1 Introduction

Despite significant progress in reducing new HIV infections and improving access to treatment, challenges remain, particularly in countries heavily affected by the epidemic such as South Africa, where the HIV prevalence is estimated at 13.7% of the population [1]. The prevention of mother-to-child transmission (PMTCT) programs have been successful in reducing vertical transmission rates, resulting in an increased number of HIV-exposed uninfected (HEU) neonates [2]. However, the health needs of this population are still largely unknown, and there is a lack of research comparing their outcomes to HIV-unexposed neonates.

While there is some research on audiological manifestations of HIV in adults and children, limited studies have focused on the audiological outcomes in HEU neonates. Previous studies have reported varied rates of hearing screening failure in HEU neonates, suggesting a possible association between HIV exposure without infection and impaired audiological function. However, the existing evidence is limited by small sample sizes, lack of control or comparison groups, and limited screening measures that do not assess the entire auditory pathway.

Studies have explored the audiological implications of HIV infection in both adult and paediatric populations. In adults, hearing loss, predominantly sensorineural, has been associated with HIV infection, disease progression, and antiretroviral treatment exposure [3,4,5]. Similarly, in paediatric populations, hearing loss prevalence in HIV-positive children ranges from 6 to 84%, with conductive hearing loss being more common [6,7,8,9]. Associations have been observed between hearing loss and factors such as ear infections, antiretroviral treatment, and disease staging. Hearing loss in HIV-positive individuals, both adults and children, significantly impacts their quality of life, especially in terms of language development and academic performance.

Despite some research in the area of HIV and audiology, limited studies have investigated the audiological outcomes of HEU neonates. Several studies have investigated audiological outcomes in the HEU population, focusing on neonates, infants, and children. However, the findings regarding the association between in utero HIV exposure and audiological function remain inconclusive. Some studies reported a higher prevalence of abnormal audiological results in the HEU population compared to unexposed individuals, while others did not find statistically significant associations [10,11,12,13,14]. These studies often highlighted the need for further research, standardization of audiological testing, and the inclusion of comparison groups to establish conclusive evidence. Therefore, further research is necessary to establish the relationship between HIV exposure without infection and audiological function in this population. The current study aims to address this gap by examining the audiological screening outcomes and case history factors in HEU and HIV-unexposed neonates, contributing to the understanding of audiological outcomes in HEU neonates and informing EHDI strategies.

The HEU neonatal population is potentially at risk of hearing loss, which, if not identified early, can have significant negative consequences on their development, educational performance, and future vocational prospects. Early Hearing Detection and Intervention (EHDI) programs aim to identify, diagnose, and provide intervention for hearing loss in newborns and infants as early as possible. These programs play a crucial role in preventing delays in speech, language, and cognitive development [15, 16]. In recognition of the importance of early detection and intervention for hearing loss, the Health Professions Council of South Africa (HPCSA) has established guidelines that prioritize intervention for children with hearing loss by eight months of age [15]. However, these guidelines do not specifically address the audiological needs of HIV-exposed and uninfected neonates.

International research has greatly influenced EHDI guidelines and practices, but studies specific to the South African context are limited. Given the high burden of HIV in South Africa and the unique healthcare context, research specific to this population is essential. Furthermore, the prevalence of hearing loss in children in sub-Saharan Africa is higher than the global average, emphasizing the importance of early intervention and monitoring in the HEU population [17, 18]. However, the HEU population often receives less attention compared to HIV-positive populations, necessitating further research to provide conclusive evidence that can inform policy and guidelines [18].

This study aims to address the gaps in knowledge by establishing relationships and comparing outcomes between case history factors and audiological screening results in HEU and HIV-unexposed neonates at a district-level hospital in Gauteng, South Africa.

2 Materials and methods

2.1 Aim

The aim of the study was to establish relationships and compare outcomes between case history factors and audiological screening outcomes in HIV-exposed uninfected (HEU) and HIV-unexposed neonates at a district-level hospital in Gauteng, South Africa.

2.2 Objectives

The specific objectives of this study were:

  1. 1.

    To describe the case history factors and audiological screening outcomes in HEU neonates.

  2. 2.

    To describe the case history factors and audiological screening outcomes in HIV-unexposed neonates.

  3. 3.

    To establish relationships between case history factors and audiological screening outcomes in HEU and HIV-unexposed neonates.

2.3 Research design

This study employed a quantitative, descriptive, cross-sectional, comparative research design that was non-experimental in nature [19]. This study aimed to assess screening results in HEU versus HIV-unexposed infants and establish associations between case history factors and screening results. Therefore, a non-experimental design was appropriate.

2.4 Research context

The study took place at South Rand Hospital (SRH), a district-level state hospital in Rosettenville, Gauteng, South Africa. SRH provides medical and allied health services, including a dedicated maternity ward. Approximately 303 neonates are born at the hospital monthly, with 78% being HIV-unexposed and 22% HIV-exposed [20]. SRH does not have a neonatal high care or Neonatal Intensive Care Unit (NICU), and patients requiring specialized services are transferred to other facilities.

Polymerase Chain Reaction (PCR) testing is routinely conducted on all HIV-exposed neonates at SRH. Prophylaxis regimens are administered based on South African National Department of Health [21]. The hospital has a dedicated Speech Therapy and Audiology Department, ensuring continuity of care for participants.

The study was conducted during the COVID-19 pandemic, but data collection was not disrupted as neonatal hearing screening was considered a priority service. Infection control measures were strengthened to comply with hospital guidelines.

2.5 Description of the participants

The study employed a nonprobability, non-proportional quota sampling method. Based on power analysis calculations aimed at achieving the desired statistical power, the study aimed to recruit a minimum total sample size of 200 participants, with 100 HEU neonates and 100 HIV-unexposed neonates. The sample comprised 212 neonates, including 100 HEU neonates and 112 HIV-unexposed neonates. Data were collected from December 2020 to October 2021. Inclusion and exclusion criteria were used to determine participant eligibility [22]. Neonates aged 28 days or less were included to align with the goal of newborn hearing screenings by six weeks of age [15]. Neonates older than 28 days were excluded to limit confounding variables related to other possible causes of hearing impairment [23]. Neonates born at South Rand Hospital Maternity Ward, both HEU and HIV-unexposed, were included in the study to allow for comparison. Neonates not born at the research site and those discharged and readmitted for further care were excluded.

Participants needed to be medically stable according to the medical officer's assessment to minimize potential complications. Only neonates whose caregivers provided written consent were included in the study.

2.6 Data collection method and procedure

Ethical clearance was obtained from the University's Human Research Ethics Committee (HREC) prior to the commencement of the study (Protocol Number: M200950). The study adhered to ethical principles outlined in the Declaration of Helsinki and aimed to prioritize the well-being of the participants. Permission was also obtained from the Chief Executive Officer and Chief Speech Therapist and Audiologist at the research site. The medical staff at the Maternity Ward were briefed about the study, and the approved research proposal was shared with them before recruitment.

Participants were recruited through posters and nursing staff who were used to inform parents about the study. Neonates whose parents or guardians agreed to participate and met the inclusion criteria were assessed.

Case history information and medical file reviews were conducted to correlate with audiological results. This included maternal history (age, RVD status, CD4 count, WHO staging, VL, treatment regimen, co-morbidities, and in utero infections), birth history (mode of delivery, gestational age, birth weight, Apgar scores, and complications), and neonate’s medical history (diagnosis, medication, investigations, prophylaxis regimen, and PCR results for HIV-exposed neonates).

The data were recorded on a form, ensuring patient confidentiality by using a preassigned participant number. Demographic information and factors potentially influencing hearing impairment were also recorded.

Audiological screening consisted of otoscopy, tympanometry, Distortion Product Otoacoustic Emissions (DPOAE), and Automated Auditory Brainstem Response (AABR) testing. Results were recorded using a data capturing form. Infection control measures were strictly adhered to throughout the testing process. Tympanometry assessed the middle ear system, and tympanograms were classified as normal or abnormal. DPOAE results were recorded as pass, refer, or could not test. AABR were also recorded as pass, refer, or could not test [15, 16]. The use of multiple assessments allowed for a comprehensive screening and improved sensitivity and specificity. Uniform pass/refer criteria were used to minimize clinician bias [24]. A unilateral or bilateral refer result indicated an overall refer hearing screening result, identifying unilateral or bilateral hearing loss or individuals at risk for progressive bilateral hearing loss.

2.7 Data analysis

For objectives one and two, descriptive statistics were used to summarize demographic data, maternal case history information, HIV treatment regimens, co-morbid conditions, birth history, and the neonates' medical information. Measures of central tendency (e.g., mean, median) and measures of dispersion (e.g., standard deviation, range) were calculated to provide a summary of the data. The dataset was also described in terms of overall pass and overall refer results obtained in both the comparison and research groups. The criteria for an overall pass or refer result were defined based on the DPOAE and AABR outcomes.

Inferential statistics were used to test for statistically significant relationships between case history factors and audiological screening outcomes in HEU and HIV-unexposed neonates, as per the third objective of the study. The Chi-squared test was employed to assess the associations between case history factors and audiological function. The null hypothesis stated that no association existed, while the alternative hypothesis stated that there was an association.

To determine if a statistically significant difference existed in audiological screening outcomes between HEU and HIV-unexposed neonates, the difference between two proportions test was used. This test compared the proportion of participants who received a pass result on the audiological screening in the comparison and research groups. A significance level (alpha) of 0.05 was used to reduce the chance of Type I errors. The statistical analyses considered sampling errors and aimed to ensure that the probability of Type I and Type II errors was within acceptable limits.

3 Results

3.1 Description of case history factors and audiological screening outcomes in HEU neonates

Table 1 summarizes the case history factors in HEU neonates (N=100). The mode of delivery was 61% C-section and 39% normal vaginal delivery (NVD). The birth weight ranged from 1300-3980 grams, with a mean of 2972 grams. Approximately 90% of the neonates were full-term, while 10% were premature. The average Apgar scores were 9 at one minute and 10 at five minutes. Common birth complications included foetal distress (6%) and other issues like umbilical cord around the neck and respiratory distress. Maternal co-morbidities were present in 1% of cases, and maternal in-utero infections (syphilis) were observed in 4% of cases. Only 5% of neonates had formal medical diagnoses. All participants' mothers were HIV-positive, with 98% on highly active antiretroviral therapy (HAART). The WHO staging of HIV in mothers revealed Stage I in 30% of cases, Stage II in 23%, Stage III in 14%, Stage IV in 17%, and an unknown stage in 16% of cases. Regarding prophylaxis regimens and HIV PCR results, 61% received AZT and NVP, 39% received only NVP, and all neonates tested negative for HIV on their birth PCR test.

Table 1 Summary of Case History Factors in HEU Neonates (N = 100)
Full size table

Figure 1 presents the overall hearing screening outcomes in HEU neonates. The results indicate that 39% passed the screening, 37% had bilateral referrals, 19% had unilateral referrals, and 5% could not be tested.

Fig. 1
figure 1

Overall Hearing Screening Outcomes in HEU Neonates (N = 100)

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3.2 The ear-specific audiological screening results in HEU neonates

Otoscopy findings showed that 9% of left ears and 11% of right ears had no abnormality detected (NAD), while 63% of both left and right ears had partial vernix occlusion. Complete vernix occlusion was observed in 28% of left ears and 26% of right ears. Tympanometry results revealed that 17% of left ears and 21% of right ears had Type A results, indicating normal middle ear function. Abnormal tympanometry results (Type B, As, Ad, C) were found in 81% of left ears and 77% of right ears. A small percentage (2%) could not be tested. Distortion product otoacoustic emissions (DPOAE) screening showed a pass in 51% of left ears and 56% of right ears, while 45% of left ears and 40% of right ears were referred for further evaluation. A small percentage (4%) could not be tested. Auditory brainstem response (AABR) screening yielded a pass in 52% of left ears and 51% of right ears, a referral in 43% of left ears and 44% of right ears, and an inability to test in 5% of both ears.

3.3 Description of case history factors and audiological screening outcomes in HIV unexposed neonates

Table 2 summarizes the case history factors in HIV unexposed neonates. Among the 112 participants, 50% were delivered via C-section, and 50% through normal vaginal delivery (NVD). The birth weight ranged from 1490–4375 g, with a mean of 3002 g. Approximately 91% of the neonates were full-term, and 9% were premature. The average Apgar scores were 9 at one minute and 10 at five minutes. The most common birth complication was foetal distress (6%), and there were fewer cases of other complications, such as respiratory distress. Maternal co-morbidities were present in 2% of cases, and maternal in-utero infections were observed in 1% of cases. Only 6% of neonates had formal medical diagnoses.

Table 2 Summary of Case History Factors in HIV Unexposed Neonates
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Figure 2 presents the overall hearing screening outcomes in HIV unexposed neonates (N = 112). The results show that 60% passed the screening, 25% had bilateral referrals, 7% had unilateral referrals, and 8% could not be tested.

Fig. 2
figure 2

Overall Hearing Screening Outcomes in HIV Unexposed Neonates (N = 112)

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3.4 The ear-specific audiological screening results in HIV unexposed neonates

Otoscopy findings revealed that 15% of left ears and 19% of right ears had no abnormality detected (NAD), while 61% of left ears and 60% of right ears had partial vernix occlusion. Complete vernix occlusion was observed in 24% of left ears and 21% of right ears. Tympanometry results indicated that 22% of left ears and 23% of right ears had Type A results, while abnormal tympanometry results (Type B, As, Ad, C) were found in 75% of left ears and 73% of right ears. A small percentage (3–4%) could not be tested. DPOAE screening showed a pass in 70% of left ears and 67% of right ears, with 25% of left ears and 28% of right ears referred for further evaluation. A small percentage (5%) could not be tested. AABR screening yielded a pass in 70% of left ears and 63% of right ears, a referral in 23% of left ears and 29% of right ears, and an inability to test in 7–8% of ears.

3.5 Associations between case history factors and audiological outcomes in HEU and HIV unexposed neonates

The study assessed associations between case history factors and hearing screening outcomes in both HEU and HIV unexposed neonates. The case history factors considered were mode of delivery, birth weight, gestational age, Apgar scores, birth complications, maternal comorbidities, and patient’s medical diagnoses. No statistically significant associations were found between case history factors and hearing screening outcomes in either group, as indicated by the Chi-squared test where the p-value calculated was greater than 0.05. However, it is important to note that only in the maternal HIV stage IV, the proportion of participants who referred on the overall hearing screening outcome was higher than what would be expected under the assumptions used in the Chi Squared test. The difference was not large enough to result in finding an association as the p-value calculated was greater than 0.05.

When comparing audiological screening outcomes between HEU and HIV unexposed neonates, findings revealed (1) no statistically significant relationship between otoscopic findings and HIV exposure; (2) no statistically significant relationship between tympanometric results and HIV exposure, however the prevalence of abnormal tympanometric results was slightly higher in the HEU group when compared to the HIV unexposed group; (3) statistically significant relationship between HIV exposure and DPOAE results, where the HEU group had a higher proportion of referrals compared to the HIV unexposed group, and for DPOAE results, where the test statistic calculated was -3.45 which was less than the critical value of − 1.64 and, as a result, the null hypothesis was rejected, therefore, a statistically significant relationship was established between HIV exposure and DPOAE results; and (4) statistically significant relationship between HIV exposure and AABR results, where there was a notable difference between the two groups, with the HIV unexposed group having a higher pass rate of 67% compared to 52% in the HEU group, the HEU group also presented with a larger percentage of refer findings when compared to the HIV unexposed group (43%, compared to 25%), and for AABR results, where the test statistic calculated was − 3.78 which was less than the critical value of − 1.64 and, as a result, the null hypothesis was rejected, therefore, a statistically significant relationship was found between HIV exposure and AABR results.

4 Discussion

The study included 212 participants, with 100 in the research group (HEU neonates) and 112 in the comparison group (HIV unexposed neonates). The sample consisted of 53% males and 47% females, reflecting a similar gender distribution to recorded South African births in 2020. The sample's demographic characteristics, such as maternal age and ethnicity, birth weight, also aligned with national statistics [1, 25, 26].

As far as description of case history factors and audiological screening outcomes in HEU neonates was concerned the mode of delivery showing a higher rate of C-sections (61%) compared to NVD (39%) could be influenced by discharge rates, as neonates born via NVD are typically discharged earlier than those born via C-section, thus most likely did not form part of the study. The prevalence of low birth weight (12%) and prematurity (10%) in the HEU neonates aligned with national and international estimates [26, 27]. Birth complications, such as foetal distress, were observed in 6% of cases. Maternal co-morbidities, in-utero infections, and formal medical diagnoses were reported in a small percentage of cases, with no significant associations found with audiological outcomes. The majority of mothers (98%) were on highly active antiretroviral therapy (HAART), following national guidelines. All neonates tested negative for HIV on their birth PCR test.

These case history factors findings in HEU neonates have important implications for the South African context. The higher rate of C-sections compared to NVD may be influenced by discharge practices in the state sector, where neonates born via NVD are often discharged earlier. This highlights the need to consider the timing of audiological screening in relation to discharge, especially for neonates born via NVD. The prevalence of low birth weight and prematurity aligning with national estimates emphasizes the importance of monitoring these factors in the context of hearing screening. The high adherence to HAART among mothers reflects the success of national guidelines, indicating the effectiveness of current treatment regimens. The negative HIV PCR test results in neonates further demonstrate the success of prevention of mother-to-child transmission programs in South Africa.

As far as the description of case history factors and audiological screening outcomes in HIV unexposed neonates was concerned, findings of an equal proportion of neonates delivered via C-section (50%) and NVD (50%), and the prevalence of low birth weight (16%) and prematurity (9%) aligned with national estimates [25, 26]. Birth complications, maternal co-morbidities, and in-utero infections were reported in a small percentage of cases, without significant associations with audiological outcomes. The overall hearing screening outcomes in this group showed a lower referral rate (32%) compared to the HEU group, potentially influenced by differences in discharge practices. Current findings for HIV unexposed neonates have implications for the South African context, particularly in terms of delivery modes and discharge practices. The equal distribution of C-sections and NVD in this group may reflect a higher rate of C-sections compared to the general population, influenced by the availability of participants who remained in the hospital for longer periods. This suggests the need for further investigation into the impact of delivery mode on audiological outcomes and the potential benefits of extended hospital stays for neonates born via NVD. The lower referral rate in the HIV unexposed group may also be influenced by discharge practices, highlighting the need for careful consideration of timing and protocols in the South African context.

The associations between case history factors and audiological outcomes in HEU and HIV unexposed neonates indicated no statistically significant associations between the case history factors investigated and audiological screening outcomes in either the HEU or HIV unexposed group. Maternal age showed no significant correlation, contrary to previous studies. Limited data on maternal VL, treatment regimens, and other factors hindered further investigation of associations. The lack of significant associations between case history factors and audiological outcomes in both groups suggests that factors such as mode of delivery, gestational age, birth weight, Apgar scores, maternal age, RPR result, and Rhesus factor may not be direct predictors of audiological outcomes in the South African population. However, further research is needed to explore the specific impact of maternal VL, treatment regimens, and other factors that were not adequately captured in the current study. The findings highlight the need for a comprehensive approach to audiological screening that goes beyond these traditional case history factors in the South African context [9].

Findings from the comparison of audiological screening outcomes between HEU and HIV unexposed neonates show significant differences in audiological screening outcomes between the HEU and HIV unexposed neonates. The overall referral rate was higher in the HEU group, indicating potential hearing issues. However, no significant differences were found in otoscopic and tympanometric findings between the two groups. Statistically significant associations were established between the HEU group and DPOAE and AABR results. The higher referral rate in the HEU group suggests a need for closer monitoring of this population in terms of their hearing health. This calls for the inclusion of HEU neonates in risk-based newborn hearing screening protocols and the development of targeted interventions for early identification and management of hearing issues. The lack of significant differences in otoscopic and tympanometric findings suggests that factors other than external and middle ear status may contribute to the observed differences in audiological outcomes. The associations found with DPOAE and AABR results highlight the potential of these measures in identifying hearing issues in HEU neonates.

Overall, the current study's findings have important implications for the South African context, particularly in terms of policy development and implementation of newborn hearing screening programs. The challenges identified, such as the high referral rate potentially influenced by discharge practices and the need for comprehensive assessment beyond traditional case history factors, highlight the need for context-specific guidelines and protocols. The study provides valuable insights into the hearing health of the HEU population in South Africa and emphasizes the importance of further research, advocacy, and support for this vulnerable population. The comparison with previous studies underlines the variability in findings, attributed to differing protocols, equipment, and population characteristics. The study's comprehensive assessment of the complete auditory system provides valuable insights for policy considerations.

The implications of the study's findings call for the inclusion of HEU neonates in risk-based newborn hearing screening protocols, as they constitute a vulnerable population. The challenges identified in the South African context, particularly the high overall referral rate, require careful consideration in policy development and implementation to minimize false negatives and optimize resource utilization. The study underscores the urgency of further research and advocacy to support this population and inform policy decisions.

Considering the overall findings, this study offers several theoretical and practical contributions. Theoretically, firstly, the study contributes to the theoretical understanding of the audiological outcomes in HEU neonates. By investigating a comprehensive set of case history factors and audiological screening results, the study adds to the existing body of knowledge on the impact of HIV exposure on hearing function in this population. The findings provide insights into the specific challenges and potential risk factors associated with hearing loss in HEU neonates. Secondly, the study contributes to the understanding of the relationship between case history factors and audiological outcomes in both HEU and HIV unexposed neonates. By examining factors such as mode of delivery, gestational age, birth weight, Apgar scores, maternal age, RPR result, and Rhesus factor, the study expands the knowledge base on potential predictors of hearing loss in neonates. The lack of significant associations found in this study suggests that additional factors, such as maternal viral load and treatment regimens, may need to be explored in future research. Thirdly, the study provides valuable insights into audiological outcomes and case history factors in the South African context. By aligning the findings with national statistics and considering the unique healthcare system and practices in South Africa, the study contributes to the understanding of audiological screening challenges specific to this setting. This contextualization enhances the applicability and relevance of the findings to the South African healthcare system.

Practically, firstly, the findings from this study have practical implications for policy development and implementation of newborn hearing screening programs in South Africa. The higher referral rates observed, particularly in the HEU group, highlight the need for targeted interventions and closer monitoring of this population. These findings can guide policymakers in considering the inclusion of HEU neonates in risk-based screening protocols and developing appropriate guidelines for the early identification and management of hearing issues. Secondly, the study sheds light on the challenges and potential barriers in audiological screening practices, such as early discharge of neonates and its impact on screening outcomes. The identification of higher referral rates and factors like excess vernix in the South African context underscores the importance of optimizing screening protocols and considering the timing of screenings relative to discharge. These practical implications can aid healthcare professionals in implementing more effective and contextually appropriate audiological screening practices. Thirdly, the findings of this study contribute to advocacy efforts for the HEU population. By highlighting the significant differences in audiological outcomes between HEU and HIV unexposed neonates, the study emphasizes the importance of recognizing HEU neonates as a vulnerable group requiring special attention. The results provide evidence to support the development of targeted interventions, resource allocation, and support services for HEU neonates and their families.

Overall, the theoretical and practical contributions of the findings from this study advance the understanding of hearing outcomes in HEU neonates, inform policy development and implementation, enhance audiological screening practices, and advocate for the needs of the HEU population in the South African context. These contributions have the potential to improve early identification and intervention for hearing issues, ultimately enhancing the overall health and well-being of HEU neonates in South Africa.

The importance of a new organizational model can be highly relevant when considering the findings of this study, especially in the context of healthcare systems and services in South Africa. Firstly, a tailored healthcare delivery approach is highlighted as this study has shed light on the specific audiological needs and challenges faced by HEU neonates in South Africa. Thus, an innovative organizational model can be designed to tailor healthcare delivery to meet the unique requirements of this population. This might involve specialized clinics, trained healthcare providers, and targeted interventions. Secondly, a need for efficiency and resource optimization is raised. By reorganizing healthcare services to better address the audiological needs of HEU neonates, it's possible to improve the efficiency of care delivery. This can lead to better resource allocation, reduced wait times, and more cost-effective interventions. Thirdly, interdisciplinary collaboration is also highlighted as HEU neonates often require a multi-disciplinary approach to healthcare due to the complex interplay of medical and social factors; therefore, an innovative organizational model can facilitate better collaboration between different healthcare professionals, including audiologists, paediatricians, infectious disease specialists, and social workers. Additionally, other important benefits of a new organizational model including early audiological screening and intervention for HEU neonates; data-driven decision-making where data analytics can be used to continuously monitor and improve the quality of care provided to HEU neonates; patient-centred care as well as community engagement; policy advocacy where findings of the study can be used to advocate for changes in healthcare policies and funding allocation to better support HEU neonates; and capacity building that includes training of healthcare providers and audiologists in the specialized care of HEU neonates can all be prioritized to ensure that infants receive timely assessments and interventions when needed. If successful, the organizational model developed for HEU neonates can serve as a template for addressing the healthcare needs of other vulnerable populations. It can be scaled up and replicated in other regions facing similar challenges.

In conclusion, the findings of the study on audiological outcomes in HEU neonates underscore the need for a forward-thinking, patient-centred, and data-driven organizational model within healthcare systems. Such a model can improve the quality and accessibility of care for HEU neonates and serve as a foundation for addressing healthcare disparities in other vulnerable populations.

5 Conclusions

This study enhances our understanding of hearing outcomes in HEU neonates, informs policy development and implementation, enhances audiological screening practices, and advocates for the needs of the HEU population in the South African context. The findings provide valuable insights that can contribute to improved early identification and intervention for hearing issues, ultimately enhancing the overall health and well-being of HEU neonates in South Africa. Further research is needed to build upon these findings and address the remaining gaps in knowledge, but this study serves as a significant step towards improving the care and support provided to HEU neonates.

Despite the valuable contributions and implications of the study, several limitations should be acknowledged. Firstly, the relatively small sample size limits the generalizability of the findings to the larger population of HEU neonates in South Africa. Secondly, the cross-sectional design adopted cannot establish causality or capture changes over time, thus understanding the trajectory of audiological outcomes and case history factors in HEU neonates cannot be done. Thirdly, the study’s focus on neonates’ audiological outcomes may have overlooked the potential impact of comprehensive maternal data, including maternal health, antenatal care, and HIV-related factors. Lastly, the study identified the potential impact of vernix occlusion on audiological screening outcomes. However, it did not directly address the impact of early discharge criteria on false negatives, which could be an important confounding factor influencing the referral rates. Despite these limitations, this study significantly advances our knowledge of audiological outcomes in HEU neonates in the South African context and provides valuable insights into the challenges and considerations of audiological screening in this vulnerable population.