INTRODUCTION
Children face the highest risk of dying in their first 28 days of life (neonatal period). At a global rate of 17 (17, 19) deaths per 1000 live births and approximately 6700 neonatal deaths every day in 2019, the neonatal period (the first 28 days of life) is the most vulnerable time for children under the age of 5. Within the neonatal period, the youngest lives are at even greater risk.
Fewer countries are on track to meet the Sustainable Developmental Goal SDG target on neonatal mortality than under-five mortality. If current trends continue, more than 60 countries will miss the target for neonatal mortality (12 or fewer deaths per 1000 live births) by 2030.[ 1 ]
The Lancet Series 2005 has been important in drawing attentions to the interventions that accelerate efforts for neonatal survival in developing countries.
Simple interventions aimed at these main causes have been tested and found to be effective in reducing the neonatal mortality.[ 2 , 3 ] Estimates have suggested that more than 70% of neonatal mortality can be reduced by existing evidence-based practices, but coverage of these interventions is low and uneven in geographic areas with the highest burden of mortality.[ 4 , 5 ]
In India, the infant mortality rate (IMR) has been declined from 89/1000 (year 1990) to 28/1000 (year 2019) and neonatal mortality rate (NMR) from 57/1000 (year 1990) to 22/1000 (year 2019). According to the National Family Health Survey (NFHS) data, in Maharashtra, the IMR has reduced to 53.2 per 1000 live births (NFHS-1, 1992–1993) to 23.2 (NFHS-5, 2019–2020). The NMR declined from 38.1 per 1000 live births (NFHS-1, 1992–1993) to 23.2 in 2019–2020 (NFHS-5, 2019–2020).
Facility-Based Newborn Care (FBNC) program is one of the key initiatives launched by the Government of India under the National Rural Health Mission and RMNCH + A strategic program to improve the status of newborn health in the country. Under the program, efforts are being made to provide different levels of newborn care at the health facilities.
FBNC has a significant potential for improving newborn survival. Provision of newborn care facilities at various levels at health facilities will not only increase the confidence in the health-care delivery system but also increase the coverage of services at the time of the greatest risk – birth and the first few days of life – and thus addresses the challenge of bringing down neonatal mortality in the country.[ 6 ]
Newborn care corner, newborn stabilization unit, and special newborn care unit (SNCU) are newborn care facilities at Medical College Hospital (MCH) level I (primary health center/SC), MCH level II (community health center/first referral unit), and MCH level III (district hospital/medical college/tertiary care hospital), respectively.
SNCU is a neonatal unit in the vicinity of labor room which is to provide special care (all care except assisted ventilation and major surgery) for sick newborns.
As FBNC including SNCU is a relatively new implementation for neonatal survival and neonatal health, operational research in this arena is very less till date. Therefore, this study was designed with the objective to assess the profile of neonates admitted to an SNCU in a district-level hospital in Maharashtra and follow them to assess the outcome of the care provided at the end of their neonatal period.
This study will provide data of newborn morbidity and mortality for health planners and care providers with analysis of critical variables. Furthermore, it will bring out the impact of this facility in newborn care practices.
Aims and objectives
We aimed to study the admission profile and treatment outcome of neonates admitted in SNCU.
MATERIALS AND METHODS
The present descriptive observational study with longitudinal design was conducted in the government-supported SNCU of District Hospital of Jalgaon district of Maharashtra. The SNCU is a 20-bedded unit and equipped with radiant warmer, phototherapy machines, and ventilation facilities. Trained workforce including pediatricians, medical officers, nurses, counselors, data entry operators, and supportive staffs is posted. All services including stay, investigations, and treatments are provided free of cost to the admitted neonates. Standard national-level guidelines and protocols are practiced for the diagnosis and management of neonates as well as recording and reporting of the information.
All the neonates admitted in SNCUs were considered as the study participants. In the present study aggregated yearly, data from January 2013 to December 2019 were collected. The source of information was SNCU reports generated from admitted (indoor cases only) neonates.
Permission from the head of institute was obtained before starting the study. Ethical approval was sought from the Institutional Ethical Committee of Government Medical College, Jalgaon. Confidentiality of data was strictly maintained at all levels.
The SNCU monthly report is in a predefined format from the Ministry of Health and Family Welfare, Government of India, which includes data on admission information, reasons of admission, course of admission, and mortality reasons (if any) with treatment outcomes. It also includes information on gender, birth weights, gestation age, and duration of stay.
These participants were categorized into two sections such as inborn, who have delivered in the same facility, and outborn, who have been referred from peripheral health facilities or community. The outcomes were classified into four groups, namely 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 collected data were entered in Microsoft excel and were analyzed using the Statistical Package for the Social Sciences (SPSS) version 20 (SPSS Inc., IBM, USA).
RESULTS
It was seen that during the study period (i.e., from January 2013 to December 2019), total 16,489 neonates were admitted to the SNCU. Out of them, 9895 (60.01%) were inborn, i.e., delivered at the same facility where SNCU is situated, while 6594 (39.99%) were outborn delivered at other health facilities or at home. [Table 1 ]
Table 1: Distribution of neonates according to type of admission
It was observed that majority (93.22%) of the deliveries were institutional deliveries while very few (5.84%) were home deliveries. Total 78 (0.47%) deliveries occurred during transit to the hospital, whereas 77 (0.47%) deliveries were from other than Jalgaon district [Table 2 ].
Table 2: Distribution of neonates according to admission profile characteristics
Maximum neonates (27.42%) were shifted to SNCU by self-arranged transportation while 12.57% used transportation provided by the government. As 60.01% of admissions were inborn, hence transportation was not required [Table 2 ].
It was found that among the total SNCU admissions, 31.31% of neonates were preterm while only 0.02% were postterm and the rest 68.67% were full term. Among the preterm, 19.16% and 8.59% of neonates had gestational age 32–36 weeks and 28–32 weeks, respectively [Table 2 ].
Among all admitted newborns, 39.43% had normal birth weight (≥2500 g) and 61.57% were low birth weight (LBW) (<2500 g). Among LBWs, 2.37% of neonates had birth weight <1000 g while 10.64% and 47.56% of neonates had it 1000–1499 g and 1500–2499 g, respectively [Table 2 ].
It was seen that majority of the neonates who were admitted to SNCU were <1 day old (58.28%) followed by 1–3 days (29.08%) [Table 2 ].
It was seen that among the total admissions, 55.72% were male neonates while 44.28% were female neonates [Table 2 ].
The most common indication for admission was meconium aspiration syndrome (MAS) (16.50%), followed by prematurity (12.68%), other LBW (1000–2499 g) (11.96%), respiratory distress syndrome (RDS) (11.29%), and birth asphyxia (10.21%), respectively. Neonatal jaundice, neonatal sepsis, hypothermia of newborn, and transient tachypnea of newborns were diagnosed among 6.74%, 4.02%, 2.40%, and 2.26% of neonates, respectively. Congenital malformations were found among 124 (0.75%) neonates [Table 3 ].
Table 3: Distribution of neonates according to final diagnosis
Out of 16489 neonates admitted, outcomes of 34 were not recorded. Among 16,455 neonates whose outcomes were recorded, 12,939 (78.63%) were discharged after successful management and 1720 (10.45%) died during treatment. Six hundred and fifty-four (3.97%) were referred to higher center for further specialized management and 1142 (6.94%) were left the hospital against medical advice [Table 4 and Figure 1 ].
Table 4: Distribution of neonates according to outcome
Figure 1: Distribution of neonates according to outcome
Major causes of mortality were prematurity (25.70%) and RDS (25.48%). Birth asphyxia (15.12%), sepsis (7.73%), MAS (7.67%), and extremely LBW (7.62%) were other important conditions leading to the death of newborns [Table 5 ].
Table 5: Distribution of neonates according to cause of mortality
DISCUSSION
The present study was conducted in the government-supported SNCU of District Hospital of Jalgaon district of Maharashtra. It provides care and support to those neonates born within the hospitals, i.e., inborn, and those who are referred from peripheral health facilities and community, i.e., outborn. Detailed information of neonates admitted during the period from January 2013 to December 2019 was gathered from available records and analyzed.
It was observed that during the study period (i.e., from January 2013 to December 2019), total 16,489 neonates were admitted to the SNCU. Out of them, 9895 (60.01%) were inborn, i.e., delivered at the same facility where SNCU is situated, while 6594 (39.99%) were outborn delivered at other health facilities or at home. Similarly, Randad et al .[ 7 ] (inborn 76.46% and outborn 23.54%), Sridhar et al .[ 17 ] (inborn 71.71% and outborn 28.29%), and Kumar et al .[ 8 ] (inborn 60.80% and outborn 39.20%) also reported a lower proportion of outborns. Comparatively lower admission of outborn newborns might be partly due to delivery of high-risk mothers at tertiary care centers where SNCUs are located and partly due to nonreferral of neonates from primary- and secondary-level facilities. Hence, issues regarding the early detection of needy newborns and their prompt referral to SNCU from peripheral health facilities should be identified and resolved compressively.
It was observed that majority, i.e., 93.22% of the deliveries, were institutional deliveries while 5.84% were home deliveries. It is a welcome finding as institutional deliveries not only decrease the risk of newborns but also increase the chances of early identification of high-risk babies and their expert management including necessary referral which will eventually decrease mortality and morbidity among them.
It was revealed that majority of the neonates (27.42%) were shifted to SNCU by self-arranged transportation while 12.57% used transportation provided by the government. It has highlighted the need of intensification of services to provide government transportation.
Birth weight and gestational age are the two important factors for assessing risk of newborns as well as determining prognosis. Definitely LBW (birth weight <2500 g) and prematurity (gestational age <37 weeks) have adverse impact on survival and well-being of neonates.
Almost one-third (31.31%) admitted newborns were preterm. Comparable findings were recorded by Ravikumar et al .[ 9 ] (30.06%), Verma et al .[ 10 ] (37.00%), and Kumar et al .[ 11 ] (35.21%). In a similar study from Maharashtra by Adikane et al. ,[ 12 ] observed lower proportion (20.28%) and from neighboring state Gujarat by Shah et al. ,[ 13 ] observed higher proportion (48.00%), while in a study from Nepal by Bastola et al. ,[ 14 ] recorded very few (only 8.33%) preterm neonates as compared to the present study.
Among the preterm, 19.16% and 8.59% of neonates had gestational age 32–36 weeks and 28–32 weeks, respectively, compared to other studies.
Among all admitted newborns, 61.57% were LBWs which was comparable to the findings by Verma et al .[ 10 ] (61.6%), Kumar et al .[ 11 ] (61.52%), Shah et al .[ 13 ] (63.00%), and Baruah and Panyang[ 15 ] (66.10%), who revealed that around 60% of neonates of SNCU were LBW. Such a high number of LBW neonates are alarming which suggest an urgent need to intensify community-level intervention to modify associated social, maternal (especially related to maternal nutrition), and biological factors to reduce the incidence of LBWs. At the same time, a comparatively lower proportion of LBWs were also recorded in Mumbai by Rndad et al .[ 7 ] (39.18%) and at Bihar by Sinha et al .[ 16 ] (27.6%).
Community-based studies indicate that LBW neonates are at 11–13 times increased risk of dying than NBW neonates. Indeed, >80% of total neonatal deaths occur among LBW/preterm neonates.
It was seen that majority of the neonates admitted to SNCU were <1 day old (58.28%) followed by 1–3 day old (29.08%). More than half of the neonates (58.28%) were admitted within 24 h of their birth similar to study results by Kumar et al .[ 11 ] (51.96%), Adikane et al .[ 12 ] (69.04%), and Sinha et al .[ 16 ] (75.25%). Early admission to SNCU/NICU is very crucial for better survival and prognosis of newborn as interventions are started immediately. Early admission depends on delivery of high-risk mother at a hospital where SNCU/NICU is established as well as early diagnosis and timely referral of peripheral needy neonates which will be achieved by regular training of concerned staff and good transport system.
The present study revealed male preponderance among admitted neonates as observed by several studies conducted in various parts of India and Nepal. Male predominance might be partly due to higher susceptibility of male gender but largely to due social and cultural situations in India where male children are given more attention by family members and preferentially brought to the health facilities.
The unique finding of the present study was that neonatal MAS (16.50%) was the most common indication for admission. Tracheal suctioning immediately after birth will clear the airway and prevent mortality as well as morbidity among the affected newborns. Ongoing training of health workers and constant motivation is essential.
Similar studies conducted by Ravikumar et al .[ 9 ] (24.72%), Adikane et al .[ 12 ] (29.25%), and Saharia et al .[ 19 ] (26.6%) recorded neonatal hyperbilirubinemia as the most common indication for SNCU/NICU admission. In the present study, neonatal hyperbilirubinemia was found among 6.74% of neonates as observed by Sridhar et al .[ 17 ] (7.02%), Verma et al .[ 10 ] (13.00%), Sharma and Gaur[ 18 ] (10.65%), Ravikumar et al .[ 9 ] (14.00%), and Batsola et al .[ 14 ] (14.33%). RDS was observed as the most common indication for admission by Verma et al .[ 10 ] (39.00%) and Shah et al .[ 13 ] (23.00%) while Sridhar et al .[ 17 ] (28.8%) and Batsola et al .[ 14 ] (49.11%) found neonatal sepsis as the most common indication for admission. The present study recorded RDS among 10.21% of neonates similar to Sharma and Gaur[ 18 ] (14.06%), Adikane et al .[ 12 ] (17.19%), Shah et al .[ 13 ] (23.00%), and Sridhar et al .[ 17 ] (23.85%). Very low (4.02%) rate of neonatal sepsis was observed in the present study which was in contrast to other similar studies by Kumar et al .[ 8 ] (20.48%), Shah et al .[ 13 ] (21.00%), and Sinha et al .[ 16 ] (31.90%) where a higher proportion of neonates were victim of sepsis. Practicing hygienic measures before and during delivery as well as handling and transport of newborns is required for the prevention of neonatal sepsis.
Birth asphyxia was found among 10.21% of neonates similar to the studies conducted by Ravikumar et al .[ 9 ] (15.7%), Shah et al .[ 13 ] (16.00%), and Baruah and Panyang[ 15 ] (16.70%). Strict intrapartum monitoring will be helpful for early diagnosis of birth asphyxia.
Congenital malformation was observed among 124 (0.75%) neonates. This finding is in line with the study results by Sinha et al .[ 16 ] (1.9%), Kumar et al .[ 8 ] (1.8%), and Saharia et al .[ 19 ] (1.7%). Comparatively higher incidence of congenital anomalies was revealed in other studies by Batsola et al .[ 14 ] (8.39%), Sharma and Gaur[ 18 ] (7.94%), Shah et al .[ 13 ] (6.00%), and Sridhar et al .[ 17 ] (4.29%). The difference might be due to different rates of admission of the neonates because of the availability of specialized care including surgical interventions of congenital anomalies in the facility where SNCU/NICU is located. Among congenital anomalies, cardiac anomalies were the most common (17.46%), followed by tracheoesophageal fistula (6.35%) and cleft lip with cleft palate (6.35%). Meningomyelocele (5.56%), congenital hydrocephalus (4.76%), and imperforated anus (4.76%) were other common congenital anomalies.
The outcomes were classified into four groups, namely expired, discharge, left against medical advice (LAMA), and referred. In the present study, 78.63% of neonates admitted in SNCU were discharged after successful management and comparable results were recorded by Sinha et al .[ 16 ] (84.30%), Ravikumar et al .[ 9 ] (83.39%), and Saharia et al .[ 19 ] (85.39%) in their study. Harsh Shah et al .[ 13 ] (67.00%) and Adikane et al .[ 12 ] (65.89%) observed a lower rate of discharge as compared to the present study.
Six hundred and fifty-four (3.97%) neonates were referred for further expert surgical and/or intensive care to higher center as these facilities were not available at SNCU. However, almost double (6.94%) neonates than the referred one were left against the medical advice. Similar rates of neonates left against medical advice were revealed by Sharma and Gaur[ 18 ] (7.89%), Baruah and Panyang[ 15 ] (6.58%), Sinha et al .[ 16 ] (9.5%), and Shah et al .[ 13 ] (10.00%) in their study. Various socioeconomic, cultural, psychological, and other factors might be responsible for leaving the neonates against the medical advice. All these factors must be carefully identified and attended at all levels because definitely leaving against medical advice would have an adverse effect on health and survival of newborn. Effective communication not only at health facility level but also at the level of community is essential to decrease the number of LAMA neonates.
The mortality rate was in the present study was found to be 10.45% which is similar to Saharia et al .[ 19 ] (13.00%), Verma et al .[ 10 ] (11.00%), and Ravikumar et al .[ 9 ] (10.4%). A study conducted in Gujarat by Shah et al .[ 13 ] reported a higher rate of mortality (16.00%), while in Bihar, Sinha et al .[ 16 ] (0.9%) and, in Mumbai, Randad et al .[ 7 ] (1.55%) recorded a lower rate of mortality among the admitted neonates. Apart from clinical condition of newborns, recovery and mortality also depends on the availability of trained health persons, specialized equipment and medicines as well as timely admission and intervention. These factors must be evaluated and taken care of while planning and implementation of SNCU services.
Major causes of mortality were prematurity (25.70%) and RDS (25.48%). Birth asphyxia (15.12%), sepsis (7.73%), MAS (7.67%), and extremely LBW (7.62%) were other important conditions leading to the death of newborns.
More than half of the neonates among those who died were due to prematurity (25.70%) and RDS (25.48%). Similarly, Rakholia et al .[ 20 ] (25.70%) and national perinatal database[ 21 ] (26.5%) in India as well as Lawn et al .[ 2 ] (28.00%) and Elhassan et al .[ 22 ] (25.7%) outside India had recorded almost one-fourth mortality due to prematurity . RDS was also the most common cause of death of neonates as observed by Adikane et al .[ 12 ] (57.14%), Sridhar et al .[ 17 ] (43.3%), Shrestha and Karki[ 23 ] (42%), Verma et al .[ 10 ] (39%), and Shah et al .[ 13 ] (23.00%). Antenatal administration of corticosteroid and broad-spectrum antibiotics (ampicillin + gentamicin) during the preterm labor is very effective to increase the survival rate of newborns and should be widely encouraged. At the same time, good antenatal care and adequate maternal nutrition is the utmost important for the prevention of respiratory distress among newborns.
Limitations
The follow-up of discharged, leaving against medical advice (LAMA), and referred neonates was not done during the study
Due to retrospective nature of the study, epidemiological factors including maternal factors that could have influenced the health and outcome could not be analyzed
The data were dependent on the extent of data available retrospectively from case records and reports
As it is a hospital-based study, the results cannot be generalized.
CONCLUSION
Thus, we conclude that the admission rate for inborn was higher as compared to outborn. MAS was observed to be the most common indication for admission, followed by prematurity , other LBW (1000–2499 g), RDS, and birth asphyxia, respectively. The discharge rate was 78.63% after successful management while the mortality rate was 10.45%. Prematurity , RDS, and birth asphyxia were the common causes of mortality. Majority of the causes of morbidity and mortality were preventable and can be reduced by strengthening the health-care programs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L Lancet Neonatal Survival Steering Team. Evidencebased, costeffectiveinterventions:How many newborn babies can we save?Lancet 2005;365:97788.
2. Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every newborn:Progress, priorities, and potential beyond survival. Lancet 2014;384:189–205.
3. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?. Lancet 2014;384:347–70.
4. Dickson KE, SimenKapeu A, Kinney MV, Huicho L, Vesel L, Lackritz E, et al. Every newborn:Healthsystems bottlenecks and strategies to accelerate scaleup in countries. Lancet 2014;384:43854.
5. Hug L, Alexander M, You D, Alkema L UN Inter-agency Group for Child Mortality Estimation. National, regional, and global levels and trends in neonatal mortality between 1990 and 2017, with scenario-based projections to 2030: A systematic analysis. Lancet Glob Health 2019;7:e710–20.
6. Facility Based Newborn Care (FBNC) Operational Guide. Guidelines for Planning and Implementation. Ministry of Health and Family Welfare. Government of India; 2011.
7. Randad K, Choudhary D, Garg A, Jethaliya R. Pattern of neonatal
morbidity and mortality:A retrospective study in a
special newborn care unit , Mumbai. Indian J Child Health 2020;7:299–303.
8. Kumar R, Mundhra R, Jain A, Jain S.
Morbidity and mortality profile of neonates admitted in
special newborn care unit of a teaching hospital in Uttarakhand, India. Int J Res Med Sci 2019;7:241–6.
9. Ravikumar SA, Elangovan H, Elayaraja K, Sunderavel AK.
Morbidity and mortality profile of neonates in a tertiary care centre in Tamil Nadu:A study from South India. Int J Contemp Pediatr 2018;5:377–82.
10. Verma J, Anand S, Kapoor N, Gedam S, Patel U. Neonatal outcome in new-borns admitted in NICU of tertiary care hospital in central India:A 5-year study. Int J Contemp Pediatr 2018;5:1364–7.
11. Kumar S, Ahmed M, Anand S.
Morbidity and mortality patterns of neonates admitted to neonatal intensive care unit in tertiary care hospital, Bhopal. Pediatr Rev 2016;3:776–8.
12. Adikane H, Surwase K, Pawar V, Chaudhari K. A prospective observational study of
morbidity and mortality profile of neonates admitted in neonatal intensive care unit of secondary care centre in central Maharashtra, India. Int J Contemp Pediatr 2018;5:1403–8.
13. Shah HD, Shah B, Dave PV, Katariya JB, Vats KP. A step toward healthy newborn:An assessment of 2 years'admission pattern and treatment outcomes of neonates admitted in special newborn care units of Gujarat. Indian J Community Med 2018;43:14–8.
14. Bastola R, Gurung R, Bastola BS, Bastola SS, Bastola L. Pattern and prevalence of congenital birth defect among neonates admitted to
Special Newborn Care Unit (SNCU) of Pokhara Academy of Health Science (PAHS), Nepal. J Biol Med Res 2017;1:9.
15. Baruah MN, Panyang PP.
Morbidity and mortality profile of newborns admitted to the Special Care Newborn Unit (SCNU) of a teaching hospital of upper Assam, India –A three year study. JMSCR 2016;4:11689–95.
16. Sinha RS, Cynthia DS, Kumar PV, Armstrong LJ, Bose A, George K. Admissions to a sick new born care unit in a secondary care hospital:Profile and outcomes. Indian J Public Health 2019;63:128–32.
17. Sridhar PV, Thammanna PS, Sandeep M.
Morbidity pattern and hospital outcome of neonates admitted in a tertiary care teaching hospital, Mandya. Int J Sci Stud 2015;3:126–9.
18. Sharma AK, Gaur A. Profile of neonatal mortality in
special newborn care unit of tertiary care hospital. Int J Contemp Pediatr 2019;6:2319–25.
19. Saharia NP, Deka A, Vivekananda MS. Mortality and
morbidity pattern of neonatal ICU of Gauhati medical college and hospital. IOSR J Dent Med Sci 2016;15:73–5.
20. Rakholia R, Rawat V, Bano M, Singh G. Neonatal
morbidity and mortality of sick newborns admitted in a teaching hospital of Uttarakhand. CHRISMED J Health Res 2014;1:228–34.
21. investigators of NNFI.
Morbidity and mortality among outborn neonates at 10 tertiary care institutions in India during the year 2000. J Trop Pediatr 2004;50:170–4.
22. Elhassan M, Elhassan L, Hassanb A, Mirghani OA, Adam I.
Morbidity and mortality pattern of neonates admitted into nursery unit in Wad Medani Hospital, Sudan. Sudan JMS 2010;1:135.
23. Shrestha S, Karki U. Indications of admission and outcome in a newly established neonatal intensive care unit in a developing country (Nepal). Nepal Med Coll J 2012;14:64–7.
