Ms. Shwetanjali Kumari

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MORBIDITY & MORTALITY PATTERN OF NEONATES TRANSFERRED TO SPECIAL NEWBORN CARE UNITS, RAJASTHAN INDIA

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“MORBIDITY & MORTALITY PATTERN OF NEONATES TRANSFERRED TO SPECIAL NEWBORN CARE UNITS, RAJASTHAN INDIA” SHWETANJALI KUMARI & DR. BEENA VARGHESE PUBLIC HEALTH FOUNDATION OF INDIA

Morbidity & Mortality pattern of neonates Transferred to Special Newborn Care units, Rajasthan India:

Morbidity & Mortality pattern of neonates Transferred to Special Newborn Care units, Rajasthan India Shwetanjali Kumari & Dr. Beena Varghese Public Health Foundation of India July 29, 2016 2 Acknowledgement: Funding agencies, Government of Rajasthan and Safe Childbirth Checklist Evaluation Team

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Background: Globally 2.7 million newborns die within first 4 weeks of life (around 70 % in 1st week itself) [UN IGME, 2015]. Nearly 70-80% of deaths that occur within 1st week, dies within three days of birth [ Enigman et al. and Bquai et al.] India alone accounts for nearly one-fourth of global deaths (NMR 28 per 1000 live births) [UN IGME, 2015] . Newborns die mostly from preventable conditions , associated with quality of intrapartum care and immediate postpartum care

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Trend of Neonatal Mortality Rate and Infant Mortality Rate Source: SRS Statistical Reports (2000-2012)

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5 Currently, there are 602 Special Newborn Care Units (SNCU) established across the country. SNCU is a 12-20 bedded unit  [ GoI ] Facility-based newborn care has significant potential for improving the survival of newborn [Darmstadt GL et al. Lancet 2005] The Ministry of Health & Family Welfare, Government of India, under National Health Mission launched Facility Based Newborn Care (FBNC) programme in 2011 to improve the status of newborn health.

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Study Rationale & Objective To understand morbidity and mortality pattern of neonates delivered in an institution and transferred to SNCUs in one of the largest states of India, Rajasthan Rajasthan is among the top 4 states with highest neonatal mortality rate (NMR)– 35 per 1000 live births [SRS 2012]. 6

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Part of a large ‘ Safe childbirth checklist ’ evaluation study; approved by the institutional ethics committee of Public Health Foundation of India & Government of Rajasthan Funded by: Children’s Investment Fund Foundation & UBS Optimus Foundation Funding and Approval

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Outcome : Morbidity and mortality associated with chief morbidity within 3-days of birth (Why?) Nearly 70-80% of deaths that occur within 1st week, dies within three days of birth [ Enigman et al. Journal of Periontology 2012 and Bquai et al . Bulletin of World Health Organization 2006] Duration of stay in SNCU is 4.7 days (Median ) [ Neogi et al. Journal of Health, Population, and Nutrition, 2011]

Methods:

Methods Study population: Neonates transferred from labor room to SNCUs Study Period : November 2013 until December 2014 (14-months) Data Source: SNCU and labor room registers Data collection: Pre-designed electronic format using mobile device or a desktop by trained data collectors Quality control: All deaths validated; 2 to 10% of alive/ discharge and referred cases validated 9

Study Site :

Study Site District Hospital SNCU 10

Methods:

Methods Study variable: Gestational age, birthweight, sex, morbidity pattern, and outcome (births with missing gestational age and birthweight information excluded) Transfers for which, more than one diagnosis was recorded, first diagnosis was considered as the primary reason for transfer Cause of death was not recorded , thus leading mortality associated with chief morbidity is presented 11

Results: :

Results: 12

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13 Category Numbers (Percentages) Admissions 6,933 Male 4,360 (62%) Maternal age in years   ≤20 years 942 (13.4%) 21 to 30 years 5,826 (83.3%) >30 years 222 (3.1%) Mean age of admission (days) 1.2 Admission on day 0 Admission on day 1 Admission on day 2 >2 days 4,679 (66.9%) 927 (13.2%) 476 (6.8%) 910 (13.0%) Average length of stay (days) 3.7 80.2%

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n =5063 Alive & discharged Labor room birth transferred to Special Newborn Care Units (6) n =7462 admissions 4641 male; 2821 female *for 1 case date of death information is missing n =502 Dead n =1395 Referred/Left against medical advice n =6993 admissions 4360 male; 2633 female n =388 (77.2 %) Died within 3-days of birth 33 Outcome missing GA missing 178 BW missing 5 GA and BW missing 14

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15 Mortality (388) Alive odds ratios Low birthweight 218 2,233 56% of total deaths 2.510 [95% CI: 2.0414, 3.0879] Normal weight 170 4,372 Mortality Alive odds ratio Preterm 152 2,211 39% of total deaths 1.279 [95% CI: 1.0374, 1.5793] Normal term 236 4,394 LBW and preterm: Odds of deaths Transfer (n) = 6,993 , Mortality within 3-days of birth = 388

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16 Morbidity (Reasons for transfer to SNCU) No. of Newborn (%) Mortality (vEND) associated with chief morbidity (%) Respiratory Distress Syndrome/RD 1875 (30.0) 125 (34.7) Birth Asphyxia (BA) 942 (15.1) 49 (13.6) Meconium Aspiration Syndrome ( M AS ) 353 (5.6) 19 (5.3) LBW/Preterm 888 (14.2) 119 (33.1) Neonatal sepsis (NSS) 831 (13.3) 26 (7.2) Neonatal Jaundice 627 (10.0) 12 (3.3) Congenital abnormality 30 (0.5) 5 (1.4) Others* 707 (11.3) 5 (1.4) Total 6253 360 740 cases reasons for transfer missing; 28 cases for vENDs *Acute vomiting, refusal to feed, excessive crying, convulsion, hypoglycaemia , hypothermia etc.

Limitations::

Limitations: Exact cause of death was not recorded in the registers and hence not collected Clinical examination was not part of the study Data was collected as recorded in the official records Outcome of referred and LAMA cases are not included 18

Conclusion :

Conclusion Facility based case fatality at the SNCU was 72.1 per 1000 newborn transfers, 55.7 within 3 days of birth (388) Chief reasons for transfers include RDS (34.7%), followed by birth asphyxia (13.6%),low birth weight/preterm (14.1%) and neonatal sepsis (13.3%) Respiratory distress along with birth asphyxia and M AS (53.6%) was leading cause of mortality associated with morbidity within 3-days of birth . Low birthweight and prematurity (33.1%) and neonatal sepsis (7.2%) were another most important reasons for mortality . 19

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Strengthen existing recording system for better action : Robust tracking system Need for simple and cost effective interventions During childbirth ( quality of intrapartum care and immediate postpartum care ) (BA, RS, MAS) Immediate newborn care (neonatal resuscitation, immediate and exclusive breastfeeding, temperature maintenance Kangaroo mother care) Improving care during pregnancy ( nutrition of the mother ) (LBW) Tracking of referred and LAMA cases to ascertain final outcome Tracking of alive/discharge newborns for any morbidity or disability for at least one year ( not only for mortality ) Correctness and completeness of information for effective decision making Recommendations

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Every Life Matters… 21

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