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BRIEF RESEARCH ARTICLE
Year : 2013  |  Volume : 57  |  Issue : 2  |  Page : 100-104  

Predictors of mortality among the neonates transported to referral centre in Delhi, India


1 Lecturer, Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
2 Senior Resident, Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
3 Professor, Department of Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
4 Professor and Head, Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India

Date of Web Publication15-Jul-2013

Correspondence Address:
Manish Narang
Lecturer, Department of Pediatrics (Ward 12), University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.115003

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   Abstract 

A descriptive study was conducted with an objective to determine the predictors of mortality among referred neonates and to ascertain their transport characteristics. A total of 300 consecutive neonates who were transferred to the centre were enrolled in the study. Following information were recorded: maternal details, birth details, interventions before transportation, details of transportation and neonatal condition at arrival. Detailed clinical assessment and management was done as per standard neonatal protocols. Birth weight <1 kg (OR 0.04; 95% CI: 0.006-0.295, P<0.01) and transportation time >1 hour (OR 5.58; 95% CI: 1.41-22.01, P=0.01) were found to be significant predictors for mortality among the transported neonate. Transport characteristics reflect road transport with limited utility of ambulances and lack of trained health personal. Hence to conclude, extreme low birth weight and prolonged transportation time were found to be significant predictors of neonatal mortality among the transported neonate.

Keywords: Ambulance, Birth weight, Neonatal transport, Road transport, Transportation time


How to cite this article:
Narang M, Kaushik JS, Sharma AK, Faridi M. Predictors of mortality among the neonates transported to referral centre in Delhi, India. Indian J Public Health 2013;57:100-4

How to cite this URL:
Narang M, Kaushik JS, Sharma AK, Faridi M. Predictors of mortality among the neonates transported to referral centre in Delhi, India. Indian J Public Health [serial online] 2013 [cited 2019 Nov 14];57:100-4. Available from: http://www.ijph.in/text.asp?2013/57/2/100/115003

In developing nation like India, almost two third of the deliveries are conducted at home, half of which are attended by skilled birth attendant. [1] As per SRS 2008, neonatal mortality rate in India is 35/1000 live births. [1] This high mortality could be attributed to delay at three levels, which include a delay in recognition of severity of illness, delay in transport of the neonate and delay in delivery of appropriate health-care. [2] Effective transport of neonate depends largely on the mode of transport, trained transport team, adequate equipment, appropriate drugs and effective communication. [3]

It is difficult to project the exact contribution of neonatal transport characteristics to neonatal mortality rate. However, mortality rate of 25-35% have been reported in previous Indian studies among the neonates transported to tertiary care center. [4],[5],[6] Despite the magnitude of need for an effective neonatal transport system in India, only few studies have examined the ground reality of transport characteristics in India. Few questions that still remain unanswered about the transported newborns in India are who are transported, how are they transported, what is their condition at their arrival in a referral center, how many succumb to death, who are the newborns who are more likely to expire. To answer these questions, a study was hence designed to determine the predictors for neonatal mortality among the referred neonates and to ascertain their transport characteristics.

A descriptive study was conducted in Department of Pediatrics at Guru Teg Bahadur Hospital and University College of Medical Sciences, Delhi, India from April 2007 to September 2007. A clearance was obtained from Institutional Ethical Committee. The study protocol was fully explained to parents/guardian and written informed consent was obtained.

During the study period of 6 months from April 2007 to September 2007, a total of 300 out-born neonates (<1 month) transferred to our neonatal intensive care unit were enrolled in the study. It included babies born at home, government centers (primary health-care center, district hospitals) or private hospitals/nursing homes and referred to our hospital for management. A pretested (on 15 subjects) proforma was used to record information regarding maternal details, birth details, interventions before transportation (intravenous fluidoxygen administration/care of temperature), details of transportation and neonatal condition at arrival.

A brief history pertaining to maternal details of gestational age (as per the last menstrual date), mode of delivery, dai handling was obtained. Birth details including place of birth (home/government institution/private hospital/nursing home), personnel who conducted the delivery (untrained or trained health personnel), birth weight, APGAR score (if available from records) and other resuscitation details were also recorded. Transport details such as mode of transport, time taken to reach the hospital, facilities provided to child during the transport, stabilization of patient prior to transport, whether accompanied by trained personnel or not an indication of transfer were recorded in the pre-designed questionnaire.

At admission, detailed clinical assessment of the baby was performed and recorded. Gestational age was noted from records and reconfirmed with modified Ballard score if <7 days of age. Weight of the baby was taken as the weight on admission. Temperature was recorded using the rectal thermometer and the baby was placed in overhead warmer. Capillary refill time, oxygen saturation and blood glucose levels were checked for all babies as per standard neonatal protocols. [7]

All babies were investigated and managed based on their admission diagnosis using a standard protocol. [7] Outcome was recorded based on whether babies survived or died. Neonates who left against medical advice were excluded from the study. Data were analyzed using SPSS version 13.0. All quantitative variables such as gestational age, birth weight were compared using student's t-test and the categorical variables were analyzed using Chi-square test or fisher exact test. P<0.05 was considered significant. Multivariate analysis (logistic regression) was used to adjust confounding factors on mortality.

A total of 300 consecutive neonates were enrolled in the study, of which 126 (42%) were males and rest 174 (58%) were females. Almost half of the transported neonates were more than 36 weeks gestation (48%). Gestational ages of rest of the neonates were 34-36 weeks in 17%, 30-34 weeks in 22.6% and those <30 weeks were 12.3%. Birth weight among the transported neonates were <1 kg (10.3%), 1-2 kg (35.3%), 2-2.5 kg (38.3%) and >2.5 kg (16%). Most of the neonates were institutional delivery (75.6%) with rest born by home delivery (24.3%).

At admission, almost 53% of neonates had normal temperature >36.5°C; rest 21% (36-36.4°C), 26% (32-35.9°C) and none of the neonates were severely hypothermic (<32°C).

Almost 29.6% of admitted neonates were hypoglycemic (<40 mg/dl) and rest 70.3% were normoglycemic (>40 mg/dl). Hypoxemia (SpO 2 <90%) was seen in 98 (32.6%) of neonates and 208 (69.3%) neonates had prolonged capillary refill time (>3 s) at admission.

Mean (range) age of the neonate at presentation was 79.8 (1-607) h. Most of the neonates were transported by either a private vehicles (hired taxis/autos/tempos/rickshaws) (123 [41%]) or by a public transport (bus/train) (88 [29.3%]). Ambulance was used for transporting only in 89 neonates (29.6%). Most of these ambulances were equipped with one oxygen cylinder, but there were no equipment for resuscitation or warming. These ambulances were manned by a driver alone and the baby was accompanied by health personnel only in 47 (15.6%) neonates. There was lack of accompanying clinical note in two-third of neonates (66.6%). Before the transport of neonate, prior information was sent to us (referral center) in only 23 neonates (7.6%); and prior counseling of parents (regarding the need of transport) were carried out in 64 neonates (21.3%).

Common indications for referral were respiratory distress in 129 (43%), prematurity in 67 (22.3%), delayed cry at birth in 60 (20%) and neonatal jaundice in 18 (6%) and abdominal distension in 13 (4.3%). Proportion of children who expired was 46.3% (95/300). Causes of mortality among the expired neonates are depicted in [Figure 1]. Baseline neonatal parameters and transport characteristics among the expired and surviving neonates are described in [Table 1].
Figure 1: Causes of neonatal mortality among transported neonates

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Table 1: Characteristics of expired and survived neonates

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Predictors of neonatal mortality are summarized in [Table 2]. It was observed that there was a significant decrease in mortality among the neonates where intervention was done before transportation (P < 0.001). Intervention prior to transport included administration of intravenous fluid, provision of warmth and/or oxygen administration. Mortality was inversely related to gestational age, birth weight and time taken to reach hospital (P < 0.001). Multivariate logistic regression analysis revealed a birth weight <1 kg (odd ratio [OR]: 0.04 [95%] confidence interval [CI]: 0.006-0.295) (P < 0.01) and transportation time >1 h (OR: 5.58 [95%] CI: 1.41-22.01) (P = 0.01) to be significantly associated with mortality of transported neonates. We observed that neonates who survived (n = 205) had a significantly higher birth weight/gestational age, received some intervention before transportation and were transported by ambulance [Table 1].
Table 2: Logistic regression analysis of parameters, which predict mortality among the transported neonates

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The results of the present study suggest that extreme low birth weight (<1 kg) and transportation time of more than 1h duration were significant predictors for mortality among the transported neonates.

Predictors of mortality in our study were similar to those reported earlier from a tertiary care center of Delhi. In the study conducted by Sehgal et al. [5] in addition to birth weight and transportation time, the other predictors were metabolic derangements such as hypothermia, hypoglycemia and prolonged perfusion. Univariate analysis in our study had also shown similar metabolic parameters. Studies have revealed that risk of mortality decreases with increasing gestational age. [6],[7] It has been shown that morbidity of preterm infants born after maternal transport (in utero) were better than a preterm neonate transported to a referral center. [8],[9] Mortality among the extremely low birth weight infants could further be averted by home based neonatal care. [10]

Prolonged neonatal transport (>1 h) was found to increase the mortality among transported neonates in the present study. Hence, we would suggest that a newborn should be transported to a center, which can be reached in <1 h time. It has been shown that long-term outcome of neonates treated at a local hospital was similar to those transported and treated at tertiary care center. [11] Possible solutions to avoiding prolonged neonatal transport could be the utilization of primary health-care facilities and home based neonatal care. In a study conducted in West Bengal, India, improved survival was shown with neonatal care units set up at strategic locations (district hospital units) with newborn stabilization units at peripheral centers and up gradation of district hospitals to 10 bedded sick newborn units. [12] Recent studies have also shown that prolonged neonatal road transport in expert hands is feasible and realistic. [13]

Univariate analysis in our study has also revealed that intervention performed before transportation decreases the mortality among the transported neonates, but we believe that with further increase in sample size, the multivariate analysis could also have depicted similar predictors in our study. Stabilization of newborn during and before transportation has been shown to improve the condition of newborn in terms of temperature, blood glucose, oxygenation and blood pressure. [13]

Incidence of hypothermia among transported neonates is comparable to previous Indian study. [8] Biochemical and temperature instabilities are common among transported neonates. Babies who were transported by ambulance had good survival rate with lesser incidence of hypothermia and hypoglycemia as compared with those who came on themselves. [9] Effective communication, documentation and pre-hospital stabilization is essential for ideal transport. [10]

An ideal community transport system must be easily accessible, affordable, safe, reliable, efficient, culturally and technologically appropriate. [2] Transport characteristics of neonates in our study were similar to those reported earlier from North India with lack of accompanying health personnel, vital monitoring and temperature maintenance and pre transport documentation of treatment/investigations. [8] Despite the economic prosperity of India, condition of road transport remains miserable in rural and peripheral urban settings. Poor neonatal transport by road is owing to either financial constraint of parents, improper road condition, lack of motivation and awareness in the medical fraternity with lack of skilled manpower in rural districts.

Procurement of trained staff, well-equipped ambulance and mode of transport system adopted is largely dependent on paying capacity of parents. However in Indian setting, ignorance and illiteracy adds to fury as often parents end up paying thousands of rupees for arranging for a private vehicle to transport the neonate rather than arranging for an ambulance. Most of the transports in India are manned by paramedical person or by a relative through their own vehicle. Quality of care at the referral center could also significantly contribute to mortality among the transported neonates. Neonates often face low standards of care regarding stabilization even in referral hospitals. The referral centers are also burdened with a large number of premature and asphyxiated neonates. Moreover, the concept of back transport of stable neonates is lacking in India, which can adds to the poor quality of care at the referral center.

Limitations of the study include lack of long-term follow-up of surviving neonates. Retrospectively, we feel that we should have examined the ambulance or vehicle in which the baby was transported and cross checked with a recommended checklist to assess the ground reality of transport characteristics. Moreover, there was a large number of low birth weight infants, which could also have contributed to high mortality and biased prediction.

Our study highlights that extreme low birth weight infants (birth weight <1 kg) and infants who require prolonged (>1 h) transport have higher chances of mortality. Hence, these newborns should be stabilized before transportation and are better managed at center, which can be reached within 1 h time frame. Improving the quality of neonatal transport and development of an effective and feasible regional transport system may reduce the mortality among the transported neonates. We feel that prolonged transport could be averted by appropriate utilization of primary health-care facilities and enhancing the home based neonatal care.

 
   References Top

1.Maternal health division. Ministry of health and family welfare. Government of India. Guidelines for Antenatal care and skilled attendance at birth. April 2010. Available from: http://www.nihfw.org/NCHRC/Publication/Guidelines%20and%20Manuals/ANM%20Guidelines%20.pdf. [Accessed on 2013 May 25].  Back to cited text no. 1
    
2.Ramji S. Transport in community. J Neonatol 2005;19:328-31.  Back to cited text no. 2
    
3.Babinard J, Roberts P. Maternal and child developmental goals: What can transport sector do? The World Bank group. Transport paper. Available from: http://www.siteresources.worldbank.org/inttransport/tp12_maternal_helath.pdf. [Accessed on 2011 Apr 21].  Back to cited text no. 3
    
4.Singh H, Singh D, Jain BK. Transport of referred sick neonates: How far from ideal? Indian Pediatr 1996;33:851-3.  Back to cited text no. 4
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5.Sehgal A, Roy MS, Dubey NK, Jyothi MC. Factors contributing to outcome in newborns delivered out of hospital and referred to a teaching institution. Indian Pediatr 2001;38:1289-94.  Back to cited text no. 5
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6.Basu S, Rathore P, Bhatia BD. Predictors of mortality in very low birth weight neonates in India. Singapore Med J 2008;49:556-60.  Back to cited text no. 6
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7.Clinical Protocols in Neonatology. WHO collaborating for training and research in newborn care. Delhi: Department of Paediatrics, All India Institute of Medical Sciences; Available from: http://www.newbornwhocc.org/clinical_protocols.htm. [Accessed on 2013 May 25].  Back to cited text no. 7
    
8.Narasimhan KL, Bhaskar V. Priorities in development of neonatal surgery in India. Indian Pediatr 2005;42:82-3.  Back to cited text no. 8
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9.Modanlou HD, Dorchester WL, Thorosian A, Freeman RK. Antenatal versus neonatal transport to a regional perinatal centre: A comparison between matched pairs. Obstet Gynaecol 1979;53:725-9.  Back to cited text no. 9
    
10.Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: Field trial in rural India. Lancet 1999;354:1955-61.  Back to cited text no. 10
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11.Kollée LA, Brand R, Schreuder AM, Ens-Dokkum MH, Veen S, Verloove-Vanhorick SP. Five-year outcome of preterm and very low birth weight infants: A comparison between maternal and neonatal transport. Obstet Gynecol 1992;80:635-8.  Back to cited text no. 11
    
12.Sen A, Mahalanabis D, Singh AK, Som TK, Bandyopadhay S, Mehta P. District level sick newborn care unit: A complimentary approach to reduction of neonatal mortality. J Perinatol 2009;29:150-5.  Back to cited text no. 12
    
13.Kumar PP, Kumar CD, Shaik F, Yadav S, Dusa S, Venkatlakshmi A. Transported neonates by a specialist team - How STABLE are they. Indian J Pediatr 2011;78:860-2.  Back to cited text no. 13
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    Figures

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    Tables

  [Table 1], [Table 2]


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