
hours

20 (62.5) 11 (22.4) 0.331

Chorioamnionitis 5 (15.6) 3 (6.4) 0.256

Caesarean section 6 (18.8) 20 (40.8) 0.071

Birth weight in g,
mean ± SD

710 ± 160 810 ± 85 0.002

Gestation age
in weeks, mean
(range)

24 (23–26) 25 (23–26) <0.001

Male 18 (56.3) 29 (59.2) 0.794

Female 14 (43.8) 20 (40.8) -

Apgar score at
1 minute, mean
± SD

3 ± 2 4.5 ± 2 0.014

Apgar at 5
minutes, mean
± SD

6 ± 2.5 7 ± 2 0.029

Received two or
more doses of
surfactant therapy

15 (46.9) 26 (53.1) 0.586

SD = standard deviation.

Changing Survival Rate of Infants Born Before 26 Gestational Weeks
Single-centre study

e354 | SQU Medical Journal, August 2015, Volume 15, Issue 3

bronchopulmonary dysplasia, respectively.
A total of 49 infants survived (survival rate:

60.5%). The demographic and clinical characteristics
of preterm infants who survived were compared
with those who died during the NICU stay [Table 4].
Among the fatality group, fewer infants received
antenatal steroids (31.3% versus 67.3%; P = 0.001) and
the mean birth weight was significantly lower (710
versus 810 g; P = 0.002) compared with the survivors.
Gestational age was also lower in comparison with
those who survived (24 versus 25 weeks; P <0.001).
Apgar scores were significantly higher in the group
that survived, both at one and five minutes (P = 0.014
and 0.029, respectively). Although pneumothorax and
IVH occurred more frequently in the group of preterm
infants who died, these differences were not significant.

Out of eight infants born at 23 gestational weeks,
only one survived. Survival rates among the cohort
at 24, 25 and 26 gestational weeks were 33.3%, 72.4%
and 75.9%, respectively. These rates were compared
with those from a multi-centre study performed

by the Eunice Kennedy Shriver National Institute
of Child Health & Human Development Neonatal
Research Network (NICHD) in the USA as well as
those reported in a previous study from SQUH [Table
5].5,9 There were more hospital admissions of infants
born <26 gestational weeks between 2006–2013
(n = 81) in comparison to 1991–1998 (n = 32).9
The overall survival rate for the present cohort had
increased to 60.5% from 41%, the rate observed a
decade previously at the same institution.9 There
was an improving survival trend for infants of 24 and
26 gestational weeks. In the current study, survival
rates for infants at 25 and 26 gestational weeks
(72.4% and 75.9%, respectively) were comparable to
those observed in the USA study (72.0% and 83.7%,
respectively); however, decreased survival was noticed
at 24 gestational weeks for the Omani infants at SQUH
(33.3% versus 54.6%).5 Overall, survival rates increased
with gestational age in both the comparative studies
and present research.5,9

Common short-term morbidities among the

Table 5: Comparison of survival rates of preterm infants in Oman and the USA

Author
and year
of study

Location Study
period

Gestational age

23 weeks 24 weeks 25 weeks 26 weeks

n Survived,
n (%)

Stoll et al.5
2010

NICHD
centres,
USA

2003–
2007

871 226 (25.9) 1,370 748 (54.6) 1,498 1,078 (72.0) 1,576 1,319 (83.7)

Manzar9
2000

SQUH,
Muscat,
Oman

1991–
1998

2 0 (0.0) 4 1 (25.0) 1 1 (100.0) 25 11 (44.0)

Current
study

SQUH,
Muscat,
Oman

2006–
2013

8 1 (12.5) 15 5 (33.3) 29 21 (72.4) 29 22 (75.9)

NICHD = Eunice Kennedy Shriver National Institute of Child Health & Human Development Neonatal Research Network; SQUH = Sultan Qaboos
University Hospital.

Table 6: Comparison of morbidities of preterm infants in Oman with very low birth weight infants in the USA and
Saudi Arabia

Author and
year of study

Location Study
period

Morbidity or treatment, %

Mean birth
weight in g

Antenatal
steroids

Bronchopulmonary
dysplasia

Severe
IVH

Necrotising
enterocolitis

PDA

Al Hazzani et
al.12 2011

KFSH,
Riyadh,
Saudi
Arabia

2006–
2008

1,062 74.2 17.7 8.1 7.5 31.2

Fanaroff et
al.13 2007

NICHD
centres,
USA

1990–
2002

1,033 79.0 22.0 10.0 7.0 29.0

Current study SQUH,
Muscat,
Oman

2006–
2013

770 53.0 34.6 14.0 12.0 28.0

IVH = intraventricular haemorrhage; PDA = patent ductus arteriosus; KFSH = King Faisal Specialist Hospital; NICHD = Eunice Kennedy Shriver
National Institute of Child Health & Human Development Neonatal Research Network; SQUH = Sultan Qaboos University Hospital.

Asad Rahman, Mohamed Abdellatif, Sharef W. Sharef, Muhammad Fazalullah, Khalfan Al-Senaidi, Ashfaq A. Khan,
Masood Ahmad, Mathew Kripail, Mazen Abuanza and Flordeliza Bataclan

Clinical and Basic Research | e355

current preterm cohort were compared with data
from American and Saudi Arabian cohorts of very
low birthweight infants between 21 and 36 gestational
weeks [Table 6].12,13 Incidences of bronchopulmonary
dysplasia, severe IVH, necrotising enterocolitis and
patent ductus arteriosus were comparable between the
present study and the two international cohorts.

Discussion

The survival of extremely preterm infants has
significantly improved over last the two decades due to
improvements in perinatal and neonatal care.1–5 Very
limited local data are available on the perinatal and
neonatal mortality and morbidity rates of extremely
preterm infants in Oman.9–11 Additionally, there is a
lack of data from the Middle East regarding common
short-term complications and morbidities of infants
born <28 gestational weeks.10–12,18–21

The findings of this study indicated a significant
increase in the number of admissions of infants born
at <26 gestational weeks in comparison to a previous
study conducted at the same institution.9 Furthermore,
the survival rate of preterm infants observed in the
current study was comparable with those of extremely
preterm infants from multi-centre studies in the USA
and Switzerland and very low birth weight infants
from another multi-centre study in the USA.5–7

Significant improvement was observed in the
survival rate of preterm infants in Oman compared
to hospital data from the 1990s.9 This may be due to
specific institutional improvements in antenatal and
postnatal care, staff training and subspecialty support
as well as the modernisation of equipment and the
implementation of standard international guidelines
for the management of extremely premature infants.

One of the limitations of this study was that infants
born between 22–24 gestational weeks who were not
admitted to the NICU were not included in the sample.
This is because it was difficult to retrieve these records
retrospectively. However, all infants born at 25 and 26
gestational weeks were admitted to the NICU during
the study period according to admission protocol.
The exclusion of non-admitted infants between 22–
24 gestational weeks may have resulted in a falsely
low mortality rate in this cohort. Furthermore, this
was a retrospective single-centre study with a small
sample size; thus, the results cannot be generalised
to all extremely preterm infants in Oman. The results
of the current study provided information regarding
mortality and the most severe short-term morbidities
only. Long-term outcomes—including formal neuro-
development follow-up data—for the survivors were

lacking. Although major developmental delays are
assessed in neonatal follow-up clinics, more resources
are needed to ensure thorough follow-up of extremely
preterm infants and thus assess the overall survival
rate of this patient group.

Conclusion

The overall survival rate of extremely premature
infants admitted to the NICU at SQUH improved
significantly from a previous study at the same
institution, suggesting an improvement in care.
This study emphasises the need for long-term
neurodevelopmental follow-up of this patient group in
order to reveal the true clinical situation concerning
preterm survival.

c o n f l i c t o f i n t e r e s t
The authors declare no conflicts of interest.

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Single-centre study

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