|Year : 2014 | Volume
| Issue : 4 | Page : 228-234
Neonatal morbidity and mortality of sick newborns admitted in a teaching hospital of Uttarakhand
Ritu Rakholia1, Vineeta Rawat2, Mehar Bano3, Gurpreet Singh1
1 Department of Pediatrics, Government Medical College, Haldwani, Nainital, Uttarakhand, India
2 Department of Microbiology, Government Medical College, Haldwani, Nainital, Uttarakhand, India
3 Department of Community Medicine, Government Medical College, Haldwani, Nainital, Uttarakhand, India
|Date of Web Publication||16-Oct-2014|
Department of Pediatrics, Government Medical College, Haldwani, Nainital - 263 129, Uttarakhand
Source of Support: None, Conflict of Interest: None
Context: India accounts for 27.3% of total neonatal deaths in the world. This rate is highest in poor and marginalized areas like hilly regions of Uttarakhand that lack medical facilities. The newborns referred from here and admitted as outborn neonates contribute to the high neonatal mortality rate (NMR) of India. Aims : To study the demographic profile and morbidity-mortality pattern of neonates admitted in Sick Neonatal Care Unit (SNCU) and study the difference between inborn and outborn neonates. Study Design: Retrospective study of medical records for 1 year (2013-2014). Subjects and Methods: The age, sex, gestational age, and morbidity and mortality profile of all SNCU admissions in 1 year was determined, and the difference between inborn (those born in Teaching Hospital) and outborn (neonates delivered outside and referred) was calculated. Modifiable risk factors to reduce NMR in Uttarakhand were determined. Statistics: The data were analyzed using appropriate statistical tools in software Statistical Package for the Social Sciences (SPSS)-18. Results : Of the 721 neonates admitted, 63.25% neonates were males, and 53.54% were outborn and 46.46% inborn. Approximately, 60% were low birth weight and 50% preterm. Respiratory distress syndrome (RDS) (21.9%), sepsis (19%), perinatal asphyxia (16.37%), and jaundice (12.9%) were the chief morbidities. The chief causes of mortality were prematurity (25.6%), sepsis (21.6%), perinatal asphyxia (19.5%), and RDS (17.3%) with a statistically higher rate in the outborn in comparison with inborn. Total 20.5% neonates died due to poor outcome of outborn neonates. Conclusion: Huge burden of neonatal death among the outborn is due to preventable causes like asphyxia and infections in Uttarakhand. Health policies must ensure increased access to essential services to target sick neonates born here.
Keywords: Morbidity, mortality, neonate, outborn
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2014 [cited 2017 Apr 28];1:228-34. Available from: http://www.cjhr.org/text.asp?2014/1/4/228/142983
| Introduction|| |
More than 8 million children die before they attain 5 years of age each year. Most of these deaths occur in developing countries, and most are caused by preventable or treatable diseases. To redeem this situation, in 2000, world leaders assembled in New York and established a goal of reducing child mortality among children less than 5 years to one-third of its 1990 level by 2015 as Millennium Development Goal 4 (MDG4).  Since the millennium Development Goals were formed, progress toward reducing child mortality has accelerated but remains insufficient to achieve MDG4.  In particular, progress toward reducing neonatal deaths-that is deaths during the first 28 days of life-has been slow and neonatal deaths now account for a greater proportion of global child deaths than in 1990. ,
Of the 40 countries with the highest NMRs in 2009, only six are from outside the African continent (Afghanistan, Pakistan, India, Bhutan, Myanmar, and Cambodia). India is the country responsible for maximum number of neonatal deaths from 1990-2009.  Simple interventions such as improved hygiene, timely effective neonatal resuscitation, temperature maintenance, advice on breast feeding and emergency obstetric care for surgical delivery in case of fetal distress can go a long way to reduce this rate. 
To achieve MDG4, a substantial reduction in early neonatal deaths will be required. The first steps in improving early neonatal survival are to document the number and rate of deaths, and identify their common causes.  Few or no published data are available concerning neonatal morbidity and mortality in Uttarakhand. In most of the African and Asian countries, highest neonatal mortality is seen among the marginalized population with limited access to health care.  Hilly areas of Uttarakhand have limited healthcare facilities and are a marginalized section of Indian population because of the difficult geographic terrain. In Uttarakhand neonatal mortality rate (NMR) is 30 per 1000 live births as per National Family Health Survey 2011.  Thus, the current study was conducted to provide caregivers and health planners with basic data necessary for interventions to reduce neonatal morbidity and mortality. It was also done to assess the level of neonatal care in a tertiary referral centre of Uttarakhand and analyze its shortcomings.
| Subjects and Methods|| |
The Sick Newborn Care Unit (SNCU) in Medical College Hospital caters to hilly areas of Kumaon and adjoining regions of Uttar Pradesh. This government hospital provides maternity services in the city, in addition to high percentage of referral of high-risk pregnancies and sick newborns from other peripheral hospitals. The medical files of the neonates were retrospectively reviewed. The SNCU is equipped with 20 radiant warmers, 6 phototherapy units, and 3 ventilators. It also provides facility for surfactant administration, exchange transfusion, and neonatal ventilation. All medications, investigations, and hospital bills were free under the government National Rural Health mission (NRHM) scheme.
Study Period: 1 year 2013-2014
- Study design: A retrospective study of medical records for the period 2013-2014
- Inclusion criteria: All newborns < 28 days of life admitted in SNCU
- Exclusion criteria: >28 days of life, neonates admitted in Pediatric Intensive Care Unit (PICU)/General ward of pediatrics department due to non-availability of beds in SNCU. Newborns born in the hospital but referred due to non-availability of beds have also not been included.
These newborns were categorized as inborn if delivered by any route in the Teaching Hospital and outborn if born outside. Most of the outborn neonates were referred from smaller government hospital in hilly areas or home delivered. The data were recorded in Proforma and definitions used for the purpose are: 
- Preterm-Live born neonate delivered before 37 weeks from 1 st day of last menstrual period (LMP) and confirmed clinically after delivery
- LBW (low birth weight) -was defined as weight < 2500 gm. Neonatal infections (sepsis, pneumonia, and meningitis)-These were diagnosed on clinical grounds along with appropriate tests, which include sepsis screen, blood culture, chest radiograph, and cerebrospinal fluid analysis. Invasive infections have been grouped together due to similar and overlapping presentation and management
- Meconium aspiration syndrome (MAS)-This was diagnosed both radiographically and clinically based on history of being born through meconium-stained amniotic fluid, chest radiograph, and respiratory distress persisting beyond 24 hours
- Congenital malformations-These were diagnosed on clinical features and diagnostic facilities like ultrasound, echocardiography, X rays, and Electrocardiography (ECG)
- Intrapartum-related complication of birth (birth asphyxia) was diagnosed clinically (apgar score < 7 at 5 minutes)
- Neonatal jaundice-This was diagnosed after assessment of serum bilirubin and found to be in pathological zone in age, weight, and gestation-specific range
- Statistics-The data were collected from the record files of admitted neonates, compiled and entered in MS Excel, and analyzed using appropriate statistical tools in software SPSS-18
- Ethics-The study was cleared by the ethical committee of the Institute.
| Results|| |
Baseline characteristics of the neonates: Sex distribution-721 neonates were admitted in 1 year out of which 63.25% were males and 36.75% were females [Table 1]. The admission of outborn neonates (53.54%) was more than inborn neonates (46.46%). On applying one sample Chi-square test for seeing the observed frequency distribution in males and females overall admitted neonates at the SNCU, it was found to be significant (P is 0.001). Z test has been used to see the observed difference in the proportion of male neonates in the inborn and outborn neonates admitted at the SNCU, and it was found to be significant [Figure 1].
Age and gestation of neonates in SNCU: The neonates were divided arbitrarily into different age and gestational groups (>2.5 kg, 2 to1.5 kg, 1-1.5 kg, <1 kg and >37 weeks, 34-37 weeks, and < 34 weeks) as the management, complications and prognosis of each group is distinct. As seen in [Table 2], most of the neonates admitted in the SNCU weighed < 2.5 kg (61.61%). The percentage of low and very low birth weight babies was similar in outborn (61.40%) and inborn neonates (59.70%). The total number of preterm babies admitted was 50.35%. Greater percentage of outborn neonates (52.33%) were preterm than inborn neonates (48.06%) [Figure 2].
|Figure 2: Weight of inborn and outborn neonates and overall admitted neonates|
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|Table 2: Weight and gestation of inborn and outborn neonates admitted at SNCU|
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Morbidity profile of admitted neonates: The chief causes of admission in SNCU were RDS (21.91%) followed by sepsis/pneumonia/meningitis (19.00%) and perinatal asphyxia (16.37%). A lesser percentage of babies were having congenital anomalies (2.64%) followed by hypoglycemia (2.91%), hypothermia (7.07%), respiratory distress due to other causes (7.49%), MAS (9.71%), and jaundice (12.90%) [Table 3].
|Table 3: Morbidity profi le of the inborn and outborn neonates admitted in SNCU|
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Respiratory distress syndrome as well as sepsis/pneumonia/meningitis were present in 22.54% and 21.24% outborn babies, whereas RDS was present in 21.19% of inborn babies and sepsis/pneumonia/meningitis was present in 16.12% inborn neonates. Respiratory distress syndrome was the major morbidity found in both inborn and outborn admitted neonates. The morbidity profile of both inborn and outborn neonates was similar [Table 3].
Mortality profile of neonates: The major causes of death in this study in decreasing order are prematurity (25.68%), sepsis/pneumonia/meningitis (21.6%), perinatal asphyxia (19.59%), and RDS (17.3%) [Table 4].
|Table 4: Comparison of mortality profi le in the inborn and outborn babies|
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The proportion of deaths due to RDS was comparatively more in the outborn babies (68%) than in inborn babies (32%). However, the difference in the proportion of deaths was not found to be statistically significant. The proportion of deaths in the neonates admitted with MAS is more in outborn babies (64.3%) than in inborn babies (35.7%), but this difference is also not statistically significant (P is 0.401, χ is 0.705, df = 1).
For the neonates with perinatal asphyxia, more outborn babies (72.4%) died than the inborn babies (27.6%) in SNCU, and this difference is statistically significant. (P is 0.016, χ is 5.845, df = 1).
For neonates admitted with congenital anomalies, as sample size is small (n = 19), P value has been calculated using Z test. As Z value (0.58) is <1.96 at 95% confidence interval (CI), the observed difference in deaths proportion of outborn babies (57.14%) and inborn babies (42.86%) is not statistically significant.
The difference in the proportion of deaths due to infections in the outborn (81.2%) and inborn babies (18.8%) is found to be statistically significant (P is 0.006, χ is 7.620, df = 1) as greater percentage of outborn babies (19.95%) were admitted in SNCU with sepsis/pneumonia/meningitis. This is again due to lack of practice of simple measures like hygiene at the time of delivery, transport, and handling the babies.
A similar percentage of preterm babies (50%) in both inborn as well as outborn died. Similar result was seen in both inborn and outborn. For comparison of deaths in inborn and outborn neonates due to other causes, jaundice, hypoglycemia, hypothermia, and respiratory distress, difference is statistically insignificant [Table 4].
Outcome of admitted neonates: As seen in [Table 5], most of the neonates admitted in SNCU survived (66.57%), being 61.40% in outborn and 72.54% in inborn neonates. The percentage of the admitted neonates who went on leave against medical advice (LAMA) was 8.32% while referred neonates were 4.58%. However, 20.53% neonates died. The death percentage is higher in the outborn neonates (25.39%) than in the inborn neonates (14.92%). For comparison of deaths in inborn and outborn neonates as seen in [Table 6], the percentages of neonates that went LAMA (N = 60, 8.32%) and referred (N = 33, 4.58%) have been excluded. Out of all neonates (N = 148, 23.6%) who died, the outborn neonates who died is more (N = 98, 66.2%) than the inborn neonates (N = 50, 33.8%), and this difference in the death rates of inborn and outborn neonates is found to be statistically significant (P is 0.0001).
| Discussion|| |
The demographic distribution of population in this study (male/female and preterm/term) is in concordance to National Neonatal-Perinatal Database (NNPD) and other studies of rural India. , The study shows a high male:female ratio. Further studies are needed to determine whether this is due to gender bias prevalent in India where male children are given more care or a greater tendency of male children to face neonatal complications.
Outborn versus inborn neonates (53.54% vs 46.46%) were similar to a study by Orimadegun and Owa JA et al. , in Nigeria, a developing country (55.3% vs 44.7%).
In the present study, the commonest causes of admission were respiratory distress (RDS contributing 18.7% and other causes 7.5%), sepsis/pneumonia/meningitis were responsible for 17.6%, perinatal asphyxia 15.7%, and neonatal jaundice 12.6% with no significant difference between inborn and outborn. The findings are similar to NNPD where systemic infections (28.4%), hyperbilirubinemia (27.9%), seizures (11.7%), hypoglycemia (11.5%), hypoxic ischemic encephalopathy (8.3%), anemia (8.9%), and hypocalcemia (8.6%) were common morbidities observed. Studies from Africa ,, show more admissions due to sepsis, jaundice, and tetanus. In the developed countries, the scenario is different with extreme prematurity, asphyxia, and congenital anomalies being the chief causes as seen a study in Canada by Simpson et al. 
Referral rate was low, and the rate of LAMA was similar to NNPD and studies in medical colleges hospital elsewhere , but much lower than studies in other hospitals of North India. 
In the present study, prematurity (25.7%) was the main cause of death followed by sepsis (21.6%), perinatal asphyxia (19.6%), and respiratory distress (17.3%) with congenital abnormalities contributing 4.7%. This is similar to the causes of the rest of India NNPD and Asian countries ,,, where infections (36.0%), prematurity-related conditions (26.5%), perinatal hypoxia (10.0%), and malformations (7.8%) were the chief causes. However, African countries show higher death rates due to jaundice and tetanus. , The results are in contrast to developed countries where extreme prematurity-related conditions, especially gastrointestinal complications and congenital malformations, are the main causes as better neonatal care ensures lesser sepsis and better survival of children with respiratory distress, MAS, and jaundice.  Asphyxia contributes to about 10% of deaths in both developing and developed countries; however, the rate in our study is much higher (16% for inborn to 21% of outborn) [Table 7]. The higher rate is probably due to lack of regular antenatal care, delayed referral of high-risk mothers, and lack of prompt and effective neonatal resuscitation. Transport is also a weak link for children who are resuscitated as they are referred without stabilization, temperature maintenance, oxygenation, and ventilation if in apnea.
|Table 7: Mortality data in studies conducted in various countries of the world as well as different parts of India|
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The mortality rate of 20.53% in the current study is much higher than developed countries like Canada  (7.6%) which are equipped with better facilities like Extra Corporeal Membrane Oxygenation (ECMO), total parenteral nutrition (TPN), and a higher doctor to patient and nurse to patient ratio. However, even developing countries like Nigeria and Sudan , have a better survival rate. The mortality rate is slightly better than countries like Nepal and Kenya. , Among the 15 countries with the highest NMRs, 12 were from the African region, and three were from the Eastern Mediterranean (Afghanistan, Somalia, and Pakistan). Throughout the period 1990-2009, India has been the country with the largest number of neonatal deaths. In 2009, the five countries with most deaths accounted for more than half of all neonatal deaths (1.7 million deaths = 52%), and 44% of global live births: India (27.8% of deaths, 19.6% of global live births), Nigeria (7.2%, 4.5%), Pakistan (6.9%, 4.0%), China (6.4%, 13.4%), and Democratic Republic of the Congo (4.6%, 2.1%). ,
Even in comparison to rest of India NNPD,  the mortality rate is higher. The mortality rate for inborn neonates is comparable to the rate in rest of India. It is the very high rate in outborn neonates that needs urgent attention. The likely causes for this high rate are as follows:
- Lack of facilities for prompt surgical delivery in case of fetal distress in the hilly areas
- Deliveries attended by personnel who are untrained in Neonatal Resuscitation
- Lack of facility-based neonatal care in difficult hilly terrain necessitating referral of high-risk neonates.
- Difficulty in transport of sick neonates, temperature maintenance, oxygenation, and ventilation in cases of apnea
- Poor doctor and nurse to patient ratio. Inadequate facilities for very preterm neonates
- Low referral rate for sick neonates.
Because of retrospective nature of the study, cause of death was determined by the extent and depth of information in the official records. Newborns admitted in general ward, PICU and those referred due to non-availability of beds were not studied and could hence modify the results. Maternal details were not studied in the present study. The study has not divided deaths into early and late neonatal period. NMR could not be calculated.
| Conclusion|| |
Mortality is significantly higher than developed and even much higher than other developing countries and rest of India mainly due to the poor prognosis of referred (outborn) neonates. Perinatal asphyxia and infection are important preventable causes of mortality, which must be urgently addressed, if India hopes to achieve Millennium Development Goals by 2015.
The data from this study will act as baseline from which effect of various interventions for newborn care can be evaluated and will help in health policy planning for hilly areas of Uttarakhand.
It will also help in giving evidence-based counseling to parents of newborns in SNCU regarding the survival chances of newborns admitted (depending on birth weight and gestation).
- Safe transport: Ambulance with warmer, oxygenation, and portable ventilator with skilled manpower
- Increasing government spending to scale up skilled attendance for simple immediate newborn care and neonatal resuscitation
- More centers with neonatal intensive care facilities in the hills.
Although an initiative in the right direction has been made by the government in the form of National Rural Health Mission much still needs to be done keeping in mind the difficult geographic terrain in Uttarakhand. Giant steps need to be taken before India can forego this dubious distinction of being the country responsible for nearly a fourth (27.6%) of global neonatal deaths.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]