ABSTRACT
Background:
India contributes to the highest number of neonatal deaths in the world, a fourth of the world’s total. Targeted interventions can be planned after a specific analysis of region-specific causes if India is to achieve the sustainable development goal (SDG 3.2) of neonatal mortality of 12 per 1000 live births.
Material and Methods:
A retrospective study of medical records of all neonates admitted in the special care neonatal unit (SCNU) over the 6-year period of 2018–23 at a teaching medical college.
Results:
A total of 9462 neonates were admitted over the 6-year period. The trends in mortality were encouraging, declining from 19.40% in 2018 to 12.34% in 2023. The reduction was more in outborn (24.32% to 11.68%) than inborn (14.86% to 12.89%) neonates. The low birth rate also declined from 40.77% in 2018 to 25% in 2023. The rate of discharges went up. The trends in etiology of death were uniform over the years with respiratory distress syndrome (RDS) (37.24%), hypoxic-ischemic encephalopathy (HIE) (29.5%), sepsis (16.12%), prematurity (11.45%), and congenital malformations (2.47%) being the chief contributors to death among newborns admitted in SNCU.
Conclusion:
The trends are encouraging but may be insufficient to meet the target of SDG 3.2. Further targeted intervention to tackle preventable cause, such as perinatal asphyxia, sepsis, better antenatal care, and better management of preterm neonates on mission mode, is need of the hour as they continue to contribute significantly to neonatal mortality.
Keywords: Mortality trends, NMR (neonatal mortality rate), SDG (sustainable development goals) 3.2, SNCU (special newborn care unit)
Introduction
In 2019, there were 5.30 million deaths of children under 5 years of age with neonates (i.e., newborns less than 28 days) contributing to 43.2%, that is, 2.44 million of these deaths.[1] This makes the first month, the most vulnerable period of one’s life responsible for 6700 deaths per day. The current worldwide neonatal (NMR), infant (IMR), and under-5 mortality rates (U5MR) are 22, 28, and 34 per 1000 live births. Sustainable development goals (SDG) 3.2 adopted in 2015 targets an NMR of 12 per 1000 live births and U5MR of 25 per 1000 live births. The SDG targets cannot be met without reducing the NMR. The NMR shows a wide fluctuation ranging from 1 per 1000 live births in Japan and 2.4 in the United Kingdom to 27 in sub-Saharan Africa and 23 per 1000 live births in Central and Southern Asia.[2,3] A neonate born in Africa has 10 times more chances of dying than if he were born in a developed country. Without tackling this inequity in the world, the SDG targets will remain an unattainable dream.
India has made huge strides in reduction of U5MR and NMR reduction. But is it sufficient to achieve SDG 3.2 targets? Due to the sheer size of its population, it has the dubious distinction of being the country responsible for a fourth of neonatal deaths, the single largest contributor to neonatal mortality (490 thousand 425-558) followed closely by Nigeria (271 thousand), Pakistan (244 thousand), Ethiopia, the Democratic Republic of Congo, China, Indonesia, Bangladesh, Afghanistan, and the United Republic of Tanzania. In India too, there is a wide variability in NMR as well as its causes.[1] The current NMR, IMR, and U5MR in India are 26, 39, and 45. NMR contributes to 53% of U5MR. The Uttarakhand state is at par or better with the rates at 26, 33, and 36. However, it lags behind states, such as Kerala, which has NMR, IMR, and U5MR of 6, 12, and 13.[4] Kerala’s performance proves that targeted interventions properly implemented can help a developing country like India to achieve SDG 3.2.
Targeted interventions for improving survival can be planned only after understanding and identifying the cause and trends specific for each region as each locale has specific problems which must be tackled if strategies are to be successful. The Uttarakhand state has a geographically difficult terrain with frequent natural disasters and a shortage of trained manpower. NMR of 26 per 1000 live births has stagnated after initial rapid reduction. The study aims to study the mortality pattern and its causes in level II special care neonatal unit (SCNU) in a medical college to plan targeted interventions.
Materials and Methods
We did a retrospective analysis of records of newborns admitted in SNCU of Dr. Sushila Tiwari Government Hospital affiliated to Government Medical College, Haldwani, over a period of the last 6 years (2018–2023).
We included all newborns admitted in SNCU during the study period in our analysis irrespective of delivery place, that is, delivered within Dr. Sushila Tiwari Hospital (inborn) or delivered elsewhere (outborn) except those newborns borne in the hospital but referred due to non-availability of beds and newborns admitted in pediatric intensive care unit (PICU)/general ward of pediatrics department due to non-availability of beds in SNCU. We extracted birth weight, outcome, cause of death, inborn/outborn, and duration of stay records from patient case sheets. The outcomes were classified into four groups viz. expired (died during the management), discharged (discharged after successful treatment), left against medical advice (LAMA), and referred (referred to higher center for further management).
The definitions used for the purpose were as follows:[5]
Low birth weight (LBW) 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.
Congenital malformations—These were diagnosed on clinical features and diagnostic facilities, such as ultrasound, echocardiography, X-rays, and electrocardiography (ECG).
Intrapartum-related complication of birth (birth asphyxia) was diagnosed clinically (Apgar score <7 at 5 minutes) or clinical features suggestive of hypoxic-ischemic encephalopathy (HIE) in a child with a history of delayed cry.
Neonatal jaundice—This was diagnosed after assessment of serum bilirubin and found to be in the pathological zone in age, weight, and gestation-specific range.
Neonates were managed as per standard facility-based newborn care protocols.[6]
The study was approved by the Institutional Ethics Committee, Govt. Medical College, Haldwani (800/GMC/IEC/2023/Reg. No. 765/IEC/R- 09-05-2024 dated 11/07/2024). Patient identifiers were removed in data analysis to maintain confidentiality. Data were entered in MS Excel. Descriptive analyses were conducted using frequency, percentages, bar chart, and line chart in MS Excel, whereas for testing associations, Chi-square and Fisher’s exact tests were applied using an online calculator. P value <0.05 was considered significant.
Results
Close to 10,000 (9462) neonates were treated in SNCU of medical college over the last 6 years with a mean death rate of 15.86%, successful discharges of 72.57%, LAMA of 7.88%, and referral of 2.62%.
The outcome of newborns admitted in SNCU showed significant improvement across years in the form of increased discharge rate from 69.18% (1201/1736) in 2018 to 80% (1524/1905) in 2023. Similar trends were also observed in the death rate which declined from 19.40% (332/1736) to 12.34% (235/1905), LAMA declined from 7.72% (134/1736) to 5.51% (105/1905), and referral reduced from 3.97% (69/1736) to 2.15% (41/1905) [Figure 1].
Figure 1.
Trends of newborns outcome admitted in SNCU
The death rate of both inborn (14.90% in 2018 to 12.90% in 2023) and outborn (24.30% in 2018 to 11.70% in 2023) newborns admitted in SNCU showed a significant decline across years with overall (19.10% in 2018 to 12.30% in 2023) decline in death rate. The death rate among outborn newborns was significantly higher across all years than among inborn newborns except in 2023 [Figure 2 and Table S1].
Figure 2.
Death rate of newborns admitted in SNCU
Table S1.
Profile of newborns admitted in SNCU
| 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | Stats | |
|---|---|---|---|---|---|---|---|
| Admission | |||||||
| Inborn | 955 (55.01%) | 784 (56.16%) | 600 (54.20%) | 776 (50.49%) | 1011 (68.26%) | 1032 (54.17%) | |
| Outborn | 781 (44.99%) | 612 (43.84%) | 507 (45.80%) | 761 (49.51%) | 770 (43.23%) | 873 (45.83%) | |
| Death | |||||||
| Inborn | 142 (14.86%) | 113 (14.41%) | 83 (13.8%) | 108 (13.92%) | 114 (11.27%) | 133 (12.89%) | χ2=17.04, df=5, P=0.004 |
| Outborn | 190 (24.32%) | 114 (18.62%) | 126 (20.88%) | 136 (17.87%) | 140 (18.18%) | 102 (11.68%) | |
| Fisher’s Exact test | P<0.0001 | P=0.04 | P<0.0001 | P=0.04 | P<0.0001 | P=0.44 | |
| Birth weight | |||||||
| <2.5 kg | 324 (18.66%) | 222 (15.90%) | 183 (16.53%) | 244 (16.07%) | 254 (14.26%) | 235 (12.49%) | χ2=31.02, df=5, P<0.0001 |
| 1.5-2.5 kg | 223 (15.53%) | 152 (10.89%) | 122 (11.02%) | 168 (11.13%) | 181 (10.16%) | 143 (7.66%) | |
| 1-1.5 kg | 63 (4.39%) | 49 (3.51%) | 45 (4.06%) | 60 (3.90%) | 51 (2.86%) | 71 (3.73%) | |
| <1 kg | 38 (2.19%) | 21 (1.50%) | 16 (1.44%) | 16 (1.04%) | 22 (1.23%) | 21 (1.10%) | |
| Duration of stay | |||||||
| <24 h | 248 (14.28%) | 66 (4.73%) | 154 (13.91%) | 168 (10.93%) | 131 (7.35%) | 262 (13.75%) | χ2=238.92, df=10, P<0.0001 |
| 24-48 h | 771 (44.44%) | 574 (41.12%) | 420 (37.94%) | 744 (48.40%) | 946 (53.12%) | 955 (50.13%) | |
| >48 h | 717 (41.30%) | 756 (54.15%) | 533 (48.15%) | 625 (40.66%) | 704 (39.53%) | 688 (36.12%) | |
There was a significant reduction in the proportion of LBW newborns admitted in SNCU across years from 40.77%% in 2018 to 25.00% in 2023. A similar pattern was also noticed in extreme LBW (<1 kg) and very low birth weight (VLBW) (1–1.5kg) [Figure 3 and Table S1].
Figure 3.
Weight distribution of newborns admitted in SNCU
The duration of stay was significant across years. The proportion of <24-hour stay and >48-hour stay decreased from 2018 to 2013, whereas the proportion of 24- to 48-hour stays increased from 2018 to 2023 [Figure 4 and Table S1].
Figure 4.
Duration of stay of newborns admitted in SNCU
Respiratory distress syndrome (RDS) (37.24%), HIE (29.5%), sepsis (16.12%), prematurity (11.45%), and congenital malformations (2.47%) were the most common cause of death among newborns admitted in SNCU [Figure 5].
Figure 5.
Distribution of cause of death among newborns admitted in SNCU
Discussion
Forty-eight million deaths of children under 5 years of age can be reduced to 11 million if all countries can achieve the SDG targets of NMR reduction to 12 deaths per 1000 live births and U5MR of 25 deaths per 1000 live births.[7] Of the 195 signatories to the SDG goals, 116 have achieved the reduced target, 16 are on track, and 63 may miss the target. Most neonatal deaths if not all are preventable. A total of 700 000 neonates die each year. Hug et al. predicted that 27.8 million deaths can be reduced to 22.7 million if SDG targets can be met. A lot of these deaths can be prevented if India achieves the SDG target[8,9] as India alone accounts for 24% of all neonatal deaths.[10,11]
A marked reduction has occurred in NMR but it is still off the target. Renewed assessment, evaluation, and intensified focus on analyzing the shortcomings must be conducted again if India is to achieve the target. Uttarakhand, which is a hilly state located in Northern India with 13 districts, has its own unique set of problems related to difficult natural terrain with frequent natural disasters and sparsely populated villages with poor access to health facilities. It has a population of about 1 crore with a predominantly 69.77% rural- and 30.23% urban-based population. The people depend predominantly on government facilities in rural areas which are poorly staffed, and transport to a referral center may take a long time in rainy or winter season. The state’s NMR, IMR, and U5MR are 22, 33, and 27, which are better than the national average. However, states, such as Kerala, Punjab, and even a geographically similar state, such as Himachal, are doing better.[12] It is equipped with five SNCUs at district hospitals where deliveries are more than 3000 and at medical colleges; 29 newborn stabilization units (NBSUs) located at all first referral units for managing selected neonatal conditions and stabilization of referred neonates; and 129 newborn care corners (NBCCs) located at all delivery points.[13] The medical college SNCU, which has services of level II NICU, caters to not just inborn referred mothers but also referred neonates from SNCU in Kumaon region, Rudrapur, Haldwani, and Almora apart from critically sick neonates from private set-ups.
Mortality rates
The mortality rate in SNCU of the hospital has shown a marked improvement from earlier studies conducted in the same set-up in 2013 (20%) to 2023 (12%).[14] It has also shown a declining trend during the study period. The rate is more than SNCU of other states similar to a 7-year study by Malkar et al.[15] (10.4% Maharashtra, Jalgaon) and less than some states, such as West Bengal.[16] It continues to be more than SNCU in Mumbai (Randed et al.; 1.55% mortality)[17] and Jammu and Kashmir (Kumar et al.; 3.26%).[18] They had high referral rates of up to 31.13% or catered to predominantly inborn neonates with good antenatal care. Other countries, such as Eritrea, Asmara (sub-Saharan Africa), have a mortality of 6.56%,[19] and the United Kingdom has a mortality rate of 2.4/1000 live births.[20]
Causes of neonatal mortality
Prematurity and its complications (35%), perinatal asphyxia (24%), sepsis (14%), and congenital malformations (11%) are the leading causes of neonatal mortality worldwide, according to the WHO fact sheet and a Lancet study by Hug et al.[8] These findings are consistent with our study and those from geographically similar regions such as Himachal Pradesh and Nepal.[21,22] Data from developed countries, such as the United Kingdom, show congenital malformations contributing to 48.7% and immaturity and its complications to be responsible for 48.7% of deaths.[20] This is similar to the trend in better-performing states, such as Mumbai (Randed et al.[17] found prematurity 24.95%, RDS 26.5%) and even countries from sub-Saharan Africa, which have a low NMR and low neonatal mortality in SNCU (Eritrea: RDS 48%, ELBW 40.5%, and VLBW 30.5%).[19] Countries and states with higher NMR, such as our SNCU, show intrapartum-related complications at 29.51%, RDS at 37.24%, prematurity at 11.45%, sepsis at 16.1%, and congenital malformations at 2.5%, similar to Tanzanian study[23] (HIE 20.4%, RDS 20.7%, prematurity 12%, sepsis 13.6%, and pneumonia 8.6%) and similar to SNCU data from Jalgaon, Maharashtra (prematurity 24.95%, RDS 26.5%).[15] States and countries with the highest mortality have a higher proportion of sepsis and intrapartum-related complications (Pakistan: intrapartum-related complication 34%, congenital infections 20%, neonatal infections 20%, and RDS 20%).[10,11]
From the above studies, it becomes evident that as the mortality rates decrease, the relative proportion of deaths due to prematurity and congenital malformations increases as asphyxia and sepsis-related deaths are avoided.
The Million Death Study, Lancet,[4] has shown a marked reduction in deaths due to infections (66% reduction) and asphyxia (76% reduction) from 2000 to 2015 saving about a million neonates. However, deaths due to prematurity and LBW have risen.
It also holds important lesson for SNCU with moderate mortality (like ours) that deaths due to sepsis and intrapartum-related complications can be further decreased and should be the focus if NMR is to be further decreased.
Inborn/outborn
The outborn neonates have a significantly higher mortality than inborn (13.4% to 18.77%) but the difference has been gradually decreasing as the mortality rates have shown a declining trend (2023 in fact showed a lower mortality among outborn 11.6% versus 12.8% in inborn). This is in contrast to earlier study from the same SNCU where the rate was 14% in inborn versus 25% in outborn[14] and National Health Mission (NHM) data of 2014–15 which showed mortality rate in Uttarakhand inborn mortality of 10% in inborn to 21% among outborn.[13]. Since then, attempts for timely referral, capacity building of workers in the first referral unit by teaching them NBSU (care of normal neonate and common conditions, resuscitation and triage, and stabilization before referral), and repeated basic resuscitation training under NSSK have probably resulted in much lower mortality of outborn neonates. The states with high SNCU death rates continue to have this difference, but better-performing SNCU (Randed et al. Mumbai)[17] shows no difference.
This too holds an important lesson that capacity building by training manpower can help in reducing the mortality.
Recommendations
Intrapartum-related complications of birth and LBW can be reduced only by proper antenatal care, monitoring during ante- and intranatal periods, maternal age, nutritional status of the mother, maternal education, birth spacing, and improving socioeconomic status.
Ensuring each delivery is attended by a person trained in neonatal resuscitation.
Strict adherence to asepsis, exclusive breastfeeding and early recognition, and prompt treatment of neonatal sepsis is need of hour.
Clear protocols and emphasis on noninvasive ventilator modes, such as continuous positive airway pressure (CPAP), may help in reducing mortality due to RDS. Greater emphasis on antenatal steroids for preterm deliveries and magsulf therapy is also needed.
Capacity building of workers in remote hilly areas (neonatal resuscitation and NBSU training) has shown an impact by reduced mortality of outborn neonates as they received pre-referral stabilization and must be maintained.
Conclusions
The trends in neonatal mortality and outcome are encouraging and headed in the right direction. Even so, the momentum must be maintained and accelerated as it may not be sufficient for India to achieve SDG target of 12 deaths per 1000 live births or single-digit NMR by 2030. How it addresses the issue of preventable neonatal deaths-perinatal asphyxia, sepsis, and prematurity in states, such as Uttarakhand (along with underperforming states, such as Bihar), will determine the success or failure of our country. Better-performing states, such as Kerala and Punjab, have shown it is possible.
Newer strategies, such as family-centric care to maintain this continuity, could be additional measures to speed the reduction in NMR.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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