Newborn care in Northern India: A study of regional and seasonal peculiarities for desired professionalism and definitive practices

ABSTRACT

Introduction:

Improvements in newborn health with study of present status, progressive perfection of practices, and data diligence for future is desirable.

Methods:

Study of mortality and morbidity patterns. Analyze findings for focus areas and for favourable advancements in practices. Corroborate with existing evidence and practice protocols.

Setting:

Tertiary care referral hospital.

Protocols:

Preterm babies given special attention. This includes, in addition to the WHO 10 main recommendations, meticulous monitoring and health education for care. Neonatal jaundice evaluation on the basis of risk factors and clinical monitoring.

Results:

A total of 1749 live, born babies (2018–2020) were studied. The neonatal mortality rate in the study was 6.29. Preterm births were 102 (5.83%), with mortality of 7.84%, that is, 8 out of 102 preterm babies, and overall 4.57 premature deaths per 1000 live births. Prematurity was the commonest cause of mortality, responsible for 8 out of 11 deaths (72.73%). Birth asphyxia incidence was 5.26% (92 babies) with a case fatality ratio of 4.35%. Newborns with severe birth asphyxia were 7, and of these 4 (all premature) had fatal outcome. The low birthweight (LBW) incidence was 13.32% with the majority (79.83%) in the 2000–2499 g range. Preventive practices for hypothermia were 100% successful. An unusual rise in incidence and severity of hyperbilirubinemia during December 2018 to February 2019 when winter was severe was noted.

Conclusion:

Mortality reduction requires focusing on prematurity. Meticulous monitoring and health education for them improves results. The unusual rise in incidence and severity of hyperbilirubinemia in severe winter points towards the need for vigilance. We need to be forewarned and forearmed for frequent extreme weather events.

Introduction

Neonatal morbidity is a major health burden. However, there is little data on the numbers.[1] Detailed numbers describing neonatal morbidity are scarce. The number of newborn deaths worldwide is a large. India was first in the list of top 10 countries with the highest number (thousands) of newborn deaths in 2019.[2] News headline reads ‘After age 1, people in Jammu and Kashmir live the longest in India. The infant mortality rate (IMR) is often regarded as a barometer for overall welfare of a community or country.[3] Maximum contribution to IMR is by neonatal mortality. Neonates are most vulnerable, demanding the utmost care. All this becomes more important in the Northern Command of the Indian Army where geography is demanding for healthcare delivery and weather necessitates holistic measures. Difficult terrains and difficult times require diligent tact. Amidst all of this, it becomes important to review the results of the armed forces tertiary care hospital.

The success of newborn intensive care is well established. Much of its success is owed to the evidence-based nature of neonatal practice.[4] Overall, newborn care is also important and needs attention. Targeted epidemiological efforts to address perinatal disorders yield progress. The World Health Organization (WHO) reiterates strengthening measures, programme-tracking, and accountability to count every newborn.[2] Primary care assumes increasing importance for reaching all newborns. Descriptive epidemiology covers time, place, and person. We have to reach out to all newborns, at all times, at all places, and in all conditions.

Materials and Methods

Objectives

Improvements in newborn health through a study of the present status, practices perfection, and data diligence for the future.

Study setting

The study was conducted at a tertiary care referral hospital located in a prominent district in the Jammu and Kashmir state of India. Referral of patients was by road, rail, and air. Helicopters with sitting and lying facilities brought patients at the helipad located inside the hospital complex. The terrain was difficult and high degree of alertness was required.

Study design

This is an observational study.

Subjects: inclusion and exclusion criteria

All newborns born in the hospital were included in the study. This included newborns delivered from mothers referred from various hospitals and field medical units in the whole of Northern Command. The exclusion criteria were that only live newborns were studied. Still births were excluded.

Methods

Study of mortality and morbidity of the newborns, and this included the seasonal trends. Analyse findings for future focus areas and advancements. Corroborate with existing evidence for progressive professionalism.

The Newborn care facilities

The neonatal intensive care unit (NICU) is a level-three unit located adjacent to the labour room inside the family ward. It caters to the needs of 600 mothers, including high-risk referred cases, for management and delivery per year. There are 20 rooming beds in the post-natal ward. Equipped with modern state-of-the-art technology, the NICU is managed by a team of paediatricians, interns, skilled nurses, and other support staff. It provides humanized, holistic, compassionate care with optimum use of technology to manage sickest and tiniest of neonates. The parents form an integral part of the team.

The protocols

Evidence-based best practices and standard operating procedures (SOPs) are in place and frequently updated.

Essential newborn care along with monitoring for and management of complications is done energetically. Every newborn receives skilled care at birth. All babies in our set-up receive the following essential care: thermal protection, hygienic umbilical cord and skin care, early and exclusive breastfeeding, assessment for signs of serious health problems or need of additional care, preventive treatment (including immunization BCG and Hepatitis B, vitamin K).[2]

Each newborn receives individualized care. Clinical features guide investigations and treatment. Standard protocols with monitoring are used. Health education of parents is regularly done. This includes early recognition of danger.

Preterm babies are given special attention. This includes practice of all the latest evidence as elaborated in the WHO 10 main recommendations on interventions to improve preterm birth outcomes. These are antenatal corticosteroids, tocolysis, magnesium sulphate, antibiotic prophylaxis, mode of preterm birth (for the mother) and Kangaroo mother care, plastic wraps, continuous positive airway pressure therapy, surfactant and oxygen therapy (for the newborn).[5] Additionally, our practices include meticulous monitoring and health education for care of preterm babies. In-patient care till the mother is able to look after the baby and baby is breast fed with positive weight trajectory is ensured. Health education includes recognition of danger signals.

Neonatal jaundice evaluation is done on the basis of risk factors and clinical monitoring. Risk designation of term and near-term well newborns is done on the basis of nomogram for hour-specific serum bilirubin values.[6] The high-risk zone is subdivided by the 95^th percentile track. The intermediate-risk zone is subdivided into upper and lower risk zones by the 75^th percentile track. The low-risk zone has been electively and statistically defined by the 40^th percentile track. For preterm babies, recommendations for operational or therapeutic total serum albumin (TSB) thresholds are used.[7]

Study variables

All data were collected as per the International Classification of Diseases (ICD) 11.[8] Standard case definitions were used for classification of conditions. Data analysis was done over a three-year period (2018–20).

Neonatal mortality: Cause-of-death analysis, a staple of epidemiologic investigation, has limitations when applied to the perinatal period. The choice of which particular epiphenomenon of preterm birth should be chosen to be listed as the primary cause of death is to some extent arbitrary.[4] We follow the WHO International form of medical certificate of cause of death. Data classified as (i) Disease or condition directly leading to death (ii) Antecedent causes: Morbid conditions, if any, giving rise to the above cause, stating the underlying condition last (iii) Other significant conditions contributing to the death, but not related to the disease or condition causing it. All the data were collected as per ‘The WHO application of ICD-10 to deaths during the perinatal period: ICD-PM’ (ICD-Perinatal Mortality),[9] for pinpointing action areas.

Ethics

The study was conducted in accordance with the Declaration of Helsinki. The study was reviewed and approved by the ethics committee, named the Command Hospital (Northern Command) Institutional Ethics Committee.

Guidelines for reporting

Reporting guidelines STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) were followed.

Results

Total live born babies in the study period were 1749 (565 in 2018, 586 in 2019, and 598 in 2020).

Mortality

Mortality details are given at Table 1. This is as per the ICD-PM groups and ICD-10 codes for neonatal deaths. There were 3 neonatal deaths in 2018, 4 in 2019, and 4 in 2020 (total deaths 11 in the three-year period of the study). The neonatal mortality rate (NMR) is 5.31 for year 2018 and 6.83 for 2019, and 6.69 for 2020. The NMR average of the three years is 6.29. The commonest underlying condition causing mortality is prematurity in 8 cases. The disease or condition directly leading to preterm death were hypoxic ischaemic encephalopathy (HIE), sepsis, respiratory distress syndrome, small for gestational age, and birth asphyxia.

Table 1.

Mortality

ICD-PM groups and ICD-10 codes for neonatal deaths		2018 Total live births=565			2019 Total live births=586			2020 Total live births=598
		Disease or condition directly leading to death	Antecedent causes (Morbid conditions, Underlying condition [UC])	Other significant conditions contributing to the death	Disease or condition directly leading to death	Antecedent causes (Morbid conditions, Underlying condition [UC])	Other significant conditions contributing to the death	Disease or condition directly leading to death	Antecedent causes (Morbid conditions, Underlying condition [UC])	Other significant conditions contributing to the death
N1 Congenital malformations, deformations and chromosomal abnormalities
N2 Disorders related foetal growth	P05.1 Small for gestational age				Case 2
N3 Birth trauma
N4 Complications of intrapartum events	P21.0 Severe birth asphyxia		Case 1		Case 4				Case 1 Case 4
N5 Convulsions and disorders of cerebral status	P91.6 Hypoxic ischaemic encephalopathy of newborn	Case 1						Case 1 Case 4
N6 Infection	P36.4 Sepsis of newborn due to Escherichia coli	Case 3
	P36.5 Sepsis of newborn due to anaerobes		Case 2 (UC)
N7 Respiratory and cardiovascular disorders	P22.0 Respiratory distress syndrome of newborn		Case 3		Case 1			Case 3
	P22.8 Other respiratory distress of newborn
	P24.0 Neonatal aspiration of meconium				Case 3			Case 2
N8 Other neonatal conditions	P60 Disseminated intravascular coagulation of foetus and newborn	Case 2
N9 Low birthweight and prematurity	P07.3 Other preterm infants		Case 1 (UC) Case 3 (UC)			Case 1 (UC) Case 2 (UC) Case 4 (UC)			Case 1 (UC) Case 3 (UC) Case 4 (UC)
	P07.0 Extremely low birth weight						Case 4
N10 Miscellaneous
N11 Neonatal death of unspecified cause
Neonatal Mortality Rate		5.31			6.83			6.69

Morbidity

The morbidity data is given in Table 2. These are presented as per the ICD 11 blocks. The low Birthweight (LBW) incidence was 10.97% (62 neonates out of 565) in 2018, 14.51% (85 out of 586) in 2019, and 14.21% (85 out of 598) in 2020. The overall incidence of LBW is 13.26% and a majority of these (80.17%) were in 2000–2499 g range.

Table 2.

Morbidity

ICD-11 Chapter 19: Certain conditions originating in the perinatal period				2018		2019		2020
				Total	NICU managed	Total	NICU managed	Total	NICU managed
BlockL1-KA0 Foetus or newborn affected by maternal factors or by complications of pregnancy, labour, or delivery				259	27	317	35	292	36
BlockL1-KA2 Disorders of newborn related to length of gestation or foetal growth	KA20 Disorders of newborn related to slow foetal growth or foetal malnutrition			19	16	28	19	27	19
	KA21 Disorders of newborn related to short gestation or low birthweight	KA21.0 Extremely low birthweight of newborn (750-999 g)		Nil	Nil	01	01	Nil	Nil
		KA21.1 Very low birthweight of newborn (1000-1499 g)		07	07	06	06	06	06
		KA21.2 Low birth weight of newborn	1500-1999 g	12	06	07	04	08	06
			2000-2499 g	43	01	72	Nil	71	01
		KA21.4 Preterm newborn		27	16	37	19	38	20
	KA22 Disorders of newborn related to long gestation or high birthweight			07	01	11	01	08	02
BlockL1-KA4 Birth injury				11	02	20	01	21	02
BlockL1-KA6 Infections of the foetus or newborn				11	05	14	01	16	03
BlockL1-KA8 Haemorrhagic or haematological disorders of the foetus or newborn				14	10	16	11	18	10
BlockL1-KB0 Neurological disorders specific to the perinatal or neonatal period				02	02	03	03	04	04
BlockL1-KB2 Respiratory disorders specific to the perinatal or neonatal period	KB21 Birth asphyxia		KB21.0 Severe birth asphyxia	02	02	03	03	02	02
			KB21.1 Mild and moderate birth asphyxia	23	04	29	05	33	09
	KB23 Respiratory distress of newborn			34	31	42	42	52	51
	KB26 Neonatal aspiration syndromes		KB26.0 Neonatal aspiration of meconium	07	07	10	10	11	11
	KB2A Apnoea of newborn		KB2A.0 Central neonatal apnoea	03	03	04	04	05	05
			KB2A.3 Apnoea of newborn, due to neurologic injury	01	01	Nil	Nil	02	02
	Total			71	49	88	64	105	80
BlockL1-KB4 Cardiovascular disorders present in the perinatal or neonatal period				01	01	Nil	Nil	01	01
BlockL1-KB6 Transitory endocrine or metabolic disorders specific to the foetus or newborn				05	02	02	Nil	02	01
BlockL1-KB8 Digestive system disorders of the foetus or newborn				Nil	Nil	01	01	Nil	Nil
BlockL1-KC0 Genitourinary system disorders specific to the perinatal or neonatal period				01	Nil	Nil	Nil	02	Nil
BlockL1-KC2 Disorders involving the integument of the foetus or newborn				94	01	102	01	99	02
BlockL2-KC3 Skin disorders associated with prematurity				26	04	26	05	28	06
BlockL2-KC5 Iatrogenic injuries involving the skin of the neonate				Nil	Nil	Nil	Nil	Nil	Nil
BlockL3-KC5 Postnatal iatrogenic skin injury				Nil	Nil	Nil	Nil	Nil	Nil
BlockL1-KD1 Disturbances of temperature regulation of newborn				05	01	08	02	07	02
BlockL1-KD3 Certain disorders originating in the perinatal period				05	02	07	Nil	04	01

Preterm births were 5.83% (102 out of 1749 total live births). Mortality of preterm babies in our study over the three-year period was 7.84%, that is, 8 out of 102 preterm babies, and 4.57 deaths per 1000 live births. Prematurity is the most common cause of mortality in the study, with 8 out of 11 deaths (72.73%).

Incidence of birth asphyxia was 5.26% (92 out of 1749 live births) with a case fatality ratio of 4.35% (4 deaths out of 92 cases of birth asphyxia). A total of 7 newborns had severe birth asphyxia, and 4 of these could not be saved (57.14% mortality in severe birth asphyxia). All of these 4 cases were preterm deliveries.

There was no case of hypothermia with all the preventive care practiced. The incidence of infections in our study was 2.34% (BlockL1-KA6). Out of the 41 cases with infections, 2 ended fatally.

Developmental anomalies were 3.77% of total live newborns. A graphic representation of details of these according to ICD 11 blocks is given Figure 1.

Figure 1.

Developmental anomalies ICD-11

Neonatal jaundice seasonal trends of (i) term and near-term well newborns (ii) Preterm Infants <35 weeks gestational age is given in Figure 2. A sudden increase in cases with high TSB are observed during December 2018 to February 2019. This period had unusually severe winter.

Figure 2.

Neonatal jaundice seasonal trends

Newborn admissions to the NICU were 16.98% of the total live newborn babies delivered. Average length of stay in the NICU is 11.01 days.

Discussion

Management of the newborn should focus on parental anticipatory guidance and early detection of conditions/complications that carry risk of morbidity or even death. Our antenatal clinic and well baby clinic are housed together for active cooperation and an atmosphere of continuum of care.

Mortality

The neonatal mortality rate (NMR) in our study was 6.29 per 1000 live births. The most common underlying condition causing mortality is prematurity (8 cases). The other antecedent morbid conditions were varied and appeared in one case each. The disease or condition directly leading to death were also varied [Table 1]. The range of NMR in the most recent worldwide data is 1–43.[10] Countries having 1 NMR are total 13, while the highest is 43 of Lesotho. The neighbouring country Pakistan has NMR of 41 while that of India is 22.[10] As per the Sample Registration System, the NMR in Jammu and Kashmir was 18 as compared to 24 in India in 2016.[11]

Effective public health interventions prevent harm or death by breaking the chain of events that lead to harm.[12] The most common underlying cause of neonatal mortality in our study was prematurity, responsible for 8 out of 11 deaths (72.73%). Globally also prematurity is the leading cause of neonatal mortality. Our focus should be on preventing prematurity and advancing care for premature babies. Primary care contributes importantly in all chain of events for better results.

Skilled care at birth is important. Incidence of birth asphyxia in our study was 5.26%, that is, 92 out of 1749 live births. Out of a total mortality of 11 in our study, cases with birth asphyxia were 4 (36.36%), and all of these suffered severe birth asphyxia. All of these four cases had preterm delivery. Similar findings have been reported.[13,14] Prematurity was associated with a 2.28-fold (95% CI: 1.69 to 3.09) higher birth asphyxia risk after adjustment for the other covariates.[13] In Gadchiroli, the case fatality for asphyxiated premature infants was 66.7% versus birth asphyxia alone (25%).[14] Uleanya et al.[15] reported that the term and post-dates are more likely to survive birth asphyxia than preterms. All this points out that utmost skilled care at birth, especially for preterm deliveries.

Neonatal morbidity

Neonatal morbidity is a major health burden. The WHO reiterates strengthening measurement and accountability to count every newborn.[2] All of this makes our findings important.

The incidence of infections in our study has been 3.26%. The hygienic practices followed as per SOPs has resulted in these low figures.

Average length of stay in NICU in our set-up was 10.44–11.79 days, lower than that generally reported.[16] This is a result of practicing the advantageous early rooming with mother.

Prematurity

According to the WHO, most neonatal deaths in 2017 were due to preterm birth, intrapartum-related complications (birth asphyxia or lack of breathing at birth), infections, and birth defects.[2]

The rate of preterm birth ranges from 5% to 18% of babies born, as per data from 184 countries.[17] In our study, preterm births were 5.83%. Our policies include all of the WHO’s antenatal care guidelines to help prevent preterm birth, and results prove the benefits of these. Globally reinforcement of these and improvements in obstetric practices needed for reducing the incidence of preterm births.

Mortality of preterm babies in our study over a three-year period is 7.84%, that is 8 out of 103 preterm babies [Table 1].

Preterm mortality is responsible for nearly 18 deaths per 1000 livebirths according to the 2018 WHO estimation.[18] Our study results are better, with 4.57 deaths per 1000 live births. Hence there is a need for popularization and practice of the 10 main recommendations of the WHO,[5] along with meticulous monitoring and health education for care of preterm babies, as was done at our centre.

Low birthweight

The incidence of low birthweight (LBW) in our study was 13.32%. The prevalence of LBW varies widely across regions—from 7.2% in more developed regions to 17.3% in Asia.[19] A newborn’s weight at birth is an important marker of maternal and foetal health and nutrition. LBW newborns have a higher NMR, and are more likely to suffer from stunted growth and lower IQ.[20,21] The LBW incidence in our set-up is a cause of concern. However, a majority (79.83%) were in the 2000–2499 g range suggesting reinforcing obstetric practices should yield results. Primary care and family physicians can contribute substantially in improving nutrition of mothers.

Neonatal jaundice

Risk factors starting from clinical history to clinical examination have been described.[22] Certain demographics, environmental and genetic risk factors, among a myriad of icterogenic contributors, merit special clinical attention in addition to haemolytic conditions.

A history of a previous sibling treated with phototherapy is an identified risk factor for hyperbilirubinemia.[23,24] This is particularly relevant if bilirubin concentrations was greater than 15 mg/dL (257 μmol/L).[25] This relationship can be due to recurrent ABO or Rh haemolytic disease. Possible causation can be due to common genetic or environmental factor[23] or both.

We highlight the environmental factors as observed in our study. A sudden increase in cases with high TSB were noted in December 2018 to February 2019. The thing different from the previous years was severe winter. It was reported as the coldest winter in three decades.[26] Further Skymet had reported that northwest India would witness the wettest spell of winter of 2019 from January 21 to 24.[27]

Similar findings were reported by Milby et al.[28] They observed a seasonal variation in the incidence of neonatal non-haemolytic, unconjugated hyperbilirubinemia in a small, predominantly agricultural community. In this study, in one hospital, an excess of cases occurred during the fourth quarter of each of the 4 years reviewed. A similar trend was apparent in the second hospital during 2 of the 3 years reviewed. Contrarily or more correctly simultaneously increased hyperbilirubinemia has been reported in summers. Bala et al.[29] observed that the higher temperature during the summer, with a greater influence of higher breastfeeding cause more severe hyperbilirubinemia. Scrafford et al.[30] reported warm air temperature as a significant risk factor for neonatal jaundice. Our findings and aetiology of the increased hyperbilirubinemia need to be explored in large studies. The severity of hyperbilirubinemia observed in our study point towards vigilance in monitoring for jaundice in winter months. This is important because extreme weather events are becoming more intense and frequent.[31] To be forewarned and forearmed is always desirable.

Hypothermia

Newborn hypothermia continues to be a global challenge, particularly in resource-limited settings. Hypothermia soon after birth has been associated with increased morbidity and mortality, prompting organizations such as the Neonatal Resuscitation Program and the WHO to stress the importance of preventing early postnatal hypothermia.[32] Hypothermia occurs easily in the neonatal period, and special precautions are needed in our setting. No case of hypothermia occurred, reinforcing the need for practice guidelines for results. Primary care and family physicians should assume responsibility for ensuring thermoregulation of all newborns. The proposed neonatal and paediatric transport national benchmark and quality metrics includes ‘Unintended neonatal hypothermia on arrival at destination’.[33]

Congenital anomalies

Congenital anomalies (also referred to as birth defects) affect approximately 1 in 33 infants. Estimated frequency of congenital malformations is 1 in 50.[34,35] In our study, developmental anomalies, as per ICD Chapter 20, incidence was 1 in 26.5. Nothing unusual was observed. Genetic counselling, periconceptional folic acid, and appropriate vaccination programs are important for prevention.

ICD

We have collected and discussed findings on the basis of ICD. ICD is the foundation for the identification of health trends globally.[9] Analyse the past, act in the present, and plan for future is all important. The optimal health management of future generations depends on the collection of high-quality data now.[36] We recommend all surveys, research studies, and textbooks to use ICD. ICD is also useful in understanding the economic impact of various morbidities in the neonatal period and infancy.[37] This is the best for evidence-based practices and policies with streamlined scientific interpretations and seamless sophisticated implementation.

Limitations

The study was carried out at a tertiary care referral centre: Command Hospital (Northern Command). At a referral hospital, more complicated cases are managed; hence numbers may not represent the general picture. However, this hospital caters to various hospitals and field medical units in the whole of Northern Command in India.

Conclusion

On the basis of our findings, the recommendations for improvements in neonatal practices and policies are (i) skilled care at birth; (ii) vigorous research for the vulnerable premature babies for NMR reduction; (iii) reinforcement of obstetric practices needed for reduction in LBW babies; (iii) preventive practices for hypothermia. The unusual rise in incidence and severity of hyperbilirubinemia in severe winter points towards the need for vigilance. We need to be forewarned and forearmed for the frequent extreme weather events. All data should be collected as per the ICD for streamlining scientific interpretation and seamless sophisticated implementation. Overall, the recommendations based on our study for improvements in newborn health are summarized as below:

“Progressive practices with evolving evidence, & Professional preparedness for extreme weather events”

Key messages

• Neonatal mortality reduction requires focus for the vulnerable premature babies. Meticulous monitoring and health education improves results.

• Skilled care at birth is important, especially for preterm babies.

• Reinforcement of obstetric practices for reduction in LBW babies.

• Meticulous preventive practices for hypothermia

• Vigilance for hyperbilirubinemia in extreme weather events.

• ICD data ensures streamlining scientific interpretation and seamless sophisticated implementation.

Human research statement

All authors affirm that research involving human subjects submitted to the journal was conducted in accordance with the ethical standards of all applicable national and institutional committees and the World Medical Association’s Helsinki Declaration.

The study was reviewed and approved by the ‘Command Hospital (Northern Command) Institutional Ethics Committee’.

Author contributions

SJ was involved in the idea for this research. All authors (SJ, JS, and IS) were involved in the subsequent manuscript planning, literature review, data collection and analysis, writing, and manuscript writing. All authors accept full responsibility for the research paper.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.