Caffeine citrate status, availability and practice across Nigeria, Ethiopia, Kenya, South Africa and five States in India

Apnea of prematurity (AOP) is a common complication among preterm infants
(<37 weeks gestation), globally. However, access to caffeine
citrate (CC) that is a proven safe and effective treatment in high income
countries is largely unavailable in low-and-middle income countries, where
most preterm infants are born. Therefore, the overall aim of this study
was to describe the demand, policies, and supply factors affecting the
availability and clinical use of CC in LMICs. A mixed methods approach was
used to collect data from diverse settings in LMICs including Ethiopia,
Kenya, Nigeria, South Africa, and India. Qualitative semi-structured
interviews and focus group discussions were conducted with different
health care providers, policymakers, and stakeholders from industry.
Additional data was collected using standard questionnaires. A thematic
framework approach was used to analyze the qualitative data and
descriptive statistics were used to summarize the quantitative data. The
findings indicate that there is variation in in-country policies on the
use of CC in the prevention and treatment of AOP and its availability
across the LMICs. As a result, the knowledge and experience of using CC
also varied with clinicians on Ethiopia having no experience of using it
while those in India have greater knowledge and experience of using it.
The in turn influenced the demand and our findings show that only 29% of
eligible preterm infants are receiving CC in these countries. There is an
urgent need to address the multilevel barriers to accessing CC for
management of AOP in Africa. These include cost, lack of national policies
and therefore lack of demand stemming from its clinical equivalency with
aminophylline.  Practical ways to reduce the cost of CC in LMICs
could potentially increase its availability and use.