Global report on preterm birth and stillbirth (4 of 7): delivery of interventions

<p>Abstract</p> <p>Background</p> <p>The efficacious interventions identified in the previous article of this report will fail unless they are delivered at high and equitable coverage. This article discusses critical delivery constraints and strategies.</p> <p>Barriers to scaling up interventions</p> <p>Achieving universal coverage entails addressing major barriers at many levels. An overarching constraint is the lack of political will, resulting from the dearth of preterm birth and stillbirth data and the lack of visibility. Other barriers exist at the household and community levels, such as insufficient demand for interventions or sociocultural barriers; at the health services level, such as a lack of resources and trained healthcare providers; and at the health sector policy and management level, such as poorly functioning, centralized systems. Additional constraints involve weak governance and accountability, political instability, and challenges in the physical environment.</p> <p>Strategies and examples</p> <p>Scaling up maternal, newborn and child health interventions requires strengthening health systems, but there is also a role for focused, targeted interventions. Choosing a strategy involves identifying appropriate channels for reaching high coverage, which depends on many factors such as access to and attendance at healthcare facilities. Delivery channels vary, and may include facility- and community-based healthcare providers, mass media campaigns, and community-based approaches and marketing strategies. Issues related to scaling up are discussed in the context of four interventions that may be given to mothers at different stages throughout pregnancy or to newborns: (1) detection and treatment of syphilis; (2) emergency Cesarean section; (3) newborn resuscitation; and (4) kangaroo mother care. Systematic reviews of the literature and large-scale implementation studies are analyzed for each intervention.</p> <p>Conclusion</p> <p>Equitable and successful scale-up of preterm birth and stillbirth interventions will require addressing multiple barriers, and utilizing multiple delivery approaches and channels. Another important need is developing strategies to discontinue ineffective or harmful interventions. Preterm birth and stillbirth interventions must also be placed in the broader maternal, newborn and child health context to identify and prioritize those that will help improve several outcomes at the same time. The next article discusses advocacy challenges and opportunities.</p

Neonatal severe bacterial infection impairment estimates in South Asia, sub-Saharan Africa, and Latin America for 2010.

BACKGROUND: Survivors of neonatal infections are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified and yet important for program priority setting. Systematic reviews and meta-analyses were undertaken and applied in a three-step compartmental model to estimate NDI cases after severe neonatal bacterial infection in South Asia, sub-Saharan Africa, and Latin America in neonates of >32 wk gestation (or >1,500 g). METHODS: We estimated cases of sepsis, meningitis, pneumonia, or no severe bacterial infection from among estimated cases of possible severe bacterial infection ((pSBI) step 1). We applied respective case fatality risks ((CFRs) step 2) and the NDI risk among survivors (step 3). For neonatal tetanus, incidence estimates were based on the estimated deaths, CFRs, and risk of subsequent NDI. RESULTS: For 2010, we estimated 1.7 million (uncertainty range: 1.1-2.4 million) cases of neonatal sepsis, 200,000 (21,000-350,000) cases of meningitis, 510,000 cases (150,000-930,000) of pneumonia, and 79,000 cases (70,000-930,000) of tetanus in neonates >32 wk gestation (or >1,500 g). Among the survivors, we estimated moderate to severe NDI after neonatal meningitis in 23% (95% confidence interval: 19-26%) of survivors, 18,000 (2,700-35,000) cases, and after neonatal tetanus in 16% (6-27%), 4,700 cases (1,700-8,900). CONCLUSION: Data are lacking for impairment after neonatal sepsis and pneumonia, especially among those of >32 wk gestation. Improved recognition and treatment of pSBI will reduce neonatal mortality. Lack of follow-up data for survivors of severe bacterial infections, particularly sepsis, was striking. Given the high incidence of sepsis, even minor NDI would be of major public health importance. Prevention of neonatal infection, improved case management, and support for children with NDI are all important strategies, currently receiving limited policy attention

The state of India's neonatal units in the mid-nineties

Background: A previous study in 1987 showed that neonatal care facilities in major hospitals in the country were of a very poor standard. The present study was done to reassess their status. Design: A survey. Methods: A pretested structured questionnaire was sent to 48 centers in 1994-95. The responses were analyzed. Results: A total of 37 centers returned the questionnaire duly filled. Of them, 22 belonged to the government sector, the rest 15 to the private sector. A nursery bed: nurse ratio of less than 1.0 was reported by only 4 centers. Majority of the centers cited inadequate nursing strength and frequent transferring out of nurses as a major problem. Twenty nine (78%) centers had ventilation facilities. Most of them had 1 or 2 ventilators. Blood gas facility was available with 29 centers and parenteral nutrition was undertaken at 20 (54%) centers. Resuscitation bag(s) were available at all the centers and incubators at all except one. In quantitative terms, the following equipment was available in satisfactory numbers: resuscitation bags, resuscitation bassinet, incubators/open care systems, vital sign monitors, infusion pumps and pulse oximeters in 78.3%, 43.2%, 72.9%, 56.7%, 64.8% and 43.5% centers, respectively. Indigenous products of the following categories were reasonably well accepted: resuscitation bags, resuscitation bassinets, incubators, open care systems and dextrometers. Conclusion: The newborn care facilities, particularly the ventilation facilities, have improved in recent years. Almost 10 units were operating at or near level III standard of newborn care. Indigenous equipment of selected categories is replacing the imported equipment. However, most units continue to face problems of shortage of nursing personnel

Birth asphyxia and neurodevelopmental outcome

Thirty six neonates with severe birth asphyxia (Apgar score less than or equal to 3 at 1 min), 32 with moderate birth asphyxia (Apgar score 4 to 6 at 1 min) and 35 controls (Apgar score greater than or equal to 7 at 1 min) matched for weight and gestation were followed up prospectively for neurodevelopmental outcome. Fetal distress occurred more frequently in babies with severe birth asphyxia when compared to controls (p less than 0.05). Six neonates with severe birth asphyxia had abnormal neurological signs such as delayed sucking, hypo or hypertonia, apneic spell or seizures. Of these, only two had delayed developmental milestones (Developmental Quotient less than 70) and features of cerebral palsy. Both of these babies developed seizures during first 24 hours, did not suck and required gavage feeding. The study highlights the fact that a vast majority of survivors of birth asphyxia enjoy good quality of life thus emphasizing the need for vigorous management of asphyxiated babies at birth

Neurodevelopmental outcome of ‘at risk’ nursery graduates

A cohort study at a tertiary care neonatal service was undertaken to determine the neurodevelopmental outcome of heonates who required intensive care. One hundred and nineteen nursery graduates were enrolled for follow up if they fulfilled any of the following risk factors : birth weight less than 1500g, Apgar score less than 4 at 5 minutes, seizure(s), and required assisted ventilation for more than 24 hours. They were subjected to periodic clinical evaluation and administered the Bayley Scales of Infant Development in early childhood. Of the total infants enrolled, 101 completed the required follow up. They included 55 infants with birth weight &#60; 1500g, 45 with low Apgar scores, 12 with seizure(s) and 28 who received assisted ventilation. An overwhelming majority of subjects (85%) had normal neurodevelopmental outcome. The adverse outcome in the remaining 15 included mental retardation in all, subnormal motor development in 14, microcephaly in 1, hearing loss in 2 and visual impairment in 4. Among the neonatal risk factors, seizures, sepsis and hypoxic ischemic encephalopathy had a significant association with adverse outcome. Despite serious neonatal morbidity, the early neurodevelopmental outcome of nursery graduates was reasonably good. The association of neonatal sepsis with neurodevelopmental sequelae merits a prospective evaluation

Correlates of mortality among hospital-born neonates with birth asphyxia

Background: Birth asphyxia is a major cause of neonatal mortality. An understanding of the determinants of mortality among asphyxiated neonates will help formulate effective management protocols. Methods: One hundred and fifty consecutive neonates with birth asphyxia (apnoea or gasping respiration at 1-minute of age) were prospectively studied. The association of the outcome variable, namely, mortality before discharge, was documented in relation to a number of clinically important risk factors. Results: The neonatal mortality of 24.7% (37/150) among asphyxiated neonates was 34.5-times compared to that of the non-asphyxiated population (p &#60; 0.001). The mortality rates in preterm-and term-asphyxiated neonates were 47.8% and 6%, respectively (p &#60; 0.0001). The relative risk of mortality increased progressively with increased birth-weight. On univariate analysis, prematurity, low birth-weight, respiratory distress, severity of asphyxia, hypoxic-ischaemic encephalopathy, apnoea, acidosis and seizures were found to be significant risk factors of death. However, on step wise regression analysis, prematurity emerged as the most significant determinant of mortality. The highest positive predictive value (58.3%) for mortality was documented for hypoxic-ischaemic encephalopathy. Conclusion: A significant reduction in mortality among asphyxiated neonates will require aggressive management of prematurity-related neonatal complications and hypoxic-ischaemic encephalopathy