Beruflich Dokumente
Kultur Dokumente
Members:
Acha, Kea Khaerloe
Alcantara, John Allen
Marcelo, Ma. Theresa Andrea
Moya, Mohanna
Napa, John Michael Joseph
Rey, Cathrina Marie
Yupangco, Maria Monica
TABLE OF CONTENTS
I. Introduction
i. Objectives
ii. Significance of the Study
iii. Conceptual Framework
II. Review of Related Literature
III. Methodolgy
IV. Results and Discussion
V. Conclusion
I Introduction
Large numbers of children die soon after birth: many of them in the first four weeks of life
(neonatal deaths), and most of those are the newborn babies who died during the first week (early
neonatal deaths). Neonatal deaths stem from poor maternal health, inadequate care during
pregnancy, inappropriate management of complications during pregnancy and delivery, poor
hygiene during delivery and the first critical hours after birth, and lack of newborn care. Several
factors such as womens status in society, their nutritional status at the time of conception, early
childbearing, too many closely spaced pregnancies and harmful practices, such as inadequate cord
care, letting the baby stay wet and cold, discarding colostrum and feeding other food, can be a
contributory factor also.
The neonatal period is one of the most vulnerable periods of life. Neonatal outcome is an
important indicator of obstetric and neonatal health care. Neonates become vulnerable to different
diseases especially the pre-term and low birth weight babies. In most cases, this diseases are
preventable. Neonatal morbidity and mortality are major global public health challenges with
approximately 3.1 million babies worldwide dying each year in the first month of life. This
represents a large proportion of overall under-5 child mortality, with the vast majority of neonatal
deaths occurring in resource-limited settings.
Globally, the neonatal mortality rate is declining. The worldwide neonatal mortality rate
fell by 47% between 1990 and 2015 from 36 to 19 deaths per 1,000 live births. Over the same
period, the number of newborn babies who died within the first 28 days of life declined from 5.1
million to 2.7 million. However, the decline in neonatal mortality in 19902015 has been slower
than that of post-neonatal under-five mortality (1-59 months): 47 percent, compared with 58
percent globally. This pattern applies to most low- and middle-income countries. Of the estimated
5.9 million child deaths in 2015, almost 1 million occur in the first day of life and close to 2 million
take place in the first week.
In the Philippines, in 2013, although the infant mortality rate slightly increased, the number
of registered infant deaths slightly decreased by more than one percent, from last years 22,254
cases to 21,992 cases. It comprised of 4.1 percent of the total deaths (531,280) reported during the
year. This represented a daily average of 60 infant deaths and was equivalent to an Infant Mortality
Rate (IMR) of 12.5 deaths per thousand live births. The top three leading causes of infant mortality
were Pneumonia (3,146; 14.3%); Bacterial sepsis of newborn (2,731; 12.4%); and Respiratory
distress of newborn (2,347; 10.7%). The listed top ten leading causes of infant mortality in 2013
were the same with what was recorded in 2012 which only differ in ranks.
While there are variations in the healthcare system of the different regions in the
Philippines, this study aims to focus on the mortality of neonates admitted in the NICU of Delos
Santos Medical Center from the years 2012 to 2016.
II Objectives
General Objectives:
To determine the mortality of neonates admitted in the De Los Santos Medical Center
Neonatal Intensive Care Unit from the years 2012 to 2016.
Specific Objectives:
To determine the causes of death of neonates admitted in the De Los Santos Medical Center
Neonatal Intensive Care Unit from the years 2012 to 2016.
To determine the prevalence of diseases in neonates in the De Los Santos Medical Center
Neonatal Intensive Care Unit
To be able to apply these information in the health care system of the hospital in terms of
prevention and management of these patients for better patient outcomes.
IV Conceptual Framework
Neonatal Mortality in DLSMC-
NICU from 2012 to 2016
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.
III Methodology
Research Design
The researchers utilized the descriptive, retrospective study design using the medical
records of all deceased neonates age 0-28 days between January 2012 to December 2016
admitted in Delos Santos Medical Center Neonatal Intensive Care Unit (NICU). Hand-written
and typewritten patient records, completed routinely by interns and residents, were transcribed to
analyze their respective demographic backgrounds that include: gender, birth weight, gestational
age, APGAR Score, delivery mode, length of stay, maternal disease and leading underlying
cause of death for the neonates.
Instrumentation
The study used medical records, patient charts and death certificates of neonates born
from January 2012 to December 2016 and were transferred to the Neonatal Intensive Care Unit
of DLSMC. The hand-written and typewritten patient records of the patients, completed
routinely by interns and residents, were retrieved and transcribed to analyze their respective
demographic backgrounds that include: gender, birth weight, gestational age, APGAR Score,
delivery mode, length of stay, maternal disease and leading underlying cause of death for the
neonates.
Data Collection
Participants of this study were deceased neonates age 0-28 days, who were born from
January 2012 to December 2016 in the Neonatal Intensive Care Unit of DLSMC. Out of the
2,579 admissions, there were a total of 16 deceased neonates who were eligible based on the
inclusion criteria. Their medical records and death certificates were transcribed and analyzed
based on their demographic backgrounds that include: gender, birth weight, gestational age,
APGAR Score, delivery mode, length of stay, maternal disease and leading underlying cause of
death for the neonates. Data unavailable in the patient records in the ward were retrieved through
review of patient charts and discharge certificates from the record office. Course in the ward of
these patients were reviewed and analyzed, as well as, management done to better understand the
cause of their deaths.
Ethical Considerations
The research upholds the confidentiality of the participants that are included in this study.
Medical records, patient charts and death certificates are only seen by the members of the
research team and its mentors. The identities were kept anonymous and confidential, as well as,
any information not related to this study were excluded.
Data Analysis
Data was analyzed using descriptive statistics, specifically frequency cumulative
frequencies, mean scores and percentage scores, which described the variables under study
namely: gender, birth weight, gestational age, APGAR Score, delivery mode, length of stay,
maternal disease and leading underlying cause of death for the neonates. Frequency distribution
was utilized in analyzing the scores of variables. This provided the researchers of view of the
general trend in the outcome of the study and the discrepancy of the scores of participants and its
variation from the mean. Creation of contingency tables was also done wherein the variables are
put in a cross-tabulated form for a simpler presentation of data.
Methodological Limitations
The major disadvantage of a non-experimental study is its weakness in revealing the
causal relationships of the variables under study. It is also susceptible to faulty interpretations if
the researcher is not careful with the analysis of data and also because there is a selection bias.
The researcher cannot also assume that the group being presented is similar before the
occurrence of the independent variable. An explanation of the preexisting differences in relation
to the current group differences on the outcome variable may then serve as a likely alternative
explanation for this phenomenon.
There are various critiques in using descriptive statistics. Adequate information, correct
use of indexes, and even presentation of data in a useful, efficient and comprehensible manner
should be taken into consideration.
RESULTS
Figure 1: Yearly census of live births and deceased neonates in DLSMC-NICU from 2012
to 2016
600
6
1 4
2 3
450
541 543 551
475 469
300
2012 2013 2014 2015 2016
Live births Deceased Neonates
Out of 2,579 live births from 2012-2016, there were 16 recorded deceased neonates (0.6%).
2012: 1 mortality (0.18%) from 541 live births
2013: 2 mortality (0.42%) from 475 live births
2014: 3 mortality (0.64%) from 469 live births
2015: 4 mortality (0.74%) from 543 live births
2016: 6 mortality (1.09%) from 551 live births
TOTAL
16 (100%)
Male
Female
SGA
AGA
Preterm
Term
NSD
CS
Open Cervix
Uterine Rupture
GDM
Pre-eclampsia
Placenta Previa
Cervicovaginitis
UTI
TOTAL
16 (100%)
Thanatropic Dysplasia
PPHN
Respiratory Insufficiency
Respiratory Failure Neonatal Cause of Death
Hypovolemic Shock
Birth Asphyxia
Septic Shock
DIC
DISCUSSION
Our findings state that from the year 2012 to 2016, out of 2579 neonates admitted to the newborn
unit, 16 were recorded deceased giving a mortality of 0.6%. 50% out of 16 deaths were due to
Disseminated Intravascular Coagulation followed by Septic Shock at 12.5%. Most of these
mortalities were mainly preterm males, Appropriate for Gestational Age (AGA), delivered via
Cesarean Section correlated with ascending infections from the urinary tract (UTI) of the mother
and had a > 7 days stay in the Neonatal Intensive Care Unit (NICU).
The relatively low number of neonatal mortality in the NICU of De Los Santos Medical Center
can be attributed to the availability of neonatal resources and good access to diagnostic modalities
that are usually covered by a tertiary hospital. In the study of Merlo et al., 2005, decreased neonatal
mortality in low-risk deliveries was seen in larger regional hospitals with full access to neonatal
care as compared to small hospitals. In addition, Lasswell et. Al., 2010 stated that very low birth
weight and very preterm infants born outside a level III hospital is significantly associated with
increased likelihood of neonatal or predischarged death. It is also emphasized by the American
Academy of Pediatrics that facilities that provide hospital care for newborn infants should be
classified on the basis of functional capabilities and that these facilities should be organized within
a regionalized system of perinatal care.
On the other hand, the prognosis and outcome of neonates with DIC are essentially dependent on
the primary disease process. In infants with DIC who experience severe bleeding, mortality rates
are reported to be increased by 60 to 80%. However, other literature now states that the majority
of infants with DIC survive due to the advances in neonatal medicine and its supportive care. DIC
is a secondary process set off by an underlying disease state that results in an imbalance of the
coagulation system and the fibrinolytic system. This disruption in hemostasis leads to
microthrombi distribution throughout the circulation concurrent with systemic hemorrhaging, and
resulting in end organ dysfunction. Male infants have been consistently noted to have a higher
infant mortality rate than female infants. The higher rate of mortality for male infants is present
both in the neonatal and the postneonatal period and persists even after other known risk factors
for mortality are controlled. Prematurity has also been the leading cause of neonatal deaths
reported by WHO. This is mainly due to the inability of the neonate to cope with extrauterine life
due to the immaturity of their organs.
Data specific to elective cesarean delivery in uncomplicated pregnancies are conflicting. Lu &
Johnson, 2014 reported that in order to improve quality and safety of maternal and neonatal care,
early elective deliveries should be reduced. Infants delivered after 37 weeks but before 39 weeks
have significantly greater risks of mortality and morbidities. However, in a meta-analysis of 9
studies including more than 33,000 women, Mozurkewich and colleagues reported a significant
increase in intrapartum and neonatal deaths among term, non-malformed infants who underwent
a trial of labor, compared to those who underwent elective repeat cesarean delivery. Yet, a recent
U.S. population-based study of neonatal and infant mortality by mode of delivery among women
with no indicated risk, however, showed that neonatal mortality was increased more than two-
fold after birth by cesarean, even after excluding infants with congenital anomalies and presumed
intrapartum hypoxic events (Apgar score < 4) and adjusting for demographic and medical
covariates In these studies and others, the reported rates of neonatal death after elective repeat or
no indicated risk cesareans are low, ranging from 0.01 0.17%.
Maternal UTI is the major risk factor identified in our study leading to neonatal DIC secondary to
neonatal sepsis, prematurity, and eventually neonatal death after an elective cesarian section
delivery. Emamghorashi et al., 2012 showed a significant relationship between maternal prenatal
UTI and neonatal infection. It is therefore important to pay attention to the control of maternal
infections prenatally in order to minimize if not totally eradicate neonatal deaths.
Our study is limited by the unavailability of all maternal risk factors and maternal data sheet that
may have helped us correlate the neonatal deaths in the NICU. Also, the availability of how the
neonates were resuscitated in detail were not disclosed. Moreover, most literature related to this
study are coming from third world government hospitals. A thorough comparison from other
tertiary private hospitals especially in the Philippines or Southeast Asia is therefore highly
recommended.
CONCLUSION
The neonatal mortality of the Neonatal Intensive Care Unit in De Los Santos Medical Center from
the year 2012-2016 is 0.6%. This is significantly low and a good indication of the proper and
efficient health care provided by the team of physicians in the pediatric department of the
institution. Neonatal disseminated intravascular coagulation secondary to neonatal sepsis and
prematurity is identified as the leading cause of death. The major risk factor associated with these
deaths is maternal urinary tract infection. Addressing the infection prenatally and preventing
prematurity is therefore crucial in lowering neonatal mortality.
Sources:
Merlo J, Gerdtham UG, Eckerlund I, et al. Hospital Level of Care and Neonatal Mortality in Low- and
High-Risk Deliveries: Reassessing the Question in Sweden by Multilevel Analysis. Medical Care. 2005
Nov; 43(11): 1092-1100. <http://journals.lww.com/lww-
medicalcare/Abstract/2005/11000/Hospital_Level_of_Care_and_Neonatal_Mortality_in.5.aspx>
Michael C. Lu, Kay A. Johnson, Toward a National Strategy on Infant Mortality, American Journal of Public
Health 104, no. S1 (February 1, 2014): pp. S13-S16. DOI: 10.2105/AJPH.2013.301855 PMID: 24410337
Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-
birth-weight and very preterm infants: a meta-analysis. JAMA. 2010;304(9):992
1000. CrossRef, Medline
Emamghorashi F, Mahmoodi N, Tagarod Z, Heydari ST, Iranian Journal of Kidney Diseases; Thran 6.3 (May 2012):
178-80