Chapter II: REVIEW OF RELATED

LITERATURE
WORLDWIDE PERSPECTIVE
Over nine million children in the world die every year during the perinatal and neonatal periods
and nearly all (98%) of these deaths occur in developing countries. Neonatal mortality
contributes between 40-70% of infant mortality. In most developing countries, nearly half of
perinatal deaths occur during the antepartum or intrapartum period, and the rest during the
first week of life. Almost 50% of these deaths are related to severe infection, tetanus and
diarrhea in countries with higher neonatal mortality rates (NMR) (NMR >45). On the other
hand, these causes are less common in countries with low NMR levels (NMR <15). Thus, the
causes of neonatal deaths are observed to vary across countries and geographical locations.
Neonatal deaths in advanced countries are largely due to unpreventable causes like congenital
abnormalities; while in developing countries, newborns die mainly from preventable causes like
infections, birth asphyxia, and prematurity. One of the most striking examples of inequity
between countries is in the area of newborn health. Of the four million neonatal deaths, 98%
belong to the worlds poorest nation.

Worldwide there has been a call for a two thirds reduction in childhood mortality by 2015.
Unfortunately, Millennium Development Goal 4 (MDG4) is unlikely to be reached in years time.
Globally, an estimate of 10.6 million children under five years died in 2000, declining to 8.8
million in 2008 and further to 7.7 million in 2010. At the same time, methods of estimation and
available sources of information for under-five mortality have improved. Of the 130 million
babies born every year, 4 million will die in the first 28 days of life, with the highest risk on the
first day of life. The highest rates are in sub-Saharan Africa, where little progress has been made
in the last 15 years towards reducing the number of deaths.
The relatively larger decline in the post-neonatal period compared to the neonatal period may
be attributable to the relatively high emphasis and global support for Primary Health Care
workforce development and programs such as nutrition, vaccination and health promotion,
relative to hospital-related workforce and infrastructure investments that are necessary for
neonatal mortality reduction, particularly in rural areasThe slow decline in neonatal mortality as
compared to post-neonatal mortality calls for attention and efforts to reverse this trend. Within
the neonatal period an estimated 50% of all deaths are within the first 24 hours while 75% are
within the first week of life. However, in lowincome countries, neonatal mortality rates,
trends, and causes have attracted relatively little attention compared to maternal deaths or
deaths among older children under 5 years, and in international public health policy, neonatal
deaths still do not receive attention commensurate with their burden. Given that a large
fraction of these deaths are preventable, a focus on mortality in the first week of life is
important in order to accelerate the millennium goal.

Information on cause of death is lacking for most neonatal deaths that occur in countries with
inadequate civil registration. Causes of death in neonate have been estimated worldwide by
analyzing the data of vital registration and reports of research studies in 2000. There are
variances of causes in neonate death in different regions, as well as in different countries of
economic development. Given the considerable variations in health systems and individual
countries, national and regional neonatal causeofdeath estimates are needed and should be a
target for future estimation exercises and data collection

UNDER FIVE MORTALITY

Fetal death is defined as any fetus born without a heartbeat, respiratory effort or movement, or
any other sign of life. It is estimated that globally 2.9 million babies experience fetal death or
die within the first week of life, with 99% of these deaths occurring in developing countries.
Studies have shown that 50% of maternal deaths occur within the first day after childbirth and
approximately 30% of stillbirths occur during labour
Neonatal death is defined as newborn death occurring within the first four weeks after birth.
The perinatal period is recognised as the most dangerous period of life because of various
problems faced by the neonates. There is evidence that there has been no measurable
reduction in early neonatal mortality over the past decade. Most programs addressing
childhood mortality focus on pneumonia, malaria, diarrhea and vaccine preventable conditions,
which are geared towards improving child survival after the first four weeks of life.

Early neonatal death is defined as all deaths of live-born infants occurring on or before the first
seven days of life. Early neonatal deaths account for 75% of all neonatal deaths worldwide, due
mainly to prematurity (40%) and complications of asphyxia (23%). Annually 18 million low-birth-
weight babies are born (14% of all births), but they account for 60 - 80% of neonatal deaths.
The World health organization (WHO) estimates that birth weight below 2500 g indirectly
contributes to about 15% of the neonatal mortality, ranging from 6% in high income countries
to 30% in low income countries, with preterm birth and related complications being the
underlying caus. Late neonatal deaths are principally due to infections (19%) with congenital
abnormalities responsible for 10% of deaths.

For example, Africa has made good progress towards reducing under- 5 mortality, still many
children continue to die from preventable causes. Neonatal deaths account for approximately
40% of all deaths in children >5 years of age in South Africa (SA). In 2009, SA was one of 8
countries in which the neonatal mortality rate (NMR) was higher than the baseline in 1990.
Starting from a rate of 21/1 000 live births in 1998, neonatal mortality needs to be reduced to
7/1 000 live births in 2015 for MDG4 to be attained.

CAUSE SPECIFIC MORTALITY

The Saving Babies 2010 - 2011 report reflects the early neonatal death rate as 21/1 000 live
births, with the majority of these deaths occurring in the 1 000 - 1 499 g weight category.
Deaths due to intrapartum asphyxia were reported as being linked to healthcare provider-
associated avoidable factors in 44% of cases.BA has for a long time been estimated to account
for 25% of neonatal mortality worldwide. However, the definition is imprecise in part because
the Apgar score, often used as an indicator to identify BA, is inaccurate or unreliable.
Furthermore, many affected infants are likely not reported or misclassified as stillbirths.
Therefore, considerable uncertainty surrounds the true estimated proportion of BA-related
mortality.

The top 5 health-worker-related factors were: (i) fetal distress monitored but not detected; (ii)
fetal distress not monitored and not detected; (iii) no intervention for prolonged second stage
of labour; (iv) delays in referring the patient and (v) delay in calling for expert assistance.

Deaths due to immaturity had patient-associated avoidable factors in 30% of cases. The top 5
factors identified being: (i) delay in seeking medical attention during labour; (ii) non-initiation of
antenatal care; (iii) booking late in pregnancy; (iv) infrequent visits to antenatal clinics; and (v)
inappropriate response to rupture of membranes.

Administrative problems contributed to deaths due to immaturity in 22% of cases, with

inadequate facilities, no accessible intensive care unit (ICU) bed with ventilator, lack of
transport and inadequate resuscitation equipment reported frequently. Recent research shows
that in high mortality settings, access to emergency obstetric care has the greatest effect in
improving neonatal survival outcomes, and that lack of access to emergency obstetric care
services in low-income countries is a serious constraint in improving pregnancy outcomes.The
belief that only high-level technology can improve neonatal outcome is not appropriate in a
developing country. Cost effective interventions such as resuscitation of the newborn baby,
breastfeeding, kangaroo mother care (KMC) and prevention of hypothermia can dramatically
reduce the number of deaths in resource-limited settings. Neonatal resuscitation training has
been reported to reduce deaths due to intrapartum asphyxia by 30%. Improved obstetric care
would also contribute to a reduced number of neonatal deaths. The majority of deaths
occurred at Community Health Centres (CHCs) or district hospitals, with the poorest quality of
care being rendered in district hospitals.
A retrospective descriptive audit conducted over a 1-year period (1 January - 31 December
2011) at Steve Biko Academic Hospital (SBAH), offers important insights into causes of neonatal
mortality. The neonatal records of all patients admitted to the Neonatal Intensive Care Unit
(NICU) were surveyed. Cause of death and avoidable factors were collected using the perinatal
death datasheet of the Perinatal Problem Identification Program (PPIP).

The health and survival of newborns has been shown to be closely linked to that of their
mothers, since inadequate maternal care during the pregnancy and postpartum period can also
affect the neonate. The top 5 primary obstetric causes of death at SBAH included spontaneous
preterm labour (38.7%), fetal anomaly (23.2%), hypertensive disorders (12%), intrapartum
asphyxia (9.9%) and antepartum haemorrhage (5.6%). The top 4 causes of neonatal death at
SBAH NICU were immaturity-related (43%), infections (26.8%), congenital abnormalities (17.6%)
and hypoxia (11.3%). Common patient-associated factors included: noninitiation of antenatal
care; attempted termination of pregnancy; and delay in seeking medical attention during labor.

Administrative problems affecting patients born in the tertiary hospital included: inadequate
facilities and equipment; lack of transport; and lack of sufficiently trained personnel. For
patients who died outside of the referral hospital, the most common problem was absence of
an accessible NICU bed with ventilator. Personnel-associated factors identified were diverse
and included hospital-acquired infection, delay in referral, antenatal steroids not given,
multiple pregnancy not diagnosed, inadequate resuscitation and monitoring, and inadequate
management of second stage of labour.

Due to these high mortality rates it is important to understand the risk factors for fetal and
neonatal mortality which are major contributors to high under five deaths globally. Fetal and
neonatal mortality is also a sensitive indicator of maternal health in society because healthy
mothers give birth to healthy babies.

WHAT CAN WE DO
Identification of cause-specific mortality in a particular setting is important to design
interventions directed to improve neonatal survival.
It has been suggested that access to antenatal care and emergency obstetric care could reduce
neonatal mortality by 10-15%. These findings confirm an earlier analysis by Kumar et al. who
report the results of a community-based strategy, where the researchers designed and
implemented a project called Saksham (Empowered) in Uttar Pradesh, Indias largest state
which accounts for a quarter of all newborn deaths in India. The project was supported by a
well-functioning emergency obstetric care system that included dedicated obstetricians,
neonatologists, culturally and technically competent community health workers and nurses
who organized the referral system from communities to respective district hospitals. Their
analysis found that within 18 months of the programs commencement, neonatal deaths
dropped by 58%There is evidence that 10% of intrapartum-related and preterm deaths can be
reduced by immediate assessment and stimulation of newborns.

In relation to neonatal mortality prevention, skilled workforce entails adequate quality,

quantity and distribution of neonatologists,mobstetricians, anaesthetists and midwives. Good
emergency obstetric care requires improving the availability, accessibility, quality and use of
services for the treatment of complications that arise during pregnancy and childbirth. The
weakest link in Emergency Obstetric Care Services is the provision of well-functioning and
appropriately staffed district and referral hospitals to provide care for complications that arise
during late pregnancy and at birth. Even in countries where such facilities are provided, delays
in obtaining care may occur at three levels: delay in deciding to seek care; delay in reaching a
first referral level facility, and; delay in actually receiving care after arriving at the facility.

Treatment with antenatal corticosteroids has been associated with a decrease in overall
neonatal deaths, especially for women with premature rupture of membranes (PROM).
Darmstadt et al. report that cost-effective and inexpensive interventions such as antibiotics for
preterm premature rupture of membranes, antenatal corticosteroids, clean delivery practices,
resuscitation of the newborn, breastfeeding, prevention of hypothermia and KMC can reduce
neonatal deaths by 41 - 72%. The use of antenatal steroids can reduce the incidence of hyaline
membrane disease, intra-ventricular hemorrhages and necrotizing enterocolitis, and ultimately
significantly reduce neonatal deaths.
Prevention and active management of hypothermia, starting in the delivery room, also reduces
mortality of premature infants significantly. Although hypothermia was documented as an
avoidable cause in only 3 of the SBAH patients, 43.2% of infants <1 500 g were hypothermic on
admission. The simple expedient of covering preterm infants <1 200 g or <28 weeks gestation in
polyethylene or plastic immediately after delivery reduces hypothermia. This should be used in
conjunction with warm delivery rooms and functioning incubators and radiant warmers.
Adequate resuscitation with proper training of health personnel and access to the correct
equipment will reduce deaths due to prematurity and due to asphyxia. Prompt and early
referral for lifesaving treatments, such as surfactant for hyaline membrane disease, and
therapeutic hypothermia for asphyxia, is critical. This is especially crucial for therapeutic
hypothermia, given the specific window of opportunity of just 6 hours.

The responsible use of oxygen should also be promoted at all levels. Adequate monitoring is
essential, especially in the premature infant <32 weeks gestation and <1 500g birth weight, as
these infants are at an increased risk for retinopathy of prematurity (ROP), a leading cause of
blindness in children. The second Benefits of Oxygen Saturation Targeting trial (BOOST II)
recently reported that lower saturations of 85 - 89%, which reduce the risk of ROP, had a
significantly higher rate of death than saturations of 91 - 95%. The unavailability of beds at
referral hospitals needs to be addressed.