Experiences of Neonatal Care in a Secondary Level Hospital

From the Departments of Community Health and Pediatrics*, Christian Medical College, Vellore 632 002, India.
Reprint requests: Dr. Anuradha Bose, Lecturer in Pediatrics, Department of Community Health, Christian Medical College and Hospital, Vellore 632 002, Tamilnadu, India.
E-mail: abraham@cmc.ernet.in
Manuscript received: August 5, 1998;
Initial review completed: September 23, 1998;

Setting and Methods

Primary health care is provided to a predominantly rural population of 100,000 in Kaniyambadi Block through the Community Health and Development Hospital (CHAD). This hospital handles about 2000 deliveries per year. Our analysis of the causes of perinatal mortality in this region revealed that 50% of the deaths were amongst babies of birth weights less than 2.0 kg. A special effort was therefore made to have low-birth weight babies referred to CHAD hospital from the periphery. A low cost nursery was established in 1987, with facilities for phototherapy, heat cradles and other simple nursing facilities.

Referral of the babies from the periphery to CHAD hospital is primarily by the community health workers and the village health nurses. The criteria for referral are: (i) birth weight less than 2.0 kg; (ii) birth asphyxia; (iii) babies with major congenital anomalies; and (iv) history of lethargy, poor feeding and those with maternal history of pyrexia. Babies of birth weight less than 1.5 kg, less than 34 weeks gestation, those with cardiac anomalies or surgical problems and those requiring exchange transfusions were advised transfer to a tertiary center.

The Nursery at CHAD has six cots. There

is central oxygen supply, a portable suction machine, and facilities for emergency electrical supply. Phototherapy is given with a double-surface phototherapy machine, locally fabricated at a cost of Rs. 5000. There are no incubators and no ventilators. One nurse, one medical intern and a resident in Community Health or Family Medicine staff it. The Hospital has facilities for simple laboratory investigations. There are no radiological or blood bank facilities in the CHAD Hospital. Gestational age assessment was done by the Dubowitz method. All babies with tachypnea, chest indrawing or other signs of respiratory distress were classfied as respiratory distress syndrome (meconium aspiration syndrome was included in this category).

Sepsis was diagnosed on the basis of clinical signs which were corrborated in some instances by positive blood or CSF cultures.

A retrospective analysis of the charts of the babies admitted to CHAD Hospital was done. Babies of birth weight 1.5 kg or over were included in the study. The charts were reviewed with attention to the birth weight, place of delivery, morbidity and outcome. The cause of death of the babies who expired in CHAD and the reasons for referral to a tertiary center were noted.

Results

During the period August 1996 to 31 March 1997, of the 1555 babies born in CHAD of birth weight 1.5 kg or over, 141 were admitted to the nursery; 34 babies who were born extra-murally were also admitted, taking the total to 175. Among the outborn babies, 14 babies were brought to CHAD after 72 hours of birth. The ratio of males: females was almost the same (51:49).

Table I shows the distribution of the babies according to birth weight and gestational age. More than 50% of the babies admitted to

Table I^__Distribution of Patients by Birth Weight and Gestational Age

CHAD were of birth weights 2.5 kg or over. Approximately 30% of the babies were less than 2.0 kg. Preterm babies made up 26% of the admissions.

Morbidity

Of the 175 babies, 45 (26%) were premature; 30 (26.7%) had hyperbilirubinemia; 27 (18%) had respiratory distress syndrome of the newborn; 11 (7.5%) had hypoxic ischemic encephalopathy and 24 (15%) had sepsis. Babies with other diagnoses such as transient metabolic disorders and major congenital anomalies were included in the miscellaneous category (Table II).

Outcome

Of the 175 babies, 6 expired, 2 were discharged against medical advice and 8 were transferred to the nursery in the tertiary hospital or to the Government Hospital. Of the 6 babies who expired, 2 babies, of term gestation died of meconium aspiration syndrome; 3 babies of 32 weeks gestation with birth weights of 1.6 kg died of presumed sepsis(2) and respiratory distress dyndrome; one term baby died of Gram negative septicemia.

Two babies with septicemia, one with Staphylococcus aureus and other with Gram-negative septicemia were transferred to the referral hospital. The others transferred were: Two babies with hemolytic disease of the newborn, one with Rhesus incompatibility and the other with ABO incompatibility, who required exchange transfusion; a preterm baby of 33 weeks gestation with respiratory distress syndrome and one baby with meconium aspiration syndrome. Two babies were transferred to the Government Hospital, on request by the relatives, with diagnoses of possible intra- cranial hemorrhage and hypoxic ischaemic encephalopathy.

Discussion

Medical care of the sick newborn will incur high costs, if it is highly technology oriented(3). Skilled personnel and adequate equipment for newborn care such as resuscitation equipment, warmers and monitoring facilities are expensive and are limited to a few major centers and only a few district health facilities. It is important to identify the kind of cases that can be looked after in such small centers, thereby optimally utilizing available tertiary level beds, and preventing denial of care to very low birth weight infants, on account of depletion of available resources(4).

Preterm, low birthweight babies form a large part of the workload in most hospitals. Prematurity is known to be an important determinant of mortality(5). Three of the six babies who expired at CHAD were 32 weeks gestation, who had refused transfer to the tertiary center. It is possible to treat preterm infants of birth weight 1.5 kg or more in secondary level hospitals. The key elements to successful outcome are meticulous attention to maintenance of temperature, asepsis and feeding. Preterm infants have a number of associated morbidities, either in isolation or combination, such as infection, respiratory distress or jaundice. Sepsis can be treated in most facilities provided trained personnel are available. Availability of microbiological support will greatly enhance the quality of care, as was seen at CHAD.

It is the practice at CHAD to treat all newborns with respiratory distress with antibiotics and supportive care. There are no facilities for monitoring oxygen saturation. Two babies in this category who died had meconium aspiration syndrome. Babies who are premature and have clinical evidence of surfactant deficiency are transferred to the tertiary hospital if the parents are willing. There are instances when parents refuse transfer as the cost of ventilating a baby is very high. Under such circumstances, supportive therapy is given. It is important, therefore, that simple and inexpensive methods of care be widely available using appropriate low cost technology. A large proportion of jaundiced infants can be managed with phototherapy. In our experience, 93% of the jaundiced infants were managed with phototherapy and only 2 babies required transfer for exchange transfusion, which can be done in smaller centers if blood banking facilities are available.

The main causes of death were sepsis, pre maturity, and meconium aspiration syndrome. This is in accordance with other studies where the causes of death were birth asphyxia, aspiration, prematurity and low birth-weight(6,7). The babies who were transferred to the tertiary nursery required facilities such as ventilation, exchange transfusions or sophisticated investigations. The babies transferred to the Government Hospital were transferred on request by the parents, and were primarily for financial reasons. No follow-up is available on these babies. All babies transferred to the tertiary hospital survived and were transferred back to CHAD Hospital. A certain proportion of patients were discharged against medical advice, in the knowledge that death is imminent or certain. These were primarily discharged at the parents' request for financial reasons (1.2%).

Introduction of standard management guidelines aid in reduction of mortality(8). With careful selection of cases and predetermined criteria for transfer to the tertiary level nursery, it is possible to care for a vast majority of the newborns in nurseries such as ours without specialist intervention.

References

1. World Health Organization. International Classification of Diseases, 10th Revision. Geneva, World Health Organization, 1992; p 1237.

2. World Health Organization. Perinatal Mortality: A Listing of Available Information. Geneva, World Health Organization, 1996.

3. Modi N, Kirubakaran C. Reasons for admission, causes of death and costs of admission to a tertiary referral neonatal unit in India. J Trop Paediatr 1995; 41: 99-102.

4. Stolz JW, McCormick MC. Restricting access to Neonatal ICU. Pediatrics 1998; 101: 344-348.

5. Paul VK, Singh M, Sundaram KR, Deorari AK. Correlates of mortality among hospital born neonates with birth asphyxia. Natl Med J India 1997; 10: 54-57.

6. Chavan YS, Dattal MS, Khadilker VV. Causes of early neonatal mortality. Indian Pediatr 1992; 29: 781-783.

7. Mukasa GK. Morbidity and Mortality in special care baby units of New Mulago Hospital, Kampala. Ann. Trop Pediatr 1992; 12: 289-295.

8. Wilkinson D. Avoidable perinatal deaths. Trop Doctor 1995; 25: 16-20.