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CARE OF PREMATURE NEWBORNS

By Dr. Rashmi GodeModerator- Dr. Subodh Gupta

Am One in 10 Births

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FRAMEWORK Introduction Definition and terminology Need of special care Complications of preterm new-born Long term Impact Intervention need high coverage Reducing Burden NMR in India and interventions Strategy and Commitment by organizations References

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INTRODUCTION Every Year-15 million babies are born preterm (1 in 10

babies) it is rising Prematurity- world’s single biggest cause of newborn

death, and 2nd leading cause of all child deaths, after pneumonia

Rate of preterm ---5% to 18% (184 countries) In low – income group half babies born at 32weeks die

due to-lack of feasible ,cost-effective care, and basic care for infections and breathing difficulties.

The high and rising incidence of preterm birth ,with death and disability is a significant Public health impact.

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EPIDEMIC OF PREMATURITY Since 1990, the worldwide mortality rate of children under-

five has declined from 90 to 46 deaths per 1,000 live births in 2013.

Annual reduction rate - 3.9 % 1990- 16.9 million were preterm births 2010-11.1% of all live births were Preterm ( 14.9 million) 2013- Globally 1 .1million death due to preterm birth

complications (2010-3.1Million) Preterm mortality rates have declined at only 2.0% annually

(WHO global mortality rate for preterm birth in 1990 and 2013). Prematurity is moving higher up on the global agenda. “We have an epidemic of preterm and newborn deaths that

represents one of the greatest health challenges of the 21st century. Two-thirds of these deaths could be prevented without intensive care.” ( ….born too soon 2012 )

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THE 10 COUNTRIES WITH THE HIGHEST RATES OF PRETERM BIRTH RATE (% OF LIVE BIRTHS) 2010 India - 13.0% (% of Global total-23.6%) China - 7.1% Nigeria - 12.2% Pakistan - 15.8% ( % Global total -5.%) Indonesia - 15.5% USA -12.% Bangladesh -14% Philippines -14.9% Democratic Republic of Congo - 11.9 % Brazil -9.2%

*Source-lancet vol.379, June 9,2012

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DEFINITION Babies born before 37th week of gestation are considered

premature or “preemies”. Are sub-categories Extremely preterm (<28 weeks)- 5% Very preterm (28 to <32 weeks)- 10% Moderate to late preterm-(32 to <37 weeks)- 83% Post term ≥ 42 weeks Survive – 24 weeks– 50% ,with Intensive care (HIC) 34 Weeks- 50% , (LMIC) Many survive with lifetime disability, including learning

disability and visual and hearing impairment 75% deaths from preterm birth can be prevented without

intensive care

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TERMINOLOGY

Low birth weight < 2.5 kg Very Low Birth Weight < 1.5 kg Extremely Low birth Weight < 1.0 kg Early still birth (ICD)- Wt ≥500gm or ≥22weeks Late still birth Wt ≥1000gm or ≥28weeks Survive - Weight 1250-1500gm, 85%-90% Weight 500-600gm, 20% survival ELGAN: Extremely Low Gestational Age Newborn < 26

weeks

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TYPES OF PRETERM BIRTH AND RISK FACTORSType Risk factor

Spontaneous Preterm-birth

Age at pregnancy and pregnancy spacingMultiple PregnancyInfectionUnderlying Maternal chronic medical conditionsNutritional Lifestyle/work related /stressMaternal psychological healthGenetic and other

Provider-initiated preterm birth

Medical induction or caesarean Obstetric indication-cervical incompetenceFetal Indication

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FOUR SETTINGS -15 MILLION PRETERM BABIES RECEIVE CARE

High Income CountriesAccess to full intensive care (1.2 M)

Middle-income countriesNeonatal care units ( 3.8 M)

Low-income countriesHome Birth and care at home(5.6M)

Low-income countriesFacility births but limited space, staff and equipment(4.4M)Source-Born too soon, 2012,chapter 5

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SURVIVAL GAP

60 % -Africa and South Asia 12% are premature in poorest countries 9% -High income countries High income countries- <10% Low income countries -90%

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NEED OF SPECIAL CARE Premature new-borns have underdeveloped systems (Lungs. Digestive system, Immune system And skin Inadequate respiration Inadequate thermoregulation Fluid and electrolyte imbalance – dehydration sunken

fontanels <1ml/kg/hr or over hydration bulging, edema and urine output >3ml/kg/hr

PDA and Hypotension Acid –Base disorders CNS developmental issues

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LONG TERM IMPACT OF PRETERM BIRTH ON SURVIVORSLong term Outcomes

Impact Example Frequency in survivors

specific physical effects

▪Visual impact▪Hearing Impairment▪Chronic lung disease of prematurity

BlindnessIncreased hypermetropia and myopia

▪25% affect▪ 5-10% in extremely preterm▪40% of extremely preterm

Neuro-development/behaviour effects

▪Mild disorders of executive functioning

▪Specific learning impairments ,dyslexia,▪Motor ImpairmentCerebral palsy

▪Affected by quality of care dependant

Family ,economic and social effects

▪Impact on family ,on health service

▪Psychosocial ,emotional, and economic▪Risk of preterm birth in offspring

▪ medical risk factors ,disability,.

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FIVE INTERVENTION NEEDS HIGH COVERAGE High Income countries Smoking Cessation Decreasing Multiple embryo

transfers during assisted reproductive technologies

Cervical cerclage Use of progesterone agents And reduction of elective

labour induction or caesarean delivery without medical indication

Low and middle income countries

Family planning; Prevention and management of

STIs Use of insecticide treated

bednets and Intermittent preventive

treatment for malaria Identification and treatment of

preeclampsia Reduction of physical workload

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REDUCING THE BURDEN OF PRETERM BIRTH –A DUAL TRACK

Preconception care package Antenatal care Effective childbirth care Policy support- No smoking,

Employment safety for Pregnant women

Essential and extra newborn care, mainly feeding support

Kangaroo mother care Neonatal resuscitation Management of

RDS ,Infections and Jaundice

Comprehensive neonatal Intensive Care

Prevention of Preterm Birth

Premature baby care

Preterm Birth reduction Mortality reduction

Preterm Labour Management

*Tocolytics to slow down labour*Steroids*Prevention of PROM by antibiotics

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WHO RECOMMENDATIONS TO INTERVENTION TO IMPROVE PRETERM OUTCOMES Antenatal corticosteroids to improve new born

outcomes Tocolytics for inhibiting preterm labour Magnesium sulphate for Fetal protection against

neurological complications Antibiotics for preterm labour Optimal mode of delivery Thermal care for preterm newborn- KMC Continuous positive airway pressure for newborn

with RDS Surfactant administration for newborn with RDS Oxygen therapy and concentration

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NMR --INDIA Neonatal deaths as % of Infants death

India’s contribution to global neonatal deaths burden

27%India

73%

RestNeonatal

Source- SRS 2012

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RURAL-URBAN NMR OF INDIA

Rural Urban0

5

10

15

20

25

30

35

33

16

Series 1

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DIFFERENCE ACROSS THE COUNTRY

Source: SRS 2012 Statistical Report

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CAUSES OF NEONATAL MORTALITY

2%

16%

3%

20%35%preterm

15%

3%

DiarrheaPneumoniaMalformationBirth asphyxiaPretermSepsisOthers

Source:LIU lancet 2012

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DISTRIBUTION OF DEATHS DUE TO PREMATURITY

Day 0 Day 1 Day 2 Day 3 Day-4 Day 5 Day 6 week 1 week2-40

10

20

30

40

50

60

70

80

36.3

7.4 10.16.6

5.1 3.4 3.5

72.9

13.5

Source- Sanskar MJ 2014 ( Systematic Review under Publication)

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INTEGRATED SERVICE DELIVERY FOR MATERNAL ,NEWBORN AND CHILD HEALTH

Clinical Reproductive care Childbirth care Emergency newborn care Emergency child care Eg- KMC

Outreach/outpatient Reproductive health care Antenatal care Postnatal care Child health care

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CONTINUED--

Family /community Adolescent and pre-pregnancy nutrition Gender violence prevention Education Prevention of STIs and HIV Optimise pre-pregnancy maternal conditions Counselling and birth preparedness Healthy Home care Intersectoral Improved living and working condition

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KANGAROO MOTHER CAREKMC- a simple and cost effective technique introduced in India in 1994KMC and optimal feeding –a step By GOI as a part of routine care. In 2003, WHO formally endorsed KMC and published KMC practice guidelines. Improvement in gas exchange and temperature in premature infants Improvement in lactation outcomes in mothers wishing to breastfeed premature infantsPositive impact on the parenting process

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MILESTONES IN INDIA FOR CHILD SURVIVAL 1992 – Child Survival and Safe Motherhood

Programme (CSSM) 1997 – RCH I 2005 – RCH II 2005 – National Rural Health Mission 2013 – RMNCH+A Strategy 2013 – National Health Mission 2014 – India Newborn Action Plan (INAP) to achieve “Single Digit NMR” by 2030,

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INTERVENTION UNDER NHM FOR NEWBORNProgramme Year Objectives Status

JSY 2005 Safe motherhood to increase institutional delivery through demand-side-financing and conditional cash transfer

▪Implemented in all states and UT▪Special focus on Low-performing States

IMNCI at community level and F-IMNCI at health facility 2008

Standard case management of major neonatal and childhood morbidity and mortality

▪Operational in ore than 500 districts▪5.9 lakhs health and other functions,26800MO and specialists at CHC/FRU

NSSK 2009 Basic newborn care and resuscitation training programme

▪1.3 lakh health provider trained to date

JSSK 2011 Zero out of pocket expenditure for maternal and infant health services

▪Implemented in all states and UT▪Benefit extended to sick children upto age 1yr

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INTERVENTION UNDER NHM FOR NEWBORN CONTINUED….

Programme Year

Objectives Status

FBNC 2011 New born care cornerNBSUs at CHC/ FRUs SNCUs at DH/SDH( All types of care except assisted ventilation and major surgeries)

▪14,135 NBCCs at delivery point▪1810NBSUs at CHC/FRUs▪548 SNCUs at DH/ SDH or Medical college▪>6300 persons got FBNC training▪Online reporting in 7 states with 245 SNCUs ▪>2.5lakhs newborns registered in data base

HBNC 2011 Essential care to NB, special care to preterm-al LBW newborns, family support for healthy practices by ASHA

▪Implemented in all states and UTs▪Most ASHA trained in NBC▪ASHAs visited .12 lakhs newborn in 2013

RBSK-2013 Screening children with birthdefects,diseases,deficiency and developmental delays

All children ages 0 to 18 yrs.> 8 crore children screened and >10lakhs identified for FRUs in 2013

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CURRENT COVERAGE LEVELS FOR 8 INDICATORS GLOBALLY

Sorce-Born Too Soon –WHO 2013

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EVIDENCE BASED STUDY Article: Incidence and risk factors of preterm birth in a rural

Bangladesh cohort Period- June 2007- september2009 Method-:CHW collected data from32,126 Mother-live born baby pairs

on household Socio demographic status ,pregnancy history ,ANC seeking and Newborn Gestational age (LMP) and intervention of delivery package kit

Results: Out of 22.3%-Preterm(<37wks)12.3%:35-36wks, 7.1%-32-34wks & 2.9% -28-31wks.

Lower risk- In primary and higher educated females.(RR 0.92;95%CI 0.88-0.97),*BNCP (RR 0.32:95% CI 0.30-0.34)

Higher risk- h/o child death under nutrition, antenatal complications and IFA only for 2-6 months

Conclusion- In minimum resource with High burden ,Preterm birth risk is reduce by close monitoring and/or frequent follow up ,encouraging women to seek ANC& to adopt BNCP

*Birth and new born care Preparedness

Source -Journal :BMC Peds 2014

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EVIDENCE BASED DATA FOR REDUCTION IN NMR –UK US

1 2 3 40

5

10

15

20

25

30

35

40

45

40

30

15

5

10

15

Phase 1

Phase 2

Phase 3 88

% to

tal r

educ

tion

Phase 1- NMR reduction associated with public Health approaches

Phase 2– improved individual patient management associated with a further halving of NMR reduction prior to NICUs

Phase 3- Neonatal intensive care introduction and scale up

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Source-Born Too Soon –WHO 2013

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STRATEGY United Nation’s Strategy – “Every Women Every Child”

Strategy-target was set for 50% reduction in preterm deaths by 2025

Mobilized 200 commitments from national governments, NGO’s and private sectors.

World prematurity day- 17th November Celebrated throughout the world, involving more than 60

countries globally, reaching nearly 1.5 billion people.

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COMMITMENTS BY ORGANIZATIONS

WHO- to regularly providing analysis of global birth levels and trends

University of Malawi-improving care for new borns by introducing technology and enhancing Kangaroo Mother care

Save the children- to catalysing scale up of effective interventions such as kangaroo mother care, in highest burden countries

The bill & Melinda gates Foundation- to reducing preterm birth with grants of $ 1.5 billion (from2010-14)

The Home for Premature babies- to establish a branch in every province in china to support families affected by preterm

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UNFPA-to strengthening mid wifery in 40 countries with emergency obstetric and new born care in 30 countries

The council of Neonatal nurses-to rising awareness about the dangers of premature birth

The March of Dimes- to prematurity Campaign through devoting 420 million annually to research

GAPPS- to Expanding collaborative efforts for global campaign for investment in research and catalyse funding for it.

The Johns Hopkins Bloomberg school of Public health- Strengthening evidence and causes of preterm births globally and developing culturally and economically appropriate interventions.

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REFERENCES Baby,Joy E Lawn,Ruth Davidge.Born too soon ,The Global

Action Report on preterm Birth,2012. http://www.who.int/mediacentre/factsheets Born Too Soon: The global epidemiology of 15 million preterm

births, Reproductive Health 2013,10(Suppl1) India newborn action plan, MHFW, GOI, September 2014 State of India’s New-borns, Public Health Foundation Of India,

Save the Children ,2014 WHO recommendations on interventions to improve preterm

birth outcomes, WHO 2015.