Neonatal Mortality in Shifa Neonatal Intensive Care Unit (NICU) in the Last Six Years

Abuhamda AF, Mustafa AMA, Sleem JAA, Shgora AS and Elmasharfa LM

Published on: 2019-02-28

Abstract

Now Shifa NICU is the largest unit in Gaza Strip. It had a high neonatal mortality of 20 per thousands in 2012. There is a lack of study about the trend of neonatal mortality in the last six years. We implemented a retrospective cross-sectional study by collection variable data from 2011-2016 to assess the trend of mortality rates among admitted babies in the Neonatal Intensive Care Unit in Shifa Hospital.

Results: There is a significant drop in death rate, neonatal mortality rate, preterm death, low birth weight death, very low birth weight death, sepsis death, asphyxia death, and congenital anomalies death(P<0.05)among newborns who were admitted to Shifa NICU.

Conclusion: Significant drop in mortality is reflecting the teamwork by evidence-based medicine.

Keywords

Shifa NICU; Gaza strip; Retrospective cross-sectional study; Neonatal mortality

Introduction

The neonatal period is the most critical time as these babies have low immunity and high liability for fatal infection since birth by different organism bacterial, fungal and viral. Neonatal infections also have high morbidity. Preterm babies need more special care and vulnerable to different complications like intraventricular hemorrhage, chronic lung disease, and necrotizing enterocolitis, for these reasons the mortality is higher in preterm babies. Congenital anomalies increased the neonatal mortality [1]. Especially in a low socioeconomic region as appropriate antenatal care, imaging, investigations and genetic counseling are not available. Good neonatal care requires enough beds, highly qualified medical staff and unlimited resources. It is well known the highest mortality in pediatric age in those under five years of age, the majority of these die in neonatal period [2]. Gaza Strip is under siege for more than 11 years.                

Background

Background

The Shifa NICU is the largest neonatal unit in Gaza Strip; it has 16 intensive care incubators, 6 high dependency cots and 8 special care costs. The unit is well equipped and provides level 3 tertiary neonatal care mainly to the newborns from the Shifa Women`s Hospital. The Shifa NICU also provides care to newborns from other regions in the Gaza Strip which has a total population of 1.9 million. There are 17 thousand to 19 thousand babies are born yearly in Shifa women`s Hospital. The monthly admission rate in the unit is about 200 cases, of which 40-45% are premature babies. Gaza strip is under siege and is facing economic and political challenges which are negatively impacting the health care services.

Objectives

  • To compare the deliveries, admissions; preterm, asphyxia, congenital anomalies, low birth weight, very low birth weight.
  • To find out the trend of mortality rates among the admitted babies in Shifa NICU.
  • To determine the incidence of neonatal mortality in Shifa NICU.
  • To Construct baseline of data for more studies and research in the future.

Methodology

The retrospective study will be used in this study. This part of the study will provide a discussion of all aspects of the methodology. It explains the design, method, the study population, the sample, setting, the methods of collection, analysis and instruments that used for data collection in addition to limitations of this project and ethical issues.

Terminology

Total delivery: Monthly the number of total live birth in Shifa Women`s Hospital

NICU admissions: Monthly the total number of a newborn who was admitted to Shifa NICU

Preterm admission: Monthly the number of preterm newborn< 37 weeks gestational age who was admitted to Shifa NICU

Preterm death: Monthly the number of preterm newborn deaths in Shifa NICU

Death: Monthly total newborn deaths in Shifa NICU

Death rate: (monthly newborn deaths in Shifa NICU) x100 / (number of newborn admission to Shifa NICU)

Neonatal mortality rate (NMR): (monthly newborn deaths in Shifa NICU) x1000 / (monthly the number of total live birth in Shifa Women`s Hospital)

LBW: Monthly the number of newborn babies less than 2500 grams who were admitted to Shifa NICU

LBW death: Monthly the deaths of newborn babies less than 2500 grams in Shifa NICU

VLBW: Monthly the number of newborn babies less than 1500 grams who were admitted to Shifa NICU

VLBW death: Monthly the deaths of newborn babies less than 1500 grams in Shifa NICU

Congenital anomalies: Monthly the number of newborn babies with congenital anomalies who were admitted to Shifa NICU

Congenital anomalies death: Monthly the deaths of a newborn with congenital anomalies in Shifa NICU

Asphyxia: Monthly the number of a newborn with hypoxic-ischemic encephalopathy (HIE) who was admitted to Shifa NICU

Asphyxia death: Monthly the deaths of a newborn with hypoxic-ischemic encephalopathy (HIE)

Sepsis: Monthly the number of the newborn who has a positive blood culture

Sepsis death: Monthly the deaths of the newborn who have a positive blood culture

Specific mortality: (Death number of the group; preterm, VLBW. etc) x100 / (Monthly the total number of a newborn who was admitted to Shifa NICU)

Case fatality rate: (Death number of the group; preterm, VLBW. etc) x100 / (monthly the number of the group; preterm, VLBW.etc in Shifa NICU)

Design and Method

A retrospective study was implemented including collection variable data over the last six years to assess the changes in the trend of mortality rates among admitted babies in the Neonatal Intensive Care Unit in Shifa Hospital.

Study setting

This study will be done in the Neonatal Intensive Care Unit of Shifa Hospital by collecting data from recorded file and data over the last 6 years (2011-2016).

Study sampling

The target population is all delivered live babies in Shifa Women`s Hospital over the last 6 years (2011-2016) and admitted babies in Shifa NICU in the same period.

Inclusion criteria

An inclusion criterion includes all recorded data and collected data in Shifa Women`s Hospital and NICU of Shifa Hospital in the period from 2011 to 2016

Exclusion criteria

The ambiguous data in records were excluded in this study.

Data management and statistical analysis

SPSS version 20th is the program that was used for analyzing data. It included data entering, data cleaning, data frequency, and tabulation.

Administration's consideration and ethical approval

The study approved by administrations of Shifa Hospital and Palestinian Ministry of Health.

Results

A retrospective study was implemented, this study includes collection variable data over the last six years and assesses the changes of the trend of mortality rates among admitted babies in Neonatal Intensive Care Unit in Shifa Hospital (NICU). Table 1 shown general characteristics and risk factors among admitted cases in NICU. The results illustrated no significant difference in total deliveries and preterm admissions from 2011 to 2016 (P≥0.05). The ANOVA test demonstrated the numbers of newborn admission per months in NICU showed a significantly elevated trend for last three years, the mean of admission was 113.9 ± 10.8, 116.6 ± 18.4, 146.8 ± 32.3, 172.8 ± 27.7, 190.5 ± 30.2 & 192.5 ± 21.3 for 2011 to 2016, respectively (P<0.001). In addition, monthly survival rate was significantly decreased 25 ± 5.3, 25.2 ± 5.1, 13.7 ± 6.7, 9 ± 2.1, 7.9 ± 2.1 & 8.0 ± 2.4 for 2011 to 2016, respectively (P<0.001). Clearly, monthly neonatal mortality rate, death, and preterm death was significantly decreased for the last four years (P<0.001). In the last three years (2014-2016), LBW death was significantly decreased compared to 2011 and 2012, VLBW and congenital deaths were significantly decreased in the last four years (2013-2016) compared to 2011 and 2012, Moreover, VLBW death were significantly decreased in the last three years (2014-2016) compared to 2011 to 2013 (P<0.05). In contrast, LBW deaths in the last three years (2014-2016), were significantly decreased and VLBW was only decreased in 2014 compared to other years (P<0.05). There was significantly decreased between 2014 compared to 2012 (P<0.05) and no difference between the other years (P≥0.05) for Sepsis deaths. Asphyxia deaths were significantly decreased in 2016 and 2013 compared to 2011(P<0.05) (Figure 1).

Discussion

The numbers of NICU newborn admission per month showed significantly elevated trend for the last three years (P<0.001) that related to the new policy of newborn admission to Shifa NICU as all babies less than 2 kg, preterm babies less than 34 weeks gestational age, large for gestational age with unstable blood sugar and all babies with respiratory distress more than 2 hours, they should be admitted for further evaluation and investigation. This policy helped too much to avoid hazardous hypoglycemia, hypoxia, detection signs of early sepsis and early management [3].

Although Shifa NICU newborn admission per month significantly increased, there is significant drop of newborn death rate, neonatal mortality rate,LBW deaths, VLBW deaths and preterm baby deaths in the last 4 years ((P<0.001) [4]. in the graphic above the drop in death rate is more significant than neonatal mortality rate as there is no significant difference in total delivery from 2011 till 2016 whereas there is a significant difference in NICU admission in the last 4 years (Figure 1). These tremendous achievements were related to many factors.

First of all ;availability of highly qualified neonatologist [5] who skilled in neonatal echocardiography which helped; early detection of congenital heart diseases and persistent pulmonary hypertension [6], other factors concerning neonatal life resuscitation training of all medical staff of Women`s Hospital and NICU [7] and updated protocols of management, also the availability of double wall incubators [8] bubble CPAP machine [9] and high frequency mechanical ventilation altogether helped contribute to gentle ventilation of the preterm babies with less complications and less hospital stay [10,11]. High-frequency ventilation with magnesium sulfate intravenous infusion as a protocol for PPHN was so effective [12]. There is a significant drop of congenital anomalies deaths in the last four years ((P<0.001) compared to 2011 and 2012 that was related to early detection, intervention, multidisciplinary team plan and management especially for congenital heart diseases [13]. Asphyxia deaths were significantly decreased in 2016 and 2013 compared to 2011((P<0.002)that was related to neonatal life support training for whole medical staff, body cooling machine and cooling treatment protocol [14]. The updated antibiotic protocol according to the last study in Shifa NICU [15], antifungal prophylaxis [16] and standardized hand hygiene contributed to control the NICU neonatal infection [17] , as sepsis deaths were significantly decreased between 2014 compared to 2012 (P<0.001).

Conclusion

There was significant neonatal mortality drop after 2012 compared to that before 2012; that related to the renovation of the units, equipping and medical staff training

Recommendations

Attendant consultant neonatologist should be available at all work shift. Nurse care in NICU should be not less one nurse to one baby in level 3 and not less one nurse care to two babies in level 2. Bed occupancy should not exceed 80%. Yearly research of the most common organisms of neonatal infection, antibiotic susceptibility to find out the appropriate initial antibiotic treatment.

References

  1. Joy EL, Wilczynska-KetendeK, Cousens SN. Estimating the causes of 4 million neonatal deaths in the year 2000. Int J Epidemiol. (2006); 35: 706-718.
  2. Jennifer B. WHO estimates of the causes of death in children.  2005; 365: 1147-1152.
  3. Van den Berg MM, Madi HH, Khader A, Hababeh M, Zeidan W, Wesley H, et al. Increasing Neonatal Mortality among Palestine Refugees in the Gaza Strip. PLoS ONE. 2015. 10: 0135092.
  4. Wiegerinck MMJ. The validity of the variable “NICU admission” as an outcome measure for neonatal morbidity. A retrospective study. Acta obstetricia gynecologica Scandinavica. 2014; 93: 603-609.
  5. Usher, Robert H. The role of the neonatologist. Pediatric Clinics of North America. 1970; 17: 199-202.
  6. Kluckow M, Seri I, Evans N. Echocardiography and the neonatologist. Pediatric cardiol. 2008; 29: 1043.
  7. Zhu XY. The impact of the neonatal resuscitation program guidelines (NRPG) on the neonatal mortality in a hospital in Zhuhai, China. Singapore Medical J. 1997; 38: 485-487.
  8. Marks KH. Oxygen consumption and temperature control of premature infants in a double-wall incubator. Pediatrics. 1981; 68: 93-98.
  9. Narendran V. Early bubble CPAP and outcomes in ELBW preterm infants. J Perinatol. 2003; 23: 195-199.
  10. Cools F, Offringa M, Askie LM. Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. The Cochrane Library(2015).
  11. Plavka R. A prospective randomized comparison of conventional mechanical ventilation and very early high frequency oscillatory ventilation in extremely premature newborns with respiratory distress syndrome. Intensive Care Med. 1999; 25: 68-75.
  12. Tolsa JF. Magnesium sulphate as an alternative and safe treatment for severe persistent pulmonary hypertension of the newborn. Archives Dis Childhood-Fetal and Neonatal Edition. 1995; 72: 184-187.
  13. Brown KL. Delayed diagnosis of congenital heart disease worsens preoperative condition and outcome of surgery in neonates. Heart. 2006; 92: 1298-1302.
  14. Shankaran S. Outcomes of safety and effectiveness in a multicenter randomized, controlled trial of whole-body hypothermia for neonatal hypoxic-ischemic encephalopathy.  2008; 122: 791-798.
  15. El-JadbaAHE, El-Yazji MS. Neonatal septicemia in Gaza city hospitals. Pak J Med Sci. 2009; 25: 226-31.
  16. Harita K. Prophylactic fluconazole in very low birth weight infants admitted to neonatal intensive care unit: randomized controlled trial. J Maternal-Fetal & Neonatal Med. 2016; 29: 624-628.
  17. Janota J. Hand hygiene with alcohol hand rub and gloves reduces the incidence of late onset sepsis in preterm neonates. Acta paediatrica. 2014; 103: 1053-1056.

 

Figures

Figure 1: Plot between Death Rate and Neonatal mortality.

Tables

Table 1: Shown general characteristics and risk factors among admitted cases in NICU.

 Variables

2011

2012

2013

2014

2015

2016

F

P

Total deliveries

1542.3 ± 178.1

1427.9 ± 163.1

1319.9 ± 196.4

1444 ± 499.3

1318.9 ± 245

1486.8 ± 239.9

1.25

0.297

(1226-1761)

(1218-1750)

(991-1537)

(542-2662)

(858-1695)

(1118-1795)

 

 

Preterm admissions

65.8 ± 8.6

72.9 ± 19.8

73.3 ± 11.6

76 ± 11.3

79.8 ± 21

77.4 ± 13.9

1.25

0.298

(52-78)

(51-114)

(53-91)

(59-95)

(51-125)

(53-99)

 

 

NICU admissions

113.9 ± 10.8

116.6 ± 18.4

146.8 ± 32.3*

172.8 ± 27.7*#

190.5 ± 30.2*#$

192.5 ± 21.3*#$

24.7

<0.001

(98-129)

(87-141)

(100-194)

(140-221)

(143-239)

(160-228)

 

 

Death rate (%)

25 ± 5.3

25.2 ± 5.1

13.7 ± 6.7*#

9 ± 2.1*#$

7.9 ± 2.1*#$

8.0 ± 2.4*#$

45.5

<0.001

(17.3-37.3)

(17.4-36)

(6.2-28.3)

(7-14.5)

     (4.4-11.3)

(5-14.4)

 

 

Neonatal mortality (/1000)

19.2 ± 4.5

21 ± 5

15.1 ± 6.7*#

12.7 ± 10.1*#

11.5 ± 3.8*#

10.3 ± 2.6*#

6.14

<0.001

(13.1­30)

(13.7­33)

(7.2­28.3)

      (7.1­44.2)

(5.8-18.9)

(6-15.9)

 

 

Death

29.6 ± 7.7

29.2 ± 7

18.8 ± 5.8*#

15.5 ± 4.1*#

15.3 ± 5.5*#

15.3 ± 4.5*#

16.7

<0.001

(17-47)

(21-45)

(11-32)

(10-24)

(8-23)

(10-26)

 

 

Preterm death

21.6 ± 7.1

20.5 ± 4.1

13.1 ± 4.6*#

10.1 ± 4.1*#

9.4 ± 4.3*#

8.8 ± 2.2*#

18.5

<0.001

(8-35)

(15-27)

(7-21)

(3-18)

(2-16)

(5-12)

 

 

LBW death

8.6 ± 3.6

8 ± 2.7

5.1 ± 2.5*

4.3 ± 1.6*#

4.9 ± 3.2*

4.8 ± 2*

5.74

<0.001

(3-17)

(3-12)

(2-10)

(2-7)

(1-12)

((3-9)

 

 

VLBW death

14.7 ± 5.5

12.3 ± 3.6

8.3 ± 4.4*

4.5 ± 2.9*#

5.2 ± 2.6*#

5.8 ± 2.2*#

15.1

<0.001

(7-23)

(6-20)

(3-16)

(0-11)

(2-9)

(2-10)

 

 

LBW

40.3 ± 5.8

44.6 ± 8.6

56.7 ± 16.6

61.8 ± 23*

65.8 ± 15.7*#

61.6 ± 13.4*

5.77

<0.001

(31-51)

(35-62)

(34-82)

(7-88)

(36-93)

(29-83)

 

 

VLBW

24.7 ± 7.6

21.4 ± 4.7

17.8 ± 6.1

14.9 ± 4.3*

18.5 ± 7.9

24.9 ± 7.2

4.62

0.001

(14-37)

(14-29)

(8-26)

(9-22)

(10-35)

(17-36)

 

 

Congenital

14.2 ± 3.8

16 ± 5.6

13.7 ± 6.1

14.5 ± 5.2

12.6 ± 3.3

15.6 ± 4.6

0.79

0.559

(8-21)

(8-27)

(6-28)

(7-24)

(8-17)

(8-25)

 

 

congenital death

7.8 ± 1.9

8.6 ± 3.6

4.8 ± 2.6*#

3.7 ± 1.2 *#

2.6 ± 1.7*#

3 ± 1.9*#

15.1

<0.001

(5-12)

(5-16)

(1-9)

(2-6)

(1-6)

(1-6)

 

 

sepsis death

1.33 ± 1.7

3.42 ± 3.57

2.4 ± 2.19

0.5 ± 0.79#

-

1.33 ± 0.88

5.07

0.001

(0-6)

(0-11)

(0-7)

(0-2)

 

(0-3)

 

 

sepsis

3.7 ± 3.68

8.1 ± 4.3*

7.3 ± 4.5£

2.1 ± 1.2#$

-

7.4 ± 3.3£

12.3

0

(0-11)

(0-16)

(3-16)

(0-4)

 

(1-12)

 

 

Asphyxia

4.4±2.6

4.4±2.6

3.8±2

4.8±1.8

3.7±2.1

4.8±2.3

0.53

0.751

(2-11)

(0-8)

(2-9)

(1-7)

(0-7)

(0-8)

 

 

Asphyxia death

2.5±1.6

2.1±1.7

0.7±0.9*

1.8±1.4

1.1±1.3

0.5±0.9*

4.24

0.002

(1-6)

(0-6)

(0-3)

(0-4)

(0-4)

(0-3)

 

 

the preterm specific mortality rate 

0.187±0.051

0.176±0.025

0.097±0.052*#

0.058±0.021*#$

0.048±0.019*#$

0.046±0.011*#$

43.3

0

(0.082­­0.278)

(0.142­­0.218)

(0.04­­0.2)

(0.021­0.109)

(0.013­­0.079)

(0.025­­0.063)

 

 

sepsis-specific mortality rate 

0.012±0.015

0.049±0.089*

0.019±0.02

 

 

0.007±0.004#

2.86

0.021

(0­0.048)

(0­­0.324)

(0­­0.061)

 

 

(0­­0.013)

 

 

asphyxia specific mortality rate  

0.022±0.015

0.017±0.014

0.005±0.007*#

0.01±0.008*#

0.006±0.007*

0.003±0.005*#

7.24

0

(0.008­­0.06)

(0­0.048)

(0.­0-023)

(0­.0­0.024)

(0­.0­0.02)

(0.0­­0.015)

 

 

congenital anomalies specific mortality rate

0.069±0.016

0.074±0.029

0.033±0.02#*

0.021±0.006#*

0.013±0.008#*$

0.015±0.01#*$

31.3

0

(0.051­­0.1)

(0.043­­0.126)

(0.006­­0.07)

(0.012­­0.032)

(0.005­­0.03)

(0.005­­0.034)

 

 

VLBW specific mortality rate

0.124±0.042

0.105±0.028

0.06±0.038*#

0.026±0.017*#$

0.026±0.011*#$

0.03±0.01*#$

29.9

0

(0.056­­0.184)

(0.06­­0.146)

(0.02­­0.152)

(0­­0.066)

(0.01­­0.044)

(0.01­­0.044)

 

 

LBW specific mortality rate  

0.075±0.035

0.068±0.021

0.038±0.023*#

0.023±0.007*#

0.025±0.016*#

0.025±0.011*#

15.1

0

(0.03­­0.17)

(0.034­­0.103)

(0.01­­0.088)

(0.01­­0.038)

(0.006­­0.06)

(0.013­­0.048)

 

 

LBW: <2500grams; VLBW<1500grams; *compare between 2011 and other years; # compare between 2012 and other years; $ compare between 2013 and other years; £  compare between 2014 and other years