south east asia regional neonatal- perinatal database (sear

South East Asia Regional Neonatal- Perinatal Database (SEAR-NPD: 2007-08)

World Health Organization South East Asia Region

Network centres

Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Gadjah Mada University, Yogyakarta, Indonesia Tribhovan University, Kathmandu, Nepal DeSoysa Hospital for Women, Colombo, Sri Lanka Queen Sirikt National Institute of Child Health, Bangkok, Thailand All India Institute of Medical Sciences, New Delhi, India (Nodal Centre)

Report

2010

South East Asia Regional Neonatal Perinatal Database (SEAR-NPD)

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South East Asia Regional Neonatal Perinatal Database (SEAR-NPD) F I N A L R E P O R T

Contents Page number

Background

Objectives & methodology

Profile of the participating institutions

Salient findings:

1. Intramural births

2. Extramural admissions

3. Individual centres

Country-wise tables

1. Bangladesh

2. India

3. Indonesia

4. Nepal

5. Sri Lanka

6. Thailand

Annexure I: Data collection tools

Annexure II: Working Definitions

2

3-5

7

9-11

13-14

16-21

24-31

33-40

42-54

56-63

65-72

74-78

80-84

86-92


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1. BACKGROUND

Improvement in neonatal-perinatal survival is priority health agenda in the South East Asia Region (SEAR). Almost 1.5 million newborn infants die every year before completing first four weeks of life in the Region, contributing to the highest proportion of neonatal mortality for any WHO region. Neonatal mortality constitutes one half to two thirds of the infant mortality in most countries of the SEAR. Likewise, perinatal mortality continues to be unacceptably high due to maternal under- nutrition, anemia and hypertension, lack of basic antenatal care and deliveries by untrained personnel. Urgent steps are therefore required to improve neonatal-perinatal health in the Region without which global MDGs 4 and 5 cannot be achieved. A fundamental pre-requisite for planning, implementing and monitoring health care programmes is to ensure an accurate assessment of the morbidity and mortality derived from a reliable database. However, there is a paucity of data on several key aspects of neonatal-perinatal health in countries of the Region. We do not have accurate estimate of major morbidity such as asphyxia, sepsis; or of the major causes of maternal, neonatal and perinatal morality. Besides, the available data is not collected on a uniform protocol, making it difficult to get the overall picture and to make comparisons. For instance, the causes of perinatal and neonatal deaths are often categorized differently by different researchers. Some researchers take low birth weight (LBW) as a cause of death, while others look at it only as a predisposing condition leading to sepsis or hypothermia that actually kills the baby. In India, a network of 18 institutions, the National Neonatal Perinatal Database , initiated by the National Neonatology Forum and supported by the Indian Council of Medical Research (ICMR), has succeeded in: (a) providing valuable information on stillbirths and neonatal morbidity and mortality including profile, burden and determinants; (b) standardizing definitions and data collection and analysis protocols; (c) developing capacity for newborn health research; and (d) developing research network mechanisms. Ten of the sites are linked to district level hospitals as well, and community extensions can be visualized in future. The WHO Collaborating Centre (WHO-CC) for Training and Research in Newborn Care at All India Institute of Medical Sciences, New Delhi was the Nodal Centre for this Network. There is a compelling need to obtain, compile, analyze and disseminate reliable data on neonatal-perinatal health collected prospectively on uniform format from different countries. It was with this goal that the establishment of a SEA Neonatal-Perinatal Database Network was proposed in year 2005. The establishment of a SEA Neonatal-Perinatal Database was recommended by two important WHO Regional meetings:

(a) WHO/SEAR Consultative Meeting on WHO Collaborating Centres and Centres of Expertise in area of Reproductive Health and Emerging / Reemerging Infectious Diseases (1997).

(b) SEAR Expert Group Meeting on Newborn Care in South East Asia (1998) sponsored by WHO/SEAR.

There have been, in the past, attempts by WHO/SEAR and other partners to develop situational analysis in different countries in the Region. These analyses are now 2-5 years old. There is a need to review the situation and develop more updated reports to inform Newborn health programs in the Region.

2. AIM To establish a SEAR Neonatal-Perinatal Database Network for generating prospective information on neonatal/ perinatal morbidity and mortality in the Region.


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3. SCOPE In the proposed initial phase (2005-2007), the SEAR Neonatal-Perinatal Database Network would be confined to neonates managed at 5 institutions of excellence in different countries of the Region.

4. OBJECTIVES The objective of the present phase (2005-2007) of the SEAR Neonatal-Perinatal Database Network was to generate and disseminate prospective data on neonatal-perinatal morbidity and mortality at the Network institutions

5. METHODOLOGY 5.1.1 Establishment of the South East Asia Regional Neonatal-Perinatal Database Network The Apex Nodal Centre (WHO/CC at AIIMS) was established for the data collection and analysis. The Apex Nodal Centre in consultation with WHO/SEARO identified 6 institutions of expertise in neonatal-perinatal care in the Region. These centres formed the South East Asia Regional Neonatal-Perinatal Database Network. 5.1.2 Development of tools for data collection (January 2007) The Nodal Centre developed the draft instruments and computer software for data collection and analysis. They included the following:

• Form A: Intramural births • Form B: Stillbirths • Form C: Extramural admissions (Annex I)

Additionally, standard definitions developed by NNF, India along with the data sheet were reviewed and revised through consensus for use by the Network. 5.1.3 Development of Computer software A computer software was developed in Microsoft ACCESS for data entry at all sites. The same was pre-tested at each site and finalized, and distributed. 5.1.4 Meeting of the Principal Investigators A 3-day meeting of the Principal Investigators (PIs) of the network centres was held with the purpose of finalizing draft instruments and finalization of data management systems in January 2007. This face-to-face meeting helped in streamlining the entire operation of the database. The feedback and suggestions obtained from the PIs on data entry forms and software were incorporated in the final data collection tool. The definitions to be used for collecting neonatal-perinatal data and the procedure of assigning the cause for neonatal deaths and stillbirths were discussed extensively and a final consensus was obtained. In addition, a ‘Hands-on’ workshop for the other PIs was held regarding (a) how to enter data (b) how to transmit data to Nodal centre. Any practical issues/difficulties in entering and transmitting the data were cleared upon in these sessions. A session was also devoted to discussing the issues in quality control – how to ensure quality of the data entered and sent to the nodal centre.


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Panel 1 Centres and principal investigators of the SEAR-NPD

Country Centre Investigators

Nepal Department of Child Health Institute of Medicine, Tribhovan University, Maharajgunj, Kathmandu Ph: 00977-1-4412202

Prof. Prakash Shreshtha Professor Department of Child Health Ph: 00977-9841276339 [email protected] Dr.Laxman Shrestha Associate Professor Ph: 00977- 9851036550 Dr.Merina Shrestha Teaching Assistant Ph: 00977- 9841268580

Bangladesh Division of Neonatology Room# 210 (1st Floor), Block # C Department of Paediatrics Bangabandhu Sheikh Mujib Medical University Shahbagh, Dhaka-1000 Ph: 0088-02-9668785

Prof. M. Shahidullah Professor & Head Department of Paediatrics Ph: 0088-01713-003110 [email protected] [email protected]

Thailand Division of Neonatology Department of Pediatrics Queen Sirikt National Institute of Child Health, 420/8 Rajavithi Rd, Rajathewee Bangkok Ph: 66 235 4833

Dr. Uraiwan Chotigat Neonatologist level 9 Institute of Child Health Ph: 00818162718 [email protected]

Sri Lanka Department of Paediatrics, DeSoysa Hospital for Women, University of Colombo, Colombo Ph: 00-94-773046605

Dr. Ishani Rodrigo Senior Lecturer Department of Paediatrics Ph: 00-94-112807484 [email protected]

Indonesia Division of Neonatology Gadjah Mada University Center for Maternal-Perinatal J1 Kesehatan 1, Yogyakarta 55284 Ph: 62 274 541565

Dr. Ekawaty Haksari Pediatrician Department of Child Health Ph: 81 126 9710 [email protected]

India Division of Neonatology, Department of Pediatrics, WHO Collaborating Centre for Training and Research in Newborn Care All India Institute of Medical Sciences, Ansari Nagar New Delhi – 110029. Ph: 91-11-26588922 Fax: 91-11-26588663 (NODAL CENTRE)

Prof. V. K. Paul Professor & Head Department of Pediatrics Ph: 91-11-26594372 [email protected] Prof. A. K. Deorari Professor & In-charge, WHO-CC for Training and Research in Newborn Care, AIIMS Ph: 91-11-26593619 [email protected] Dr. Ramesh Agarwal Assistant Professor, Department of Pediatrics Ph: 91-11-26593621 [email protected] Dr. M. Jeeva Sankar Senior Research Associate Department of Pediatrics


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5.1.5 Data collection (Feb 2007-Feb 2008) Formal data collection started in February 2007 and was carried out for a total period of one year (until February 2008). Each centre would send monthly data to the nodal centre at All India Institute of Medical Sciences, New Delhi by e-mail. At the nodal centre, quality checks were conducted on the data received and feedback sent to the individual centres. After due corrections, data from all the centres was amalgamated. 5.1.6 Analysis and report The collected data was analyzed using STATA 9.2 statistical software and Microsoft Excel 2003. The reports of the collated and analyzed data are presented here.

[email protected] Dr. Deepak Chawla Assistant Professor (Pediatrics) Govt Medical College, Chandigarh Ph: 91-172-2665545 [email protected]


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SALIENT LESSONS • This initiative established a network of centres of excellence in the SEA Region who successfully

collaborated on a sustained research activity.

• The conceptualization, tools development and implementation of the database activity was carried out collectively.

• Each centre successfully engaged local collaborators and colleagues to implement the program.

• New insights into the profile of neonatal-perinatal epidemiology were generated. These are depicted in following sections.

• The new insights and estimates would be highly useful in planning new research and for quality improvement.

• Each centre can publish their research work carried out in this project in journals of repute.

• The individual sites are now in a position to partner with other centres, secondary and tertiary level, to develop their own networks at national level.

• For WHO SEARO, the network teams offer an accomplished resource for research and networking.

RECOMMENDATIONS

• Each site should develop a national level database network of 5-10 institutions each.

• Each site should extend the activity to district and sub-district facilities, for quality monitoring.

• The WHO/SEAR should be strengthened and expanded with assured support from WHO/SEARO.


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Profile of the Participating Centres


8

Profile of the participating centres

Bangabandhu Sheikh Mujib

Medical University Dhaka

Bangladesh

All India Institute of Medical Sciences New Delhi India

Sardjito Hospital,

Yogyakarta Indonesia

TU Teaching Hospital

Kathmandu Nepal

De Soysa Hospital for Women Colombo Sri Lanka

Queen Sirikit National

Institute of Child Health Bangkok Thailand

Government Yes Yes Yes Yes Yes Yes

Teaching hospital Yes Yes Yes Yes Yes Yes

Number of beds 20 10+4 10

Deliveries attended by

Resident/ faculty

Fellows/ residents

Fellows/ residents

Nursing staff / Doctors

Nursing staff / Doctors

Fellows/ residents

Extramural admissions

Yes No Yes No No Yes


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Salient findings: Intramural births


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Intramural births (data from 5 centers)

Live-births

o A total of 11,628 births and 11,449 live births occurred in the participating institutions during the 1-year study period;* the centers from Sri Lanka and Nepal together contributed to about 70% of the total births

o There were 126 neonatal deaths across all the 4 centers; the neonatal mortality rate varied from 2.7 per 1000 live births (Bangladesh) to 31.9 per 1000 live births (Indonesia)

o The mean incidence of low birth weight (LBW; <2500g) was 19%. The incidence was highest in the centre from India (30.3%)

o A total of 1453 (13.1%) neonates were born premature (before 37 completed weeks of gestation); the incidence of prematurity was again highest in the center from India

o Majority of pregnant women (96.7%) received proper antenatal care (at least 3 visits) o The incidence of systemic sepsis was 5.7%; it was lowest in the center from Sri Lanka (2.6%) o While 96.6% of neonates were discharged home, 1.2% died and 0.8% left against medical advice o The commonest primary cause of neonatal death was found to be prematurity (34.4%); infections

and malformations (21.9% each) were the next most common causes. Perinatal asphyxia was responsible for only 9.4% of neonatal deaths.

Still-births

o There were a total of 152 still-births during the study period contributing to a still-birth rate of 13.5 per 1000 total births

o The cause of still-birth could not be established in about three-fourth (71.0%) of still-births.

* Due to practical problems, the centre from Bangladesh could not provide data for the entire one year period (only a few months’ data was available for analysis)


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Intramural births: Major neonatal, perinatal and maternal outcomes*



Bangladesh*


Sardjito Hospital


TU Teaching Hospital Nepal

De Soysa Hospital for Women Colombo Sri Lanka

Total

Total births

396* 1979 1562 4038 3653 11628

Total live births

369* 1948 1503 3992 3637 11449

Still births 27 31 59 46 16

179

Neonatal deaths

1 29 48 25 23 126

Neonatal mortality rate (per 1000 live births)

2.7 14.9 31.9 6.3 6.3 -

Perinatal deaths

27 52 100 66 37 282

Perinatal mortality rate (per 1000 births)

68.2 26.3 64.0 16.3 10.1 -

Maternal deaths

0 1 9 1 0 11

* Data not available for the entire one year period


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Intramural live births: Demographic profile, major neonatal morbidities and outcomes



Bangladesh*


Sardjito Hospital


TU Teaching Hospital Nepal

De Soysa Hospital

for Women Colombo Sri Lanka

Total

Total live births

369* 1948 1503 3992 3637 11449

Males

192 (52%) 1036 (53.2%)

816 (54.3%) 2196 (55.0%)

1879 (51.7%)

6119 (53.4%)

LBW (<2500g) 140 (37.9%) 591 (30.3%)

303 (20.2%) 493 (12.3%)

717 (19.7%)

2244 (19.6%)

ELBW (<1000g)

3 (0.8%)

36 (1.8%) 16 (1.1%) 10 (0.2%) 17 (0.5%) 82 (0.7%)

Preterm (<37 weeks)

118 (32%) 471 (24.2%)

224 (14.9%) 382 (9.6%) 376 (10.4%)

1571 (13.7%)

Antenatal care (at least 3 visits)

303 (82.1%) 1743 (89.5%)

1491 (99.2%)

3850 (96.4%)

3635 (99.9%)

11022 (96.3%)

Perinatal asphyxia (1-min Apgar <7)

97 (26.3%) 87 (4.4%) 447 (29.8%) 405 (10.1%)

30 (0.9%) 1066 (9.3%)

Systemic sepsis

23 (6.2%) 59 (3.0%) 156 (10.4%) 329 (8.2%) 93 (2.6%) 660 (5.8%)

Outcomes: Discharged Died LAMA Referred

368 (99.7%)

1 (0.3%)

0 0

1809

(92.9%) 30 (1.5%) 3 (0.2%) 1 (0.05%)

1367

(90.9%) 49 (3.3%) 4 (0.3%) 83 (5.5%)

3923

(98.3%) 27 (0.7%) 31 (0.8%) 11 (0.3%)

3601

(99.0%) 24 (0.7%) 12 (0.3%)

0

11068 (96.7%)

131 (1.1%) 50 (0.4%) 95 (0.8%)

Primary causes of neonatal death: Asphyxia Prematurity Infections Malformations Other causes

N=1 0 0

1 (100%) 0 0

N=30

1 (3.3%) 8 (26.7%) 6 (20.0%) 7 (23.3%) 8 (26.7%)

N=47

5 (10.6%) 10 (21.3%) 14 (29.8%) 14 (29.8%) 4 (8.5%)

N=27

6 (22.2%) 10 (37.0%) 7 (25.9%) 3 (11.1%) 1 (3.7%)

N=24 0

16 (66.7%) 1 (4.2%) 4 (16.7%) 3 (12.5%)

N=129

12 (9.3%) 44 (34.1%) 29 (22.5%) 28 (21.7%) 16 (12.4%)

(LBW, Low birth weight; ELBW, Extremely low birth weight; PT, phototherapy; LAMA, left against medical advice) * Data not available for the entire one year period


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Salient findings: Extramural admissions


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Extramural admissions (data from 2 centers)


o A total of 1550 neonates were admitted in the two centers that provided data for the 1-year period (Indonesia and Thailand)

o One-third of the admitted neonates were born premature (before 37 completed weeks of gestation) o About 38% of neonates had a birth weight of less than 2500g o Septicemia was the commonest morbidity noted in these neonates (66.3%) o About 13% of the admitted neonates died while about 3% left against medical advice o Malformations and sepsis were the most common causes of death (31.8% and 27.9% respectively);

perinatal asphyxia contributed to about 23.4% of deaths.


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Extramural admissions: Major neonatal outcomes

Sardjito Hospital


Queen Sirikit National Institute of Child Health Rajavithi Hospital, Thailand

Total admissions

639 911

Males

377 (59.0%)

390 (42.8%)

Preterm 150 (23.5%)

367 (40.3%)

LBW

237 (31.1%) 353 (38.8%)

Place of delivery: Home Hospital Clinic/health centre Elsewhere

72 (11.3%) 367 (57.4%) 194 (30.3%) 6 (0.9%)

12 (1.3%) 889 (97.6%) 1 (0.1%) 9 (1.0%)

Hypothermia (<35.50C) at admission

79 (12.4%) 2 (0.2%)

Seizures 69 (10.8%)

24 (2.6%)

Systemic sepsis 515 (80.6%)

513 (56.3%)

Outcome: Discharged Died Left against advice

419 (65.6%) 168 (26.3%) 52 (8.1%)

878 (96.4) 33 (3.6)

0

Primary causes of death: Perinatal asphyxia Prematurity Infections Malformations Other causes

N=168 46 (27.4%) 9 (5.4%) 52 (30.9%) 45 (26.8%) 16 (9.5%)

N=33 1 (3.0%) 4 (12.1%) 4 (12.1%) 19 (57.6%) 5 (15.1%)

Data presented as number (%)


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Salient findings: Individual centers


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Bangladesh

Live-births

o Data was available for a total of 396 births and 369 live births o Males constituted 52% of all live births o Almost one third of the live births (32%) were born premature (before 37 weeks gestation) o The prevalence of low birth weight (LBW; <2500g) was 37.9% and very low birth weight 5.4% o More than two-thirds of the infants (70.7%) were delivered by Caesarean section o Only one infant died in the neonatal period, the cause of death being systemic sepsis o About 26.3% of the infants had moderate birth asphyxia (Apgar score <7at 1 minute) and 1.4% had

severe asphyxia (Apgar <4 at 1 minute of life) o The incidence of systemic sepsis was found to be 6.2%

Still-births

o Majority of still-births were born pre-term (81.5%) and were LBW (88.9%) o Fresh still-births contributed to 70.4% while macerated ones constituted 29.6% of all still-births o The predominant cause of still-birth was malformations (44.4%); no cause could be established in

about one-fourth (25.9) of the still births


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India

Live-births

o There were 1,948 live births and 29 neonatal deaths. o Sex ratio amongst live births was 876 females per 1000 males. o About a quarter (24.2%) of live births were born preterm (<37 weeks gestation). o The prevalence of low birth weight (<2500g) was 30.3% and very low birth weight 4.7%. o While 92.9% of infants were discharged home, 1.5% died and 0.2% were referred to other

specialties. o The commonest primary cause of neonatal death was infections (20.0%). Other major causes were

prematurity (26.7%), congenital malformations (23.3%), and perinatal asphyxia (3.3%). Other causes contributed to the remaining 26.7% of deaths.

o While 4.4% of the infants had moderate birth asphyxia (Apgar score at 1 minute <7), 0.8% had severe asphyxia (Apgar <4 at 1 minute of life).

o The incidence of systemic infections was found to be 3.0%. o Hyperbilirubinemia was detected in 13.0% neonates. Antibiotics were used in 3.2% while intravenous

(IV) fluids and oxygen were administered in 7.8% and 5.6% respectively. Mechanical ventilation (CPAP/IMV) was provided to 6.3% of infants.

Still-births

o Males constituted 54.8% of still-births. o Majority of still-births were pre-term (61.2%). o About two-thirds (67.7%) of still births were detected before onset of labor and 32.3% after/during

labor; about 22.6% of them were delivered by cesarean section.


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Indonesia

Live-births

o A total of 1,503 live births and 48 neonatal deaths occurred during the study period o Males constituted 54.3% of all live births o Majority of live births were full-term infants (84.3%); 14.9% were preterm and a minority (0.8%)

were post-term infants. o The prevalence of low birth weight (<2500g) was 20% and very low birth weight 4.1%. o While 90.9% of infants were discharged home, 3.3% died and 5.5% left against medical advice. o The commonest primary causes of neonatal death were infections and malformations (29.8% each).

Other causes included prematurity (21.3%), perinatal asphyxia (10.6%), and others (8.5%). o While 21.2% of the infants had moderate birth asphyxia (Apgar score at 1 minute <7), 8.6% had

severe asphyxia (Apgar <4 at 1 minute of life). o The incidence of systemic infection was found to be 10.4%.

Still-births

o Majority of still-births were born pre-term (57.6%); 67.8% were found to have low-birth-weight. o Fresh still-births contributed to 69.5% while macerated ones constituted 30.5% of all still-births. o The cause of still-birth could not be established in most of the cases (96.6%).


o The sex distribution was as follows: males 59.0%; females 40.8%, thus there were only 692 females per 1000 males.

o Birth weight was less than 2500 g in 37.1% of the infants; about 8% of the admitted neonates weighed <1500g at birth.

o Almost two-thirds (63.1%) of infants were delivered by a doctor. A nurse or auxillary nurse midwife attended the delivery in 33.6% of the instances.

o Septicemia was the commonest morbidity noted in these neonates (80.6%). o About a quarter (26.3%) of the admitted neonates died while about 8% left against medical advice. o The mortality rate was highest in infants with birth weights of <1000g (85.7%). o Sepsis was the most common cause of death (30.9%); asphyxia and malformations contributed to

27.4% and 26.8% of deaths respectively. Prematurity was the underlying cause in 5.4% of the infants.


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Nepal

Live-births

o There were 3,992 live births and 25 neonatal deaths. o Sex ratio amongst live births was 817 females per 1000 males. o Majority of live births were full-term infants (89.9%); 9.6% were preterm and a minority (0.03%)

were post-term infants. o The prevalence of low birth weight (<2500g) was 12.3% and very low birth weight 0.9%. o 98.3% of infants were discharged home, 0.7% died and 0.8% left against medical advice. o The commonest primary cause of neonatal death was prematurity (37.0%). Other major causes

were infections (25.9%), perinatal asphyxia (22.2%), and congenital malformations (11.1%). o 8.2% of the infants had moderate birth asphyxia (Apgar score at 1 minute <7), 1.9% had severe

asphyxia (Apgar <4 at 1 minute of life). o The incidence of systemic infection was found to be 8.2%. There were no cases of tetanus

neonatorum. o The commonest cause of respiratory distress was found to be transient tachypnea of newborn

(1.6%). Respiratory distress syndrome, pneumonia, and meconium aspiration were diagnosed in 0.4%, 0.5% and 0.9% respectively.

o Amongst disorders of the central nervous system, hypoxic ischemic encephalopathy accounted for 0.8%, seizures 0.5% and intraventricular hemorrhage 0.1%.

Still-births

o A total of 46 still-births occurred during the study period. o Majority of still-births were pre-term (84.8%) and of low birth weight (76.1%). o Fresh still-births contributed to 41.3% while macerated ones constituted 58.7% of all still-births. o The cause of still-birth could not be established in almost half of the cases (47.8%). In those still

births in which a cause could be established, asphyxia and malformations were found to be the commonest causes (39.1% and 10.9% of the total).


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SriLanka

Live-births

o There were 3,637 live births and 46 neonatal deaths. o Males constituted 51.7% of all live births and females 48.3%. o Majority of live births were full-term infants (89.3%) o The prevalence of low birth weight (<2500g) was 19.7% and very low birth weight 1.6%. o While 99.0% of infants were discharged home, 0.7% died and 0.3% were referred to higher centres. o The commonest primary cause of neonatal death was prematurity (66.7%). Other major causes were

congenital malformations (16.7%), infections (4.2%), and other causes (12.5%). There were deaths secondary to perinatal asphyxia.

o While 0.7% of the infants had moderate birth asphyxia (Apgar score at 1 minute <7), 0.2% had severe asphyxia (Apgar <4 at 1 minute of life).

o The incidence of systemic infections was found to be 2.6%. o Hyperbilirubinemia was detected in 6.7% neonates; hypoglycemia (1.9%), hypothermia (0.6%), and

apnea (0.5%) were the other common morbidities. Still-births

o Males formed 56.2% of all still-births and females 37.5%. o Majority of still-births were pre-term (75.0%); about half (56.2%) were found to have low-birth-

weight. o 62.5% of still births were detected before onset of labor and 37.5% after/during labor. o Fresh still-births contributed to 37.5% while macerated ones constituted 62.5% of all still-births. o Malformations alone contributed to half of the still births (50.0%); no cause could be established in

31.2% of the cases.


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Thailand


o A total of 911 neonates were admitted during the study period. o The sex distribution was as follows: males 42.8% and females 57.2%. o Birth weight was less than 2500 g in 38.7% of the infants; about 11.4% of the admitted neonates

weighed <1500g at birth. o Majority of the infants (97.6%) were born in hospital/clinic/health centre. o Almost all the neonates were delivered by a doctor or other skilled attendants (95.4%); only 0.5% of

the deliveries were attended by a traditional birth attendant. o Systemic sepsis was diagnosed in 56.3% of the infants. Pneumonia occurred in 13.6% of the

neonates. There were no cases of tetanus neonatorum. o Hyperbilirubinemia was the commonest morbidity noted in these neonates (64.0%). o The mortality rate of extramural neonates was 3.6%. The rate was highest in infants with birth

weights of <1000g (16.0%). o Malformations alone contributed to more than half of these deaths (57.6%); infections, prematurity,

and asphyxia contributed to 12.1%, 12.1%, and 3.0% of deaths respectively. Other causes were found in 15.1% of the infants.


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Country-wise Tables


24

I . BANG LAD E SH


25

BANGLADESH: Major Neonatal, Perinatal and Maternal outcomes

Total births 396 Total live births 369 Still births 27 Total neonatal deaths 1 Early neonatal deaths 0 Late neonatal deaths 1 Perinatal deaths 27 Post-neonatal deaths 0 Maternal deaths 0 Neonatal mortality rate (NMR) 2.7 per 1000 live births Still birth rate 68.2 per 1000 births Perinatal mortality rate 68.2 per 1000 births


26

1A.INTRAMURAL LIVEBIRTHS

Table 1.1: Sex distribution and gestation group details Category Number of infants

(n=369) Proportion (%)

Sex distribution Males Females

192 177

52.0 48.0

Gestation groups * Preterm (<37 weeks) Term Post-term (>42 weeks)

118 251 0

32.0 68.0 -

Table 1.2: Birth weight categories

Category Number of infants (n=369)

Proportion (%)

Low birth weight (LBW) Very low birth weight (VLBW) Extremely low birth weight (ELBW)

140 20 3

37.9 5.4 0.8

Table 1.3: Details of singletons and multiple live births


Proportion (%)

Singletons Twins Triplets Higher order

350 7 6 6

94.8 1.9 1.6 1.6

Table 1.4: Antenatal/labor details


Proportion (%)

Antenatal care (at least 3 visits) Gestational hypertension Gestational diabetes Meconium stained liquor Fetal bradycardia Antenatal steroids

303 37 30 18 65 94

82.1 10.0 8.1 4.9 17.6 25.5


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Table 1.5: Mode of delivery Category Number of infants


Vaginal delivery Cesarean section Others

108 261 0

29.3 70.7 -

Table 1.6: Apgar scores Category Number of infants


At 1 minute 0 - 3 4 - 6 >7

5 92 272

1.4 24.9 73.7

At 5 minutes 0 - 3 4 - 6 >7

1 19 349

0.3 5.1 94.6

Table 1.7: Resuscitation measures used Category Number of infants


Free flow oxygen Bag-mask ventilation Chest compressions Intubation for meconium Intubation otherwise Epinephrine Volume expanders

109 1 0 1 0 0 0

29.5 0.3 - 0.3 - - -

Table 1.8: Respiratory morbidities Category Number of infants


Hyaline membrane disease Transient tachypnea of newborn Pneumonia Meconium aspiration Pneumothorax

7 10 2 1 1

1.9 2.7 0.5 0.3 0.3


28

Table 1.9: Central nervous system morbidities Category Number of infants


Hypoxic ischemic encephalopathy Seizures Intraventricular hemorrhage (IVH) Intracranial bleed other than IVH

2 0 0 1

0.5 - - 0.3

Table 1.10: Congenital malformations Category Number of infants


Cardiac Hydrocephalus Neural tube defect Cleft lip/palate Gastro-intestinal Genito-urinary Down syndrome

0 1 0 0 0 0 0

- 0.3 - - - - -

Table 1.11: Miscellaneous morbidities Category Number of infants


Hyperbilirubinemia requiring phototherapy Rh isoimmunization Hypothermia Apnea Hypoglycemia Hypocalcemia Anemia Polycythemia NEC ROP PDA Bleeding due to vitamin K deficiency Neonatal cholestasis Major birth trauma

24 3 6 1 3 2 3 1 2 1 1 0 0 0

6.5 0.8 1.6 0.3 0.8 0.5 0.8 0.3 0.5 0.3 0.3 - - -

Table 1.12: Neonatal infections Category Number of infants


Superficial infections Pyoderma Umbilical sepsis Conjunctivitis Thrush

0 0 0 0

- - - -


29

Systemic infections Systemic sepsis Pneumonia Tetanus neonatorum

23 2 1

6.2 0.5 0.3

Table 1.13: Therapy given Category Number of infants


IV fluids Antibiotics Oxygen CPAP IMV Surfactant Blood/plasma transfusion Phototherapy Exchange transfusion Parenteral nutrition

71 71 39 1 0 0 6 19 1 11

19.2 19.2 10.6 0.3 - - 1.6 5.1 0.3 3.0

Table 1.14: Outcomes Category Number of infants


Discharged Died Referred Left against advice

368 1 0 0

99.7 0.3 - -

Table 1.15: Mortality – major indices (total deaths=1) Number Proportion (%) Neonatal deaths (0-28 days) Early neonatal deaths (0-7 days) Deaths at <24 hours Deaths 1-7 days Late neonatal deaths (7-28 days)

1 0 0 0 1

100 - - - 100

Post neonatal deaths 0 - Neonatal mortality rate - 2.7 per 1000 live births Late neonatal mortality rate - 2.7 per 1000 live births

Table 1.16: Mortality rates in selected categories Category Number of infants Number of

deaths Mortality rate (%)

Low birth weight (LBW) Very low birth weight (VLBW) Extremely low birth weight (ELBW) Preterm neonates

140 20 3 118

1 1 1 1

0.7 5.0 33.3 0.8


30

Table 1.17: Primary causes of deaths by broad categories Category Number of deaths


Perinatal asphyxia Prematurity Infections

0 0 1

- -

100


31

1B. STILL-BIRTHS

Table 1.18: Sex distribution and gestation group details

Category Number of still-births (n=27) Proportion (%) Sex distribution Males Females

12 15

44.4 55.6

Gestation groups Preterm (<37 weeks) Term Post-term (>43 weeks)

22 5 0

81.5 18.5 -


Category Number of still-births (n=27)

Proportion (%)


24 8 17

88.9 29.6 63.0



Proportion (%)

Antenatal care (at least 3 visits) Gestational hypertension Gestational diabetes Oligohydramnios Polyhydramnios Antepartum hemorrhage Meconium stained liquor Foul smelling liquor

17 1 1 9 4 3 10 4

63.0 3.7 3.7 33.3 14.8 11.1 37.0 14.8

Table 1.21: Time of detection of still birth Category Number of still-births


Before labor After labor

17 10

63.0 37.0

Table 1.22: Types of still birth Category Number of still-births


Fresh Macerated

19 8

70.4 29.6


32

Table 1.23: Birth weight distribution of still births Birth weight group (gm) Number of still-births


<750 750-999 1000-1249 1250-1499 1500-1749 1750-1999 2000-2249 2250-2499 2500-2999 3000-3499 >3500

5 3 6 3 3 2 2 0 1 2 0

18.5 11.1 22.2 11.1 11.1 7.4 7.4 - 3.7 7.4 -

Table 1.24: Gestational age distribution of still births Gestational age group (weeks) Number of still-births


<28 29-30 31-32 33-34 35-36 37-42 >42

1 12 4 3 2 5 0

3.7 44.4 14.8 11.1 7.4 18.5 -

Table 1.25: Primary causes of still births Category Number of deaths


Malformation Other causes Not established

12 8 7

44.4 29.6 25.9


33

I I . I ND I A


34

INDIA: Major Neonatal, Perinatal and Maternal outcomes

Total births 1,979 Total live births 1,948 Still births 31 Total neonatal deaths 29 Early neonatal deaths 21 Late neonatal deaths 8 Perinatal deaths 52 Post-neonatal deaths 1 Maternal deaths 1 Neonatal mortality rate (NMR) 14.9 per 1000 live births Early NMR 10.8 per 1000 live births Late NMR 4.1 per 1000 live births Still birth rate 15.7 per 1000 births Perinatal mortality rate 26.3 per 1000 births


35




Sex distribution Males Females Ambiguous

1036 908 4

53.2 46.6 0.2


471 1475 2

24.2 75.7 0.1



Proportion (%)


591 92 36

30.3 4.7 1.8



Proportion (%)


1891 52 5 0

97.1 2.7 0.3 -



Proportion (%)

Antenatal care (at least 3 visits) Gestational hypertension Pre-eclampsia Gestational diabetes Meconium stained liquor Fetal bradycardia Antenatal steroids

1743 119 35 98 92 134 107

89.5 6.1 1.8 5.0 4.7 6.9 5.5


36



Vaginal delivery Forceps Cesarean section Vacuum extraction Others

1053 111 763 21 0

54.1 5.7 39.2 1.1 -



At 1 minute 0 - 3 4 - 6 >7

16 71 1861

0.8 3.6 95.5

At 5 minutes 0 - 3 4 - 6 >7

2 22 1924

0.2 1.1 98.8




132 103 3 16 34 2 6

6.8 5.3 0.2 0.8 1.8 0.1 0.3



Hyaline membrane disease Transient tachypnea of newborn Pneumonia Meconium aspiration

24 103 21 4

1.2 5.3 1.1 0.2




16 16 8 3

0.8 0.8 0.4 0.2


37



Cardiac Hydrocephalus Neural tube defect Cleft lip/palate Gastro-intestinal Genito-urinary malformation Down syndrome

13 0 3 1 8 10 1

0.7 - 0.2 0.05 0.4 0.5 0.05




253 29 1 15 20 8 16 16 3 16 8 0 6 2

13.0 1.5 0.05 0.8 1.0 0.4 0.8 0.8 0.2 0.8 0.4 - 0.3 0.1




0 0 9 0

- - 0.6 -

Systemic infections Systemic sepsis Tetanus neonatorum

59 0

3.0 -


38



IV fluids Antibiotics Oxygen CPAP IMV Surfactant Blood/plasma transfusion Exchange transfusion Parenteral nutrition Laser for ROP Surgery

153 63 112 67 57 22 31 31 38 4 14

7.8 3.2 5.6 3.4 2.9 1.1 1.6 1.6 1.9 0.2 0.7




1809 30 3 1

92.9 1.5 0.2 0.05

Table 2.15: Mortality – major indices (total deaths=30) Number Proportion (%)

Neonatal deaths (0-28 days) Early neonatal deaths (0-7 days) Deaths at <24 hours Deaths 1-7 days Late neonatal deaths (7-28 days)

29 21 8 13 8

96.7 70.0 26.7 43.3 26.7

Post neonatal deaths 1 3.3 Neonatal mortality rate - 14.9 per 1000 live births Early neonatal mortality rate - 10.8 per 1000 live births Late neonatal mortality rate - 4.1 per 1000 live births

Table 2.16: Mortality rates in selected categories Category Number of infants Number of deaths Mortality rate (%)


591 92 36 471

23 14 8 24

3.9 15.2 22.2 5.1


39



Perinatal asphyxia Prematurity Infections Malformation Other causes

1 8 6 7 8

3.3 26.7 20.0 23.3 26.7


40

2B. STILL-BIRTHS

Table 2.18: Sex distribution and gestation group details Category Number of still-births



17 14

54.8 45.2


19 12 0

61.2 38.8 -



Proportion (%)

Singletons Twins

28 3

90.3 9.7



Proportion (%)

Antenatal care (at least 3 visits) Gestational hypertension Gestational diabetes Oligohydramnios Antepartum hemorrhage Meconium stained liquor

21 8 4 3 4 0

67.7 25.8 12.9 9.7 12.9 -

Table 2.21: Mode of delivery Category Number of still-births


Vaginal delivery Cesarean section Vacuum extraction

23 7 1

74.2 22.6 3.2




21 10

67.7 32.3


41




4 3 24

12.9 9.7 77.4


42

I I I . I NDONE S I A


43

INDONESIA: Major Neonatal, Perinatal and Maternal outcomes

Total births 1,562 Total live births 1,503 Still births 59 Total neonatal deaths 48 Early neonatal deaths 41 Late neonatal deaths 7 Perinatal deaths 100 Post-neonatal deaths 1 Maternal deaths 9 Neonatal mortality rate (NMR) 31.9 per 1000 live births Early NMR 27.3 per 1000 live births Late NMR 4.6 per 1000 live births Still birth rate 37.8 per 1000 births Perinatal mortality rate 64.0 per 1000 births Maternal mortality ratio 598.8 per 100000 live births


44





816 687 0

54.3 45.7 -


224 1267 12

14.9 84.3 0.8



Proportion (%)


303 64 16

20.2 4.3 1.1



Proportion (%)


1453 40 6 4

96.7 2.7 0.4 0.3



Proportion (%)

Antenatal care (at least 3 visits) Pre-eclampsia Eclampsia Gestational diabetes Fetal bradycardia Antenatal steroids

1491 99 23 4 48 8

99.2 6.6 1.5 0.3 3.2 0.5


45




844 2 590 66 1

56.1 0.1 39.2 4.4 0.07



At 1 minute 0 - 3 4 - 6 >7

129 318 1056

8.6 21.2 70.3

At 5 minutes 0 - 3 4 - 6 >7

33 111 1359

2.2 7.4 90.4




296 131 49 20 49 16 8

19.7 8.7 3.3 1.3 3.3 1.1 0.5




21 56 4 24

1.4 3.7 0.3 1.6




1 7 2 2

0.07 0.5 0.1 0.1


46



Cardiac Hydrocephalus Neural tube defect Cleft lip/palate Gastro-intestinal Down syndrome

10 4 5 3 6 7

0.7 0.3 0.3 0.2 0.4 0.5



Hyperbilirubinemia requiring phototherapy Rh isoimmunization Hypothermia Apnea Hypoglycemia Hypocalcemia Anemia Polycythemia NEC ROP PDA Bleeding due to vitamin K deficiency Neonatal cholestasis

141 2 160 34 85 51 9 2 2 4 1 2 1

9.4 0.1 10.6 2.3 5.7 3.4 0.6 0.1 0.1 0.3 0.07 0.1 0.07




6 14 81 46

0.4 0.9 5.4 3.1


156 4 0

10.4 0.3 -


47



IV fluids Antibiotics Oxygen CPAP IMV Surfactant Blood/plasma transfusion Phototherapy Exchange transfusion Parenteral nutrition Laser for ROP Surgery

174 148 171 65 55 9 18 122 1 54 2 2

11.6 9.8 11.4 4.3 3.7 0.6 1.2 8.1 0.07 3.6 0.1 0.1




1367 49 4 83

90.9 3.3 0.3 5.5

Table 3.15: Mortality – major indices (Total deaths=49) Number Proportion (%) Neonatal deaths (0-28 days) Early neonatal deaths (0-7 days) Deaths at <24 hours Deaths 1-7 days Late neonatal deaths (7-28 days)

48 41 25 16 7

98.0 83.7 51.0 32.7 14.3





303 64 16 224

38 22 11 38

12.5 34.4 68.8 17.0


48




5 10 14 14 4

10.6 21.3 29.8 29.8 8.5


49

3B. STILL-BIRTHS




31 28

52.5 47.5


34 24 1

57.6 40.7 1.7



Proportion (%)


40 32 21

67.8 54.2 35.6



Proportion (%)

Antenatal care (at least 3 visits) Gestational hypertension Gestational diabetes Oligohydramnios Polyhydramnios Antepartum hemorrhage Meconium stained liquor

59 3 0 0 0 1 0

100.0 5.1 - - - 1.7 -



Vaginal delivery Cesarean section Vacuum extraction

47 10 2

79.7 16.9 3.4



Fresh Macerated

41 18

69.5 30.5


50



<750 750-999 1000-1249 1250-1499 1500-1749 1750-1999 2000-2249 2250-2499 2500-2999 3000-3499 >3500

10 11 7 4 4 0 4 0 7 6 6

16.9 18.6 11.9 6.8 6.8 - 6.8 -

11.9 10.2 10.2



<28 29-30 31-32 33-34 35-36 37-42 >42

12 8 5 5 4 24 1

20.3 13.6 8.5 8.5 6.8 40.7 1.7




1 1 57

1.7 1.7 96.6


51

3C. EXTRAMURAL ADMISSIONS




377 261 1

59.0 40.8 0.2

Gestation groups Preterm (<37 weeks) Term Post-term (>42 weeks) Not known

150 474 12 3

23.5 74.2 1.9 0.5

Table 3.27: Birth weight category of admitted neonates

Birth weight (gm) Number of infants (n=639)

Proportion (%)

<1000 1000-1499 1500-2499 >2500

7 43 187 402

1.1 6.7 29.3 62.9

Table 3.28: Age at admission


Proportion (%)

<1 day 1 to 3 days 4 to 7 days 8 to 14 days 14 to 28 days >28 days

233 183 88 53 62 20

36.5 28.6 13.8 8.3 9.7 3.1

Table 3.29: Place of delivery


Proportion (%)

Home Hospital Clinic/Health centre Elsewhere

72 367 194 6

11.3 57.4 30.3 0.9


52

Table 3.30: Person conducting delivery Category Number of infants


Doctor Nurse/ANM/Mid-wife/Skilled birth attendant Traditional birth attendant Others

403 215 21 0

63.1 33.6 3.3 -

Table 3.31: Symptoms/signs at admission Category Number of infants


Feeding difficulty History of convulsions Temperature >380C Temperature <35.50C Tachypnea (respiratory rate >60/min) Grunting Severe chest in-drawing Seizures at admission Severe dehydration

272 18 55 79 203 210 95 54 18

42.6 2.8 8.6 12.4 31.8 32.9 14.9 8.4 2.8

Table 3.32: Respiratory morbidities Category

Number of infants



26 124 64 46 7

4.1 19.4 10.0 7.2 1.1




39 69 29 7

6.1 10.8 4.5 1.1


53



Cardiac Hydrocephalus Neural tube defect Cleft lip/palate Gastro-intestinal Genito-urinary Down syndrome Limb defects

43 20 18 11 130 13 31 8

6.7 3.1 2.8 1.7 20.3 2.0 4.8 1.2




214 3 241 137 202 197 86 3 10 8 14 6 18 5

33.5 0.5 37.7 21.4 31.6 30.8 13.5 0.5 1.6 1.2 2.2 0.9 2.8 0.8




32 42 109 174

5.0 6.6 17.1 27.2


515 64 0

80.6 10.0 -


54




487 481 358 82 167 20 126 177 12 232 9 64

76.2 75.3 56.0 12.8 26.1 3.1 19.7 27.7 1.9 36.3 1.4 10.0




419 168 0 52

65.6 26.3 - 8.1

Table 3.39: Mortality rates in different weight groups Birth weight (gm) Number of infants

(n=639) Number of

deaths (n=168) Intra group mortality (%)

<1000 1000-1499 1500-2499 >2500

7 43 187 402

6 21 60 81

85.7 48.8 32.1 20.1




46 9 52 45 16

27.4 5.4 30.9 26.8 9.5


55


56

I V . NE PA L


57

NEPAL: Major Neonatal, Perinatal and Maternal outcomes

Total births 4,038 Total live births 3,992 Still births 46 Total neonatal deaths 25 Early neonatal deaths 20 Late neonatal deaths 5 Perinatal deaths 66 Post-neonatal deaths 2 Maternal deaths 1 Neonatal mortality rate (NMR) 6.3 per 1000 live births Early NMR 5.0 per 1000 live births Late NMR 1.3 per 1000 live births Still birth rate 11.4 per 1000 births Perinatal mortality rate 16.3 per 1000 births Maternal mortality ratio 25.0 per 100, 000 live births


58





2196 1795 1

55.0 44.9 0.03


382 3592 18

9.6 89.9 0.4



Proportion (%)


493 36 10

12.3 0.9 0.25



Proportion (%)

Singletons Twins Triplets

3917 73 2

98.1 1.8 0.05



Proportion (%)


3850 89 8 515 103 18

96.4 2.2 0.2 12.9 2.6 0.4


59




2935 7

1022 24 4

73.5 0.2 25.6 0.6 0.1



At 1 minute 0 - 3 4 - 6 >7

76 329 3587

1.9 8.2 89.9

At 5 minutes 0 - 3 4 - 6 >7

12 80 3900

0.3 2.0 97.7




610 146 10 69 21 3 9

15.3 3.7 0.2 1.7 0.5 0.1 0.2




15 64 20 36

0.4 1.6 0.5 0.9


60



Hypoxic ischemic encephalopathy Seizures Intraventricular hemorrhage (IVH)

32 21 3

0.8 0.5 0.1




3 1 1 4 2 6 0

0.1 0.03 0.03 0.1 0.05 0.15 -



Hyperbilirubinemia requiring phototherapy Rh isoimmunization Hypothermia Apnea Hypoglycemia Hypocalcemia Anemia Polycythemia NEC PDA Bleeding due to vitamin K deficiency Neonatal cholestasis Major birth trauma

76 9 13 15 28 2 6 1 16 3 2 1 2

1.9 0.2 0.3 0.4 0.7 0.05 0.15 0.03 0.4 0.1 0.05 0.03 0.05

Table 4.12: Neonatal infections Category Number of infants (n=3992) Proportion (%) Superficial infections Pyoderma Umbilical sepsis Conjunctivitis Thrush

5 1 7 1

0.1 0.03 0.2 0.03


61

Systemic infections Systemic sepsis (septicemia/pneumonia/meningitis) Pneumonia Tetanus neonatorum

329 20 0

8.2 0.5 -




251 334 201 0 0 0 13 76 3 0 0 0

6.3 8.4 5.0 - - - 0.33 1.9 0.01 - - -



Discharged Died Left against advice Referred

3923 27 31 11

98.3 0.7 0.8 0.3

Table 4.15: Mortality – major indices (total deaths=27) Index Number Proportion (%) Neonatal deaths (0-28 days) Early neonatal deaths (0-7 days) Deaths at <24 hours Deaths 1-7 days Late neonatal deaths (7-28 days)

25 20 13 7 5

92.6 80.0 52.0 28.0 20.0



62




493 36 10 382

21 13 2 23

4.3 36.1 20.0 6.0




6 10 7 3 1

22.2 37.0 25.9 11.1 3.7


63

4B. STILL-BIRTHS




30 16

65.2 34.8

Gestation groups Preterm (<37 weeks) Term

39 7

84.8 15.2

Table 4.19: Birth weight categories Category Number of still-births



35 22 8

76.1 47.8 17.4

Table 4.20: Antenatal/labor details Category Number of still-births



33 10 2 4 4 2 4

71.7 21.7 4.3 8.7 8.7 4.3 8.7



Vaginal delivery Cesarean section

36 10

78.3 21.7



Fresh Macerated

19 27

41.3 58.7


64



<750 750-999 1000-1249 1250-1499 1500-1749 1750-1999 2000-2249 2250-2499 2500-2999 3000-3499 >3500

2 6 8 6 7 2 2 2 7 3 1

4.3 13.0 17.4 13.0 15.2 4.3 4.3 4.3 15.2 6.5 2.2



<28 29-30 31-32 33-34 35-36 37-42 >42

6 6 11 12 4 7 0

13.0 13.0 23.9 26.1 8.7 15.2 -



Asphyxia Malformation Other causes Not established

18 5 1 22

39.1 10.9 2.2 47.8


65

V . S R I L ANKA


66

SRI LANKA: Major Neonatal, Perinatal and Maternal outcomes

Total births 3,653 Total live births 3,637 Still births 16 Total neonatal deaths 23 Early neonatal deaths 21 Late neonatal deaths 2 Perinatal deaths 37 Post-neonatal deaths 1 Maternal deaths 0 Neonatal mortality rate (NMR) 6.3 per 1000 live births Early NMR 5.8 per 1000 live births Late NMR 0.5 per 1000 live births Still birth rate 4.4 per 1000 births Perinatal mortality rate 10.1 per 1000 births


67





1879 1757 1

51.7 48.3 0.03

Gestation groups * Preterm (<37 weeks) Term Post-term (>42 weeks)

376 3250 11

10.4 89.3 0.3



Proportion (%)


717 58 17

19.7 1.6 0.5



Proportion (%)


3566 66 2 3

98.0 1.8 0.05 0.1



Proportion (%)


3635 154 264 172 153 154

99.9 4.2 7.3 4.7 4.2 4.2


68




2340 56 1130 107 4

64.3 1.5 31.1 2.9 0.1



At 1 minute 0 - 3 4 - 6 >7

6 24 3607

0.2 0.7 99.2

At 5 minutes 0 - 3 4 - 6 >7

5 6

3626

0.1 0.2 99.7




318 295 8 28 10 9 1

8.7 8.1 0.2 0.8 0.3 0.2 0.03




19 117 4 23 5

0.5 3.2 0.1 0.6 0.1


69




1 3 3 2

0.03 0.1 0.1 0.05




13 4 5 1 9 16 1

0.4 0.1 0.1 0.03 0.2 0.4 0.03




245 1 21 19 71 2 1 0 0 0 0 0 0 3

6.7 0.03 0.6 0.5 1.9 0.05 0.03 - - - - - - 0.1




0 22 8 1

- 0.6 0.2 0.03


70


93 4 0

2.6 0.1 -



IV fluids Antibiotics Oxygen CPAP IMV Surfactant Blood/plasma transfusion Phototherapy Exchange transfusion

303 317 274 30 9 5 55 268 2

8.3 8.7 7.5 0.8 0.2 0.1 1.5 7.4 0.05




3601 24 12 0

99.0 0.7 0.3 -

Table 5.15: Mortality – major indices (total deaths=24) Number Proportion (%) Neonatal deaths (0-28 days) Early neonatal deaths (0-7 days) Deaths at <24 hours Deaths 1-7 days Late neonatal deaths (7-28 days)

23 21 12 9 2

95.8 87.5 57.1 42.8 8.3





717 58 17 376

20 16 12 18

2.8 27.6 70.6 4.8


71




0 16 1 4 3

- 66.7 4.2 16.7 12.5


72

5B. STILL-BIRTHS

Table 5.18: Sex distribution and gestation group details

Category Number of still-births (n=16) Proportion (%) Sex distribution Males Females Ambiguous

9 6 1

56.2 37.5 6.2


12 4 0

75.0 25.0 -



Proportion (%)


9 2 1

56.2 6.2 12.5



Proportion (%)


16 2 4 0 0 0 1

100.0 12.5 25.0 - - - 6.2




10 6

62.5 37.5



Fresh Macerated

6 10

37.5 62.5


73



<750 750-999 1000-1249 1250-1499 1500-1749 1750-1999 2000-2249 2250-2499 2500-2999 3000-3499 >3500

1 0 0 1 2 0 3 2 3 2 2

6.2 - - 6.2 12.5 -

18.7 12.5 18.7 12.5 12.5



<28 29-30 31-32 33-34 35-36 37-42 >42

0 4 3 1 4 4 0

- 25.0 18.7 6.2 25.0 25.0 -




8 3 5

50.0 18.7 31.2


74

V I . T HA I LAND


75

EXTRAMURAL ADMISSIONS




390 521 0

42.8 57.2 -

Gestation groups Preterm (<37 weeks) Term Post-term (>42 weeks) Not known

367 538 2 4

40.3 59.1 0.2 0.4

Table 6.2: Age at admission Category Number of infants


<1 day 1 to 3 days 4 to 7 days 8 to 14 days 14 to 28 days >28 days

309 142 164 121 143 32

33.9 15.6 18.0 13.3 15.7 3.5

Table 6.3: Place of delivery Category Number of infants


Home Hospital Clinic/Health centre Elsewhere

12 889 1 9

1.3 97.6 0.1 1.0

Table 6.4: Person conducting delivery Category Number of infants


Doctor Nurse/ANM/Mid-wife/Skilled birth attendant Traditional birth attendant

892 14 5

97.9 1.5 0.5


76

Table 6.5: Birth weight category of admitted neonates Birth weight (gm) Number of infants


<1000 1000-1499 1500-2499 >2500

25 79 249 558

2.7 8.7 27.3 61.2

Table 6.6: Symptoms/signs at admission Category Number of infants


Feeding difficulty Convulsions Temperature >380C Temperature <35.50C Tachypnea (respiratory rate >60/min) Grunting Severe chest in-drawing Severe dehydration

95 13 47 2 292 80 25 9

1.04 1.4 5.2 0.2 32.0 8.8 2.7 1.0



Hyaline membrane disease Transient tachypnea of newborn Pneumonia Meconium aspiration Pneumothorax Pulmonary hemorrhage

75 54 124 30 17 8

8.2 5.9 13.6 3.3 1.9 0.9




7 24 23 2

0.8 2.6 2.5 0.2


77




100 6 1 4 18 7 16

11.0 0.7 0.1 0.4 2.0 0.8 1.8



Hyperbilirubinemia requiring phototherapy Rh isoimmunization Hypothermia Apnea Hypoglycemia Hypocalcemia Anemia Polycythemia NEC ROP PDA Neonatal cholestasis Major birth trauma

583 1 18 82 87 27 142 14 53 20 118 16 14

64.0 0.1 2.0 9.0 9.6 3.0 15.6 1.5 5.8 2.2 12.9 1.8 1.5




13 24 29 2

1.4 2.6 3.2 0.2


513 124 0

56.3 13.6 -


78




653 516 431 98 247 23 145 584 9 306 7 76

71.7 56.6 47.3 10.8 27.1 2.5 15.9 64.1 1.0 33.6 0.8 8.3




878 33 0 0

96.4 3.6 - -

Table 6.14: Mortality rates in different weight groups Birth weight (gm) Number of infants

(n=911) Number of deaths (n=33)

Intra group mortality (%)

<1000 1000-1499 1500-2499 >2500

25 79 249 558

4 6 7 16

16.0 7.6 2.8 2.8




1 4 4 19 5

3.0 12.1 12.1 57.6 15.1


79


80

Annexure – I


81


82


83


84


85


86

Annexure – II


87

South East Asia Regional

NEONATAL - PERINATAL DATABASE World Health Organization (South-East Asia Region)

Working Definitions I GENERAL INTRAMURAL BABY A baby born within premises of your center EXTRAMURAL BABY Baby not born within premises of your center FETUS Fetus is a product of conception, irrespective of the duration of pregnancy, which is not completely expelled or extracted from its mother BIRTH Birth is the process of complete expulsion or extraction of a product of conception from its mother. LIVE BIRTH A live birth is complete expulsion or extraction from its mother of a product of conception, irrespective of duration of pregnancy, which after separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movements of voluntary muscles. This is irrespective of whether the umbilical cord has been cut or the placenta is attached. [Include all live births >500 grams birth weight or >22 weeks of gestation or a crown heel length of >25 cm] STILL BIRTH Death of a fetus having birth weight >500 g (or gestation >22 weeks or crown heel length >25 cm) or more. BIRTH WEIGHT Birth weight is the first weight (recorded in grams) of a live or dead product of conception, taken after complete expulsion or extraction from its mother. This weight should be measured within 24 hours of birth; preferably within its first hour of live itself before significant postnatal weight loss has occurred. LOW BIRTH WEIGHT (LBW) Birth weight of less than 2500 gm VERY LOW BIRTH WEIGHT (VLBW) Birth weight of less than 1500 gm EXTREMEY LOW BIRTH WEIGHT (ELBW) Birth weight of less than 1000 gm


88

GESTATIONAL AGE (best estimate) The duration of gestation is measured from the first day of the last normal menstrual period. Gestational age is expressed in completed days or completed weeks. PLEASE PROVIDE THE BEST ESTIMATE OF GESTATION. IT MEANS THAT, IN YOUR JUDGEMENT, BASED ON ALL THE HISTORICAL, ULTRASOUND AND BABY EXAMINATION DATA, THE ESTIMATE AS ENTERED IN THE DATABASE IS MOST ACURATE. PRETERM Gestational age of less than 37 completed weeks (i.e. less than 259 days) TERM Gestational age of 37 to less than 42 completed weeks (i.e. 259 to 293 days) POST TERM Gestational age of 42 completed weeks or more (i.e. 294 days or more). PERINATAL PERIOD Commences from 22 weeks (154 days) of gestation (the time when the birth weight is 500 g), and ends at 7 completed days after birth. NEONATAL PERIOD It refers to the period of less than 28 days after birth. Early neonatal period refers to the period before 7 days of age. Late neonatal period refers to the period from completion of 7 days upto 28 days of life. MATERNAL DEATH A maternal death is the death of a woman known to be pregnant within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accident or incidental causes. PROLONGED RUPTURE OF MEMBRANES Rupture of membranes or leaking for > 18 hours. ANTEPARTUM HEMORPHAGE Bleeding per vaginum after 20 weeks of gestation SEVERE MATERNAL ANEMIA Hemoglobin of less than 7g/dl FETAL BRADYCARDIA Fetal heart rate of less than 120 per minute FETAL TACHYCARDIA Fetal heart rate of more than 160 per minute


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II NEONATAL DETAILS BIRTH ASPHYXIA Definition I (For extramural babies) Moderate birth asphyxia: Slow gasping breathing at 1-minute of age. Severe birth asphyxia: No breathing at 1-minute of age. Definition II (For intramural babies) Birth asphyxia: Apgar score of less than 7 at 1 minute of age Moderate birth asphyxia: Apgar score between 4 to 6 at 1-minute of age Severe birth asphyxia: Apgar score of 3 or less at 1-minute of age. RESPIRATORY DISTRESS Presence of at least 2 of the following criteria:

1. Respiratory rare > 60/minute 2. Chest indrawing 3. Expiratory grunt/groaning

(Note: the baby should be evaluated in between the feeds and in a quiet state. Respiratory rate should be recorded for at least 1 minute. TRANSIENT TECHYPNEA/DELAYED ADAPTATION Respiratory distress in a term or preterm neonate starting within 6 hours after birth, often requiring supplemental oxygen, but recovering spontaneously within 3-4 days and showing characteristic x-ray changes (linear streaking at hila and interlobar fluid). HYALINE MEMBRANE DISEASE (A) Presence of all of the following three criteria

• Pre-term neonate • Respiratory distress having onset within 6 hours of birth • Amniotic fluid L/S ratio of <1.5, or negative gastric aspirate shake test, or skiagram of chest

showing poor expansion with air bronchogram/ reticulo-granular pattern/ ground glass opacity.

(B) Autopsy evidence of HMD. MECONIUM ASPIRATION SYNDROME Presence of two of the following:

• Meconium staining of liquor or staining of nails or umbilical cord or skin. • Respiratory distress soon after birth, within one hour of birth • Radiological evidence of aspiration pneumonitis (atelectasis and/or hyperinflation).

PNEUMONIA In a neonate with respiratory distress, pneumonia is diagnosed in the presence of a positive blood culture or if any two of the following are present.

• Existing or predisposing factors: maternal fever, foul smelling liquor, prolonged rupture of membranes (>18 hours) or gastric polymorphs more than 5 per high power field.

• Clinical picture of septicemia (poor feeding, lethargy, poor reflexes, hypo, hyperthermia, abdominal distension etc.)

• X-ray picture suggestive of pneumonia. • Positive septic screen (see septicemia)


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SEPTICEMIA (SYSTEMIC BACTERIAL INFECTION): CULTURE NEGATIVE (CLINICAL) In an infant having clinical picture suggestive of septicemia, the presence of any one of the following criteria is enough for assigning probable diagnosis of infection:

• Existence of predisposing factors: maternal fever or foul smelling liquor or prolonged rupture of membranes (>18 hrs) or gastric polymorphs (>5 per high power field).

• Positive septic screen (two of the four parameters (namely, TLC (<5000/mm, band to total polymorph ratio of > 0.2, absolute neutrophil count less than 1800 / cmm, C-reactive protein >1mg/dl and micro ESR>10 mm 1st hour).

• Radiological evidences of pneumonia. CULTURE POSITIVE SEPSIS In an infant having clinical picture suggestive of septicemia, pneumonia or meningitis along with either of the following.

• Isolation of pathogens from blood or CSF or urine or abscess(es) • Pathological evidence of sepsis on autopsy.

EARLY/ LATE ONSET SEPSIS (Pneumonia, septicemia, Meningitis, NEC, UTI etc.) Early onset: Onset <72 hours. Late onset: Onset >72 hours. MENINGITIS In the setting of septicemia, if CSF culture is positive; or CSF microcopy and biochemistry are suggestive of meningitis. NECROTISING ENTEROCOLITIS (NEC) In a baby at risk for NEC (pre-maturity, sepsis, umbilical venous/arterial catheterization, birth asphyxia, extreme pre-maturity, formula feeding) presence of any two of the following:

• Pre feed gastric aspirate of >50% of previous feed or abdominal distension. • Bloody stools or occult blood in the stools. • Radiological evidence of pneumatosis intestinalis/portal air/free air under the diaphragm.

HYPERBILIRUBINEMIA Total serum bilirubin level needing phototherapy and/or exchange transfusion HYPOTHERMIA Skin temperature <360C HYPOGLYCEMIA Whole blood glucose of less than 45mg/dL HYPOCALCEMIA Any one of the following:

• Serum total calcium <7 mg/dl. or • Serum ionized calcium <4 mg/dl. • QOTC >0.2 seconds on ECG which normalizes after calcium therapy.


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INTRAVENTRICULAR HEMORRHAGE (IVH) CLINICALLY SUSPECT if at least 3 clinical criteria in a pre-term infant in whom hypoglycemia and pyogenic meningitis have been excluded:

• Onset of symptoms within 0-72 hours of age • Apneic attacks or seizures • Sudden pallor or falling hematocrit • Gross hypotonia • Flat or bulging fontanel

CONFIRMED if corroborated by ultrasound or CT or autopsy findings ANEMIA Hemoglobin <13 g/dl or PCV <40 percent Vitamin K Deficiency Bleeding Bleeding from any site especially from the gastrointestinal tract Onset 2nd to 5th day of postnatal life Prolonged pro-thrombin time and thrombin time, with normal platelet count. APNEIC SPELL Period of respiratory arrest of a duration of more than 20 seconds: or of less than 20 seconds if accompanied by bradycardia (<100/minute) and/or cyanosis. POLYCYTHEMIA Capillary hematocrit of more than 70% or venous hematocrit more than 65% after 24 hours of age MAJOR CONGENITAL MALFORMATION A malformation that is life threatening or requires surgical correction. CHRONIC LUNG DISEASE Oxygen requirement at 36 weeks post-menstrual age


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III. CAUSES OF NEONATAL DEATH (This entry should be verified by the PI) Important Note: You will be first asked the cause(s) of death and you would choose from the following 11 causes of death. You may assign more than one cause of death at this stage. You will then be asked to identify the single most important cause of death. Here you will choose only one cause. This is the primary or underlying cause of death which is defined as disease or injury, which initiated the train of morbid events leading directly to death. You will exercise your judgment to assign this cause keeping in mind this definition 1. Perinatal asphyxia: Death of a neonate in the setting of and with features of perinatal hypoxia

and / or birth asphyxia followed by manifestations of or hypoxic ischemic injury of brain (hypoxic ischemic encephalopathy ) or other organs

2. Birth trauma: Death due to birth trauma 3. Extreme prematurity: Extreme prematurity as a cause of death is assigned to infants having birth

weight of less than 1000 gm 4. Hyaline membrane disease: Death in a neonate attributable to hyaline membrane disease 5. Intraventricular hemorrhage: Death in a neonate attributable to intraventricular hemorrhage 6. Pneumonia/Septicemia/Meningitis: Death in a neonate attributable to pneumonia or septicemia

or meningitis 7. Tetanus neonatorum: Death due to tetanus neonatorum 8. Congenital malformations: Death due to lethal congenital malformations 9. Others: Mention the cause not classified by above 10. Not established : Cause of death not established


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IV CAUSES OF STILLBIRTHS (This entry should be verified by the PI) Important Note: You will be first asked the cause(s) of stillbirth and you would choose from the following 11 causes of death. You may assign more than one cause of stillbirth at this stage. You will then be asked to identify the single most important cause of stillbirth. Here you will choose only one cause. This is the primary or underlying cause of death which is defined as disease or injury, which initiated the train of morbid events leading directly to death. You will exercise your judgment to assign this cause keeping in mind this definition 1. Aspyhxia: Death of a fetus in the setting of preeclampsia, hypertension, eclampsia, fetal growth

retrdation, oligihydramnios, prolonged / obstructed / precipitate labor, meconium passage, cord around the neck, fetal heart slowing or instrumentation.

2. Trauma : Death of a fetus in the setting of cephalopelvic disproportion or obstructed labor or

instrumentation with obvious evidence of traumatic lesions 3. Infection: Death of a fetus in the setting of intrauterine infections (TORCH group) or

chorioamnionitis (maternal fever, abdominal tenderness, foul smelling liquor) 4. Congenital malformations: Death of a fetus due to lethal congenital malformation 5. Rh isoimmunization : Death of a fetus attributable to erythroblastosis fetalis 6. Others: Mention the cause not classified by above 7. Not established : Cause of death not established

south east asia regional neonatal- perinatal database (sear

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