|Year : 2016 | Volume
| Issue : 3 | Page : 183-188
Pattern of neonatal morbidity and mortality: A prospective study in a District Hospital in Urban India
Navdeep Saini1, Sanjay Chhabra1, Sunny Chhabra1, Lalit Garg2, Nidhi Garg2
1 Department of Pediatrics, Sigma Child and Maternity Hospital, Jalandhar, Punjab, India
2 Department of Obstetrics and Gyanecology, Kamal Child and Maternity Hospital, Jalandhar, Punjab, India
|Date of Web Publication||28-Sep-2016|
Dr. Navdeep Saini
57, Indira Park, Wadala Road, Jalandhar, Punjab
Source of Support: None, Conflict of Interest: None
Objective: To determine the cause and disease pattern of neonatal morbidity and mortality in the secondary care neonatal unit of a district hospital. Study Design: Descriptive prospective study. Setting: Department of Pediatrics, General Hospital, Sec 16, Chandigarh. This hospital is providing optimal neonatal Level 2 care. Participants: All neonates who born in General Hospital Sec 16, Chandigarh, over 1 year were enrolled in the study. Outside born neonates and those who were re-admitted in the neonatal nursery after their discharge from hospital were excluded from the study. Methods: All consecutive live-born babies in the period of 1-year were included in the study. Babies received in labor room or operation theater were assigned Apgar score, and vital parameters were recorded. Sick babies were shifted to neonatal nursery as per admission policy, and rest of the babies were shifted with mother. All the babies were examined within 24 h of birth and daily thereafter till their discharge from the hospital. Main Outcome Measure: Antenatal and postnatal services, maternal education. Results: There were 6509 live births, of which 50 were twin pairs and 6409 were singleton birth. About 4.33% babies were born prematurely (<37 weeks), 21.7% babies were low birth weight (LBW) (<2500 g) including 0.4% very LBW (VLBW) babies (<1500 g), and 0.26% as extra LBW (ELBW) (<1000 g) babies. Five hundred and ninety-two (9.09%) babies were suffered from various morbidities, and 67 (1.03%) died during the hospital stay. Hyperbilirubinemia (7%) was the leading cause of neonatal morbidity followed by sepsis (3.99%) and respiratory distress (3.9%) among the various causes of respiratory distress transient tachypnea of the newborn was the leading cause (33%) followed meconium aspiration syndrome (20.5%) and pneumonia (14.9%). Hyaline membrane disease was seen in 11.8% of cases. Congenital malformations were seen in 1.75% of cases. Limb defects (31.3%) were the most common malformation followed by cardiac 49.9%, neural tube defect (13.9%), and Down syndrome 7.8%. Birth asphyxia (29.85%) and respiratory distress (22.38%) were the leading cause of death followed by extreme prematurity (22.3%) and sepsis (14.9%). Morbidity and mortality among LBW babies (22.3% and 3.53%) and ELBW (100% and 88%) and VLBW (84.6% and 46.2%) were higher as compared to normal birth weights (5.44% and 0.33%). Morbidity and mortality among preterm babies (58.5% and 11.7%) were high as compared to term babies (6.97% and 0.53%). Morbidity was higher among large for date babies (41%) as compared to small for date (SFD) (17.7%) and appropriate for date (AFD) (6.8%) babies higher mortality was seen in SFD babies (1.9%) as compared to 0.8% in AFD babies. Conclusion: Hyperbilirubinemia, sepsis, and respiratory distress were the leading causes of morbidity in our study. Birth asphyxia, prematurity, and neonatal sepsis were the leading causes of neonatal mortality in our study. Interventions to reduce preterm delivery, LBW, and birth asphyxia should be planned and implemented by health-care managers at the community level. Improvements in neonatal care at different levels will definitely reduce the neonatal deaths.
Keywords: Millennium Development Goal 4, neonatal morbidity, neonatal mortality
|How to cite this article:|
Saini N, Chhabra S, Chhabra S, Garg L, Garg N. Pattern of neonatal morbidity and mortality: A prospective study in a District Hospital in Urban India. J Clin Neonatol 2016;5:183-8
|How to cite this URL:|
Saini N, Chhabra S, Chhabra S, Garg L, Garg N. Pattern of neonatal morbidity and mortality: A prospective study in a District Hospital in Urban India. J Clin Neonatol [serial online] 2016 [cited 2020 Feb 17];5:183-8. Available from: http://www.jcnonweb.com/text.asp?2016/5/3/183/191258
| Introduction|| |
Neonatal period is defined as up to first 28 days of life and further divided into very early (birth to <24 h), early (birth to <7 days), and late neonatal period (7 days to <28 days). Neonatal period is the most vulnerable period of human life as it accounts for very high morbidities and mortalities and most of these are preventable. It is estimated that 130 million neonates are born each year and out of these, 4 million die in first 28 days of their life. In the neonatal period, 50% of all deaths are within first 24 h while 75% are within first 7 days of life. Hence, necessary interventions and strategies to reduce 1st week neonatal mortality (NNM) can help us to achieve Millennium Development Goal 4 (MDG4). The aim of MDG4 is to reduce under-five mortality to 30/1000 live births by 2015. In the year 2000, an estimate of 10.6 million children under 5-year age died, which decreased to 8.8 million in 2008 and 7.7 million in 2010. Unfortunately, the share of neonatal deaths has increased from 37% in 2000 to 41% in 2008. It is alarming and warrants an urgent attention of health managers and political leaders to make necessary strategies and interventions to reduce this trend.
Of the 4 million neonatal deaths that occur every year, 98% are in the poorest countries of the world. While the South Central Asian countries account for the highest numbers of neonatal deaths, the countries with highest rates are generally in sub-Saharan Africa. Ten countries account for 75% of all neonatal deaths, with India, China, Pakistan, and Nigeria leading the pack. India has the highest Neonatal Mortality Rate(NMR) as many as 1.09 million children die annually with the NMR rate varies by state but, overall, it was reported to be 43 per 1000 live births. Globally important causes of NMR are prematurity, birth asphyxia, and sepsis in low-income country, whereas prematurity and malformations are the leading causes of death in developed countries. To plan the strategy to reduce NNM rate and prioritization of resources, it is important to know the contribution of various factors to neonatal deaths. Low birth weight (LBW), birth asphyxia/birth trauma, and infections are responsible for majority of deaths in the community.
NNM statistics serve as sensitive indicators of the availability, utilization, and effectiveness of maternal child health service in the community. The incidence of NNM rate is variable from place to place and is also different from hospital to hospital and home born babies. Data derived from hospital record do not truly represent NNM rate and its various causes in the community at large but has the advantage of being more reliable in term of causes of death and reflect the quality of service available.
Reducing NNM is a prerequisite for attaining MDG 4. Increased investment in health by various governments is necessary to tackle the factors predisposing to the unacceptably high NNM rates in developing countries like India., Strengthening of health systems includes the provision of a suffi cient number of well-equipped health facilities and with proportional spread to meet local needs. Health facilities for the management of uncomplicated pregnancies and deliveries should be within the reach of every woman in every community.
| Methods|| |
The present study was conducted in the Department of Paediatrics, Sec 16, Chandigarh. All consecutive live-born babies in the period of 1-year were included in the study. Babies received in labor room or operation theater were assigned Apgar score, and vital parameters were recorded. All the babies were examined within 24 h of birth and daily thereafter till their discharge from the hospital. All the babies were followed daily in the nursery and postnatal wards. In postnatal wards, if any baby was found sick, they were shifted to the septic nursery for the treatment. All details regarding history, examination, and investigation were recorded in a predesigned performa. At the time of discharge, detailed examination was done and recorded. Diagnosis of various causes of morbidity and mortality was made on the basis of the standard definition given by the National Neonatology Forum. The inclusion criteria were all those neonates born in general hospital. Neonates readmitted in the neonatal nursery after their discharge from hospital were excluded from the study. Diagnosis was mainly clinical and based on the WHO criteria and Wigglesworth classification. Diagnostic support from laboratory and radiology was available and used to confirm diagnosis. The primary disease was considered as the final diagnosis even the baby developed complications of the primary disease or having more than one disease. The WHO definitions were used for prematurity, LBW, very LBW (VLBW), extra LBW (ELBW), and congenital malformation. Meconium aspiration syndrome (MAS) was diagnosed on the basis of history, clinical, and radiological findings. Birth asphyxia syndrome was diagnosed clinically plus Apgar score. Sepsis evaluation was based on clinical and laboratory indices such as complete blood counts, erythrocyte sedimentation rate, C-reactive protein, and cultures collectively. It is our hospital protocol that sick babies were shifted to neonatal nursery as per admission policy, and rest of the babies were shifted with mother. Sick babies with maternal history of prolonged rupture of membrane (<24 h) or multiple per vaginum examination (>4) or unclean per vaginum examination or Dai handling were shifted to septic nursery and rest of the babies were shifted to neonatal nursery.
The study involved meticulous history taking, thorough physical examination, and investigative procedure as per the standard hospital protocol. This study did not interfere with the routine management, and no additional intervention was made part of the study. The data thus collected were fed on the computer and subjected to statistical analysis using Chi-square test. P <0.05 was taken as significant.
| Results|| |
In the present study, 6717 births were included during the year, but 6509 live births were considered, 208 normal babies could not enroll in the study because some of them left against medical advice before the enrollment in the study and other did not give consent for the study. Of the total 6509 deliveries, 5368 (82.5%) were normal vaginal deliveries, 1027 (15.8%) were lower segment cesarean section, 75 (1.2%) were ventouse, and 38 (0.6%) were forceps deliveries. There were fifty pairs of twin and rest 6409 were single tone birth. Of the total 6509 births, 3549 (54.56%) were male and 2958 (45.44%) were female, and ambiguous genitalia was seen in two babies. The incidence of total morbidity and mortality during the study period was 9.09% and 1%, respectively, and 0.4% of babies were referred to the higher institute for further management.
[Table 1] shows the major cause of morbidities. Hyperbilirubinemia (7.0%) was the leading cause of neonatal morbidity followed by birth asphyxia/trauma (4.04%), sepsis (3.99%), and respiratory distress (3.9%). Among the various causes of respiratory distress, transient tachypnea of the newborn (TTNB) (33%) was the leading cause of respiratory distress followed by MAS (20.5%), pneumonia (14.9%), and hyaline membrane disease (11.8%). Th e incidence of neonatal seizure was 0.3% and of congenital malformation was 1.75%. Hematological and metabolic morbidities were seen in 1.6% and 0.5% of babies, respectively. Birth asphyxia is seen in 4% babies, and out of which 60% had moderate and 40% had severe birth asphyxia. Sepsis was seen in 260 babies (3.99%) and out of which 77 had a deep infection and rest were superfi cial (183) infection. Th e congenital malformation was seen in (1.75%) babies and out of which limb defect seen in 36 (31.3%) babies, neural tube defect was seen in 15 (13.9%) babies, cardiac defect was seen in 17 (14.8%) babies, cleft lip palate in 13 (11.3%) babies, and Down syndrome was seen in 9 (7.8%) babies. Hematological morbidities were present in 1.6% of babies and out of which polycythemia was seen in 72.4%, anemia was 23.8%, and hydronephrosis was present in 3.8% cases. Hypothermia was seen in 43 (0.7%) babies. In the present study, the overall incidence of mortality was 1.03%, i.e., 67 babies were died with various causes. [Table 2] signifies the leading cause of death in the present study was birth asphyxia seen in twenty babies (29.85%) followed by respiratory distress in 17 babies (25.3%) and HMD was the commonest cause of respiratory distress in preterm babies. Extreme prematurity as a cause of death was seen in 22.38% and sepsis was seen in 14.9% of total death. Of the total death, 32 were male (47%) and 37 (53%) were female.
[Table 3] reveals that the neonatal morbidity and mortality are the highest among the LBW and preterm babies as compared to normal birth weight and term babies. It was observed as the birth weight of the babies increased the mortality and morbidity were decreased. Of the 592 babies with various morbidities, 315 (53.2%) were LBW babies and similarly out of 67 babies who died 50 (74.6%) were LBW (P = 0.001). There was no significant difference in morbidity in weight groups of 2000-2499 g, 2500-2999 g, and >3000 g, while mortality was increased significantly if birth weight fell below 2000 g. Similarly, mortality was higher among the babies <1500 g. Among the ELBW baby's morbidity was 100% and mortality was 88.2%, while VLBW babies had morbidity in 80.7% and mortality was seen in 46% babies. [Table 4] reveals the morbidity and mortality were higher among the preterm babies <37 weeks, and it was much higher among babies <32 weeks. Of the total 282 preterm babies, morbidities were found in 155 (55%) babies, whereas of the total 6227 term babies, 437 (7%) babies showed various morbidities. Similarly, mortality among preterm babies was 11.3% as compared to term babies (0.6%). Neonatal morbidity and mortality were found to be inversely related to birth weight and gestation (P = 0.001).
|Table 3: Neonatal morbidity and mortality according to weight and gestation |
Click here to view
|Table 4: Neonatal morbidity and mortality distribution according to gestation |
Click here to view
As shown in [Table 5], the morbidity among large for date (LFD) babies (41%) and small for date (SFD) (17.7%) was higher as compared to appropriate for date (AFD) (6.8%). None of the babies died among LFD babies and 1.9% of mortality was seen in SFD babies as compared to AFD babies (0.8%). Again it showed a significant relationship between the intrauterine growth of babies and neonatal morbidity (P = 0.001) and mortality (P = 0.003).
|Table 5: Neonatal morbidity and mortality distribution according to intrauterine growth |
Click here to view
| Discussion|| |
NNM statistics serve as sensitive indicators of the availability, utilization, and effectiveness of maternal child health service in the community. The incidence of NNM rate is variable from place to place and is also different from hospital to hospital and home born babies. Data on neonatal outcome in district hospitals dealing with large population are scarce. Therefore, we planned to study the pattern of neonatal morbidity and mortality in this hospital which is providing Level 2 neonatal care facilities.
These findings are not surprising and probably apply to many other under-resourced settings and developing countries such as India, Pakistan, and Bangladesh. This study showed male preponderance (54.3%). Again it is consistent with local literature reported by NNPD (52.9% male versus 47% female), Rakholia et al. (63.25% male vs. 36.75% female), and international studies from Nigeria (54.3% male vs. 45.7% female), Pakistan (63.75% male vs. 36.25% female) and from South Africa (57.8% male vs. 42.2% female). It may be due to biological, cultural, and social factors. The incidence of LBW was 21.7% and of premature babies 4.3% in the present study. The similar observation of LBW (29.9% and 31.3%) reported by Manzar et al. and NNPD. However, higher number of preterm reported by Manzar et al. (22%), Lala and Talsania (10.20%), and NNPD (14.5%). Th e study has done in a developing country such as Pakistan by Hussain (53.8%) and in South Africa by Hoque et al. (43.7%) found the very high incidence of LBW. Th is could be explained by the special characteristics of the institution dealing with a much higher number of high-risk pregnancies leading to higher number of LBW and premature babies as compared to our hospital.
In the present study, the most common causes of neonatal morbidity were neonatal jaundice and prematurity (7% and 4.3%); perinatal asphyxia was responsible for 4%, sepsis 3.99%, and respiratory distress 12.6%. Garg et al. also reported hyperbilirubinemia (23.2%) as the leading cause of morbidity followed by birth asphyxia (14.8%) in a community level hospital in Delhi. The findings are similar to NNPD and Nahar et al. where hyperbilirubinemia and asphyxia are the common cause of morbidity after prematurity. Higher incidences of jaundice in neonates have been reported from other studies from India,,,,,, and other developing countries, such as Pakistan and Nigeria (11.3% and 9.5%, respectively)., Neonatal hyperbilirubinemia resulting in clinical jaundice is a common problem among infants. Information about the incidence of NNJ in developing countries is lacking as the vast majority of births occur at home. The majority of the data are from tertiary care or intensive care nurseries with no population denominator. Studies from Africa show more admissions due to sepsis, jaundice, and asphyxia. In the developed countries, the scenario is diff erent with extreme prematurity, asphyxia, and congenital anomalies being the chief causes as seen a study in Canada by Simpson et al. Th e incidence of prematurity is also increasing in developing country like India,,,,, and Pakistan,, being most common cause of neonatal morbidity nowadays. Respiratory distress is also the important cause of neonatal morbidity, and it causes not only varies from center to center but also depends on the place of delivery whether it is institutional or home delivery. TTNB was the leading cause of respiratory distress seen in 33% of respiratory distress followed by MAS (20.5%). Mathur et al. have reported pneumonia (66.7%) as the most common cause of respiratory distress in their study on outborn babies and referred babies which are much higher as compared to our study (14.9%). The difference may have been due to the different set of the study population in Mathur et al. Congenital malformation was seen in 1.75% of babies in our study which is slightly higher than studies in Pakistan, and NNPD but low when compared to Rakholia et al. and Hussain.
Percentage (per 100 live births) of NNM in our study was 1.03% as compared to the reported percentage of 2.5% by NNPD and 3.31% in a study done by Niswade et al. in the rural community in India. The low incidence of mortality in the present study could be because of high-risk pregnancies being referred to tertiary care centers dealing with higher number of high-risk pregnancies as compared to our hospital. Mortality rate (per 100 morbidities) in our study is 11.3%. In literature, it is reported different from different places. Manzar et al. have reported 8% and Kumar et al. 13.6% from India. From neighboring countries, it is 20.6%, 20.3%, and 17.15% from Bangladesh, Nigeria, and Pakistan, respectively. This variation may be due to sample nature and facilities available in the neonatal unit because the survival of neonates also depends on care provided to them. In our study, we found birth asphyxia (29.85%) as the leading cause of NNM followed by respiratory problem (25.3%), prematurity (22.38%), and sepsis accounted for <15% of death. NNPD and Nagarajarao et al. reported birth asphyxia was the leading cause of NNM followed by prematurity and sepsis. Preterm birth has a major impact on NNM, accounts for 35%-70% of neonatal deaths, and mortality rate is increasing due to preterm birth day by day. Agarwal et al. (33.7%) and Rakholia et al. (25.68%) from India reported that prematurity was the most common cause of NNM and very high incidence >50% of NNM due to prematurity reported in studies in Pakistan., Sepsis was the leading cause of death in studies done by Manzar et al. in Pakistan and Ugwu in Nigeria. Again these variations might be due to the availability of modern facilities like ventilation and surfactant use in these neonatal units. Hence, it reveals that prematurity, birth asphyxia, and sepsis are the major leading cause of NNM but the incidence varies from center to center but also varies in the same center time to time as it evident by NNPD data; thence, studies should be conducted periodically to assess the leading cause of mortality and tackle the problem accordingly.
| Conclusion|| |
Interventions should be planned and implemented at different levels of community to prevent and reduce preterm delivery,low birth weight and birth asphyxia, which are leading causes of neonatal deaths.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Carlo WA. Overview of mortality and morbidity. In: Kliegman RM, Stanton BF, SP Geme III JW, Schor NF, Behrman RE. Nelson Textbook of Pediatrics. 19 th
ed., Vol. 87. Philadelphia: Elsevier, WB Saunders; 2011. p. 532.
Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet 2005;365:891-900.
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226-34.
Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al.
Global, regional, and national causes of child mortality in 2008: A systematic analysis. Lancet 2010;375:1969-87.
Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, et al.
Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: A systematic analysis of progress towards Millennium Development Goal 4. Lancet 2010;375:1988-2008.
Ngoc NT, Merialdi M, Abdel-Aleem H, Carroli G, Purwar M, Zavaleta N, et al.
Causes of stillbirths and early neonatal deaths: Data from 7993 pregnancies in six developing countries. Bull World Health Organ 2006;84:699-705.
Registrar General of India. Annual Family Health Survey. Sample, Registration System, New Delhi; 2011.
Ugwu GI. Pattern of morbidity and mortality in the newborn special care unit in a tertiary institution in the Niger Delta region of Nigeria: A two year prospective study. Glob Adv Res J Med Med Sci 2012;1:133-8.
Nagarajarao V, Ahmed M, Ravi A, Pattabhirama GH, Balasundaram K. A study of early neonatal morbidity profile in a district teaching hospital, Mysore, India. Int J Med Public Health 2014;4:396-9. Available form: http://www.ijmedph.org
. [Last cited on 2015 Jul 21].
Ali SR, Ahmed S, Lohana H. Disease patterns and outcomes of neonatal admissions at a secondary care hospital in Pakistan. Sultan Qaboos Univ Med J 2013;13:424-8.
Manzar N, Manzar B, Yaqoob A, Ahmed M, Kumar J. The study of etiological and demographic characteristics of neonatal mortality and morbidity - A consecutive case series study from Pakistan. BMC Pediatr 2012;12:131.
Abhimanyu N, Sanjay PZ, Suresh U, Shrikant IB. Neonatal morbidity and mortality in tribal and rural communities in central India. Indian J Community Med 2011; 36:1.
Million Death Study Collaborators, Bassani DG, Kumar R, Awasthi S, Morris SK, Paul VK, et al.
Causes of neonatal and child mortality in India: A nationally representative mortality survey. Lancet 2010;376:1853-60.
Agarwal R, Agarwal K, Acharya U, Christina P, Sreenivas V, Seetaraman S. Impact of simple interventions on neonatal mortality in a low-resource teaching hospital in India. J Perinatol 2007;27:44-9.
Rakholia R, Rawat V, Bano M, Singh G. Neonatal morbidity and mortality of sick newborns admitted in a teaching hospital of Uttarakhand. Chrismed J Health Res 2014;1:228-34. Available from: http://www.cjhr.org/text.asp?2014/1/4/228/142983
. [Last cited on 2015 Jul 17].
Nahar J, Zabeen B, Akhter S, Azad K, Nahar N. Neonatal morbidity and mortality pattern in the special care baby unit of Birdem. Ibrahim Med Coll J 2007;1:1-4.
Hussain S. Neonatal morbidity and mortality pattern in a tertiary care neonatal unit of a teaching hospital. Ann Pak Inst Med Sci 2014;10:7-11.
National Neonatology Form of India. National Neonatology Perinatal Database Report for Year 2002-2003. New Delhi: National Neonatology Form of India; 2003.
Garg P, Krishak R, Shukla DK. NICU in a community level hospital. Indian J Pediatr 2005;72:27-30.
Bang A, Reddy MH, Deshmukh MD. Child mortality in Maharashtra. Econ Polit Wkly 2002;37:4947-65.
Bhandari N, Bahl R, Taneja S, Martines J, Bhan MK. Pathways to infant mortality in urban slums of Delhi, India: Implications for improving the quality of community-and hospital-based programmes. J Health Popul Nutr 2002;20:148-55.
Kumar M, Paul VK, Kapoor SK, Anand K, Deoraria AK. Neonatal outcomes at a subdistrict hospital in north India. J Trop Pediatr 2002;48:43-6.
Bang AT, Bang RA, Baitule S, Deshmukh M, Reddy MH. Burden of morbidities and the unmet need for health care in rural neonates - A prospective observational study in Gadchiroli, India. Indian Pediatr 2001;38:952-65.
Aggarwal AK, Kumar R, Kumar P. Early neonatal mortality in a hilly north Indian state. Indian J Prev Soc Med 2003;34:46-51.
Niswade A, Zodpey SP, Ughade S, Bangdiwala SI. Neonatal morbidity and mortality in tribal and rural communities in central India. Indian J Community Med 2011;36:150-8.
Lala MK, Talsania NJ. Study of evaluation and prediction of neonatal morbidity and mortality using ICMR antenatal scoring method. Indian J Community Med 2005;26:10-12.
Hoque M, Haaq S, Islam R. Causes of neonatal admissions and deaths at a rural hospital in KwaZulu-Natal, South Africa. South Afr J Epidemiol Infect 2011;26:26-9.
Simpson CD, Ye XY, Hellmann J, Tomlinson C. Trends in cause-specific mortality at a Canadian outborn NICU. Pediatrics 2010;126:e1538-44.
Mathur NB, Garg K, Kumar S. Respiratory distress in neonates with special reference to pneumonia. Indian Pediatr 2002;39:529-37.
Kumar MK, Th akur SN, Singh BB. Study of morbidity and the mortality patterns in NICU at tertiary care teaching hospital in Rohtas district, Bihar, India. JCDR 2012;6:282-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]