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

Care of Healthy as well as Sick Newborns in India: A Narrative Review

Majority of neonatal deaths occur in developing countries. There is an increase in the proportion of neonatal deaths as part of the under-5 mortality over the past decade. Hence we need to accelerate further to achieve the goal of single digit neonatal mortality rate (NMR) by 2030. The two major arms of NMR reduction include facility-based neonatal care (FBNC) and home-based neonatal care (HBNC). FBNC addresses care at birth, care of the normal newborn, and care of small and sick newborns. HBNC provides continuum of care for newborn and post-natal mothers facilitated by Accredited Social Health Activist (ASHA) workers. One of the main challenges is to maintain good quality of neonatal care. Zero separation, linkage of community & facility and roles of professional bodies are considered way forward to achieve India Newborn Action Plan (INAP) goals. This review summarizes existing programs for newborn health and diseases and provides an over-arching view of the way-forward.

Assessment of Health Status of Newborns Discharged From Sick Newborn Care Units of the Five Cyclone Fani Affected Districts of Odisha, India

OBJECTIVE

This study was undertaken to assess the health status of newborns discharged from Sick Newborn Care Units (SNCU) of the Cyclone Fani affected districts of Odisha, which is amongst the highest neonatal mortality rate states in the country.

METHODS

Cyclone Fani hit the coast of Odisha on May 3, 2019. This cross-sectional study was conducted in 5 districts and targeted the babies discharged from SNCU's from January to May 2019. A telephonic interview of the caregivers was conducted to assess the health status of the newborns. Data was collected in a web-based portal and analyzed by statistical package for social sciences SPSS (IBM Corp., Armonk, New York, USA).

RESULTS

We inquired about 1840 babies during the study period but only 875 babies could be followed up, with the highest proportion of the babies from the most affected district. Out of 875 babies, 111 (12.7%) had 1 or more illnesses during follow up. Distance from the health facility and time constraints were the major reasons for not seeking health care. Of the babies, 35.7% were reported as being underweight. Poor breastfeeding (14.1%) and kangaroo mother care (31.7%) practices were reported. Only 32% of the babies were completely immunized.

CONCLUSION

The health status of the babies discharged from the SNCUs was found to be poor. Newborn care can be strengthened by improving home-based and facility-based newborn care.

Quality of inpatient care of small and sick newborns in Pakistan: perceptions of key stakeholders

BACKGROUND

In LMICs including Pakistan, neonatal health and survival is a critical challenge, and therefore improving the quality of facility-based newborn care services is instrumental in averting newborn mortality. This paper presents the perceptions of the key stakeholders in the public sector to explore factors influencing the care of small and sick newborns and young infants in inpatient care settings across Pakistan.

METHODS

This exploratory study was part of a larger study assessing the situation of newborn and young infant in-patient care provided across all four provinces and administrative regions of Pakistan. We conducted 43 interviews. Thirty interviews were conducted with the public sector health care providers involved in newborn and young infant care and 13 interviews were carried out with health planners and managers working at the provincial level. A semi-structured interview guide was used to explore participants' perspectives on enablers and barriers to the quality of care provided to small and sick newborns at the facility level. The interviews were manually analyzed using thematic content analysis.

FINDINGS

The study respondents identified multiple barriers contributing to the poor quality of small and sick newborn care at inpatient care settings. This includes an absence of neonatal care standards, inadequate infrastructure and equipment for the care of small and sick newborns, deficient workforce for neonatal case management, inadequate thermal care management for newborns, inadequate referral system, absence of multidisciplinary approach in neonatal case management and need to institute strong monitoring system to prevent neonatal deaths and stillbirths. The only potential enabling factor was the improved federal and provincial oversight for reproductive, maternal, and newborn care.

CONCLUSION

This qualitative study was insightful in identifying the challenges that influence the quality of inpatient care for small and sick newborns and the resources needed to fix these. There is a need to equip Sick Newborn Care Units with needed supplies, equipment and medicines, deployment of specialist staff, strengthening of in-service training and staff supervision, liaison with the neonatal experts in customizing neonatal care guidelines for inpatient care settings and to inculcate the culture for inter-disciplinary team meetings at inpatient care settings across the country.

Impact of regionalisation and case-volume on neonatal and perinatal mortality: an umbrella review

OBJECTIVE

This umbrella review summarises and critically appraises the evidence on the effects of regulated or high-volume perinatal care on outcome among very low birth weight/very preterm infants born in countries with neonatal mortality <5/1000 births.

INTERVENTION/EXPOSITION

Perinatal regionalisation, centralisation, case-volume.

PRIMARY OUTCOMES

Death.

SECONDARY OUTCOMES

Disability, discomfort, disease, dissatisfaction.

METHODS

On 29 November 2019 a systematic search in MEDLINE and Embase was performed and supplemented by hand search. Relevant systematic reviews (SRs) were critically appraised with A MeaSurement Tool to Assess systematic Reviews 2.

RESULTS

The literature search revealed 508 hits and three SRs were included. Effects of perinatal regionalisation were assessed in three (34 studies) and case-volume in one SR (6 studies). Centralisation has not been evaluated. The included SRs reported effects on 'death' (eg, neonatal), 'disability' (eg, mental status), 'discomfort' (eg, maternal sensitivity) and 'disease' (eg, intraventricular haemorrhages). 'Dissatisfactions' were not reported. The critical appraisal showed a heterogeneous quality ranging from moderate to critically low. A pooled effect estimate was reported once and showed a significant favour of perinatal regionalisation in terms of neonatal mortality (OR 1.60, 95% CI 1.33-1.92). The qualitative evidence synthesis of the two SRs without pooled estimate suggests superiority of perinatal regionalisation in terms of different mortality and non-mortality outcomes. In one SR, contradictory results of lower neonatal mortality rates were reported in hospitals with higher birth volumes.

CONCLUSIONS

Regionalised perinatal care seems to be a crucial care strategy to improve the survival of very low birth weight and preterm births. To overcome the low and critically low methodological quality and to consider additional clinical and patient-reported results that were not addressed by the SRs included, we recommend an updated SR. In the long term, an international, uniformly conceived and defined perinatal database could help to provide evidence-based recommendations on optimal strategies to regionalise perinatal care.

PROSPERO REGISTRATION NUMBER

CRD42018094835.

Clinical profile and predictors of mortality among the referred neonates at a tertiary care centre in north India: a prospective observational study

The National Family Health Survey (NFHS-4) shows encouraging improvement in infant and under-five mortality rates in India. However, the neonatal mortality rate (NMR) still remains high as India contributes to about one-fifth of global deaths. This prospective study was conducted from 15 January to 30 April 2016 to examine the clinical profile and predictors of mortality among referred neonates at our centre. Among 301 neonates, prematurity (40%) was the most common indication for referral followed by need for ventilation (38%) and birth asphyxia (28%). Approximately 73% neonates were referred within 24 h of birth. Ninety (29.9%) neonates died; of these, 63% died within 24 h of presentation. Prematurity, birth asphyxia, hypothermia, shock at presentation and extreme low birth weight were the most significant predictors of mortality. Adequate training of peripheral health personnel, dedicated teams for neonatal referral and strengthening of peripheral sick newborn care units (SNCUs) seem to be promising interventions for favourable outcome.

The Profile, Health Seeking Behavior, Referral Patterns, and Outcome of Outborn Neonates Admitted to a District and Regional Hospital in the Upper West Region of Ghana: A Cross-Sectional Study

Neonatal mortality is the major contributor to under-five mortality rates in many low and middle income countries. We examined the health practices, care-seeking behavior, and referral of sick outborn neonates to a district and regional hospital in the Upper West Region of Ghana. The study was a cross-sectional study conducted over an eight (8) month period in 2018. Data were obtained from caregiver interviews and case notes. Altogether, 153 outborn neonates were examined. Inappropriate practices including the use of enemas, cord care with cow dung, and herbal baths were found. Three babies treated this way died. The majority of caregivers sought care at a health facility. However, 67 (44%) sought care only after their babies were ill for ≥7 days, suggesting the influence of a period of confinement on health seeking. More than half, 94 (61.4%), of the facilities visited referred patients to destination hospitals without giving any treatment. Delayed care-seeking was associated with a low birth weight, using home remedies, and a maternal age of ≥30 years. Altogether, 12 neonates (7.8%) died, consisting of three males and nine females (p = 0.018). Socio-cultural factors strongly influence health seeking behavior and the health outcome of neonates in this setting. There appeared to be a limited repertoire of interventions for treating neonatal disease in primary care.

Admissions and mortality over a 5-year period in a limited-resource neonatal unit in Ghana

Objective

To review admissions and deaths at the neonatal intensive care unit (NICU) of the Korle Bu Teaching Hospital (KBTH), Ghana from 2011 to 2015, for the purposes of documentation of outcomes and identification of areas for improvement.

Design

A retrospective descriptive study of NICU Admissions & Discharges from 2011 to 2015. All data in the NICU Admissions & Discharge books were transferred into a spreadsheet and analysed.

Setting

The NICU of KBTH provides secondary and tertiary care for premature and critically ill term babies in the southern half of Ghana.

Results

Over the 5-year period, 9213 babies were admitted to the NICU. Admission weights ranged from 300 to 6700g with median of 2400g. Overall mortality rate was 19.2%. Mortality rates were progressively and significantly higher in babies with lower admission weights and earlier gestations.

Conclusions

We report a high NICU mortality rate of 19.2%, compared to the worldwide range of 3.1% to 29%. This wide range of outcomes is attributable to differences in the severity of illness of patients and to the organisation of resources devoted to obstetric and neonatal care. To substantially improve perinatal and neonatal outcomes, there is a need for wider coverage and better quality of health care; and to consider rationing of care. Complex interventions are necessary to improve outcomes, not just an increase in the allocation of particular resources.

Funding

None declared.

The Impact of the World Health Organization Essential Newborn Package on Newborn Care Practices and Survival Rates in Sub-Saharan Africa: A Systematic Literature Review

Sub-Saharan Africa, has the highest child mortality rate in the world (World Health Organization [WHO], 2016). However, there is a paucity of current systematic reviews on the impact of essential newborn care interventions in Africa. Therefore, the aim of this systematic review was to summarize evidence about the impact of essential newborn care interventions in Africa. Numerous databases were searched to retrieve articles that reported interventions in newborn care in Africa. The search was limited to the English language and to articles published between 2007 and 2017. Nine articles were selected for inclusion in this systematic review. Overall, these papers demonstrated an increase in performance of health workers (between 8 and 400%) following a test of knowledge, while health workers practical performance increased by 34%. Moreover, neonatal mortality was reduced by 45%, while perinatal mortality was reduced by 30%. Training healthcare workers is one of the most effective ways of improving newborn care and neonatal survival in Africa. However, there is a need for additional evidence to support this, because none of the reviewed studies assessed the impact of training by examining variables such as trainees' satisfaction with training, the knowledge and skills developed, and the health outcomes achieved.

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.

Health providers' perception of quality of care for neonates in health facilities in a municipality in Southern Ghana

Purpose The purpose of this paper is to assess available human resources for neonatal care and their skills, in order to explore health providers' perceptions of quality of neonatal care in health facilities in Ghana. Design/methodology/approach Data were gathered using qualitative interviews with health providers working in the maternity and paediatric wards and midwives; direct observation; and documentary review at a regional hospital, a municipal hospital and four health centres in a municipality in a region in Southern Ghana. Data were analysed using thematic framework through the process of coding in six phases to create and establish meaningful patterns. Findings The study revealed that health providers were concerned about the number of staff available, their competence and also equipment available for them to work more efficiently. Some essential equipment for neonatal care was either not available or was non-functional where it was available, while aseptic procedures were not adhered to. Moreover, personal protective equipment such as facemask, caps, aprons were not used except in the labour wards where staff had to change their footwear before entering. Research limitations/implications Limited number of health providers and facilities used, lack of exploration of parents of neonates' perspective of quality of neonatal care in this study and other settings, including the teaching hospitals. The authors did not examine issues related to the ineffective use of IV cannulation for neonates by nurses as well as referral of neonates. Additionally, the authors did not explore the perspectives of management of the municipal and regional health directorates or policy makers of the Ministry of Health and Ghana Health Service regarding the shortage of staff, inadequate provision of medical equipment and infrastructure. Practical implications This paper suggests the need for policy makers to redirect their attention to the issues that would improve the quality of neonatal health care in health facilities in Ghana and in countries with similar challenges. Social implications The study found that the majority of nursing staff catering for sick newborns were not trained in neonatal nursing. Babies were found sleeping in separate cots but were mixed with older children. The study suggests that babies should be provided with a separate room and not mixed with older babies. Originality/value There seemed to be no defined policy framework for management of neonatal care in the country's health care facilities. The study recommends the adoption of paediatric and neonatal care nursing as a specialty in the curricula of health training institutions. In-service trainings should encompass issues related to management of sick babies, care of preterm babies, neonatal resuscitation and intravenouscannulation, among others.

Neonatal outcomes in a level II regional neonatal intensive care unit

BACKGROUND

Improvement of neonatal mortality is a challenge in developing countries such as Iraq due to increased demand and overload of maternity services. The aim of this study was to document the number, disease patterns and outcome of admitted newborns and the improvement after implementation of clinical protocols, and to identify possible future target measures.

METHOD

A descriptive study was conducted at the neonatal intensive care unit (NICU) of a regional hospital from 2011 to 2013. Of 72 320 deliveries, 4694 newborns were admitted and met selection criteria. Clinical guidelines, clinical skills training of nurses and resident doctors, and improvement of medical records were implemented during the study period. All patient demographics, causes of admission/death and mortality were analyzed.

RESULTS

From a total of 4694 admitted newborns; 42% were delivered vaginally, 60% were male, 43% were <2500 g, and 31% were premature. The neonatal deaths consisted of 1076 newborns, 84% of whom died before 7 days of age, and 39% of whom weighed ≤1500 g. Respiratory distress syndrome was the main cause of death (62.2%). Due to the increased total number of deliveries, and hence the corresponding increased number of vaginal deliveries (R = 0.97), the number of NICU admissions was significantly increased (R = 0.569, P = 0.009). Notably, the mortality rate was significantly decreased (R = -0.487, P = 0.004).

CONCLUSIONS

Maternity overload contributed to the high neonatal mortality, whereas implementation of clinical guidelines and of medical staff training improved neonatal outcomes. Future target interventions include optimized timing of cesarean section and the detection of potentially complicated deliveries.

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.

Is facility based neonatal care in low resource setting keeping pace? A glance at Uganda's National Referral Hospital

OBJECTIVES

To identify reasons for neonatal admission and death with the aim of determining areas needing improvement.

METHOD

A retrospective chart review was conducted on records for neonates admitted to Mulago National Referral Hospital Special Care Baby Unit (SCBU) from 1(st) November 2013 to 31(st) January 2014. Final diagnosis was generated after analyzing sequence of clinical course by 2 paediatricians.

RESULTS

A total of 1192 neonates were admitted. Majority 83.3% were in-born. Main reasons for admissions were prematurity (37.7%) and low APGAR (27.9%).Overall mortality was 22.1% (Out-born 33.6%; in born 19.8%). Half (52%) of these deaths occurred in the first 24 hours of admission. Major contributors to mortality were prematurity with hypothermia and respiratory distress (33.7%) followed by birth asphyxia with HIE grade III (24.6%) and presumed sepsis (8.7%). Majority of stable at risk neonates 318/330 (i.e. low APGAR or prematurity without comorbidity) survived. Factors independently associated with death included gestational age <30 weeks (p 0.002), birth weight <1500g (p 0.007) and a 5 minute APGAR score of < 7 (p 0.001). Neither place of birth nor delayed and after hour admissions were independently associated with mortality.

CONCLUSION AND RECOMMENDATIONS

Mortality rate in SCBU is high. Prematurity and its complications were major contributors to mortality. The management of hypothermia and respiratory distress needs scaling up. A step down unit for monitoring stable at risk neonates is needed in order to decongest SCBU.

Hospital Care for Newborn Babies: Quality Assessment, A Systematic Review

Context:

Neonatal mortality rate is declining globally. The aim of the present study is to identify relevant indicators for assessing newborn care in hospitals by a systematic review.

Evidence Acquisition:

A search on electronic data base and manual searches of personal files for studies on quality indicators of newborn care were carried out. Searching 9 bibliographic databases, we found 85 articles of which 22 exactly related ones were selected and studied. Hand search yielded 1 record were also searched and 2 records were included.

Results:

A list of 87 structure, process and outcome indicators was formulated from the articles. Also 26 excess measures were identified in gray literature. After removing duplicates, and categorizing in 3 domains, 18 measures were input, 41 process and 34 outcome measures.

Conclusions:

These 93 indicators provide a framework for assessing how well the hospitals are providing neonatal care. These measures should be discussed in each context expert panels to address nationally applicable indices of neonatal care and may be adapted for local health settings.

Association of unit size, resource utilization and occupancy with outcomes of preterm infants

OBJECTIVE

Assess association of NICU size, and occupancy rate and resource utilization at admission with neonatal outcome.

STUDY DESIGN

Retrospective cohort study of 9978 infants born at 23-32 weeks gestation and admitted to 23 tertiary-level Canadian NICUs during 2010-2012. Adjusted odds ratios (AOR) were estimated for a composite outcome of mortality/any major morbidity with respect to NICU size, occupancy rate and intensity of resource utilization at admission.

RESULTS

A total of 2889 (29%) infants developed the composite outcome, the odds of which were higher for 16-29, 30-36 and >36-bed NICUs compared with <16-bed NICUs (AOR (95% CI): 1.47 (1.25-1.73); 1.49 (1.25-1.78); 1.55 (1.29-1.87), respectively) and for NICUs with higher resource utilization at admission (AOR: 1.30 (1.08-1.56), Q4 vs Q1) but not different according to NICU occupancy.

CONCLUSION

Larger NICUs and more intense resource utilization at admission are associated with higher odds of a composite adverse outcome in very preterm infants.

Current status of NICUs in India: a nationwide survey and the way forward

The number of Neonatal Intensive Care Units (NICUs) and Special Care Newborn Units (SCNUs) in the country has increased exponentially. However, their current status of functioning is not known. A structured questionnaire survey of 70 NICUs spread across the country was conducted to assess their infrastructure, staffing, equipment, patient profile and their involvement in research and training. Majority of the units were well staffed and led by neonatologists trained in India and abroad. All had facilities for mechanical ventilation and were equipped with sophisticated imported equipment. Yet, availability of in-house blood gas and X-ray, microbiology facility, invasive blood pressure monitoring and support of ophthalmologist was not universal. More than half had published papers in scientific journals and were having recognized training programs in neonatology. Though tremendous progress is visible since the last surveys, the number of NICUs is still grossly insufficient. The current and future gap in trained manpower is however daunting, and intensive efforts for expanding the in-service training programs and innovative approaches to training are required. There is an urgent need to improve the quality of care by launching collaborative quality improvement programs and mandatory periodic accreditation managed by independent empowered organizations. The focus has to move forward from simply 'survival till discharge' to 'intact complete life survival'. Simultaneously, the NICU care has to stay available and affordable for the masses.

Intra-hospital mortality among neonates transported by ambulance in Colombia

BACKGROUND

The aims of this study were to identify the main variables associated with intra-hospital mortality among patients transferred to a specialized neonatal care center, and to evaluate agreement and accuracy of referring and admission diagnoses.

METHODS

A 6 month observational study was conducted to obtain clinical variables for intra-hospital mortality among patients requiring interfacility transport. Association among variables was estimated using Poisson regression with robust variance. Agreement was evaluated between diagnosis before and after transfer using Cohen's kappa, sensitivity, specificity and Youden's I.

RESULTS

The study included 191 neonates, 12.57% of whom died. Increased mortality was associated with the Transport Risk Index of Physiologic Stability (TRIPS). The associated variables were as follows: TRIPS (adjusted prevalence ratio [aPR], 1.05; 95% confidence interval [CI]: 1.02-1.08), weight 1500-2499 g (aPR, 0.08; 95%CI: 0.01-0.40), weight >2500 g (aPR, 0.56; 95%CI: 0.02-0.19), cardiopathy (aPR, 0.20 95%CI: 0.05-0.75), congenital defects (aPR, 4.59; 95%CI: 0.97-21.82) and renal failure (aPR, 3.69; 95%CI: 1.26-10.78). Diagnosis remained unchanged for 71.15% of the neonates. The greatest differences were hyaline membrane disease (49.4%) followed by transient tachypnea (59.9%). Youden's I for referral diagnosis was 0.22 for transient tachypnea, 0.66-0.69 for cardiopathy, esophageal atresia and pneumonia, 0.72-0.74 for hyaline membrane disease and pulmonary hypertension, and >0.90 for the remaining diagnoses.

CONCLUSIONS

Weight <1500 g, renal failure, congenital defects (except congenital cardiopathies) and high TRIPS were associated with a higher risk of intra-hospital mortality. The findings suggest that improving transfer time and quality of care in ambulances would decrease mortality.