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ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 130-135

Morbidity and mortality patterns among outborn referral neonates in central India: Prospective observational study


Department of Pediatrics, Government Medical College, Nagpur, Maharashtra, India

Date of Web Publication2-Aug-2018

Correspondence Address:
Dr. Rajkumar Motiram Meshram
Department of Pediatrics, Government Medical College, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_27_18

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  Abstract 


Background: Accurate assessment of morbidity and mortality patterns of neonates are reported of inborn babies treated in neonatal intensive care unit, but data on outborn neonates treated suboptimally in general pediatric ward is lacking. Objective: The objective of the study is to document the morbidity and mortality pattern of outborn referral neonates. Materials and Methods: This was a prospective observational study undertaken at a tertiary care teaching government hospital, for 1 year. All outborn referral neonates admitted were included in the study. Relevant maternal and neonatal data were included and analyzed. Results: A total of 1077 outborn referral neonate were admitted during the study, out of which 39 were excluded from the study. As a result, 1038 neonates were included for analysis with 58.96% male and 41.04% female giving a male to female ratio 1.4:1. Most of them were from rural area and lower socioeconomic class. About 96.92% mothers were registered either at primary, secondary, or tertiary health-care facilities. The average distance traveled by neonate was 84.81 km. The leading cause of admission was sepsis (37.37%), prematurity with respiratory distress syndrome (14.55%), perinatal asphyxia (17.53%), jaundice (9.73%), and others such as malformations, meconium aspiration syndrome, genetic syndrome, and metabolic complication. Neonatal mortality rate was 31.98% and more than two-thirds deaths were within 1st week of life, with no sex predilection. The most common cause of mortality was sepsis (34.94%), followed by perinatal asphyxia (22.29%) and prematurity with respiratory distress. Conclusion: Neonatal mortality was 31.98% in our study. Systemic infection, prematurity with respiratory distress and perinatal asphyxia were the leading causes of admission in our study. These preventable causes should be urgently addressed if we hope to achieve the millennium developmental goal.

Keywords: Morbidity, neonatal mortality, outborn neonate, referral neonate


How to cite this article:
Bokade CM, Meshram RM. Morbidity and mortality patterns among outborn referral neonates in central India: Prospective observational study. J Clin Neonatol 2018;7:130-5

How to cite this URL:
Bokade CM, Meshram RM. Morbidity and mortality patterns among outborn referral neonates in central India: Prospective observational study. J Clin Neonatol [serial online] 2018 [cited 2018 Aug 15];7:130-5. Available from: http://www.jcnonweb.com/text.asp?2018/7/3/130/238402



[TAG:2]Introduction[/TAG:2]

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 the first 28 days of their life, and 75% of neonatal deaths occur in the 1st week.[1] The global burden of neonatal death is primarily concentrated in the developing countries where care of neonate is practically nonexistent.[2] India contributes to one-fifth of global live births and more than a quarter of neonatal death. In India, nearly 0.75 million neonates died in 2013, the highest for any country in the world and the current neonatal mortality rate is 25 per 1000 live births with interstate, rural-urban variation and in most backward and disadvantaged population especially scheduled caste and scheduled tribe population.[3],[4],[5] Globally, prematurity (29%), infections (29%), asphyxia (23%), congenital malformations (8%), and other (11%) are important causes of neonatal death in low-income country while prematurity and malformation contribute in developed countries.[6]

Accurate assessment of morbidity and mortality pattern of neonates are reported in generally inborn babies treated in the neonatal intensive care unit. However, accurate data of outborn neonates is scanty. Outborn neonates have been previously admitted to a different institution or might be home delivered, and sometimes older at the time of admission. Due to above-mentioned differences, morbidity and mortality pattern may be different from those found in the inborn unit and such data are lacking in India and globally.

With this background, this study aims to document the morbidity and mortality pattern of these neonates and review their management to identify areas that need improvement, to optimize their care.

[TAG:2]Materials and Methods[/TAG:2]

This was a prospective observational study undertaken at one of the largest tertiary care teaching government referral hospital that provide care to underprivileged, socioeconomically deprived population of central India (Vidarbha region of Maharashtra, Madhya Pradesh, Chhattisgarh, and Telangana) over a period of 1 year from May 2016 to April 2017. This hospital is a 1200 bedded tertiary health-care facility, and 400 bedded super specialty hospital. Daily around 3000 patients attend outpatient department and around 700—800 patients are admitted to various specialties. In pediatric specialty, there are three wards of 40 beds in each and four units working functionally by rotation, 20 bedded Neonatal Intensive Care Unit and 10 bedded Pediatric Intensive Care Unit functioning effectively with 13 teaching faculty and 33 postgraduate resident and adequate quantity of nursing staff. There are sufficient phototherapy machines, multipara monitor, and ventilators for caring of neonate at Neonatal Intensive Care Unit (NICU). As per the policy of the hospital, outborn and referral neonates are not admitted to our NICU; and hence, they are kept in the general pediatric ward where there are separate cabinets in each ward, equipped with radiant warmer, phototherapy machine, bubble continous positive airway pressure (CPAP), and central oxygen supply.

All outborn referral neonates admitted through either outpatient or emergency department were included in study after approval from institutional ethical committee and informed valid consent from parents and those who left the hospital against medical advice and not willing to participate in the study were excluded. Data were collected following admission, from either the mother or caregiver in a specially designed pro forma for study. The data extracted include maternal age, gravida, parity, previous abortion, availability of health facility, antenatal care provider, either booked or unbooked, distance from institute, referral person, maternal diseases, obstetrics complications, mode of delivery, and place of delivery. Neonatal data, including gestational age, gender, age at admission, weight at admission, diagnosis at admission, duration of hospital stay, and Apgar score were noted either from available document or estimated from mothers based on data whether baby cried immediately after birth, details of activity, color, and respiratory effort of the newborn after birth. The 5 min Apgar score was used to diagnose and grade the degree of perinatal asphyxia. Temperature was not recorded at the time of admission.

All neonates were observed for clinical and management events such as antibiotic use, blood transfusion, exchange transfusion, phototherapy, surgery, method and type of feeding till discharge or death. Diagnosis of neonatal illness and estimation of the cause of death was done using clinical information and necessary laboratory investigations.

Statistical analysis

The data were entered into excel sheet and analysis was done using software Epi-info version 7.2.2.6 (Atlanta, USA). The data regarding the numerical variable were summarized through percentage, average, median, and deviation pattern. Comparisons of categorical data were carried out using Pearson's Chi-square or Fisher's exact test where appropriate. P < 0.05 was taken as statistically significant.

[TAG:2]Results[/TAG:2]

A total of 1077 outborn referral neonate were admitted during the study, out of which 39 were excluded because they left the hospital against medical advice. As a result 1038 neonates were included for the data analysis of which 612 (58.96%) were male and 426 (41.04%) were female giving a male to female ratio 1.4:1 and most of them were from rural area and from lower socioeconomic class. Although health-care facilities were available for 1036 (99.81%) mothers, only 1006 (96.92%) mother were registered case either at primary, secondary, or tertiary health-care facilities and 609 (58.67%) mother received antenatal care from medical officer. 868 (83.62%) neonates were referred by medical officer and 271 neonates died. 170 (16.38%) neonates referred by paramedical persons and 61 died. Mortality was not statistically significant between referral person. Average distance traveled by nonsurvival neonate was 94.13 ± 77.58 Km and 80.38 ± 74.96 Km in survival neonates and this difference was statistically significant (P = 006).

Seven hundred and thirty-two (70.52%) mothers were suffering from anemia followed by 170 (16.38%) having hypertension during pregnancy, while preeclampsia and eclampsia was the commonest obstetric complication during labor. Nine hundred and seventeen (88.34%) neonates were delivered by vaginal route and 121 (11.66%) by cesarean section and 1011 (97.40%) deliveries were occurred in either primary, secondary, or tertiary care level hospital [Table 1]. 703 (67.73%) neonates were term and 334 (32.18%) were preterm. Five hundred and one (48.27%) neonates were average birth weight, 343 (33.04%) low birth weight, 137 (13.20%) very low birth weight, 47 (04.53%) extremely low birth weight, and 10 (0.96%) were above average weight [Figure 1].
Table 1: Sociodemographic, maternal, and neonatal profile of the study population

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Figure 1: Weight-wise admission and mortality

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The leading cause of admission were sepsis (37.37%), prematurity with respiratory distress syndrome (RDS) (14.55%), perinatal asphyxia (17.53%), jaundice (9.73%), and other morbidities that necessitated admission such as malformations, meconium aspiration syndrome, genetic syndrome and metabolic complication, perinatal varicella (3 cases), congenital cytomegalovirus hepatitis (one case), and birth injury (one case) as shown in [Table 2].
Table 2: Morbidity and mortality pattern of outborn referral neonate

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A total of 332 neonatal deaths were recorded during the study accounting for 31.98% of the total neonatal admissions. Out of this number, 167 were male and 164 were females giving a male to female ratio of 1.01:1. The most common cause of mortality was sepsis (34.94%), followed by perinatal asphyxia (22.29%) while case fatality was highest with respiratory distress other than prematurity followed by perinatal asphyxia [Table 2]. About 82.53% neonatal deaths were in 1st week of life and half of them in first 24 h of life [Table 3].
Table 3: Outcome in relation to age at admission

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[TAG:2]Discussion[/TAG:2]

Documentation of morbidity and mortality data is very important and beneficial for the health-care provider, investigators, researchers, and the decision makers to design intervention for prevention and treatment and hence improving the quality of care. Most published data studies on neonatal morbidity and mortality in the world have been conducted in the newborn unit of well-equipped tertiary hospitals and community levels.[7],[8],[9],[10] Very few studies have been conducted on outborn referral neonates which were managed at suboptimal care and treated in general pediatric wards.[11],[12]

In the present study, most of the neonates were male (male:female ratio 1.43:1) of rural areas and from low socioeconomic class. The sex distribution is in concordance with the National Neonatal Perinatal Database (NNDP) and other studies.[13],[14] Such male predominance in this study may be due to gender bias in India where male babies are given more care and biological vulnerability of male neonate. Our institute is the largest referral tertiary care and caters to the underprivileged and socioeconomically deprived population, so most of the cases were referred from rural areas. As the management, complications, and prognosis of neonates depends on gestational age and birth weight, we classified the neonate into preterm, term, postterm and average birth weight, low birth weight and above average weight as per the WHO classification on the basis of gestational age and weight on admission. We observed 76.35% term babies and 43.33% low birth weight babies in our study. Similar types of observation were noted by Okposio and Ighosewe,[12] Fahmy et al.[15] Although the antenatal care improved, the average distance traveled by neonate is 84.81 km. Hence, the safe transport facility should be improved.

In the present study, the most common cause of admission were sepsis/pneumonia/meningitis (37.57%), perinatal asphyxia (22.29%), respiratory distress due to prematurity (20.48%), jaundice (9.73%), congenital malformation (5.97%), congenital heart disease (5.9%), and respiratory distress other than prematurity (5.39%). The findings are similar to NNDP which showed systemic infections (28.4%), perinatal asphyxia (23%), prematurity (29%), congenital malformation (8%), and other causes (11%). Studies from Africac and Vietanm show more admissions due to sepsis, jaundice, and tetanus.[11],[12],[16],[17] In the developed countries, the scenario is different with extreme prematurity, malformation, and congenital anomalies being the major causes as reported by Fahmy et al. from Egypt and Simpson et al. from Canada.[18]

We observed sepsis (34.94%) was the major cause of death followed by perinatal asphyxia (22.29%), prematurity with RDS (20.48%), respiratory distress other than prematurity (12.95%), congenital heart disease (4.22%), jaundice (1.50%), malformation (1.5%), meconium aspiration syndrome (1.2%), and one baby of Down syndrome with tracheoesophageal fistula. Our results are in concordance with the Indian and Asian studies [Table 4].[19],[20],[21],[22] However, an African study shows higher deaths due to jaundice and tetanus.[11],[12],[16] The results are in contrast to developed countries where extreme prematurity-related conditions and congenital malformations are the main cause of mortality as better neonatal care and safe, timely transport facility ensure lesser sepsis and better survival of neonates with respiratory distress.[18] The neonatal mortality rate in our study was 31.98% and 82.53% deaths were in the 1st week of life and half of them in first 24 h of life which was quite higher than other studies from different parts of India. The likely causes for this high mortality rate are as follows:
Table 4: Morbidity and mortality pattern in various

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  • Most of the neonates were delivered by vaginal route at primary or secondary health-care level by paramedical workers with inadequate aseptic precaution and untrained in neonatal resuscitation
  • Transport of sick neonate from a long distance without medical attendance and proper transport facility
  • Lack of facility for prompt surgical delivery in case of fetal distress
  • Lack of facility of neonatal intensive care for outborn referral neonate at our institute with inadequate doctor and nurse ratio in general pediatric ward.


[TAG:2]Conclusion[/TAG:2]

Systemic infection, prematurity with respiratory distress and perinatal asphyxia were the leading causes of admission in our study. Neonatal mortality was 31.98% and more than two-third deaths were within 1st week of life. Sepsis, Perinatal asphyxia, and prematurity with RDS were the important preventable causes of mortality, which must be urgently addressed, if India hopes to achieve Millennium Developmental Goals. There is urgent need to provide better neonatal care for referral outborn neonate in intensive care unit as they are more vulnerable for acquiring infection and high mortality.

Recommendations

  • Provision of safe and timely transport in the ambulance with warmer, oxygenation, and portable ventilation facility with skilled workforce
  • Strengthening the maternal health services by obstetrician at primary and secondary health-care level and to established neonatal health facility for providing the essential neonatal care
  • Urgently, the government should establish neonatal intensive care facility for such critically sick outborn neonate in all tertiary care centers.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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