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Indian Pediatr 2011;48:
931-935 |
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Challenges in Scaling up of Special Care
Newborn Units- Lessons from India |
Sutapa Bandyopadhyay Neogi, Sumit Malhotra, Sanjay Zodpey and *Pavitra
Mohan
From Indian Institute of Public Health-Delhi, Public
Health Foundation of India and *UNICEF, India Country Office.
Correspondence to: Dr Sutapa B Neogi, Associate
Professor, Indian Institute of Public Health (IIPH- Delhi), Public Health
Foundation of India (PHFI), Plot No 34, Sector 44, Gurgaon, Haryana,
India.
Email: [email protected]
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Neonatal mortality rate in India is high and stagnant. Special Care
Newborn Units (SCNUs) are being set up to provide quality level II
newborn care services in district hospitals of several districts to meet
this challenge. The units are located in some of the remotest districts
where the burden of neonatal deaths and accessibility to special care is
a concern. A recently concluded evaluation of these units
indicates that it is possible to provide quality level II newborn care
in district hospitals. However, there are critical constraints such as
availability and skills of human resources, maintenance of equipment and
bed occupancy. It is not the SCNU alone but an active network of SCNU
(level II care), neonatal stabilization units (level I care) and newborn
care corners can impact neonatal mortality rate reduction higher. Number
of beds is also not sufficient to cater to the increasing demand of such
services. Available number of nurses is a problem in many such units. An
effective and sustainable system to maintain and repair the equipment is
essential. Scaling up these units would require squarely addressing
these issues.
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Facility based newborn care has assumed an
importance in developing countries owing to its potential to reduce
Neonatal Mortality Rate (NMR) by 23-50% in different settings [1].
Regionalized neonatal/perinatal care with a good network of facilities at
various levels has emerged as an effective strategy to tackle neonatal
disease burden [2,3]. Evidence supports that in places where
regionalization is not present, secondary level units can also lower NMR
significantly [4-9]. Establishing such neonatal units is currently one of
the thrust areas in South-east Asian countries. However, scaling up of
these units across the region to deliver quality services confront
challenges in the health system. Infrastructure, human resource and
equipment issues remain critical concerns to be addressed. This paper
captures such challenges identified through a systematic process of
evaluation in India and proposes solutions suitable for similar settings.
Special Care Newborn Units (SCNUs) in India
Provision of secondary level care or Special Care
Newborn Units (SCNUs) in India is a big leap to reduce the stagnant NMR.
The first unit was established in 2003 in one of the remote districts and
within a span of 3-4 years of initial success, scaling up has taken place
rapidly, now covering more than 150 districts [10]. An evaluation was
undertaken in 2009-10 to gain an insight into the functioning of 8 such
units across different states in India. These units are located in
hospitals with an annual delivery load of more than 5000. The admission
rate had progressively increased over a period of 3-4 years. Sepsis, birth
asphyxia and low birth weight/ prematurity were the prime morbidities
managed at these units. Within 1 year of functioning, there had been a
reduction in neonatal mortality rate among admitted cases by 4-40% across
the SCNUs. Reduction was observed in mortality due to low birth weight and
sepsis but not on asphyxia. The amount of reduction was greatly influenced
by the trainings conducted and hand holding done during induction.
Adherence of the staff to guidelines and protocols, aseptic measures
followed in the units were the key determinants of the performance of a
unit. However, a reversal of trend in the decline has been observed in
some units in the second year of its functioning. Though indicative, the
reversal was mostly related to shortage of beds in the units that
compelled twin or even in some cases triple admissions and poor adherence
to admission and discharge criteria, In one unit, a sudden reduction in
the number of nurses was the most probable factor behind rise in case
fatality rate. Introspection into the performance of the units had
indicated major challenges in terms of infrastructure, human resources and
equipment. The assessment offered key learning that are pertinent while
establishing and scaling up such units.
Infrastructure
The estimated number of beds was 12 for each SCNU
assuming the delivery load to be 3000 per year. However, the requirement
was far more than the number existing currently. One of the possible
reasons was possibly the significant increase in numbers of births due to
Janani Suraksha Yojana since the unit was set up. While the initial
calculation of the number of beds was done based on the number of births
at the time of setting up the unit, the number of births increased
significantly in last two years making the number of neonatal beds
insufficient. Apart from number of deliveries, a number of other
parameters like average length of stay, proportion of babies requiring
special care and proportion of low birth weight infants should also be
considered for calculating bed strength per unit [11,12]. (Table
I) An increase in the number of beds by 30-50% in the existing units
can address much of the problem, though it will lead to a proportionate
increase in infrastructure and resources and finally would add to the
cost.
TABLE I Requirement of Beds in Assessed SCNUs
District SCNU (State) |
Existing |
Number |
|
number of |
estimated |
|
beds |
[20] |
Tonk (Rajasthan) |
12 |
20 |
Dibrugarh (Assam) |
17 |
23 |
Mayurbhanj (Orissa ) |
12 |
25 |
Purulia (West Bengal) |
14 |
32 |
Lalitpur (Uttar Pradesh) |
12 |
25 |
Vaishali (Bihar) |
13 |
32 |
Guna (Madhya Pradesh) |
20 |
32 |
Port Blair(Andaman & Nicobar Islands) |
14 |
10 |
There were several factors that affected the admission
rates. One was the delivery load of the institution. Secondly, it was also
affected by the admission policies of the units. In some units, the
admission policy was strict that led to several admissions in the
pediatric wards, which were not captured in SCNU figures. On the other
hand, there were units with very flexible admission policies leading to
many "almost normal" newborns admitted to the unit, creating a situation
with high admission rates but low mortality.
In the evaluation undertaken, bed occupancy rate ranged
from 28-139% (median:103%). The reasons for low bed occupancy were related
to increased dependency on private sector and shortage of staff. In some
of the units, twin sharing of beds was a common phenomenon. The
relationship between bed occupancy rate and mortality followed a U-shaped
distribution. Units with very low and very high occupancy rates had worse
mortality figures.
While SCNU can influence facility based NMR, a good
network of functional newborn care corners (NCC) at every site of
delivery, neonatal stabilization units (NSU) at primary level, SCNU at
secondary level and neonatal intensive care units (NICU) at tertiary level
is essential to reduce NMR at the population level. Establishing a network
of NCCs, NSUs and SCNU as an integrated unit has not been given due
emphasis during inception. In our assessment, an attempt towards
establishing such a system was not evident everywhere. In one of the units
having good network with peripheral NSUs, the catchment area was wider in
contrast to other units that derived patients from close vicinity.
Although we found that NCCs were available in every
district hospital, yet not all of them were equipped to handle emergencies
at birth. As a result, there was a tendency to refer neonates
unnecessarily to SCNUs posing an additional burden. Even NCCs which were
functional earlier had become redundant reflecting undue over dependence
on SCNU.
In our assessment, expansion of SCNUs did not match
with the corresponding increase in the number of NSUs and newborn care
corners. Too much of an emphasis on setting up of such secondary level
units had resulted in admission overload in these units. Admissions beyond
the limits of SCNUs are likely to dilute the impact that an SCNU might
have. Settings developing neonatal care system should accord importance to
operationalize a well coordinated network of neonatal units at different
levels for enhancing wider coverage and reach with neonatal care services.
Human Resources
Availability of adequate number of doctors and nurses
is critical for providing care. Besides numbers, the skills and motivation
level of staff are prime pre requisites. It has been estimated that the
odds of mortality of newborns admitted in SCNUs increase significantly
when one nurse cares for more than 1.7 newborns [13]. Pediatric staff
ratios are inversely related to mortality rates [14]. While nurses are
critical, availability of doctors is important, especially for units
providing higher levels of sophisticated care such as ventilation and for
survival of very low birth weight babies [15].
In our assessment, it was noted that three out of eight
units had less number of nurses than the recommended nurse: bed ratio of
1:1.2 and 3 had less number of doctors than recommended doctor: bed ratio
of 1:4. Nurses appeared to play a crucial role in improving newborn
survival in these units – the mortality rate across the units dropped with
improved bed: nurse ratios. Units having poor ratios had worse outcomes.
Almost 15% of the variation in neonatal mortality rate across the units
could be explained by the nurses: bed ratio. Number of doctors, though
important, did not influence NMR. Qualification of nurses and doctors (in
terms of their post graduation status) did not appear to have any
influence on the mortality rates. It is pertinent to note that almost 68%
of the nurses and one-third of doctors were hired on a contractual basis
in the SCNUs surveyed. This approach may help address shortages in
specific circumstances, but not likely to resolve the problem in the long
run.
Since district is a unit of planning, the estimated
number of doctors for each district is 90 and for nurses it is 300.
Investments directed towards recruiting, enhancing the competencies and
retaining the nursing staff to work with high motivation levels in
neonatal units will go a long way in improving neonatal outcomes.
Equipment
Availability of adequate number of functional equipment
and drugs are crucial to the functioning of SCNUs and is directly linked
to quality of care. The major share of the investment that goes into
setting up of each unit is on equipment, thus ensuring optimal utilization
of the same is critical.
Shortage of basic equipments and supplies such as
resuscitation equipment, oxygen delivery systems and feeding tubes at a
Special Care Baby Unit (SCBU) in Uganda contributed to poor perinatal care
[16]. In Kabul, Afghanistan, one of the maternity hospitals with 14000
deliveries annually, it was reported that none of the wards were equipped
with resuscitation equipment, functioning warmers or oxygen delivery
system [17]. District hospitals in Kenya also lacked between 30- 56% of
items considered necessary for the provision of care to the ill born [18].
In the 8 units surveyed, the equipment were donated by
the UNICEF during the initial phase of setting up. In the due course of
time, the responsibility of maintenance and repair of equipment got
transferred to the local government. With nearly 100 percent bed occupancy
at most of the units, the load on equipment was huge. The major equipment
on an average have a shelf life of 6 yrs beyond which they would need
replacement. It was quite evident that more than the adequacy of essential
equipment and drugs, availability of functional equipment was a problem.
None of the units had an adequate number of functional baby warmers and
only 50% of them had an adequate number of phototherapy units. Most of the
equipment in the SCNUs visited did not have Annual Maintenance Contract (AMC).
The average time for repair varied from 2 weeks to six months.
Having an AMC with a provision to cover both preventive
and on-call corrective interventions should be considered while procuring
equipment. Local engineers should be identified and imparted basic
training to augment the process of repair. Besides, capacity building of
the hospital staff on preventive maintenance and troubleshooting is also
suggested.
Policy Implications
In the current analysis, we have focused on 3 major
health system issues that have a bearing on the performance and outcomes
of SCNUs. To address the challenges related to infrastructure, the bed
requirement of every unit should be examined in the light of local
parameters like prevalence of low birth weight babies and average length
of stay in addition to delivery load. Where deficient, the numbers may be
increased by a certain proportion, may be 30%. Attempts should be made to
have functional newborn care corners at every site of delivery. An active
network of NCC, NSU and SCNU can rationalize admissions of sick newborns
in appropriate units. Equal emphasis should be given to up-gradation or
creation of tertiary level neonatal units in medical colleges.
With a dearth of doctors and most importantly nurses
affecting almost every unit and positions lying vacant, we need to
consider the issue of task shifting. Graduate doctors with an additional
training in newborn care can resolve the deficit to a great extent. Local
women with 10-12 years of schooling and 6 months of hands-on training in
SCNUs functioning as nursing aides can be a promising option, especially
for performing less skilled activities [19]. Neonatal settings should
resort to local innovative solutions to address the shortage of manpower.
Added incentives to work in difficult areas will also attract personnel in
these units. A provision for increase in salary of contractual staff could
keep the motivation level of people high.
The challenges faced in the procurement and maintenance
of equipment can be resolved by adhering to the standard specifications
and ensuring AMC compulsorily. A local engineer trained by the
organization providing AMC is also an immediate solution. In addition,
there should be designated funds towards repair of equipment that should
be made readily available, bypassing administrative hassles, in times of
need.
Conclusion
Provision of secondary level care is a big step taken
up by different countries to improve facility based newborn care. Scaling
up is much needed but constraints existing in the currently running units
ought to be addressed on a priority basis. Challenges are many and one
size may not fit all. However, these lessons are important to learn and
analyze before embarking on the massive task especially in middle and low
income countries. Only then, all these efforts will pay rich dividends in
the days to come.
Contributors: SBN: drafted the
manuscript and would be the guarantor for the paper. SM :
data collection, analysis and finalization of the manuscript. SZ : data
analysis and approval of the final version. PM: inputs on the analysis and
approved the final version.
Funding: None.
Competing interests: None stated.
References
1. Darmstadt G, Bhutta ZA, Cousens S, Admas T, Walker
N, Bernis LD. Evidence based, cost-effective interventions: how many
newborn babies can we save? Lancet. 2005;365:977-88.
2. Mullem CV, Conway AE, Mounts K, Weber D, Browning
CA. Regionalization of care in Winconsin: a changing health care
environment. WMJ. 2004;103:35-8.
3. Kirby RS. Perinatal mortality: the role of hospital
at birth. J Perinatol. 1996;16:43-9.
4. Jivani SKM. Evolution of neonatal intensive care in
a district general hospital. Arch Dis Child. 1986;61:148-52.
5. Berge LN, Rasmussen S, Dahl LB. Evaluation of fetal
and neonatal mortality at the University Hospital of Tromso, Norway, from
1976 to 1989. Acta Obstet Gynecol Scand. 1991;70:275-82.
6. Subramaniam C, Dadina ZK. Intensive care for high
risk infants in Calcutta. AJDC. 1986;140:885-88.
7. Were FN, Mukhwana BO, Musoke RN. Neonatal survival
of infants less than 2000 grams born at Kenyata National hospital. East
Afr Med J. 2002;79:77-9.
8. Mootabar H, Fox HE. Level 2 hospital delivery of low
birth weight infants 1970-1979. Int J Gynaecol Obstet. 1983;21:27-32.
9. Hotrakitya S, Tejavej A, Siripoonya P. Early
neonatal mortality and causes of death in Ramathibodi Hospital: 1981- 90.
J Med Assoc Thai. 1993;76:119-29.
10. Sen A, Mahalanabis D, Singh AK, Som TK,
Bandyopadhyay S. Impact of a district level newborn care unit on neonatal
neonatal mortality rate: 2 year follow up. J Perinatol. 2009;29:150-5.
11. Swyer PR. The regional organization of special care
for the neonate. Ped Clin North Am. 1970;17:761-76.
12. Northern neonatal network. Requirements for
neonatal cots. Arch Dis Child. 1993;68:544-9.
13. Laryea CCE, Nkyekyer K, Rodrigues OP. The impact of
improved neonatal intensive care facilities on referral pattern and
outcome at a teaching hospital in Ghana. J Perinatol. 2008;28:561-5.
14. Mugford M, Szczepura A, Lodwick A, Stilwell J.
Factors affecting the outcome of maternity care II: neonatal outcomes and
resources beyond the hospital of birth. J Epidemiol Community Health.
1988;42:170-6.
15. Cooper PA, Rothberg AD, Davies VA, Herman AA. Needs
for special care beds for the newborn in the Witwatersrand area. S Afr Med
J. 1987;71:645-6.
16. Mukasa GK. Morbidity and mortality in the Special
Care Baby Unit of New Mulago Hospital, Kampala. Ann Trop Paediatr.
1992;12:289-95.
17. Williams JL, McCarthy B. Observations from a
maternal and infant hospital in Kabul, Afghanistan-2003. J Midwifery
Womens Health. 2005;50:e31-5.
18. English M, Ntoburi S, Wagai J, Mbindyo P, Opiyo N,
Ayieko P, et al. An intervention to improve pediatric and newborn
care in Kenyan district hospitals: understanding the context. Implement
Sci. 2009;4:42.
19. Sen A, Mahalanabis D, Singh AK, Som TK,
Bandyopadhyay S, Roy S. Newborn aides: an innovative approach in sick
newborn care at district level special care unit. J Health Popul Nutr.
2007;25:495-501.
20. Toolkit for setting up of special care newborn
units, stabilization units and newborn corners. Available at : http://www.unicef.org/india/SCNU_book1_April_6.pdf
(Accessed on August 20, 2009).
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