Development and effects of a neonatal care unit in rural India

An analysis of the impact of newborn survival policies in Pakistan using a policy triangle framework

Introduction

Pakistan has made slow progress towards reducing the newborn mortality burden; as a result, it has the highest burden of newborn mortality worldwide. This article presents an analysis of the current policies, plans, and strategies aimed at reducing the burden of newborn death in Pakistan for the purpose of identifying current policy gaps and contextual barriers towards proposing policy solutions for improved newborn health.

Methods

We begin with a content analysis of federal-level policies that address newborn mortality within the context of health system decentralization over the last 20 years. This is then followed by a case study analysis of policy and programme responses in a predominantly rural province of Pakistan, again within the context of broader health system decentralization. Finally, we review successful policies in comparable countries to identify feasible and effective policy choices that hold promise for implementation in Pakistan, considering the policy constraints we have identified.

Results

The major health policies aimed at reduction of newborn mortality, following Pakistan’s endorsement of global newborn survival goals and targets, lacked time-bound targets. We found confusion around roles and responsibilities of institutions in the implementation process and accountability for the outcomes, which was exacerbated by an incomplete decentralization of healthcare policy-making and health service delivery, particularly for women around birth, and newborns. Such wide gaps in the areas of target-setting, implementation mechanism, and evaluation could be because the policy-making largely ignored international commitments and lessons of successful policy-making in comparable regional counties.

Conclusions

Inclusion of clear goals and targets in newborn survival policies and plans, completion of the decentralization process of maternal and child healthcare service delivery, and policy-making and implementation by translating complex evidence and using regional but locally applicable case studies will be essential to any effective policy-making on newborn survival in Pakistan.

Improved referral and survival of newborns after scaling up of intensive care in Suriname

BACKGROUND

Scaling up neonatal care facilities in developing countries can improve survival of newborns. Recently, the only tertiary neonatal care facility in Suriname transitioned to a modern environment in which interventions to improve intensive care were performed. This study evaluates impact of this transition on referral pattern and outcomes of newborns.

METHODS

A retrospective chart study amongst newborns admitted to the facility was performed and outcomes of newborns between two 9-month periods before and after the transition in March 2015 were compared.

RESULTS

After the transition more intensive care was delivered (RR 1.23; 95% CI 1.07-1.42) and more outborn newborns were treated (RR 2.02; 95% CI 1.39-2.95) with similar birth weight in both periods (P=0.16). Mortality of inborn and outborn newborns was reduced (RR 0.62; 95% CI 0.41-0.94), along with mortality of sepsis (RR 0.37; 95% CI 0.17-0.81) and asphyxia (RR 0.21; 95% CI 0.51-0.87). Mortality of newborns with a birth weight <1000 grams (34.8%; RR 0.90; 95% CI 0.43-1.90) and incidence of sepsis (38.8%, 95% CI 33.3-44.6) and necrotizing enterocolitis (NEC) (12.5%, 95% CI 6.2-23.6) remained high after the transition.

CONCLUSIONS

After scaling up intensive care at our neonatal care facility more outborn newborns were admitted and survival improved for both in- and outborn newborns. Challenges ahead are sustainability, further improvement of tertiary function, and prevention of NEC and sepsis.

Inpatient care of small and sick newborns in healthcare facilities

Neonatal units in teaching and non-teaching hospitals both in public and private hospitals have been increasing in number in the country since the sixties. In 1994, a District Newborn Care Programme was introduced as a part of the Child Survival and Safe Motherhood Programme (CSSM) in 26 districts. Inpatient care of small and sick newborns in the public health system got a boost under National Rural Health Mission with the launch of the national programme on facility-based newborn care (FBNC). This has led to a nationwide creation of Newborn Care Corners (NBCC) at every point of child birth, newborn stabilization units (NBSUs) at First Referral Units (FRUs) and special newborn care units (SNCUs) at district hospitals. Guidelines and toolkits for standardized infrastructure, human resources and services at each level have been developed and a system of reporting data on FBNC created. Till March 2015, there were 565 SNCUs, 1904 NBSUs and 14 163 NBCCs operating in the country. There has been considerable progress in operationalizing SNCUs at the district hospitals; however establishing a network of SNCUs, NBSUs and NBCCs as a composite functional unit of newborn care continuum at the district level has lagged behind. NBSUs, the first point of referral for the sick newborn, have not received the desired attention and have remained a weak link in most districts. Other challenges include shortage of physicians, and hospital beds and absence of mechanisms for timely repair of equipment. With admission protocols not being adequately followed and a weak NBSU system, SNCUs are faced with the problem of admission overload and poor quality of care. Applying best practices of care at SNCUs, creating more NBSU linkages and strengthening NBCCs are important steps toward improving quality of FBNC. This can be further improved with regular monitoring and mentoring from experienced pediatricians, and nurses drawn from medical colleges and the private sector. In addition there is a need to further increase such units to address the unmet need of facility-based care.

Congenital heart disease in pregnancy in a low-income country

OBJECTIVE

To assess maternal and perinatal outcomes among pregnant women with congenital heart disease (CHD) in a low-resource country.

METHODS

A prospective, observational study was conducted at a teaching hospital in Kolkata, India, between January 1, 2008, and December 31, 2010. All pregnant women with CHD were followed up from first prenatal visit to discharge. Both maternal and perinatal outcomes were analyzed.

RESULTS

Of 174 pregnant women with heart disease, 27 (16%) had CHD. Mean age was 23.5±3.6 years. Four (15%) patients were diagnosed with CHD during the index pregnancy. Nine (33%) women had undergone surgical correction before conception. Cesarean delivery was performed in 12 (44%) women. Fifteen (56%) neonates weighed less than 2500 g, and 4 (15%) were born preterm. Mean birth weight was slightly higher in women with corrected heart lesions than in those with uncorrected ones (2593±480 g vs 2294±620 g; P=0.22). Three (11%) neonates died, but no stillbirths occurred. One (4%) woman died after delivery owing to atonic postpartum hemorrhage.

CONCLUSION

Delayed diagnosis, lack of treatment, and unplanned pregnancy are major challenges for women with CHD, which need to be addressed to improve maternal and neonatal outcomes in low-resource countries.

50 years of neonatology in India, progress and future

India has made impressive gains in its child survival indices during the past half a century with infant mortality rates declining from 159.3 in 1960 to 44 in 2011 and neonatal mortality rate declining from 47 (1990) to 32 (2010). Neonatal health is now an integral part of the countrys flagship program; National Rural Health Mission. Facility based newborn care is not only available in large public and private sectors hospitals, but also in about 300 of Indias district hospitals. Complementing these efforts is home based newborn care being delivered by community health volunteers. The last two decades has also witnessed an increase in newborn research and its incorporation into medical and paramedical education as a major course component. Neonatology now is an independent super-specialty in India. The National Neonatology Forum has had a major role in spearheading reforms in neonatal care in India.

Ongoing trials of simplified antibiotic regimens for the treatment of serious infections in young infants in South Asia and sub-Saharan Africa: implications for policy

BACKGROUND

The current World Health Organization (WHO) recommendation for treatment of severe infection in young infants is hospitalization and parenteral antibiotic therapy. Hospital care is generally not available outside large cities in low- and middle-income countries and even when available is not acceptable or affordable for many families. Previous research in Bangladesh and India demonstrated that treatment outside hospitals may be possible.

RESEARCH

A set of research studies with common protocols testing simplified antibiotic regimens that can be provided at the lowest-level health-care facility or at home are nearing completion. The studies are large individually randomized controlled trials that are set up in the context of a program, which provides home visits by community health workers to detect serious illness in young infants with assessment and treatment at an outpatient health facility near home. This article summarizes the policy implications of the research studies.

POLICY IMPLICATIONS

The studies are expected to result in information that would inform WHO guidelines on simple, safe and effective regimens for the treatment of clinical severe infection and pneumonia in newborns and young infants in settings where referral is not possible. The studies will also inform the inputs and process required to establish outpatient treatment of newborn and young infant infections at health facilities near the home. We expect that the information from research and the resulting WHO guidelines will form the basis of policy dialogue by a large number of stakeholders at the country level to implement outpatient treatment of neonatal infections and thereby reduce neonatal and infant mortality resulting from infection.

Does facility based newborn care improve neonatal outcomes? A review of evidence

CONTEXT

Facility based newborn care is gaining importance as an intervention aiming at reduction of neonatal mortality.

OBJECTIVE

To assess different factors that affect effectiveness of facility based newborn care on neonatal outcomes.

EVIDENCE ACQUISITION

Electronic search using key search engines along with search of grey literature manually. Observational and interventional studies published between 1966-Aug 2010 in English having a change in neonatal mortality as an outcome measure were considered.

RESULTS

A total of 40 articles were fully reviewed for generating synthesized evidence. All were observational studies. The exposure variables that affected neonatal outcomes were grouped into three categories- regionalization of perinatal care (17 articles), strengthening of lower level neonatal facilities (12), and other miscellaneous factors (11). Regionalization played a key role in advancing newborn care practices. It increased in-utero transfer of high risk newborns and improved survival outcomes especially for very low birth weight neonates at level III facilities. It led to reduction in neonatal mortality owing primarily to enhanced survival of low birth weight infants. Strengthening of lower level units contributed significantly in reducing neonatal mortality. High patient volume (>2,000 deliveries/year), inborn status, availability of referral system and inter-facility transfers, and adequate nursing care staff in neonatal units also demonstrated protective effect in averting neonatal deaths.

CONCLUSIONS

Countries investing in facility based newborn care should give impetus to establishing regionalized systems of perinatal care. Strengthening of lower level units with high case loads, can yield optimal reduction in NMR.

Impact of a district level sick newborn care unit on neonatal mortality rate: 2-year follow-up

OBJECTIVE

To evaluate the impact of creating a sick newborn care unit (SNCU) in a district hospital on neonatal mortality rate (NMR).

STUDY DESIGN

This study was conducted in a district hospital with 6500 deliveries a year. A 14 bed SNCU that included controlled environment, individual warming and monitoring devices, infusion pump, central oxygen and oxygen concentrators, resuscitation and exchange transfusion, portable X-ray and in-house laboratory was created. Doctors and nursing personnel were trained. Baseline data for 10 months were compared with 2 years data of SNCU operation.

RESULTS

Compared with the baseline neonatal mortality in the district hospital, neonatal mortality was reduced by 14% in the first year and by 21% in the second year after SNCU became functional. Estimated neonatal deaths averted were 329, which would reduce NMR of the district from 55 to 47 in 2 years.

CONCLUSION

A modern sick newborn care facility created in a district hospital can substantially reduce hospital neonatal deaths and NMR of the district. This model may be an effective tool to reduce NMR of the country.

Intrapartum transcervical amnioinfusion for meconium-stained amniotic fluid

OBJECTIVE

To assess the rates of cesarean deliveries and perinatal outcome following intrapartum transcervical amnioinfusion in women with meconium-stained amniotic fluid (MSAF) in a setting with no electronic fetal monitoring or specialized neonatal care.

MATERIALS AND METHODS

In this prospective comparative study with 150 women who were in labor and had MSAF, 50 of the women received a transcervical amnioinfusion and the remaining 100 women received standard care. The inclusion criteria were a pregnancy of at least 37 weeks' duration, a single live fetus in cephalic presentation, no major medical or obstetric complications, and no known fetal malformation. The amnioinfusion was performed with 1000 mL of normal saline solution through a red rubber catheter.

RESULTS

Amnioinfusion was associated with a significant decrease in the incidence of low Apgar score (<7) at 1 min (12% vs. 47%; relative risk [RR], 0.26; 95% confidence interval [CI], 0.12-0.56); low Apgar score at 5 min (4% vs. 23%; RR, 0.17; 95% CI, 0.04-0.71); and meconium aspiration syndrome (4% vs. 18%; RR, 0.22; 95% CI, 0.05-0.92). There was also a trend towards a lesser incidence of cesarean deliveries (18% vs. 30%; RR, 0.6; 95% CI, 0.31-1.16) and perinatal deaths (4% vs. 13%; RR, 0.31; 95% CI, 0.07-1.31). The incidence of maternal hospital stays longer than 3 days was significantly lower in the amnioinfusion than in the control group (24% vs. 48%; RR, 0.5; 95% CI, 0.29-0.85). There were no major complications related to amnioinfusion.

CONCLUSIONS

Intrapartum amnioinfusion for MSAF is a simple, safe, effective, and inexpensive procedure feasible in settings where intrapartum monitoring is limited. It is associated with improved perinatal outcome and could lower cesarean delivery rates in low-resource countries.

Impact of simple interventions on neonatal mortality in a low-resource teaching hospital in India

OBJECTIVE

To evaluate impact of simple interventions on neonatal mortality in a low-resource teaching hospital in India.

STUDY DESIGN

Before-and-after intervention trial setting: limited resource teaching hospital;

DESIGN

Before and after study.

INTERVENTIONS

A package of simple interventions was evolved. The interventions included: rational admissions and early discharge, entrusting mothers in care-giving, enforcing asepsis routines, aggressive enteral feeding, abandoning unnecessary interventions, protocol-based management, rational antibiotics and training and empowerment of nurses.

STATISTICAL METHODS

The categorical and continuous variables were compared with chi (2) and two-tailed tests, respectively.

RESULTS

Neonatal mortality rate declined significantly during the intervention period as compared to control period (20.3 versus 29.3 per 1000 live births; relative risk 0.69, 95% confidence interval (CI) 0.57 to 0.85). Most significant decline occurred in sepsis-related deaths. The survival of neonates with birth weight 1000 to 1499 improved over two folds (56.7% versus 24.5%, P<0.01). There was a significant decline in antibiotics use (635/878, 72.3% versus 299/897, 23.2%; P=0.00). The duration of stay in neonatal unit was decreased by a mean of 1.5 day (95% CI 0.9 to 2.8 days) after interventions.

CONCLUSIONS

Simple interventions can result in a significant decline in neonatal mortality in hospitals with limited resources. This package is likely to be effective in hospitals with a high proportion of the sepsis deaths.

The right to a healthy newborn

A woman's right to health includes her right to a healthy childbirth and newborn, and the baby possesses his or her own right to life as well. While overall child mortality has declined, 4 million newborns still die each year, primarily in the first days of life. Most could be prevented through existing, cost-effective interventions. Field trials and programs show that low-cost, home- or community-based neonatal care can quickly lead to dramatic decline in neonatal mortality. Newborn health should be integrated with maternal and child health-and these programs should be strengthened and expanded-in order to achieve both the child and maternal survival Millennium Development Goals. Policies and programs should include participatory household and community-based care, with links to the formal health system. Despite recent attention to newborn health, much remains to be done to achieve sustained, high coverage of effective interventions, especially in poor communities where most newborns are born and die, mostly in the first week of life.

The current state of newborn health in low income countries and the way forward

Of the 4 million neonatal deaths that occur worldwide each year 99% of these occur in developing countries. South Asia and sub-Saharan Africa regions account for two thirds of the global burden. Skilled professionals attend only 35% deliveries in South Asia and 41% in sub-Saharan Africa. Known, affordable interventions delivered through a rational mix of outreach, family/community and clinical services can reduce over 70% of all neonatal deaths. The Millennium Development Goal of reducing the mortality of children under 5 years by two thirds by the year 2015 from the 1990 baseline would require a substantial reduction in neonatal mortality in the next decade. For this, the low and middle-income countries must urgently review their existing programs, and design and implement improved, integrated action plans for maternal, newborn and child health. International community, including the academics, institutions and professional bodies in developed countries can play a crucial role to make this mission a success.