NICU OUTCOME IN A LOW RESOURCE TEACHING HOSPITAL SETTING
Shruti Sarkar, Dipankar Sarkar, Sheela Longia, Sibi Dinesh
Department of Paediatrics, Peoples College of Medical Science and Research Center, Bhopal, MP
Address for Correspondence
Dr Shruti Sarkar, HIG 13, A Block, Peoples Medical College Campus, Bypass Road, Bhanpur, Bhopal, MP 462037.
Email
shrutidipankar@gmail.com
Abstract
Objective: To study the mortality pattern in a level 3 neonatal intensive care unit (NICU) with special reference to the problems faced in a low resource teaching hospital.

Methods: A retrospective study was conducted over a period of three years from January 2007 to December 2009. The medical records of all babies who died after being admitted to the NICU were reviewed. Survival was defined as the discharge of a live infant from the hospital. Data regarding birth weight, gestational age, stay in NICU, final cause of death and diagnosis or co-morbidities leading to death was analyzed. Exclusion criteria were to exclude (A) babies who came in the NICU for a few hours observation and were shifted to mother. (B) Any baby who could not be successfully resuscitated in labour room and (C) babies who left the hospital against medical advice and calculation of survival was done after subtracting them from total admission.

Results: A total of 687 babies were admitted in this 3 year period in our NICU. Out of these, 573 babies survived (92.4%) and 47 babies expired (7.5%). The total number of deliveries in these three years was 2912 and the neonatal mortality rate (NMR) in this study was 16.1 per 1000 live births. In the very low birth weight (VLBW) group the survival was 75.4% (n=85) and in extremely low birth weight (ELBW) group it was 22.2% (n=25). In low birth weight (LBW) group 95.8% babies survived (n=367). Overall NICU mortality was 9.7%. Total Survival of VLBW & ELBW together was 63%. Out of 47 expired babies 91.4% (n=43) were premature and 43% babies (n=21) were below 30 weeks of gestational age. Sepsis was the predominant cause of death (31.9%) followed by hyaline membrane disease (HMD) (25.5%) and necrotising enterocolitis (NEC) (9%) in these 47 babies. But when the data was analysed to check the diagnosis or co-morbidities in these babies leading to the cause of death it was found that prematurity was the commonest problem (82%) followed by HMD (63%) and sepsis 48%.

Conclusion: We conclude that the overall survival of newborns in our unit is comparable to many previously published reports.
Keywords
NICU, Neonatal Mortality, Low resource setting, Cause of death
Introduction
According to the National Family Health Survey - 3 (NFHS) report, the current neonatal mortality rate (NMR) in India of 39 per 1,000 live births accounts for nearly 77% of all infant deaths (57/1000) and nearly half of under-five child deaths (74/1000) (1). International data suggests that 60-80% of all neonatal mortality and morbidity is due to preterm birth (2) and preterm birth is one of the major clinical problems in obstetrics and neonatology as it is associated with increased perinatal mortality and morbidity (3). There is scanty data available regarding overall neonatal mortality in Indian neonatal intensive care units (NICU) and even if it is there it is mainly from postgraduate teaching hospitals in major cities (4). Data from tertiary care NICUs in smaller cities in India catering to very poor people is scarce. The objective of the study was to study the mortality pattern in a level 3 NICU with special reference to the problems faced in a low resource teaching hospital.
Methods & Materials
A retrospective study was conducted in the NICU, Dept of Pediatrics, Peoples College of Medical Science & Research Center, Bhopal, MP, India, over a period of three years from January 2007 to December 2009. The medical records of all babies who died after being admitted to the NICU were reviewed with the help of Medical Records Section. Survival was defined as the discharge of a live infant from the hospital. Data regarding birth weight, gestational age, stay in NICU, final cause of death and diagnosis or co-morbidities leading to death was analyzed. Exclusion criteria were to exclude (A) babies who came in the NICU for a few hours observation and were shifted to mother. (B) Any baby who could not be successfully resuscitated in labour room and (C) babies who left the hospital against medical advice and calculation of survival was done after subtracting them from total admission as their outcome was not known.

Description of NICU

10 bedded NICU with 5 intensive care beds and 5 beds as step down nursery. This NICU is providing level 3 care in a low resource undergraduate teaching hospital setting. NICU has 10 warmer beds, 2 neonatal ventilators including continuous positive airway pressure (CPAP facilities), multipara monitors, infusion & syringe pumps, electronic weight machine etc. The NICU is manned by round the clock paediatrician and nursing staff along with on call faculty members. There are 24 hours basic laboratory facilities including blood gas analysis and 24 hours radiology facility. There is a support of 2 pediatric surgeons if and when required. This hospital caters for population which is mainly rural, semi urban and some urban patients with a significant number of below poverty line (BPL) income group patients. Deliveries are just under 1000 per year with a large number of unbooked mothers and mothers with complicated obstetric or antenatal history referred from district/ rural hospitals. Admission criteria to the NICU were prematurity <35 weeks, birth weight
Certain policies and interventions were implemented in NICU which have been previously shown to reduce neonatal mortality and the cost of neonatal care in view of low resource setting in form of mother centred care in step down nursery where routine care was provided by mother, stress on strict hand washing by all staff, minimal investigations, minimising needle pricks and trying to coincide blood investigations with insertion of cannula, rarely using central line, arterial line and total parental nutrition (TPN), capillary blood gas estimation from heel prick sample and early discharge from the NICU to step down nursery and then to postnatal ward as soon as possible.
Results
A total of 687 babies were admitted in this 3 year period in our NICU. Out of these, 573 babies survived (92.4%) and 47 babies expired (7.5%). Total number of babies, left the hospital against medical advice (LAMA) was 67 (9.7%). In the very low birth weight (VLBW) group the survival was 75.4% (n=85) and in extremely low birth weight (ELBW) group it was 22.2% (n=25). In low birth weight (LBW) group 95.8% babies survived (n= 367). Mortality was highest in ELBW group (77.7%) with the smallest birth weight recorded 585 gms. The mortality rate in other weight category was 24.5% in VLBW and 4.1% in LBW group. (Figure 1) Overall NICU mortality was 9.7%. Total Survival of VLBW & ELBW together was 63%. Out of 47 expired babies, 91.4% (n=43) were premature and 43% babies (n=21) were below 30 weeks of gestational age, 12 babies were in the age group of 30-34 weeks, 6 babies were between 35-37 weeks and 8 babies were more than 37 weeks of gestational age.

Sepsis was the predominant cause of death (31.9%) followed by hyaline membrane disease (HMD) (25.5%) and neonatal enterocolitis (NEC) (9%) in these 47 babies. (Table 1)

Figure 1: NICU outcome in different birth weight groups


TABLE 1: Final cause of death in expired babies in different birth weight groups
Final cause of death
Birth weight
 Total  <1kg  1-1.499 kg  1.5-2.5kg  >2.5 kg
 Hyaline membrane disease  12  7  3  2  0
 Sepsis  15  4  8  3  0
 Neonatal enterocolitis  4  1  1  2  0
 Intraventricular hemorrhage  2  2  0  0  0
 Pneumonia  2  0  1  1  0
 Pneumothorax  2  0  1  1  0
 Congenital Anomalies  2  0  1  1  0
 Meconium Aspiration  1  0  0  1  0
 Hypoxic ischemic encephalopathy  2  0  0  1  1
 Congenital cyanotic heart disease  2  0  0  2  0
 Severe pulmonary Hypertension  2  0  0  0  2
 Hydrops  1  0  0  0  1
 Total number  47  14  15  14  4


But when the data was analysed to check the diagnosis or co-morbidities in these babies leading to the cause of death, it was found that prematurity was the commonest problem (82%) followed by HMD (63%) and sepsis 48%. (Table 2)

TABLE 2: Diagnosis or co-morbidities leading to cause of death
Co-morbidity
Birth weight
 % (out of expired  babies)
 Total  <1kg  1- 1.499kg  1.5- 2.5kg  >2.5  kg
 Prematurity  14  15  0  0  39  82.9
 HMD  14  14  2  0  30  63.8
 Sepsis  7  9  7  0  23  48.9
 NEC  1  1  0  0  2  4.2
 IVH  1  1  0  0  2  4.2
 Congenital heart  disease
 0  1  2  0  3  6.3
 Pneumonia  0  1  0  0  1  2.1
 Congenital anomalies  0  1  5  0  6  12.7
 Birth asphyxia  0  0  5  2  7  14.8
 Diaphragmatic hernia  0  0  0  2  2  4.2
 Non immune hydrops  0  0  0  1  1  2.1


Out of 47 expired babies, 15 (31.9%) babies died within a day and 9 (19%) babies died after one week. Early neonatal mortality was 82.9% of all neonatal deaths. In our hospital, the total number of deliveries in these three years was 2912 and out of these 687 babies got admitted in the NICU which is 23.59% of all deliveries. The total number of death was 47. So, the neonatal mortality rate (NMR) in this study was 16.1 per 1000 live births.
Discussion
Though more data is now being collected and reported at national level on the mortality and morbidity pattern from different Indian NICUs, these are mainly from tertiary care centres in metropolitan cities (4). Data from hospitals in smaller cities and NICUs of low resource setting is very limited. In smaller cities number of NICUs are less and level 3 NICUs are even lesser and there are very few published reports from these hospitals (5). There is a great variation in neonatal mortality statistics between NICUs from different parts of the world. This variation probably reflects the difference in the attending population, antenatal care, admission criteria, specific exclusion & inclusion criteria and level of neonatal care. In some studies from Canada, Pakistan & Brazil mortality rates were 4% (6), 9% (7) & 6% (8) respectively. Higher rates have been reported from Saudi Arabia (22.4%) (9), Kenya (24.6%) (10) and Togo (27%) (11). Data from national neonatal perinatal database 02-03 in which 18 centres countrywide have participated reports the neonatal mortality to be 25.4 per 1000 live births (4). The overall mortality in our study was 16.1 per 1000 live births. The participating centres in the national database are all tertiary care centres in metropolitan cities; they are likely to have more high risk pregnancies than other centres. The newborns reported in this database are therefore likely to have more problems and so be sicker than others.

The mortality in ELBW babies in our unit is 77.7%, which is much higher than that reported in the national perinatal database. Families of ELBW babies leaving the hospital against medical advice are also much higher in our unit (7 out of 25). Of the 14 deaths in the ELBW babies, 35% have died within 24 hrs and 85% have died by 7 days. HMD is the final cause of death in 50% of those. Of the 14 who died, only 1 received surfactant. So unavailability of surfactant because of financial limitations has been an important factor in the high mortality. Sehgal et al (12) have reported a mortality of 43% in a cohort of 52 ELBW babies. Roy et al (3) have reported a mortality of 33.3%. Both of these reports are from tertiary care postgraduate institutes.

The mortality of VLBW babies in our unit is 24.5% which is comparable to the national perinatal database (29.7%). Other studies from India showed mortality of 36.9% (5) and15.7% (3). The mortality in LBW group is 4.1% which is also comparable to the national perinatal database (6.1%).

On analysis of the primary cause of death, it was found that sepsis is the leading cause of death at 32% and Hyaline membrane disease following at 26%. Birth asphyxia as the cause of death was seen in only 4% of the babies in our unit as opposed to being the leading cause in the national perinatal database (28.8%) (4). Basu et al (5) in a cohort of 260 cases out of which 96 died, have reported birth asphyxia as the leading cause of death at 32.2% followed by respiratory distress syndrome at 23.96%. Sepsis as the cause of death in their unit is reported to be 7.29%. Garg et al (13) from a community level NICU have reported birth asphyxia as the leading cause of death followed by sepsis.

A low resource NICU has many inherent problems relating to the population catered by it. Population we cater to are mostly people with financial limitations. Out of the population attending the hospital, a majority is represented by the farming and related community so their attendance to the hospital is largely governed by their farming priorities of sowing, reaping etc. This is reflected in the large number of unbooked pregnancies, women coming to the hospital for the first time in labour and women who although booked are very irregular in obstetric visits and so have received inadequate antenatal care. Hence, the babies that we admit in our NICU although all are inborn but many to mothers who have come to the hospital for the first time in labour and so are likely to have more problems. With the limited finances and time commitment the compliance of these patients is also suboptimal. Low resource hospitals have to work with these handicaps. For such units to work effectively it is wise to adopt certain policies by which "intensive care" is provided, but not necessarily "invasive care". Some such practices adopted in our unit are mother centered care, minimal invasive investigations, minimal use of central lines and TPN and pro enteral feeding policy. Fernandez et al (14) have advocated usefulness of similar interventions for low resource NICUs. Agarwal et al (15) have shown the effectiveness of these simple interventions in a low resource teaching hospital and the reduction in mortality in their unit with these measures were statistically significant.

We conclude that the overall survival of newborns in our unit is comparable to many previously published reports. We advocate that more data be published from centres all over the country. More and more units providing intensive care should report their data and also contribute to the national database to increase the awareness in the variability of neonatal morbidity and mortality countrywide and the reasons behind them. In developing countries and specially in low resource areas more stress should be given to babies more than 1000 gms birth weight as it is in this group that the quality of care will have significant impact on "intact survival".
Funding
None
Conflict of Interest
None
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Last Updated : Thursday, July 01, 2010 Vol 7 Issue 7 Art #38
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Sarkar S, Sarkar D, Longia S, Dinesh S. NICU OUTCOME IN A LOW RESOURCE TEACHING HOSPITAL SETTING . Pediatric Oncall [serial online] 2010[cited 2010 July 1];7. Art #38. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=315&type=J&tid=&imgid=&reportid=138&tbltype=
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