Shortfall of equipment for neonatal intensive care and the introduction of budget holding contracts.

As adequate allowance must be made for the costs of purchasing, maintaining, and updating equipment during the development of contracts the current standing of neonatal units with regard to available equipment was assessed. Data were collected as part of a one year prospective survey of the 17 perinatal units in the Trent region. Adequacy of provision of equipment for recognised intensive care cost was assessed using the recommendations of the British Paediatric Association and British Association of Perinatal Paediatrics. It was assumed that units without recognised intensive care cost had to be able to equip one cot to a standard of intensive care level 1 in the short term. Equipment more than 5 years old was considered likely to warrant replacement or major maintenance within the next two years. With these guidelines over 600,000 pounds would be required to provide sufficient equipment for all recognised level 1 intensive care cost and to allow units without funded cost to provide this level of care in the short term and to replace existing equipment more than 5 years old for these cost alone. This amount could be reduced by 25% by subdividing intensive care cost into levels 1 and 2, thereby reducing equipment requirements, but this would impair the units'' ability to perform level 1 care at funded provision, which has already been shown to need expansion. Neither figure takes account of equipment requirements for infants requiring special care. In addition, no allowance has been made for purchase or update of ultrasound scanners or blood gas analysers. If the government''s proposed reforms are to be implemented clinicians need to revise guidelines regarding essential equipment, and plans must be made to correct any existing shortfalls so that they do not become inherited financial liabilities for future budget holders.     

Short term outcome in babies refused perinatal intensive care.

OBJECTIVE--To compare the mortality in babies refused admission to a regional perinatal centre with that in babies accepted for intensive care in the centre. DESIGN--Retrospective study with group comparison. SETTING--Based at the Royal Maternity Hospital, Belfast, with follow up of patients in all obstetric units in Northern Ireland. PATIENTS--Requests for transfer of 675 babies to the regional perinatal centre (prenatally and postnatally) were made from hospitals in Northern Ireland between January 1984 and December 1986. In all, 343 babies were refused admission to the centre, and complete data were available for 332 of them. These babies were either admitted to other neonatal intensive care units (261 babies) or remained in hospitals with only special care cots (71 babies). MAIN OUTCOME MEASURE--Short term mortality. RESULTS--Seventy of the 332 babies refused admission to the centre died compared with 51 of the 333 who were admitted. Multivariate analysis based on a logistic model showed a non-significant increase in mortality among babies treated in other intensive care units compared with babies treated in the centre (relative odds 1.2; 95% confidence interval 0.7 to 1.9). The increase in mortality in babies who remained in a special care baby unit, however, was significant (3.5; 1.7 to 7.0). This increase was particularly significant in babies born at less than or equal to 32 weeks'' gestation and who weighed less than 1500 g (8.4; 2.5 to 28.1). CONCLUSIONS--The results of the study confirm the benefits of neonatal intensive care and its particular value in improving survival in babies of low birth weight. As the babies were refused admission to the regional perinatal centre because intensive care cots were not available this deficiency should be corrected.     

Study of special-care baby services in North-west Thames region.

During three months in 1975 admissions to 17 of the 21 special-care baby units in the North-west Thames region were analysed by birth weight and category of care. Of the 1,718 babies admitted, one-third needed only observation. Neonatal intensive care formed only a small proportion of the work load in most units. Considerable variation in the pattern of admissions was found. There was some evidence of concentration, about 100 babies being transferred for urgent medical or surgical reasons, and the work load of one unit suggested that it was serving as a referral centre. It is concluded that the quality of care given to some infants needing intensive care might be improved by greater concentration, and that some units should review their admission policies in order to prevent unnecessary postpartum separation of mother and baby.     

Outcome of breech delivery at term.

OBJECTIVE--To compare neonatal mortality and morbidity in term infants presenting by the breech and delivered vaginally or by caesarean section. DESIGN--Population based comparison of outcomes. Data derived from the St Mary''s maternity information system. SETTING--North West Thames Regional Health Authority, 1988-90. SUBJECTS--3447 singleton fetuses presenting by the breech at term. MAIN OUTCOME MEASURES--Intrapartum and neonatal mortality, low Apgar scores, intubation at birth, and admission to special care baby units. RESULTS--After the exclusion of babies with congenital anomalies the incidence of intrapartum and neonatal death associated with vaginal birth was 8/961 (0.83%) compared with 1/2486 (0.03%) in babies born by caesarean section (relative risk 20, 95% confidence interval 2.5 to 163). The numbers of low Apgar scores and neonatal intubation were doubled in babies born vaginally or by emergency caesarean section compared with those delivered by elective operation. CONCLUSIONS--The good neonatal outcome associated with elective caesarean delivery of the term breech fetus may influence the decision of women and their obstetricians about mode of delivery.     

Patterns of low birth weight in the Bengali newborns

This paper examines the distribution of low birth weight (2500 g or less) by gestation time, sex, maternal age, parity (birth order), socioeconomic conditions, and season of birth among 5117 single live births born to Bengali mothers at the Ramakrishna Mission Seva Pratisthan Hospital in Calcutta, India. Preterm infants have low birth weight significantly more often than their full term counterparts. Female infants have low birth weights significantly more often than male infants. The infants of poor mothers have lower birth weights in higher order births more often than infants of higher orders born to well-off mothers. Teenaged mothers produce low birth weight babies significantly more often than older mothers. Although the relationship is not significant, low birth weight infants occur more often among 1st and late born infants and less often among 2nd born infants. The season of birth is not significantly associated with birth weight. Less than 10% of low birth weight infants are pre-term, while the rest are full term. The great majority of low birth weight infants are small-for-gestational-age; the minority are small due to curtailed gestational age. The proportion of infants weighing less than 2001 g is only 9%; this figure tallies closely with earlier studies of India.     

Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey

AimTo compare perinatal morbidity and mortality for babies delivered in water with rates for babies delivered conventionally (not in water).DesignSurveillance study (of all consultant paediatricians) and postal survey (of all NHS maternity units).SettingBritish Isles (surveillance study); England and Wales (postal survey).SubjectsBabies born in the British Isles between April 1994 and March 1996 who died perinatally or were admitted for special care within 48 hours of birth after delivery in water or after labour in water followed by conventional delivery (surveillance study); babies delivered in water in England and Wales in the same period (postal survey).Results4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water, but 2 admissions were for water aspiration. UK reports of mortality and special care admission rates for babies of women considered to be at low risk of complications during delivery who delivered conventionally ranged from 0.8/1000 (0.2 to 4.2) to 4.6/1000 (0.1 to 25) live births and from 9.2 (1.1 to 33) to 64/1000 (58 to 70) live births respectively. Compared with regional data for low risk, spontaneous, normal vaginal deliveries at term, the relative risk for perinatal mortality associated with delivery in water was 0.9 (99% confidence interval 0.2 to 3.6).ConclusionsPerinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally. The data are compatible with a small increase or decrease in perinatal mortality for babies delivered in water.

Key messages

• Data on adverse effects of delivery in water have been limited
• Perinatal mortality and risk of admission for special care is similar for babies delivered in water and for low risk deliveries that do not take place in water
• The risk of perinatal mortality for babies delivered in water is similar to the risk for babies born by normal vaginal delivery to women at low risk of adverse outcome
• Delivery in water may have caused water aspiration in two babies and contributed to snapped umbilical cord in five

     

Effectiveness of neonatal transport.

The condition of 259 infants transferred to the neonatal intensive care unit (NICU) of the Montreal Children''s Hospital from Oct. 1, 1974 to Mar. 31, 1975 was evaluated. Their transport was provided by personnel and equipment from the Montreal Children''s Hospital. When the transport team arrived at the referring hospital hypothermia (temperature of less than 36 degrees C) was present in 25.2% of the 163 infants for whom complete temperature measurements were available. Most (77.3%) of the infants were warmed during transport and only 3.1% arrived at the NICU with a temperature of less than 35 degrees C. The mortality was significantly higher in babies of all birth weight groups whose core temperature had been below the optimal temperature for survival (36 to 37 degrees C). It appears that the use of appropriate equipment and trained personnel can reduce the incidence of hypothermia and therefore the mortality in infants requiring transfer.     

Confidential paediatric inquiry into neonatal deaths in Wessex, 1981 and 1982.

From 1 January 1981 to 31 December 1982, 66 256 births and 386 neonatal deaths were recorded in the Wessex Regional Health Authority, giving a neonatal mortality of 5.8/1000 live births. An experienced consultant paediatrician undertook a confidential inquiry into each death shortly after it had been reported. One hundred and forty four deaths (37%) were found to be due to lethal or severe malformations, an incidence of 2.2/1000 births. Of the 242 normally formed infants, 111 (46%) died within 24 hours of birth. Seventy seven (32%) weighed over 2500 g at birth. Factors operating before delivery accounted for 104 (43%) of the deaths of normally formed infants. The commonest factors were short gestation and low birth weight, and intrauterine hypoxia and birth injury. Factors after delivery accounted for 81 deaths (33%), the commonest being infections and sudden infant deaths. In the remaining 57 deaths (24%) it seemed that a combination of factors before and after birth had led to the death. Factors before birth thus played a part in two thirds of all deaths. Possible adverse factors in medical care were sought in 154 potentially viable babies and were identified in 38--that is, 10% of all neonatal deaths. Better provision and training of district staff in immediate care at birth would achieve more in lowering neonatal mortality in Wessex than the setting up of a regional unit specializing in advanced neonatal intensive care. Moreover, the greatest scope for improving the outcome of childbirth in Wessex would be offered if there were further advances in obstetric rather than neonatal care.     

The role of degradation of fetal haemoglobin in the energy supply of very low body weight pre-term babies

Low body weight premature babies born before the 32nd gestational week were studied to analyse the postnatal fall in plasma haemoglobin and in quantitative changes in amino acid levels. Red blood cells of premature low body weight infants were found to disintegrate more rapidly than those of mature newborns. Thin-layer ion-exchange chromatographic studies showed that amino acids originating from the degrading haemoglobin-F lead to rise in plasma amino acids. These amino acids might play a role as substrates for gluconeogenesis in the energy supply of low body weight premature babies during the special fasting state just after birth.     

Protective effect of breast feeding against infection.

OBJECTIVE--To assess the relations between breast feeding and infant illness in the first two years of life with particular reference to gastrointestinal disease. DESIGN--Prospective observational study of mothers and babies followed up for 24 months after birth. SETTING--Community setting in Dundee. PATIENTS--750 pairs of mothers and infants, 76 of whom were excluded because the babies were preterm (less than 38 weeks), low birth weight (less than 2500 g), or treated in special care for more than 48 hours. Of the remaining cohort of 674, 618 were followed up for two years. INTERVENTIONS--Detailed observations of infant feeding and illness were made at two weeks, and one, two, three, four, five, six, nine, 12, 15, 18, 21, and 24 months by health visitors. MAIN OUTCOME MEASURE--The prevalence of gastrointestinal disease in infants during follow up. RESULTS--After confounding variables were corrected for babies who were breast fed for 13 weeks or more (227) had significantly less gastrointestinal illness than those who were bottle fed from birth (267) at ages 0-13 weeks (p less than 0.01; 95% confidence interval for reduction in incidence 6.6% to 16.8%), 14-26 weeks (p less than 0.01), 27-39 weeks (p less than 0.05), and 40-52 weeks (p less than 0.05). This reduction in illness was found whether or not supplements were introduced before 13 weeks, was maintained beyond the period of breast feeding itself, and was accompanied by a reduction in the rate of hospital admission. By contrast, babies who were breast fed for less than 13 weeks (180) had rates of gastrointestinal illness similar to those observed in bottle fed babies. Smaller reductions in the rates of respiratory illness were observed at ages 0-13 and 40-52 weeks (p less than 0.05) in babies who were breast fed for more than 13 weeks. There was no consistent protective effect of breast feeding against ear, eye, mouth, or skin infections, infantile colic, eczema, or nappy rash. CONCLUSION--Breast feeding during the first 13 weeks of life confers protection against gastrointestinal illness that persists beyond the period of breast feeding itself.     

A REPORT FROM AUSTRALIA: WHICH BABIES ARE TOO EXPENSIVE TO TREAT?

The author examines current practices and attitudes of Australian neonatologists regarding the treatment of low birth weight infants. One intensive care unit adheres to criteria of treatment based on weight and its perceived connection with prognosis even when there are available beds and equipment. Another unit treats infants of much lower weight with poorer prognoses. A survey of Australian neonatologists revealed that although most knew of varying practices, over half were opposed to disclosing this knowledge to parents. The physicians were also queried on allocation of resources among infants of varying weights in the units, and on prevention of prematurity. Singer discusses the QALY (quality adjusted life year) and its application in comparing the benefits of resource allocation to neonatal intensive care and to adult care.     

Early discharge of infants of low birth weight: a prospective study.

A total of 495 African infants of low birth weight were discharged from Harari Maternity Hospital, Salisbury, between October 1972 and September 1973. Criteria used for discharge were (a) no clinical evidence of disease, (b) satisfactory feeding by mouth (breast or bottle or both), and (c) stable temperature control under normal room conditions. Of the 495 babies 264 fulfilled these criteria when they weighed 1801-1900 g (group 1), 99 when they weighed 1901-2000 g (group 2), and 132 (group 3) when they weighed 2001-2500 g. The overall follow-up rate of those infants living in greater Salisbury was 85-5%, the health visitor playing an important contributory role in their progress, especially those in group 1. More than two clinic visits in the first four to five weeks after discharge were essential for continuing weight gain in groups 1 and 2 but not in group 3. The mean daily weight gain for all babies at the end of four to five weeks was 26 g. Readmission rates for babies in groups 1,2, and 3 were 9-5%, 1%, and 0-8%, respectively, the largest single cause for readmission being bronchopneumonia associated with hypothermia. Altogether 60% of the readmissions occurred during the two winter months (June and July). Hypothermia, associated with low environmental temperatures played a significant part in morbidity and mortality, and twins, particularly in group 1, had a mortality rate three times greater than singletons in the same group. In general, even in underdeveloped communities singleton babies born outside the winter months with reasonable clinic or home visiting facilities can be discharged at a weight of 1800 g or more.     

Prognosis for infants with idiopathic respiratory distress syndrome.

Infants with the idiopathic respiratory distress syndrome admitted to the intensive care unit during January 1972 to September 1974 were reviewed. The overall mortality rate for infants whose birth weight was 1000 g or more was under 10%, and for those who established spontaneous respiration after birth it was less than 5%. The hyperoxia test was not a useful guide to prognosis. It was possible on the basis of the infants'' ability to establish spontaneous ventilation after birth to divide them into two groups. In those who established adequate ventilation the mortality rate was 4-5%; in those who did not it was 57%. This test should be generally applied, since not only does it give an immediate guide to the severity of the disease, which is better than that provided by birth weight, gestational age, or the hyperoxia test, but it may be applied to infants born in and outside a hospital providing neonatal intensive care. Improvement in the outlook for infants with a bad prognosis will be achieved only by improvements in perinatal care designed to minimize severe intrapartum asphyxia in infants of low birth weight.     

Care in a birth room versus a conventional setting: a controlled trial.

A controlled clinical trial was carried out to assess whether a birth room setting would influence the care of mothers and newborns. Of the 163 low-risk women enrolled, 49 (30%) manifested some prenatal risk and were excluded. The remaining 114 were allocated by strict alternation to a birth room or a conventional setting. Of the 56 women allocated to the birth room, 63% of the primiparas and 19% of the multiparas were later transferred. The numbers in the two settings who had oxytocin stimulation, epidural anesthesia, forceps delivery or cesarean section did not show statistically significant differences. The episiotomy rates were slightly lower in the birth room than in the conventional setting, and the rates of an intact perineum were higher in the birth room. Neither the Apgar scores nor the morbidity rates of the infants showed statistically significant differences related to the setting to which the mother had been allocated, although more infants from the conventional setting were admitted to a special care unit. Both "experimental" groups of women less often received routine perineal shaving, enemas or intravenous infusions than did an obstetrically similar nonexperimental comparison group. Despite the apparent inability in this setting for the birth room to influence the rate of major obstetric procedures (except for episiotomy) and outcomes, the authors believe that a birth room is desirable in tertiary care centres as well as in community hospitals.     

General practitioner obstetrics in the Northern region in 1983.

In late 1983 a four page questionnaire on general practitioner obstetrics was sent to a 50% random sample of general practitioners in the Northern region of England; 84% responded. Half of them said that they had access to general practitioner facilities for delivery, and half of these used them. A quarter of all respondents had provided intranatal care previously but had given it up, most of them during the late 1970s. Younger general practitioners were more highly qualified in obstetrics than older ones but did not do more intranatal work. Isolated general practitioner maternity units were much more likely to be used than those that were alongside consultant units or integrated with them. Ninety per cent of respondents provided antenatal care, 77% of these at special clinics and 88% with midwives in attendance. Teamwork, however, was not well developed. Increasing general practitioner participation in obstetric care seems feasible but depends heavily on more appropriate training and intranatal facilities being provided for general practitioners in association with specialist units.     

Attitudes to viability of preterm infants and their effect on figures for perinatal mortality.

OBJECTIVE--To examine how local attitudes to management of extreme preterm labour can influence data on perinatal mortality. DESIGN--One year prospective study in a geographically defined population. SETTING--The 17 perinatal units of Trent region. PATIENTS--All preterm infants of less than or equal to 32 weeks'' gestation in the Trent region. INTERVENTIONS--Infants who had been considered viable at birth were referred for intensive care; those who had been considered non-viable received terminal care. MAIN OUTCOME MEASURES--Whether each infant was born alive, dead, or alive but considered non-viable. RESULTS--Large differences were observed among units in the rates of delivery of infants of less than or equal to 27 weeks'' gestation (rates varied from 7.2 to 0 per 1000 births). These differences were not present in the data relating to infants of between 28 and 32 weeks'' gestation. The variation seemed to result from different approaches to the management of extreme preterm labour--that is, whether management took place in a labour ward or a gynaecology ward. CONCLUSIONS--Place of delivery of premature babies (less than or equal to 27 weeks'' gestation) may influence classification and hence figures for perinatal mortality. In addition, the fact that the onus of judgment regarding viability and classification is often placed on relatively junior staff might also affect the figures for perinatal mortality. The introduction of a standard recording system for all infants greater than 500 g would be advantageous.     

Perinatal mortality rates in isolated general practitioner maternity units.

OBJECTIVE--To determine the perinatal mortality rate among normally formed, singleton babies with birth weights greater than or equal to 2500 g in Bath health district based on the intended place of delivery at the time of onset of labour or at the time of diagnosis of intrauterine death. DESIGN--The numbers of live births and stillbirths were collected monthly returns from the maternity units concerned. Deaths of infants aged less than or equal to 1 week were collected in the same returns. The intended place of delivery was confirmed at the monthly perinatal mortality meeting, during which maternal and fetal factors were discussed. SETTING--A rural health district of 400,000 population where one third of all deliveries occurred in seven isolated general practitioner maternity units, 8% in the integrated general practitioner unit, and the remainder in the consultant unit. SUBJECTS--All babies of women whose deliveries were booked in the district before the onset of labour or the diagnosis of intrauterine death, excluding twins, babies with lethal congenital malformations, and those less than 2500 g. MAIN OUTCOME MEASURES--Outcome of all deliveries and parity of mothers. RESULTS--14,415 Deliveries were analysed. The perinatal mortality rate was 2.8/1000 births in the consultant unit (7950 deliveries), 4.8 in the isolated general practitioner units (5237 deliveries), and zero in the integrated general practitioner unit (1228 deliveries). Perinatal deaths attributable to asphyxia were more common in the isolated general practitioner units (1.5 per 1000) than the consultant unit (0.6 per 1000). The perinatal mortality rate among babies born to nulliparous women was 3.2/1000 births in the consultant unit and 5.7 in the isolated general practitioner units; for those born to multigravid women it was 2.4 and 4.2 respectively. CONCLUSIONS--The outcome of delivery was not influenced by parity. Both antenatal and intrapartum care were responsible for the higher perinatal mortality rate in the isolated general practitioner units. The integrated unit, which shared midwifery staff with the consultant unit, seemed to work well. Analysis by intended place of delivery at the time of onset of labour or diagnosis of intrauterine death suggested that the care given in isolated units needs to be improved, perhaps by better training of general practitioners and consultant supervision of antenatal care.     

Congenital heart block and maternal systemic lupus erythematosus.

The association between infants with congenital heart block (CHB) and the presence or later development of maternal systemic lupus erythematosus or other connective-tissue disease (CTD) was reviewed in 67 cases. In 24 cases CHB was diagnosed at or before birth. Of nine necropsies on affected infants, seven showed endomyocardial fibrosis. The results suggest that one in three mothers who deliver babies with CHB have or will develop CTD. The association is probably explained by placental transfer of a maternal antibody. Awareness of the association may lead to prevention of the birth of children with CHB and better neonatal care of affected children.     

Distance to Care,Facility Delivery and Early Neonatal Mortality in Malawi and Zambia

Background

Globally, approximately 3 million babies die annually within their first month. Access to adequate care at birth is needed to reduce newborn as well as maternal deaths. We explore the influence of distance to delivery care and of level of care on early neonatal mortality in rural Zambia and Malawi, the influence of distance (and level of care) on facility delivery, and the influence of facility delivery on early neonatal mortality.

Methods and Findings

National Health Facility Censuses were used to classify the level of obstetric care for 1131 Zambian and 446 Malawian delivery facilities. Straight-line distances to facilities were calculated for 3771 newborns in the 2007 Zambia DHS and 8842 newborns in the 2004 Malawi DHS. There was no association between distance to care and early neonatal mortality in Malawi (OR 0.97, 95%CI 0.58–1.60), while in Zambia, further distance (per 10 km) was associated with lower mortality (OR 0.55, 95%CI 0.35–0.87). The level of care provided in the closest facility showed no association with early neonatal mortality in either Malawi (OR 1.02, 95%CI 0.90–1.16) or Zambia (OR 1.02, 95%CI 0.82–1.26). In both countries, distance to care was strongly associated with facility use for delivery (Malawi: OR 0.35 per 10km, 95%CI 0.26–0.46). All results are adjusted for available confounders. Early neonatal mortality did not differ by frequency of facility delivery in the community.

Conclusions

While better geographic access and higher level of care were associated with more frequent facility delivery, there was no association with lower early neonatal mortality. This could be due to low quality of care for newborns at health facilities, but differential underreporting of early neonatal deaths in the DHS is an alternative explanation. Improved data sources are needed to monitor progress in the provision of obstetric and newborn care and its impact on mortality.     

Human milk bank in a district general hospital.

A human milk bank was organised in the special care baby unit of a district general hospital. The staff of the unit and members of a voluntary organisation helped to contact donors and arrange collection of milk samples. Over two years 2093 samples of expressed breast milk were collected from 187 donors and examined bacteriologically. Of these samples, 1171 (56%) grew no bacteria. If the organism count exceeded 2.5 X 10(6)/1 but was less than 1 X 10(9)/1 samples were subjected to mild heat treatment. If the count exceeded 1 X 10(9)/1 the milk was not fed to babies. Sixty-five babies received milk from the bank during the second year. Although these infants were vulnerable, mortality and morbidity were not adversely affected by the banked milk they received. The cost of establishing and running a human milk bank need not be high. Extensive resources such as extra staff and laboratory and transport facilities were not needed. Enthusiastic co-operation and good will between hospital staff, voluntary helpers, and donors contributed greatly to the success of the scheme.