Care practices and neonatal survival in 52 neonatal intensive care units in Telangana and Andhra Pradesh, India: A cross-sectional study

Providing optimal care in the neonatal care units in India: How Covid-19 exacerbated existing barriers

Nearly one quarter (600,000) of all neonatal deaths worldwide per year occur in India. To reduce neonatal mortality, the Indian Ministry of Health and Family Welfare established neonatal care units, including neonatal intensive care units and specialized neonatal care units to provide immediate care at birth, resuscitation for asphyxiation, postnatal care, follow up for high-risk newborns, immunization, and referral for additional or complex healthcare services. Despite these efforts, neonatal mortality remains high, and measures taken to reduce mortality have been severely challenged by multiple problems caused by the Covid-19 pandemic. In this qualitative study, we conducted seven focus group discussions with newborn care unit nurses and pediatric residents and 35 key informant interviews with pediatricians, residents, nurses, annual equipment maintenance contractors, equipment manufacturers, and Ministry personnel in the Vidarbha region of Maharashtra between December 2019 and November 2020. The goal of the study was to understand barriers and facilitators to providing optimal care to neonates, including the challenges imposed by the Covid-19 pandemic. Covid-19 exacerbated existing barriers to providing optimal care to neonates in these newborn care units. As a result of Covid-19, we found the units were even more short-staffed than usual, with trained pediatric nurses and essential equipment diverted from newborn care to attend to patients with Covid-19. Regular training of neonatal nursing staff was also disrupted due to Covid-19, leaving many staff without the skills to provide optimate care to neonates. Infection control was also exacerbated by Covid-19. This study highlights the barriers to providing optimal care for neonates were made even more challenging during Covid-19 because of the diversion of critically important neonatal equipment and staff trained to use that equipment to Covid-19 wards. The barriers at the individual, facility, and systems levels will remain challenging as the Covid-19 pandemic continues.

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.

Correlates of low birth weight and preterm birth in India

BACKGROUND

In the 21st century, India is still struggling to reduce the burden of malnutrition and child mortality, which is much higher than the neighbouring countries such as Nepal and Shri Lanka. Preterm birth (PTB) and low birth weight (LBW) predispose early-age growth faltering and premature mortality among children below the age of five. Thus, highlighting the determinants of LBW and PTB is necessary to achieve sustainable development goals.

OBJECTIVE

The present study provides macro-level estimates of PTB and LBW and aims to highlight the nature of the association between various demographic, socioeconomic, and maternal obstetric variables with these outcomes using a nationally representative dataset.

METHODS

Data on 170,253 most recent births from the National Family health survey (NFHS-5) 2019-21 was used for the analysis. The estimates of PTB and LBW are measured by applying sample weights. The correlates of LBW and PTB were analyzed using logistic models.

RESULTS

There were cross-state disparities in the prevalence of PTB and LBW. In India, an estimated 12% and 18% of children were LBW and PTB, respectively, in 2019-21. Maternal obstetric and anthropometric factors such as lack of antenatal care, previous caesarean delivery, and short-stature mothers were associated positively with adverse birth outcomes such as LBW and PTB. However, a few correlates were found to be differently associated with PTB and LBW. Mothers belonging to richer wealth status had higher chances of having a preterm birth (OR = 1.16, 95% CI: 1.11-1.20) in comparison to poor mothers. In contrast, the odds of having LBW infants were found to be increased with the decreasing level of the mother's education and wealth quintile.

CONCLUSIONS

In India, PTB and LBW can be improved by strengthening existing ante-natal care services and evaluating the effects of the history of caesarean births on future pregnancies.

Global Prevalence of Severe Neonatal Jaundice among Hospital Admissions: A Systematic Review and Meta-Analysis

Evidence regarding the adverse burden of severe neonatal jaundice (SNJ) in hospitalized neonates in resource-constrained settings is sparse. We attempted to determine the prevalence of SNJ, described using clinical outcome markers, in all World Health Organization (WHO) regions in the world. Data were sourced from Ovid Medline, Ovid Embase, Cochrane Library, African Journals Online, and Global Index Medicus. Hospital-based studies, including the total number of neonatal admissions with at least one clinical outcome marker of SNJ, defined as acute bilirubin encephalopathy (ABE), exchange blood transfusions (EBT), jaundice-related death, or abnormal brainstem audio-evoked response (aBAER), were independently reviewed for inclusion in this meta-analysis. Of 84 articles, 64 (76.19%) were from low- and lower-middle-income countries (LMICs), and 14.26% of the represented neonates with jaundice in these studies had SNJ. The prevelance of SNJ among all admitted neonates varied across WHO regions, ranging from 0.73 to 3.34%. Among all neonatal admissions, SNJ clinical outcome markers for EBT ranged from 0.74 to 3.81%, with the highest percentage observed in the African and South-East Asian regions; ABE ranged from 0.16 to 2.75%, with the highest percentages observed in the African and Eastern Mediterranean regions; and jaundice-related deaths ranged from 0 to 1.49%, with the highest percentage observed in the African and Eastern Mediterranean regions. Among the cohort of neonates with jaundice, the prevalence of SNJ ranged from 8.31 to 31.49%, with the highest percentage observed in the African region; EBT ranged from 9.76 to 28.97%, with the highest percentages reported for the African region; ABE was highest in the Eastern Mediterranean (22.73%) and African regions (14.51%). Jaundice-related deaths were 13.02%, 7.52%, 2.01% and 0.07%, respectively, in the Eastern Mediterranean, African, South-East Asian and European regions, with none reported in the Americas. aBAER numbers were too small, and the Western Pacific region was represented by only one study, limiting the ability to make regional comparisons. The global burden of SNJ in hospitalized neonates remains high, causing substantial, preventable morbidity and mortality especially in LMICs.

Improving the Quality of Health Care in Special Neonatal Care Units of India: A Before and After Intervention Study

BACKGROUND

We evaluated the efficacy of training health care workers (HCWs) in point-of-care quality improvement (POCQI) and a preterm newborn health care package (PHCP), followed by remote mentoring and supportive supervision in improving health care practices, neonatal survival, and morbidities in special neonatal care units (SNCUs).

METHODS

This pre- and postintervention quality improvement study was conducted at 3 SNCUs in Madhya Pradesh, India from February 2017 to February 2019. Clinical care teams comprising doctors and nurses from the study sites were trained in POCQI and the PHCP. The teams identified, prioritized, and analyzed problems and designed quality improvement initiatives at their respective health facilities. Change ideas were tested by the local teams using sequential plan-do-study-act cycles. Facilitators maintained contact with the teams through quarterly review meetings, fortnightly videoconferencing, on-demand phone calls, and group chat service. State SNCU coordinators made follow-up visits to supplement coaching. Study research staff independently collected data on admissions, health care practices, and outcomes of neonates.

FINDINGS

A total of 156 HCWs were trained in the POCQI methodology and PHCP. Sixteen quality improvement projects were formulated and implemented. Among 13,821 enrolled neonates (birth weight 2275±635 g; gestation: 35.8±2.8 weeks), improvement was seen in reduction of use of oxygen (36.1% vs. 48.0%; adjusted odds ratio [aOR]=0.60, 95% confidence interval [CI]=0.55, 0.66), antibiotics (29.4% vs. 39.0%; aOR=0.76, 95% CI=0.68, 0.85), and dairy milk (33.8% vs. 49.4%; aOR=0.34, 95% CI=0.31 to 0.38). Enteral feeds were started within 24 hours of admission in a larger number of neonates, resulting in fewer days to reach full feeds. There was no effect on survival at discharge from the hospital (aOR=0.93; 95% CI=0.80, 1.09).

CONCLUSION

A collaborative cross-learning quality improvement approach with remote mentoring, coaching, and supportive supervision was successful in improving the quality of care at SNCUs.

AK, Murki S, Roehr CC. ELBW and ELGAN outcomes in developing nations-Systematic review and meta-analysis

Context

Morbidity and mortality amongst extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGANs) in developing nations has not been well studied.

Objectives

Evaluate survival until discharge, short- and long-term morbidities of ELBW and ELGANs in LMICs.

Data sources

CENTRAL, EMBASE, MEDLINE and Web of Science.

Study selection

Prospective and retrospective observational studies were included.

Data extraction and synthesis

Four authors extracted data independently. Random-effects meta-analysis of proportions was used to synthesize data, modified QUIPS scale to evaluate quality of studies and GRADE approach to ascertain the certainty of evidence (CoE).

Results

192 studies enrolling 22,278 ELBW and 18,338 ELGANs were included. Survival was 34% (95% CI: 31% - 37%) (CoE–low) for ELBW and 39% (34% - 44%) (CoE—moderate) for ELGANs. For ELBW neonates, the survival for low-income (LI), lower middle-income (LMI) and upper middle income (UMI) countries was 18% (11% - 28%), 28% (21% - 35%) and 39% (36% - 42%), respectively. For ELGANs, it was 13% (8% - 20%) for LI, 28% (21% - 36%) for LMI and 48% (42% - 53%) for UMI countries. There was no difference in survival between two epochs: 2000–2009 and 2010–2020. Except for necrotising enterocolitis [ELBW and ELGANs—8% (7% - 10%)] and periventricular leukomalacia [ELBW—7% (4% - 11%); ELGANs—6% (5%-7%)], rates of all other morbidities were higher compared to developed nations. Rates of neurodevelopmental impairment was 17% (7% - 34%) in ELBW neonates and 29% (23% - 37%) in ELGANs.

Limitations

CoE was very low to low for all secondary outcomes.

Conclusions

Mortality and morbidity amongst ELBW and ELGANs is still a significant burden in LMICs. CoE was very low to low for all the secondary outcomes, emphasizing the need for high quality prospective cohort studies.

Trial registration

PROSPERO (CRD42020222873).

Effect of collaborative quality improvement on stillbirths, neonatal mortality and newborn care practices in hospitals of Telangana and Andhra Pradesh, India: evidence from a quasi-experimental mixed-methods study

Background

Improving quality of care is a key priority to reduce neonatal mortality and stillbirths. The Safe Care, Saving Lives programme aimed to improve care in newborn care units and labour wards of 60 public and private hospitals in Telangana and Andhra Pradesh, India, using a collaborative quality improvement approach. Our external evaluation of this programme aimed to evaluate programme effects on implementation of maternal and newborn care practices, and impact on stillbirths, 7- and 28-day neonatal mortality rate in labour wards and neonatal care units. We also aimed to evaluate programme implementation and mechanisms of change.

Methods

We used a quasi-experimental plausibility design with a nested process evaluation. We evaluated effects on stillbirths, mortality and secondary outcomes relating to adherence to 20 evidence-based intrapartum and newborn care practices, comparing survey data from 29 hospitals receiving the intervention to 31 hospitals expected to receive the intervention later, using a difference-in-difference analysis. We analysed programme implementation data and conducted 42 semi-structured interviews in four case studies to describe implementation and address four theory-driven questions to explain the quantitative results.

Results

Only 7 of the 29 intervention hospitals were engaged in the intervention for its entire duration. There was no evidence of an effect of the intervention on stillbirths [DiD − 1.3 percentage points, 95% CI − 2.6–0.1], on neonatal mortality at age 7 days [DiD − 1.6, 95% CI − 9–6.2] or 28 days [DiD − 3.0, 95% CI − 12.9—6.9] or on adherence to target evidence-based intrapartum and newborn care practices. The process evaluation identified challenges in engaging leaders; challenges in developing capacity for quality improvement; and challenges in activating mechanisms of change at the unit level, rather than for a few individuals, and in sustaining these through the creation of new social norms.

Conclusion

Despite careful planning and substantial resources, the intervention was not feasible for implementation on a large scale. Greater focus is required on strategies to engage leadership. Quality improvement may need to be accompanied by clinical training. Further research is also needed on quality improvement using a health systems perspective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-020-01058-z.