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Neonatal Care In DistrictsDr.Ravikumar ChodavarapuD.C.H; D.N.B; F.I.A.P(Nephrology)Professor of PediatricsKakatiya Medical College & M.G.M.HospitalWarangal1WORLD - N.M.R - MAGNITUDE

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NEONATAL CARE UPGRADATIONWHAT FOR (GOAL or OBJECTIVE) To reduce NMR or CFR.

WHAT IS TO BE UPGRADED? KNOWLEDGE, SKILLS, ATTITUDE.

WHAT IS THE EVIDENCE FOR IT?3How many depressed babies require increasing levels of interventions?PCNA, JUN 2009, VOL56, No 3, P 516.Most compromised neonates who require assistance in the transition from intrauterine to extrauterine life respond to effective PPV.

Only 1% of all neonates require further intervention in the form of chest compressions or administration of intravenous fluids or medications.(Kattwinkel J, editor. Textbook of neonatal resuscitation. 5th edition. Elk Grove Village (IL): American Academy of Pediatrics and American Heart Association;2006.)4

What does it mean?At the most 1% of compromised babies require high-technological assistance of cardio-pulmonary management. All that may reduce NMR by 10.

Presently N.M.R is 44 in our country?

Other reasons if identified and corrective strategies implemented, N.M.R can be reduced further.

What are those causes & strategies? 5CAUSES N.M.RMOST ORIGINATE FROM LACK OF BASIC NEONATAL CARE

6MAIN REASONS FOR N.M.RImmediate, Basic neonatal care, from the time of delivery is not available to majority of babies.

Lack of prompt basic care leads to much mortality & morbidity.

Skilled clinical care is not reachable & affordable.7Community Care or Clinical Care StrategiesOutreach and family-community services : access of the poor to basic services while professional clinical care is being strengthened and made more equitable.

Even with a weak health system, measurable mortality reduction can be achievedby starting with outreach and at the family-community level.

Greatest success comes when both are linked. (www.thelancet.com Vol 365 March 19, 2005 )8WHAT IS THE ROLE OF STRATEGIES TO REDUCE N.M.R?

9WHAT ARE THE COSTS OF THOSE STRATEGIES?

Figure 4: Estimated current expenditures by service delivery category for implementation of evidence-based interventions, and additional costs to implement these interventions at expanded coverage of 90% in 75 countries.10MYTH - FACTCountries or programmes should wait until post-neonatal deaths are reduced before addressing neonatal mortality

Fact: Neonatal mortality accounts for 38% of deaths in children aged younger than 5 years.

Neonatal interventions, such as exclusive breastfeeding and improved care of LBW infants will reduce post-neonatal mortality in addition to neonatal mortality11MYTH - FACTOnly developed countries with high GDP have succeeded in reducing neonatal mortality

Fact: Countries such as Honduras, Indonesia, Moldova, Nicaragua, Sri Lanka, and Vietnam have reduced neonatal mortality despite having fairly low GDPs12

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MYTH - FACTHigh-tech interventions, such as neonatal intensive care units, are needed to reduce neonatal mortality

Fact: Most countries with a low NMR achieved substantial reductions in neonatal mortality (to an NMR of about 15 per 1000) before neonatal intensive care became widely available.14

MYTH - FACTThere are few effective, low-cost interventions

Fact: Several low-cost interventions are effective in reducing mortality, including tetanus toxoid vaccination, exclusive breastfeeding, K.M.C for LBW infants, and antibiotics for neonatal infections.Hand Hygiene15Evidence Based, Cost-effective interventionsLancet 2005; 365: 97788

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17MYTH - FACTOnly facility-based, professional care can save newborn babies

Fact: There is convincing evidence that neonatal mortality can be greatly reduced by community-based interventions delivered through non-midwife community health workers.

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MYTH - FACTNeonatal-specific interventions are not needed, since current safe motherhood and child survival strategies are sufficient to reduce deaths of newborn babies

Fact: Although maternal care is essential for neonatal survival, there are several specific neonatal care interventions that can reduce neonatal deaths and should be systematically included within the relevant programmes.

There has been insufficient attention paid to neonatal health in both maternal and child health programmes.19

20Reductions in N.M.R in developed countries preceded the introduction of expensive neonatal intensive care.In England, for example, the NMR fell from more than 30 in 1940 to 10 in 1975, a reduction linked to the introduction of free antenatal care, improved care during labour, and availability of antibiotics.

MacFarlane AJ, Johnson A, Mugford M. Epidemiology. In Rennie JM, Roberton, NRC, eds. Textbook of neonatology (3rd edn). Edinburgh: Churchill Livingstone, 1999: 333.21Reductions in N.M.R in developed countries preceded the introduction of expensive neonatal intensive care. In Sweden, perinatal mortality declined at the end of the 19th century by 1532% in those who used midwives for home deliveries.

The training of midwives at that time, working largely in community settings, emphasised keeping the baby warm, neonatal resuscitation with tactile stimulation, daily cord care, early breastfeeding, and the use of aseptic techniques.

Hogberg U. The decline in maternal mortality in Sweden: then and now. Am J Public Health 2004; 94: 131220.

Andersson T, Hogberg U, Bergstrom S. Community-based prevention of perinatal deaths: lessons from nineteenth-century Sweden. Int J Epidemiol 2000; 29: 54248.

22N.M.R REDUCTION DEVELOPING COUNTRIESBorn without the Basic careCommunity neonatal care was more cost effective than institutional care.(Committee on Improving Birth Outcomes, Board on Global Health. Improving birth outcomes. Meeting the challenge in the developing world. Washington, DC: National Academies Press, 2003.)

Bang and colleagues showed a 62% reduction in neonatal mortality in rural India through a community based approach that included training of TBAs and local women to treat sick newborn infants at home.(Bang A, Bang R, Baitule S, Reddy M, Deshmukh M. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354:1955-61.)

A trial in Nepal of a less intensive community intervention showed a 30% reduction in neonatal mortality and, surprisingly, a significant reduction in maternal mortality.

(Manandhar D, Osrin D, Shrestha B, Mesko N, Morrison J, Tumbahangphe K, et al. The effect of a participatory intervention with womens groups on birth outcomes in Nepal: cluster randomized controlled trial. Lancet 2004;364:970-9.23N.M.R REDUCTION DEVELOPING COUNTRIESWhere the IMR is more than 30. HBNC has a proven record of reducing it to below 30.(Abhay T. Bang, Rani A. Bang, Hanimi M. Reddy. Home-Based Neonatal Care: Summary and Applications of the Field Trial in Rural Gadchiroli, India (1993 to 2003). Journal of Perinatology 2005; 25:S108S122)

It is worth noting that Sri Lanka reduced its IMR down to the level of 15, despite having only 50 NICU beds in the entire country. (Harenda de Silva DG. Perinatal Care in Sri Lanka: secrets of success in a low-income country. Sem Neonatology 1999;3(4):201 8.)

This was done mostly by a decentralized health care system reaching almost every mother and newborn.24LIMITATIONS OF NICU CAREThe substantial improvement in newborn survival in the United States over the past several decades is mostly due to better access to improved neonatal care for low-birth-weight infants.

Although survival has improved, the proportion of births born before term continues to increase and the rate of disability among the preterm survivors has not decreased. P.C.N.A.JUN 2009.VOL 56. NUMBER 3

25LIMITATIONS OF NICU CARELow birth weight in general is thought to place the infant at greater risk of later adult chronic medical conditions, such as diabetes, hypertension, and heart disease.

Can NICU care prevent them Evidence so far tells that NICU care is not related to the problem.

In that case prevention of LBW is needed for that purpose.

26NEONATAL MORTALITY PROBLEM & CURRENT PRACTICE SOLUTIONS ARE DIFFERENTNot practicing what is already known.

Not delivering the service to where it is needed.

Misconception that expensive, high-tech approaches are necessary to save newborn lives.

Many countries - UK, Sweden, Sri Lanka - achieved neonatal mortality rates of 15 per 1000 or less before such care was available.Bulletin of Tropical Medicine and International Health. Volume 13:No.1, 200727

PRIORITIES IN NEONATAL CARE IN DISTRICTS PUBLIC SECTORTrain TBAs, Community in Antenatal and early neonatal care & early referral.

Promote institutional delivery & delivery room care.

Warmth, Breast feeding,, Infection prevention measures Core neonatology of any level

Simple & effective neonatal care of LBW & Preterm Basic NICUs - Care and Monitoring Vs Gadgets

Parental & Family education in Neonatal Care Hand Hygiene, Warmth, Feeding properly

Technology & intensive care for select cases.28INDIVIDUAL PEDIATRICIAN LEVEL NEONATAL CARE PACKAGESPRIVATE SECTORPediatrician + Obstetrician practice at one place Develop Antenatal, Perinatal Care, Emergency care

Training their staff Nurses etc in neonatal care.

Educating parents to improve home care of babies, recognition of illness, early care seeking.

Type and Level of NICU as per the practicing areas Clinical/Curative needs.

29ENOUGH EVIDENCE TO SAYFeasible, highly cost effective interventions are available that could avert up to 72% of neonatal deaths.

NMRs of about 15 per 1000 are achievable with the basic intervention packages.30

REDUCTION OF N.M.R IS TO BE A PASSIONNICU IS NOT TO BE A FASHION,BUT A PERCEPTION..31