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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 25-28

Causes and pattern of neonatal mortality in tertiary care neonatal unit of medical college hospital at Jammu, Jammu and Kashmir


Department of Paediatrics, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Submission23-Jun-2021
Date of Decision02-Nov-2021
Date of Acceptance16-Nov-2021
Date of Web Publication31-May-2022

Correspondence Address:
Mohammad Irfan Dar
Department of Paediatrics, Government Medical College, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIMPH.JIMPH_4_21

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  Abstract 

BACKGROUND: Infant mortality rate is the best indicator of effectiveness of maternal and child health services in general. Seventy percent of total infant deaths fall in neonatal period that is the neonatal mortality rate. The neonatal mortality is not uniform across the country. Substantial variations are observed in survival rates between the states and between districts within states. Focusing on local changes using local data can lead to improved outcomes. Health facility-based interventions can reduce neonatal mortality by 23%–50% in different settings. OBJECTIVES: This research article provides an overview of the causes of neonatal mortality and the relative public health importance of different causes that will help in reorganization and strengthening of neonatal services in our setup. MATERIALS AND METHODS: This was a record-based observational study of all the neonatal deaths in the neonatal unit over a period of 2 months from November 1, 2019 to December 31, 2019. Details of each neonatal death were analyzed. RESULTS: Most common cause of death was prematurity (56.44%) followed by neonatal sepsis (37.62%), birth anoxia (30%), and respiratory distress syndrome (26.73%). Seventy percent (71.29%) of deaths were inborn, whereas 24.75% and 3.96% were outborn and home-delivered, respectively. Sixty-seven percent (67.32%) were less than 2.5 kg among which 36.63% were less than 1.5 kg. Median weight was 2 kg. Fifty-seven (57%) of deaths occurred within 48 h after birth and median age at admission was 2 h and median hospital stay was 1.5 days. CONCLUSIONS: Improvement in female literacy rate, nutritional status of mother, providing good and essential antenatal care will reduce endogenous factors (prematurity and birth injuries) of neonatal mortality. Improving level 2 special newborn care and level 3 neonatal intensive care unit (NICU) beds, upgrading and operationalizing the newborn stabilization unit beds along with quality improvement and a functional back-referral system will substantially bring down neonatal mortality

Keywords: Child health services, neonatal mortality, neonatal sepsis, prematurity


How to cite this article:
Dar MI, Jamwal A, Raina S, Bhat V. Causes and pattern of neonatal mortality in tertiary care neonatal unit of medical college hospital at Jammu, Jammu and Kashmir. J Integr Med Public Health 2022;1:25-8

How to cite this URL:
Dar MI, Jamwal A, Raina S, Bhat V. Causes and pattern of neonatal mortality in tertiary care neonatal unit of medical college hospital at Jammu, Jammu and Kashmir. J Integr Med Public Health [serial online] 2022 [cited 2022 Jun 27];1:25-8. Available from: http://www.jimph.org/text.asp?2022/1/1/25/346308




  Introduction Top


Neonatal mortality continues to be a major contributor to infant mortality in developing countries. The daily risk of mortality in neonatal period is ~30 times higher than that from 1 month to 5 years of age.[1] Current neonatal mortality rate (NMR) of India is 21.6 per 1000 live births (2020).[2] Given the infant and under-five child mortality rates of 28.26 (2020) and 34.27 (2020) per 1000 live births, respectively,70% of total infant deaths and more than 50% of under-five deaths fall in neonatal period. Although NMR has declined from 29.6 per 1000 live births in 2010 to 25.8 per 1000 live births in 2015 with the introduction of the National Rural Health Mission in mid-2005 but the rate of decline is so slow that India missed the target to achieve the fourth Millennium Development Goal (MDG-4), which aimed to reduce IMR by two-thirds between 1990 and 2015.[1] Infant mortality rate is the best indicator of maternal and child health services in general. The government is trying to improve the situation and has now come up with the India newborn Action Plan (INAP) to reduce the NMR to a single digit per 1000 live births by the year 2030.[3] The neonatal mortality is not uniform across the country. Substantial variations are observed in survival rates between the states and between districts within states. The underlying system-based causes of neonatal mortality need to be better understood. One size cannot fit all, especially in such a large country.[4] Focusing on local changes using local data can lead to improved outcomes, as has been shown in Canada.[5] It has been estimated that about 70% of neonatal deaths could be prevented if proven interventions are implemented effectively with high coverage.[6] Health facility-based interventions can reduce neonatal mortality by 23%–50% in different settings.[7]

This research article provides an overview of the causes of neonatal mortality in neonatal intensive care unit (NICU) of a medical college hospital and relative public health importance of different causes that will help in reorganization and strengthening of newborn health services in our setup.


  Subjects and Methods Top


Retrospective review of records of neonatal deaths that died between 1st November 2019 and 31st December 2019 was done after approval from institute ethics committee. Neonates that left against medical advice and those who were referred to higher centre for further evaluation and management were excluded from study. Along with demographic data, neonates were assessed for age at time of admission, type of admission (outborn/inborn/home), diagnosis at admission, gestational age, birth weight, duration of hospital stay and final diagnosis.

Statistical analysis

The presentation of the data was done in the form of number and percentage (%). On the other hand, the quantitative data were presented as the means ± SD and median with 25th and 75th percentiles (interquartile range).

The data entry was done in the Microsoft EXCEL spreadsheet and the final analysis was done with the use of Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, Illinois, version 21.0.


  Results Top


Median age at admission was 2 h (range 0.17 to 624) and median hospital stay was 1.5days(IQR 1 to 5 days) with range 0.2 to 47 days. A total of 101 deaths occurred over a period of 2 months. Seventy-one percent (71.29%) deaths were inborn, whereas 24.75% and 3.96%were outborn and home-delivered, respectively. Sixty-seven (67.32%) deaths were of less than 2.5 kg weight among which 36.63% were less than 1.5 kg weight [Figure 1]. Median weight was 2 kg with SD of 0.8 kg. Fifty-seven (57%) of deaths occurred 48 h after birth.
Figure 1: Distribution of neonatal deaths with respect to weight (A) and gestation (B)

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Prematurity was seen in 56.44% of deaths [Figure 1], whereas mean gestational age was 34 weeks (SD 4.18 weeks). Sepsis screen was positive in 53.47% of neonatal deaths.

Congenital malformations were seen in 11.88% of neonatal deaths among which acyanotic congenial heart disease was most common, seen in 4.95% of deaths.

In final diagnosis, the most common cause of death was prematurity (56.44%) followed by neonatal sepsis (37.62%), birth anoxia (30%), and respiratory distress syndrome (26.73%).[Figure 2]
Figure 2: Final diagnosis of neonatal deaths (HIE = hypoxic ischemic encephalopathy, HMD = Hyaline membrane disease)

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Seventy-one percent of deaths were from rural, whereas 29% were urban background


  Discussion Top


Although based on hospital records, the present study provides insight into neonatal health in a tertiary care hospital referred from its wide catchment area, the mortality pattern gives an insight of the status and the ways to modify the pattern to reduce the problems in a well-equipped set-up.

In our study the most common cause of death was prematurity (56.44%) followed by sepsis (37.62%). A systematic analysis of global, regional, and national causes of child mortality in 2013 also identified preterm birth complications and infections to be the two major causes of neonatal deaths in India.[1]

Our study showed birth anoxia (30%) as third, respiratory distress syndrome (26.73%) as the fourth, and congenital malformations (11%) as the fifth common cause of neonatal mortality, similar to the results of Million Death study in India.[8] In our study, 57% of neonates died within the first 48 h, consistent with the study done by Lawn et al.[9] Neonatal mortality is a measure of the intensity with which endogenous factors (prematurity and birth injuries) affect life. High rate of neonatal deaths with endogenous causes suggests the need to improve the antenatal and neonatal services to expectant mothers.[10]

Our findings suggest that perinatal period is the crucial period as most of the deaths occurred in this period. In order to reduce neonatal mortality, major healthcare interventions and programs should target this time period at all health care levels (primary, secondary as well as tertiary care level). Strengthening immediate neonatal care will reduce both neonatal sepsis as well as birth asphyxia which are 2nd and 3rd main causes of deaths in our study. Key interventions should target health education regarding breastfeeding, availability of NICU beds with respect to population, adequate NICU bed space, ratio of NICU beds, nursing staff and doctors as per recommended norms. Other finding in our study was the prematurity which was seen in more than half of neonatal deaths. It suggests the need to improve antenatal services to expectant mothers like treatment and prevention of anemia and malnutrition, adequate birth spacing, adequate antenatal check-ups all affected by female literacy.

The median maternal age at first childbirth in India is 19.9 years; ~30% of girls give birth before the age of 20 and account for 21% of all deliveries.[11]

It is estimated that the risks of neonatal mortality and low birth weight (LBW) are increased by almost 50% if maternal age at childbirth is 20 years. It is also estimated that shifting age at childbirth to above 20 years would reduce overall NMR by 9.4%. Evidence shows that improving maternal education is the most effective and proven strategy to improve neonatal survival, as it improves preventive behaviors and increases the utilization of maternal and neonatal health-care services. Kerala’s achievement of stabilizing population growth and low levels of infant and neonatal mortality is partly attributed to its high female education levels.[1]

Quality improvement efforts that target process improvement alone do not achieve their full potential benefits. The Indian Government’s flagship insurance scheme—the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana—holds great promise of rapidly expanding the pool of hospital beds by enrolling existing private healthcare facilities. However, the effect on availability of level 3 NICU beds is yet to be seen. Upgrading and operationalizing the underused newborn stabilization unit beds across the country along with a functional back-referral system could substantially augment the number of level 2 beds available.[4]


  Conclusion Top


There is an interplay of different demographic, educational, socioeconomic, biological, and care-seeking factors, which are responsible for the disparities and the high burden of neonatal mortality. We have to increase the coverage of key preventive as well as curative interventions. Improvement in female literacy rate, nutritional status of mother, providing good and essential antenatal care will reduce endogenous factors (prematurity and birth injuries) of neonatal mortality. Improving level 2 special newborn care and level 3 NICU beds, Upgrading and operationalizing the newborn stabilization unit beds along with quality improvement and a functional back-referral system will substantially bring down neonatal mortality.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sankar MJ, Neogi SB, Sharma J, Chauhan M, Srivastava R, Prabhakar PK, et al. State of newborn health in India. J Perinatol 2016;36:3-8.  Back to cited text no. 1
    
2.
UN Inter-agency Group for Child Mortality. Unicef Data. Available from: https://childmortality.org/data/India. [Last accessed on 2021 May 4].  Back to cited text no. 2
    
3.
India Newborn Action Plan. Available from: http://nrhm.gov.in/images/pdf/programmes/inap-final.pdf. [Last accessed on 2021 May 12].  Back to cited text no. 3
    
4.
Kumar P, Singhal N. Mapping neonatal and under-5 mortality in India. Lancet 2020;395:1591-3.  Back to cited text no. 4
    
5.
Lee SK, Beltempo M, McMillan DD, Seshia M, Singhal N, Dow K, et al. Outcomes and care practices for preterm infants born at less than 33 weeks’ gestation: A quality-improvement study. CMAJ 2020;192:E81-91.  Back to cited text no. 5
    
6.
Baqui AH, Darmstadt GL, Williams EK, Kumar V, Kiran TU, Panwar D, et al. Rates, timing and causes of neonatal deaths in rural India: Implications for neonatal health programmes. Bull World Health Organ 2006;84:706-13.  Back to cited text no. 6
    
7.
Anuradha D, Rajesh Kumar S, Aravind MA, Jayakumar M, Ganesh J. Profile on the spectrum of neonatal mortality and morbidity pattern of extramural neonates in the Specialised Neonatal Care Unit (SNCU) in a tertiary care hospital. Int J Contemp Pediatr 2018;5:427-31.  Back to cited text no. 7
    
8.
Bhutta ZA. The million death study in India: Cam it help in monitoring the millennium development goals? PLoS Med 2006;3:e103.  Back to cited text no. 8
    
9.
Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet 2005;365:891-900.  Back to cited text no. 9
    
10.
Gupta P, Dhingra D. Indicators of child health. In: Gupta P, Menon PSN, Ramji S, Lodha R, editors. PG Textbook of Pediatrics. Vol. 3, 2nd ed. New Delhi: Jaypeee Brothers; 2018. p. 3216-22.  Back to cited text no. 10
    
11.
Upadhyay RP, Chinnakali P, Odukoya O, Yadav K, Sinha S, Rizwan SA, et al. High neonatal mortality rates in rural India: What options to explore? Isrn Pediatr 2012;2012:968921.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Introduction
Subjects and Methods
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