Improving neonatal outcomes through down- referral and integrated health services in Gauteng, South Africa

Background. Tembisa Provincial Tertiary Hospital (TPTH) in Gauteng, South Africa, operates one of the busiest neonatal units in the province, routinely exceeding its approved bed capacity. Chronic overcrowding contributes to reduced nurse-to-patient ratios, increased hospital-acquired infections (HAIs), and elevated neonatal mortality. Optimising district-level capacity through kangaroo mother care (KMC) down-referral may reduce congestion and improve neonatal outcomes. Objectives. To evaluate the effect of a structured KMC down-referral intervention on overcrowding and neonatal outcomes at TPTH. Methods. A retrospective comparative study analysed routinely collected data for two 6-month periods before (February - July 2024) and during (August 2024 - January 2025) the implementation of a KMC down-referral system. Stable KMC mother–infant pairs were transferred to underutilised KMC units at district hospitals with specialist telephonic support. Indicators measured were inpatient-days, bed utilisation rate, neonatal mortality rate, number of neonatal deaths and HAI rates. Data were summarised descriptively and compared using t-tests. Results. A total of 203 neonates were down-referred between August 2024 and January 2025. During the intervention period, mean bed utilisation was lower compared with the pre-intervention period (145.7% v. 159.8%; p=0.0490). Mean monthly inpatient-days also decreased (3437.5 v. 3707.3; p=0.0916). The mean neonatal mortality rate declined from 21.2 to 16.3 per 1 000 live births (p=0.1534), and the mean number of neonatal deaths decreased from 24.8 to 17.2 per month (p=0.0516). The mean rate of HAIs per 1 000 inpatient-days was 6.1 pre-intervention and 5.5 during the intervention period (p=0.8313). Conclusion. The KMC down-referral intervention was associated with reduced bed utilisation and lower mean values in other neonatal indicators. This shows that strengthening district-level KMC capacity and formalising integrated referral pathways may improve neonatal outcomes in resource-constrained settings.