S p e c i a l Ar t i c l e Indian J Pediatr 1995; 62 : 139-144

Organization of Neonatal Services in Developing Countries

Meharban Singh and V.K. Paul

Department of Pediatrics, All India Institute of Medical Sciences, New Delhi

The newborn baby signifies the beginning of life and provides a foundation for future health of a nation. If is, therefore, essential that a baby is bom mature and healthy and grows Optimally to become a strong adult who can participate in the developmental activities of the country effectively. The importance and relevance of neonatal care can be realised from the fact that over 50 per cent of all infant deaths occur among newborn babies. The infant mortality rate can, therefore, be effectively reduced by improving neonatal survival. The improved perinatal care is also crucial for enhancing the quality of life among survivors which is a fundamental prerequisite for optimal human resource development. Moreover, the neonatal care is highly cost effective because saving the life at birth is associated with survival for several years of productive life as opposed to saving the life in old age due to stroke or cancer. Above all, it has been shown beyond doubt that improved neonatal survival is mandatory for effective fertility control because frequent perinatal losses are associated with frequent pregnancies leading to birth of high risk pre-term and low birth weight babies and consequent deleterious effects on the health of th~ mother.

Reprint requests: Professor Meharban Singh, Head, Department of Pediatrics, All India Institute of Medical Sciences, New l~lhi-110029.

THE CURRENT STATUS OF NEWBORN CARE FAarmF.s

The current status of maternal and child health is dismal in most developing countries) The major bottlenecks for effective delivery of neonatal care facilities include : female iIliteracy, ignorance, lack of health awareness, poo r infrastructure, non-availabihty of esSential equipment for neonatal care and lack of referral facilities due to poor transport and comm~.mication facilities. Most deliveries are non- institutional and are attended by untrained health personnel. Between 70-90 per cent deliveries take place in rural areas with problems of accessability and acceptability of available health services. The quality of health professionals is rather poor and

,referral system is practically non-existent. The specialised neonatal care facilities are by and large unavailable or are unsatisfactory.

The inadequacy of perinatal services is reflected in the form of high incidence of low birth weight babies (25% to 40%) and prevailing neonatal mortality of over 50 per thousand live births in most developing countr ies) The incidence of neonatal tetanus is high because a large proportion of pregnant women are still not given tetanus toxoid. The maternal mortality in the range of 400-850 per 1,00,000 births in the developing world is a stark reality.

140 THE INDIAN JOURNAL OF PEDIATRICS 1995; Vol. 62. No. 2

PRIORrn'ES IN NEONATAL CARE

"lhe neonatal care and survival can be im- proved by providing basic or minimal perinatal care in the community. Early identification of pregnancy, provision of antenatal supervision and care, ensuring safe delivery and providing basic facilities for resuscitation of all newborn babies at birth are mandatory. The provision of warmth, prevention of infections by uni- versal immunization of all pregnant women with two doses of tetanus toxoid and ensuring asepsis and provision of ad- equate- nutrition by promoting feeding with human milk are of fundamental im- portance. The availability of round-the- clock water supply and plenty of disposables are essential for prevention of bacterial infections which are a leading cause of neonatal mortality in developing countries. The knowledge and skills of per- sormel charged with the responsibility of newborn care should be enhanced at all levels. During first phase, initial strategies for improving neonatal survival should fo- cus on babies weighing more than 1200g at birth for effective utilisation of meagre re- sources. Optimal level II newborn care fa- cilities should be established to prevent and manage common neonatal problems such as birth asphyxia, hypothermia, sepsis, hyperbilirubinemia and metabolic disorders. Apart from strengthening spe- cial care neonatal services, developmental screening facilities should be established to follow the survivors among high risk new- born babies to assess their quality of life.

Primary or Level I Neonatal Care

A three-tier system for delivery of new- born care should be established. 22 Most

deliveries are taking place in the commu- nity. Primary neonatal care forms the base of the system. Primary neonatal care is provided by the mother and the grassroots workers. It should be strengthened by training the health professionals like auxil- iary nurse midwives, traditional birth at- t~adants and provision of basic equipment (such as disposable sterile Dai-kits, por- table spring balance or tri-colored measur- ing tapes and mucus suction trap with a catheter). The sub-centre or village health post should be provided with basic equip- ment for providing antenatal care and ef- fective resuscitation of newborn babies. The basic equipment required at the health post include sphygmomanometer, weigh- ing scale, urine sticks, hemoglobinometer, radiant warmer, Ambu bag and mask or face mask with mouth tube and a steriliser. The health professionals should be able to identify high risk mothers early during pregnancy, by means of few simple high risk factors provided to them preferably in the form of pictorial charts. The high ~isk mothers should be referred to a district hospital or medical college hospital pro- viding highel' level of medical care. Table 1 lists the common causes of high risk preg- nancy and all health professionals should be trained to identify these pregnant women well in time for appropriate refer- ral.

The primary care of the newborn is best provided by the mothers who should be trained in the art of mothercraft. As opposed to the health professional, mother shows greater concern, commitment, attachment and affection to the child and of course she is instinctively guided to protect her infant. She is reliable to provide constant observation regarding the behaviour of the child and can easily

1995; Vol. 6Z No. 2

TABLE 1. High-risk Pregnancies

Antenatal

Maternal age < 18 years or > 35 years. Height < 140 cm or < 40 kg. Primigravida or grand multipara. Previous abortions, still births or neonatal

deaths. Previous difficult, instrumental or operative

delivery. Previous preterm or low birth weight baby. Chronic systemic disease (Cardiac, renal,

pulmonary). Extremely pale or weak (Hemoglobin < 8 rag/

dl). Pregnancy-induced hypertension (headache,

swelling of legs, blurring of vions etc.). Poor weight gain during pregnancy (< 5 kg.).

Poor fetal growth. Antepartum hemorrhage.

Twin pregnancy.

Intranatal (Labor)

Early rupture of membranes before start of labor pain

Onset of labor pains before 37 weeks of gestation.

Vaginal bleeding before delivery. Prolonged labor (> 18 hours). Cord, hand or foot prolopse. Malpresentation or transverse lie near term. Maternal fever (> 78~

Delay in delivery of placenta (> 30 minutes after birth of the baby).

identify minor neonatal problems. She should be encouraged and motivated so that all newborn babies are exclusively breast fed during first 5 to 6 months of life without any prelacteal and complementary

THE INDIAN JOURNAL OF PEDIATRICS 141

prolacteal feeds.

Intermediate or Level II Special Care Neoinatal Facilities

The referral system for perinatal care can- not function unless level II maternal and neonatal specialised services are estab- lished in the district, provincial and State teaching and non teaching hospital s . The level II newborn care facilities are required for babies with a birth weight of 1200-1800 g or gestafional age of 30-34 weeks. It is de- sirable to establish a 10-bedded special care neonatal'unit catering to about 2000 to 3000 deliveries per year. There should be adequate infrastructure for providing opti- mal resuscitation facilities at birth, mainte- nance of thermoneutral environment, fa- cilities for administration of oxygen with ease and safety, administration of intrave- nous infusions, blood and blood products etc. with the help of microburette sets and infusion pumps. Facilities should be estab- lished for management of newborn babies with pathological jaundice with the help of phototherapy and exchange blood transfu- sion. Short term mechanical ventilation with bag and mask or endotracheal tube and CPAP facilities with an improvised in- digenous system should be available for management of severely asphyxiated ba- bies and infants with mild respiratory dis- tress syndrome or recurrent apneic attacks.

The special care nursery should be lo- cated adjacent to the delivery area and ob- stetrical operation theatre. Adequate and abundant space, specially trained and skilled nurses and availability of basic tools and equipments are of fundamental prerequisites for providing specialised neonatal care. The main nursery should comprise of two large rooms to provide in-

142 Till = P~q)IAN JOUI~AL OF PEDIA'IRICS 19~5; VoL 62. No. 2

termediate care facilities to 10 babies at a rate of 50-100 sq .ft. area per baby. Addi- tional space should be available for hand washing and s&"ubbing before entering the nurse, y, isolation room with two cribs, feeding room f ~ promotion of breast feed- ing and expression of breast milk, labora- tory. end a nursing station. Avoidance of overcrowding and congestion is of para- mount importance to reduce the risk of nosocomial infections. Apart from round- the-clock running water facilities, the nurs- ery complex should be provided with a large number of electrical outlets for use of

electronic monitoring equipments. Each room should be provided faith wash-has- kets with polythene hampers for disposal of soiled linen, cotton swabs, gauze pieces, infusion sets etc_ The walk of the nursery, should be made of washable ceramic tiles and floor should be covered with vinyl sheets for easy and effective washing to maintain asepsis. The walls should be pro- vided with open cupboards for stacking equipmems, d isposab~ and drugs etc.

The d~livery room should be provided with a resuscitation troller or a table lo- cated in a comer which is kept warm with

T ~ 2. Equipments Required for Special Care Neonatal Unit Catering to 21Y33_. Dehvefies per Year

S. No. Item Quanti~,

1. Complete resuscitation sets 2

2. Incubators with servo-control 2

3. Open-care ~-stems with servo<ontrol 2

4. Bassinets 6

5. Radiant warmers/heaters 4

6. l'hoiothempy units 2

7. Oxygen head boxes 4

8. Oxygen an~,zers 2

9. Foot-operated suction machines 2

10. Non-invash.e BP momitors 2

11. Heart rate-almea monitors 2

I2. Infusion Pumps 2

13. Electronic infant weighing scales 2

14. Oxygen saturaticn monitor I

15. Portable x-ray machine i

16. Refrigerator 1

17. t'tenty of disposables, feeding tubes, cath~-4~as, ET tubes, neoflons, small-veir~ microburette sets, umbilical c a ~ , dispesable ~-rin~, :-~dles, exd'~ange transfusion sets etc.

1995; Vol. 62. No. 2 INDIAN JOURNAL OF PEDIATRICS 143

the help of a radlaut heater. There should be ' enough Ambu bags, infant laryngoscopes endotracheal tubes and suc- tion catheters of different sizes and De Lee suction traps etc. There should be a foot- operated or electrical suction machine and oxygen cylinders. The detailed list of equipments required in the special care nursery is given in Table 2.

The availability of plenty of disposables and promotion of feeding with human milk is essential for reducing nosocomial infections. There should be no provis ion for bottle feeding in the nursery. Nasogastric feeIling should be weaned to feeding with a spoon and cup so that there is no poss;bility of nipple confusion and risk of infection due to bottle feeding. The nursery should be provided with a small laboratory for examination of gastric aspi- rate, hemogram, urine analysis, blood sugar and bilirubin. It should be equipped with a microscope, dextrometer, bilirubinometer and microcentrifuge.

There is a need for a team of dedicated staff specially trained in the field of neona- tology. The success of a special care neonav tal unit largely depends on the availabili6/ of trained staff nurses. One nurse should be provided to look after 4 babies round- the-clock with additional 25 per cent nurses to provide for the exigencies like leave/duty off. There is thus a need for a minimum of 8 nurses to look after a 10- bedded special care neonatal unit. Addi- tional nursing help in the form of trainee nurses or nursing aides is useful. One Pub- lic Health Nurse charged with the respon- sibility of lactation management and social assistance would serve as a useful member of the team. The unit should be provided with 5 class 'D' staff to ensure round-the- clock coverage by at least one worker for

cleaning of the nursery, equipments and transport of blood samples and other ma- terials etc. The unit should be provided with printed stationery for maintaining case records, admissions and discharge slips etc. A master register should be main- tained to record all the relevant details per- taining to babies admitted in the special care neonatal unit and rooming-in ward. A manual highlighting house keeping activi- ties and feeding routines of the nursery should be prepared for orientation of nurses and doctors. The detailed policies regarding breast feeding and avoidance of prelacteal feeds should be laid down for the compliance of pediatric and obstetric staff. There should be a provision for in- service training of nurses on a regular peri- odic basis.

Tertiary Neonatal Care (Level III) Facilities

Intensive neonatal care is required for a minority of babies (about 3%) who weigh less than 1200 g or are born before 30 weeks of gestation. It is highly cost inten- sive and labor intensive, requiring the ser- vices or specially trained neonatologists and neonatal nurses. The unit should be equipped to provide assisted ventilation, parenteral nutrition and developmental follow-up. There should be round-the- clock facilities for monitoring of blood gases. The unit should be provided with ventilators, multi channel, vital sign moni- tors, infusion pumps portable ultrasound and portable ABER facilities. There should be at least one specially trained neonatal nurse for one or at the most 2 babies in the NICU. A trained chest physiotherapist and biomedical engineering technician are es- sential for supervision of ventilation and

144 THE INDIAN IOURNAL OF PEDIATRICS 1995; Vol. 62. No. 2

various electronic equipments used in the unit. The establishment of te.rtiary neohatal care facilities is not a priority'in develop- ing countries and they should be devel- oped in a phased manner. The neonatal mortality rate must be brought down to 30 per 1000 live births b'y development of op- timal level II neonatal care before a centre is upgraded to provide tertiary care.

G ~ . A L , ECONOMIC AND SOCIAl. D~OeM'orr

the neonatal and infant_mortality can be re- duced to a significant extent by improve- ments in the socio economic status, educa- t ion, health awareness and environmental sanitation even in the absence of any sig- nificant increase in GNP. The health of the fetus and newborn baby is more depen- dent upon the health of the mother (and not of the father) because she is both the seed as well as the soil. Women must be recognised as the creators of progeny and accorded due status, recognition and at- tention in order to improve the health sta- t u s of the nation. There is thus an urgent need for social, cultural, religious and p o - litical actions to improve the status of women in society. The present sense of de-

spair at the birth of a female child must be replaced by the awareness and hope that she is the creator of life. There should be no discrimination against female children and instead they must be provided with good nutrit ion throughout the childhood but most crucially during adolescence, pregnancy and lactation. Girls must be

p r o v i d e d with formal and non-formal health educat ion specially in the art of mothercraft , child nutrition and health care of children. A revolution should be created in the field of health communica- tion, information and community educa- tion to highlight the importance of nutri- tion of female children, hazards of early and consanguineous marriages, benefits of antenatal check ups, avoidance of drugs during pregnancy etc.

REFERENCES

1. UNICEF : The Stateofthe World's Children. New York : Oxford University Press, 1992.

2. NafionalNeonatology Forum. Recommen- dations on Neonatal Care in India. New Delhi, 1980.

3. Rbport of the Task Force on Minimum Perinatal Care, Government of India, Ministry of Health & Family Welfare, New Delhi, 1982.