|Year : 2019 | Volume
| Issue : 2 | Page : 128-132
Admissions to a sick new born care unit in a secondary care hospital: Profile and outcomes
Ravi Shekhar Sinha1, D Sharon Cynthia2, P Vinod Kumar3, Lois J Armstrong4, Anuradha Bose5, Kuryan George5
1 Field Research Officer – VL, CARE India, Patna, India
2 Assistant Professor, Department of Community Medicine, Government Vellore Medical College, Vellore, Tamil Nadu, India
3 Paediatric Infectious Diseases Fellow, Department of Child Health – Unit 3, Christian Medical College, Vellore, Tamil Nadu, India
4 Research Coordinator, Epidemiology and Research Department, Duncan Hospital, Raxaul, Bihar, India
5 Professor, Department of Community Medicine, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||18-Jun-2019|
D Sharon Cynthia
Department of Community Medicine, Government Vellore Medical College, Adukkamparai, Vellore - 632 011, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: To reduce neonatal mortality in North Bihar, evidence is required about the impact of sick newborn care units (SNCUs) in secondary level hospitals on mortality at the end of the neonatal period. Objectives: The objective of the study is to assess the profile of neonates admitted to an SNCU and the outcome at the completion of neonatal period. Methods: A cohort of neonates admitted from March to June 2014 to an SNCU was assessed through family interviews and hospital records. Demographic details (age, sex, and socioeconomic status) and clinical details (antenatal care, birthplace, weight, diagnosis, and family history) were documented. Follow-up was done at discharge or death or referral and the completion of neonatal period. The primary outcome was survival at the completion of neonatal period. Secondary outcomes were case fatality rate at discharge and weight gain. Results: Of 210 neonates assessed, 87.6% (95% confidence interval [CI] 82.4–91.4) survived till the end of the neonatal period. The case fatality rate at the time of discharge was 0.9% (95% CI 0.3–3.4). Majority of the diagnoses were infections, hyperbilirubinemia, and infant of diabetic mother. Mean weight gain at the end of neonatal period (n = 157) was 706 g (P = 0.00). Sex ratio at admission was 567 girls to 1000 boys (95% CI 428/1000–751/1000). No neonate from lower socioeconomic families was admitted. Conclusions: SNCUs in remote areas can bring down neonatal mortality in North Bihar. Unequal access of SNCUs services to girls and lower socioeconomic groups highlighted the existing barriers which require attention.
Keywords: Access, North Bihar, reason for admission, sick newborn, survival
|How to cite this article:|
Sinha RS, Cynthia D S, Kumar P V, 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
|How to cite this URL:|
Sinha RS, Cynthia D S, Kumar P V, 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 [serial online] 2019 [cited 2020 Jan 18];63:128-32. Available from: http://www.ijph.in/text.asp?2019/63/2/128/260591
| Introduction|| |
Every year, an estimated 26 million children are born in India and reducing neonatal mortality is one of the thrust areas in public health for India. Four states including Bihar contribute to 56% of total neonatal deaths in India and 14% of the global neonatal deaths. From the National Family Health Survey-4 (NFHS-4) data, it is estimated that India's neonatal mortality rate is on average 2.4 times higher than the target for Sustainable Development Goal 3. However, district-wise estimates show wide disparities with some areas already having achieved much lower levels than the target whereas districts such as in Bihar requiring five times the current reduction level to reach the target by 2030.
Improvement of the neonatal survival demands the availability and adequacy of trained personnel providing quality neonatal care at sick newborn care units (SNCUs) in secondary and community level hospitals which are accessible to populations at risk in remote areas. As most of the studies on SNCU outcomes in India are from tertiary care centers in cities, there is a need to document the challenges and opportunities that SNCUs face in remote areas. Therefore, this study was designed with the objective to assess the profile of neonates admitted to an SNCU in a secondary level hospital in Bihar and follow them to assess the outcome of the care provided at the end of their neonatal period.
| Materials and Methods|| |
A descriptive observational study with longitudinal design was used to assess the morbidity and mortality among a cohort of neonates admitted to Duncan Hospital SNCU between March and June 2014 after obtaining ethics approval from the Institutional Review Boards at Christian Medical College, Vellore (IRB minute no. 9127) and Emmanuel Hospital Association, New Delhi (Protocol no. 122). The study was carried out in a 230-bed hospital in North Bihar which conducts nearly 5000 deliveries and about 2000 admissions to the SNCU per year. The purpose of this SNCU is to provide essential newborn care services to the under-served areas of East Champaran district where only 22.8% of the government's newborn care corners (NBCCs) are reported to be fully functional.
The main catchment area in the area comprises three community development (CD) blocks, namely Raxaul, Adapur, and Ramgarhwa, each with a population of nearly 0.2–0.3 million and one government primary health center with partially functioning labor room and nonfunctioning NBCCs. Being on the Indo-Nepal border, patients come to the hospital both from North Bihar and the southern provinces of Nepal. Duncan hospital along with other development partners is involved in capacity building of government doctors, nurses, and frontline health workers in this area.
A sample size was calculated for 80% power and 5% significance using a prevalence of 14% mortality in SNCU. The inclusion criterion was admission registered at the Duncan SNCU during the study coming from any one of the three CD blocks mentioned earlier. Neonates whose families lived in other blocks or Nepal were excluded. During the study, 463 neonates were admitted of which 250 neonates were outside the study area (231 neonates from Nepal and 19 from other blocks in Bihar).
The parent/guardian was contacted during the visiting hours to request their consent for participation. Of 213 eligible participants, consent was given by 210 guardians. Demographic details of the neonate (age and sex) and the mother (education and socioeconomic status), details of the pregnancy and childbirth (antenatal visits, place of delivery, and breastfeeding status) and the cost of the current SNCU treatment were recorded by interviewing the guardians. The clinical details at admission (gestational age, weight, diagnosis, and high-risk status of the mother) were obtained from hospital records. These clinical details were validated by the attending physician.
The operational definitions were as follows: neonatal period was up to 28 days after birth. Adequate antenatal care was taken as more than four visits. Gestational age <37 weeks was preterm. More than 36 months of spacing was considered adequate. Very low birth weight was <1500 g. Birth asphyxia was defined as gasping, and ineffective breathing at 1 min of life and Apgar score <7 at 5 min. High-risk status of the mother was based on the operational guidelines of the National Health Mission. Socioeconomic status was classified based on the Modified Kuppuswamy scale.
Duncan Hospital SNCU provides care to patients in line with the India Newborn Action Plan. The services were provided partly through the patients' out-of-pocket expenses and partly through donated funds. The government-run health insurance programme called Rashtriya Swasthya Bima Yojana was not functional and coverage by private health insurance schemes was negligible.
The follow-up of each neonate was done by a trained medical professional at discharge and at the end of neonatal period. The primary outcome was survival rate at the completion of neonatal period. Secondary outcomes were satisfactory recovery at discharge and weight gain at the end of neonatal period. Being discharged well implied satisfactory recovery. Weight gain as compared to the weight at admission was used as a proxy for well-being and development.
Data were entered and analyzed into Epi Info software (version 7). Descriptive statistics was used for the demographic variables. Odds ratio (OR) was used to measure the association of risk factors to mortality.
| Results|| |
Profile of sick newborn care unit admissions
Mean age of the 210 neonates admitted to the SNC was 1.92 days with mean birth weight of 2.76 kg (SD 0.648). Two-thirds (64%) were male. The sex ratio of admissions was 567 girls per 1000 boys. The families in the study came from a mean distance of 9 km (±5.76) (range 1–22 km) from the hospital. Nearly half of the neonates (42.9%) belonged to the lower upper socioeconomic class. None of the admitted neonates was from lower socioeconomic status. Literacy of mothers shows that 85 (40.5%) were illiterate and 51 (24.3%) had attended primary school.
About 27.6% of the neonates were underweight at birth (<2500 g) and 31 (14.8%) had preterm birth. 125 (59.5%) of mothers were from high-risk category.
Three-fourths of neonatal admissions (158 neonates) were on the 1st day of life and the rest were admitted mostly within 7 days. Three neonates were admitted between days 8 and 28. About 28.8% of the admissions (17 neonates) were delivered at home. Out of these, only 4 (23%) could reach the hospital within 24 h of birth.
The mean duration of stay was 4.94 days irrespective of the neonates' discharge status with a minimum duration of admission of 0 day (baby was discharged on the same day of the admission) and a maximum duration of 32 days. Sepsis/infection was the most common diagnosis (31.9%) followed by hyperbilirubinemia (16.7%).
Reasons for admission and average direct cost of the treatment of patients admitted to SNCU have been described in [Table 1]. The median direct medical cost was 3162 INR (IQR 1528-6151). The cost of treating a preterm and low birth weight neonate was the highest among all conditions due to the use of ventilators. One baby with sepsis was treated at a cost of INR 125,000.
|Table 1: Reasons for admission and cost of the treatment for the patients admitted to sick newborn care units|
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One hundred and fifty (81.5%) of the babies were on exclusive breastfeeding and the rest had a combination of breastfeed with formula feed. Combination feeding practice was more common in preterm and low birth weight subjects (76.1%).
Outcome of sick newborn care unit admissions
At discharge, there were 208 alive and 2 deaths. Among the 208 living neonates, there were 11 (5.2%) babies referred and 20 (9.5%) left against medical advice (LAMA). 177 neonates (84.3% (95% confidence interval [CI] 78.8–88.6)) were healthy at the time of discharge which implied satisfactory recovery. The case fatality rate at the time of discharge was 0.9% (95% CI 0.3–3.4).
One hundred and ninety-three babies (92%) were followed up till the end of the neonatal period. 184 (87.6%) were alive (95% CI 82.4–91.4), 9 (4.3%) died (95% CI 2.2–7.9), and 17 (8.1%) were lost to follow-up (95% CI 5.1–12.5). Out of the 184 who were alive, 153 were present at home. 27 were out of study area and 4 were still in the hospital.
Five of the 20 LAMAs had died by the end of the neonatal period and four were lost in follow-up. Two out of 11 referred cases had died. The highest mortality was among preterm/low birth weight babies (12%).
Mean weight gain at the end of the neonatal period (n = 157) was 706 g (95% CI 642–771, P = 0.00). Ten (6.3%) neonates had lost weight as compared to their status at admission.
The factors significantly associated with death at the end of the neonatal period were the previous history of neonatal and infant death (OR 4.91 [95% CI 1.40–22.38]), preterm delivery (OR 4.52 (95% CI 1.29–15.85), weight <1.5 kg (OR 6.6 [95% CI 1.6–26.87), and neonates who LAMA (OR 27.34 [95% CI 5.7–129.8) [Table 2]. Of these, previous abortion or stillbirth and status of the neonate at the time of discharge were significant in multivariate analysis.
|Table 2: The association of risk factors and neonatal outcome at the end of the neonatal period|
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| Discussion|| |
Even though the profile and outcome of SNCUs have been well reported in several studies, there is no evidence of outcomes on follow-up after discharge from the hospital. This study provides information on what happens to the babies discharged from SNCU at the end of the neonatal period, in an area with neonatal mortality higher than the national average.
The unique finding of this study is the survival rate of 87.6% at the end of the neonatal period. Compared to the findings of the special report on SNCUs from the Ministry of Health and Family Welfare from the same period as this study, the proportion of neonates who had satisfactory recovery and were discharged well from Duncan SNCU is higher. The case fatality rate of 0.9% at the time of discharge is much lower (10% among inborn and 15% among outborn neonates as per the MoHFW report).
The current evidence indicates prematurity and birth asphyxia as the major causes of neonatal mortality., However, in this cohort, asphyxia accounted for merely 7.1% of the admissions. Infections, hyperbilirubinemia, infant of diabetic mother, prematurity/low birth weight, and meconium stained aspiration were the top five reasons for admission. The reason for this is the high number of inborn admissions (92%) and the quality of care in the Duncan hospital labor room. The lesser incidence of birth asphyxia by proper intrapartum monitoring is an important factor in the lowered case fatality rate of Duncan SNCU.
In East Champaran, according to NFHS-4, institutional births constitute only 44.9% of all births. If the rest of the babies born at home had equal access to the SNCU, then the same proportion should be reflected in the admissions. However, among the study cohort, only one in about ten was found to have been born at home. Considering these findings, it could be hypothesized that many asphyxiated newborns delivered at home were unable to reach the hospital in time.
The proportion of LAMAs was higher in this study as compared to the MoHFW report. Discharge status at the hospital was found to be statistically significantly associated with neonatal mortality (OR 27.34 [95% CI 5.7–129.8]) with high mortality among LAMAs. The underlying socioeconomic factors which cause a family's decision of stopping a newborn's treatment even against medical advice need closer attention.
The sex ratio of 567 girls per 1000 boys (95% CI 428/1000–751/1000) in the SNCU has highlighted the evident societal inequality toward care of female infants. Despite being naturally endowed with better chances at survival, the girl babies are selectively deprived of care. Willis et al. in a study done in rural Uttar Pradesh have reported that households with a female newborn have a lower incidence of perceiving illness and spend significantly lesser on medical treatment as compared to households with a male newborn. The reasons behind this are deeply rooted in the socio-cultural norms and preferences which need to be studied further. Although the difference between males and females in terms of admissions exists in other studies,, it is more marked in this cohort.
In this study, 80.5% (95% CI 74.5–85.2%) of neonates belonged to the upper lower class and lower middle class. None were from the lower socioeconomic status. This finding highlights the findings of other studies that out-of-pocket expenditure is a significant barrier to access basic health care for newborns in North Bihar.
The risk factors other than previous family history of neonatal death, previous abortion or still birth and current preterm birth and/or low birth weight lacked statistical significance in their association with neonatal mortality. This could be because the study was powered only for assessing the profile of SNCU admissions and their outcomes. The finding however highlights the importance of documenting previous obstetric and family history.
Due to its location close to the Nepal border, Duncan SNCU has a large turnout of patients from Nepal (nearly 50%). These patients had to be excluded from the study as it was not feasible to follow them up. This is a limitation of the study and is a scope for future research projects.
The other limitations of the study are as follows: (a) at least four babies were had multiple admissions during the neonatal period but the study registers only their first admission to the hospital; (b) the direct expenses incurred in other hospitals for babies who were referred and those who left against medical advice could not be validated; and (c) the ten babies who failed to gain weight at the end of the neonatal period were unable to be assessed in detail.
In Duncan SNCU, despite its remote location survival rate of 87.6% could be possible because of certain key points in the functioning of the hospital. Standard operating protocols in Duncan labor room and SNCU are regularly reviewed, revised if necessary and communicated to both the nursing and medical teams through weekly in-house teaching sessions. Emergency admissions and deaths are reviewed daily by the entire team of doctors. The management of complicated patients is discussed with experts from higher institutions. Essential equipment is well maintained and regularly serviced. External factors that adversely affect neonatal survival are the low coverage of antenatal care in the area and the location of tertiary care referral centers far away (nearly 200 km) from the hospital. The availability of nurses and doctors willing to work in this remote area is another important factor to be considered.
The findings of this study were reported to the district health authorities and other partner NGOs such as CARE India to be used as evidence for advocacy toward ensuring equitable access. The study findings have also helped the Community Health department of the hospital to start a program in the area with the objective to close the existing gaps in access among girl babies and home births through activities such as training of ANMs and ASHAs of the government primary health centers and motivating important stakeholders in the community such as self-help group women, local elected body members, and religious leaders.
| Conclusions|| |
This study gives evidence for the feasibility of setting up neonatal care systems in remote areas and their impact on the survival of newborns after leaving the hospital. In situ ations, where the government facilities are yet to be developed, credible voluntary agencies can provide care, given that the cost is managed by cross-subsidy or government funding. Ensuring equitable access to these facilities among all strata of the society through more comprehensive approaches is crucial to achieve the long-term goal of improving neonatal survival in North Bihar.
Financial support and sponsorship
This study was supported by Christian Medical College, Vellore Fluid Grant (Ref: IRB Min No. 9127 [OBSERVE] dated 12.11.2014).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]