Quality of neonatal intensive care in Africa: a systematic review and meta-analysis

High-quality neonatal intensive care can prevent a significant proportion of neonatal deaths. A neonatal intensive care unit (NICU) is essential for managing life-threatening complications among small and sick newborns. However, little is known about the quality of neonatal intensive care units in Africa. Therefore, this study aimed to estimate the pooled proportion of neonates who received essential quality of care in NICUs, assess care outcomes, and investigate variability across care elements. A systematic review and meta-analysis were conducted using studies reporting neonatal care from African countries, following the PRISMA guidelines. Process quality of care is measured as the proportion of neonates who received essential care elements in the NICUs. Neonatal care outcome quality is evaluated by neonatal health outcomes, including survival, mortality, full enteral feeding, sepsis, weight gain, and hypothermia within the first 28 days of the NICU stay. Data were extracted from PubMed, Web of Science, Scopus, EMBASE, CINAHL, and Cochrane, as well as Google Scholar and grey literature, from July to August 2025. Quality appraisal checklists and tools were employed from the Cochrane risk of bias assessment for randomized trials, and the Joanna Briggs Institute for observational studies. Narrative analysis and meta-analysis were performed, presenting pooled estimates with 95% confidence intervals. Heterogeneity (I2) was assessed, and findings were summarized using tables and forest plots. Among neonates admitted to NICUs, pooled estimates of essential quality of care in African studies were 0.78 (95%CI: 0.64–0.93) for vital signs monitoring, 0.65 (95%CI: 0.44–0.87) for antibiotic use, 0.46 (95%CI: 0.34–0.58) for oxygen therapy, 0.52 (95%CI: 0.30–0.74) for trophic feeding, 0.51 (95%CI: 0.33–0.70) for CPAP use, and 0.55 (95%CI: 0.33–0.77) for thermal care. For clinical outcomes, the pooled incidence was 0.58 (95%CI: 0.31–0.86) for hypothermia, 0.34 (95%CI: 0.11–0.57) for sepsis, 0.19 (95%CI: 0.14–0.23) for mortality, and 0.76 (95%CI: 0.69–0.82) for recovery. A small proportion of neonates admitted to NICUs in Africa received essential quality of care, highlighting the need for targeted strategies, including quality improvement initiatives and capacity building, to enhance neonatal care and reduce adverse outcomes.