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Neonatal Mortality Armed forces Hospital Programme Southern Region 2001-2006 Dr.AbdulRahman Alnemri Assistant professor peadiatric Consultant Neonatologist.

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Presentation on theme: "Neonatal Mortality Armed forces Hospital Programme Southern Region 2001-2006 Dr.AbdulRahman Alnemri Assistant professor peadiatric Consultant Neonatologist."— Presentation transcript:

1 Neonatal Mortality Armed forces Hospital Programme Southern Region Dr.AbdulRahman Alnemri Assistant professor peadiatric Consultant Neonatologist

2 غافر

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4 Background  Each year 4 million children die in the first 4 weeks of life  Global average of 30-36/1000 Live Birth Geneva WHO report,2005  Many neonatal deaths are preventable with existing low-cost intervention  Planners and policy makers required reliable cause-of –death information Int J Epidemiol 2003;

5  The reduction of child mortality has been included among the Millennium Development Goals(MDG-4) that the United Nations has set to be attained by year With out reduction in global NMR MDG-4 will not be achieved Strategies, which address inequalities both within a country and between countries, are necessary if there is going to be further improvement in global perinatal health. Report of the Secretary General. New York, NY: United Nations; UN document A756/326 4 million neonatal deaths: when? where? Why? Lancet 2005;365:

6 Causes of Neonatal Deaths  Estimation  WHO report before 2005 provide little detail with respect to perinatal-neonatal causes of death WHO,the world helth Report:2004Geneva  Neonatal infection the single largest cause of deaths globally national inst of science2003,pp.1-333

7 Estimating the cause of 4 million neonatal death in the year 2000  NMRs ranged from 2 to 18 per 1000 livebirths.  Based on 193 countries; the major causes  Infection (sepsis/pneumonia, tetanus, and diarrhea 35%  Preterm birth 28%  Asphyxia 23%  98% information on cause of death is lacking because of inadequate vital registration (VR) International Journal of Epidemiology 2006;35:706–718

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9 The estimated distribution of causes for 4 million neonatal deaths for the six WHO regions in the year Size of circle represents number of deaths in each region. Afr = Africa, Amr = Americas, Emr = Eastern Mediterranean, Eur = Europe, Sear = Southeast Asia, and W pr = Western Pacific

10 1.El Shafei AM, Sandhu AK, Dhaliwal JK. Perinatal mortality in Bahrain. Aust N Z J Obstet Gynaecol 1988;28:293–98. 2.Ebrahim AH. Perinatal mortality in Ministry of Health Hospitals- Bahrain, 1985 and J Bahrain Med Soc 1998;10:95–99. 3.Kishan J, Soni AL, Elzouki AY, Mir NA. Perinatal mortality and neonatal survival in Libya. J Trop Pediatr 1988;34:32–33. 4.el-Zibdeh MY, Al-Suleiman SA, Al-Sibai MH. Perinatal mortality at King Fahd Hospital of the University Al-Khobar, Saudi Arabia. Int J Gynaecol Obstet 1988;26:399– Asindi AA, Archibong E, Fatinni Y, Mannan N, Musa H. Perinatal and neonatal deaths. Saudi Med J 1998;19:693–97. 6.Dawodu A, Varady E, Verghese M, al-Gazali LI. Neonatal audit in the United Arab Emirates: a country with a rapidly developing economy. East Mediterr Health J 2000;6:55–64. 7.Yassin KM. Indices and sociodemographic determinants of childhood mortality in rural Upper Egypt. Soc Sci Med 2000;51:185–97. 8.Campbell O, Gipson R, el Mohandes A et al. The Egypt National Perinatal/Neonatal Mortality Study J Perinatol 2004;24:284–89.

11 Year IMRRank% ChangeDate %2003 est %2004 est %2005 est est. Source: CIA World Factbook - Unless otherwise noted, information in this page is accurate as of November 1, 2006 Infant and NMR in Saudi Arabia

12 DateFIFA Ranking position Mar Feb Jan Saudi Arabia average position from FIFA World Ranking creation is 38

13 Neonatal Mortality Rate North Saudi Arabia  NMR account for 60% of all infant deaths  (65.6%) occured in the neonatal period  Three main causes of death were identified: perinatal causes, genetic disorders and infection  44% of infant deaths considered as preventable JELLY A. E. (1) ; WARNASURIYA N. (1) Saudi medical journal 1998, vol. 19, no2, pp Avery’s Neonatology: Pathophysiology& Management of the Newborn. 6th ed. Philadelphia,Pa: Lippincott Williams & Wilkins;2005:459–489

14 Perinatal and neonatal deaths Department of Pediatrics, Abha Maternity Hospital, Abha  The average perinatal mortality rate was 14 per 1000 total births and the neonatal mortality rate was 9.6 per 1000 live-births during the period.  The major death determinants were low birth weight (LBW)/ prematurity, congenital malformation and birth asphyxia.  Respiratory insufficiency (89.9% of cases) and sepsis (36% of cases) were the main causes of neonatal deaths in low birth weight infants. Ann Saudi Med 1997;17(5):

15 Causes of neonatal deaths in ACH Causes of death No. of infants% of total (n=169) Low birth weight Congenital malformation Infection Birth asphyxia137.7 Meconium aspiration syndrome 21.2 Inborn error of metabolism21.2 Ann Saudi Med 1997;17(5):

16 Factors contributing to death in 77 LBW infants. Conditions No. of cases Hyaline membrane disease33 Sepsis23 Necrotizing enterocolitis14 Pulmonary hemorrhage4 Intraventricular hemorrhage3 Persistent pulmonary hypertension 3 Undetermined10 Ann Saudi Med 1997;17(5):

17 Neonatal vital statistics: a 5-year review in East P of Saudi Arabia.  The overall neonatal mortality rate declined from 15.6 to 8.1/1000 live births (LB), and after excluding lethal malformations mortality fell from 14.0 to 5.6/1000 LB  Congenital malformations, RDS, and asphyxia were the 3 most common causes of death. These conditions and severe immaturity account for 74% of deaths. Ann Trop Paediatr Sep;8(3):

18 CAUSE-SPECIFIC INFANT MORTALITY RATE IN QATIF AREA, EASTERN PROVINCE, SAUDI ARABIA Hussain Abu Srair, FRCP(C), FAAP; Joshua A. Owa, FNMC (Nig), FWAC; Hussain Ahmed Aman, MD Hussain Abu Srair, FRCP(C), FAAP; Joshua A. Owa, FNMC (Nig), FWAC; Hussain Ahmed Aman, MD  Forty-five (70.3%) of the deaths occurred in the neonatal period Major causes of IMR were  premature delivery (39.1%)  infections (25%)  birth defects (18.8%)  difficult delivery (4.7%) Ann Saudi Med 1995;15(2):

19  The NICU N mortality rate between 1990 and 2000 decreased from 8.3 to 5.7 per 1000 live births.  Prematurity related IVH & Sepsis(36%)  Congenital malformation 23% Alnemri, etal CP Resh 2002;6(1):1-6 NMR At KKUH

20 Prematurity and LBW Rate 1.Spain 1% 2.Finland, Sweeden, Ireland 4% 3.Jordan, Japan, Egypt 5% 4.Oman 6% 5.UK., USA,Chile 7% 6.Kuwait 7% 7.AFHSR 15.5% Unicef Report 2000

21 Neonatal vital statistics: a sex-year review in AFHSR. Dr.AbdulRAhman Alnemri,MD Dr.Ibrahim Alhefzi,MD Dr.Khaled Rashid,MD Dr.Ahmad Hellal Dr.Suliman Alfifi, MD

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24 Objective  To describe trend in neonatal mortality in AFH Southern region between 1 st January 2001 to 31 st Dec 2006  Determine the major causes of death in different birth weight group  The data could be used to plan the future direction of perinatal neonatal care at Armed Force hospitals south regions  Compare the outcome with Armed force hospitals programme.

25 METHODS  AFH SR NICU, is the tertiary centre in the region accommodate up to 40 newborns  There are 3 levels of care IC, IMC& feeder and grower  Descriptive analysis of data of all neonates died IN neonatal intensive care unit at AFHSR from January 2001 to Dec 2006  All perinatal and neonatal data collected from the maternal and neonatal medical records  The “underlying cause of death” is derived from the diagnosis listed on each death certificate according to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), ( 4th edition, Craig D. Puckett: volume 1,2,3 channel publishing LtdLotus approach 97 data program

26 METHODS  In cases where the cause of death was in doubt, case notes were reviewed with the doctor who certified the death of the neonate to arrive at a consensus direct cause of death  Exclusion criteria (DR DEATHS+STILL BIRTH)  The birth weight of 6-year study period was grouped into 3 groups 1)ELBW infants below 1000gm 2)VLBW infants gm 3)Near term infant more than or equal to 1500gm

27 General Statistic yrBirthSt.birthC.PMRENDLND (3.7)6 Total The average perinatal mortality rate was 14 per 1000 total births and the neonatal mortality rate was 9.6 per 1000 live-births

28 yearT. admissionT D (%) (6.5) (4.5) (4) (4.3) (7.4) (7.3) Total4352 (11.6%)247 (5.7) General Statistic NICU Mortality Review

29 Inborn Vs out-born NICU Death *Saudi med. j 2003, vol. 24, no12, pp out-borne neonate Mortality (9) 15.5%

30 CORRECTED MORTALITY * 58% ELBW* 26% 41% 22.5% 32.5%

31 MORTALITY EAR DISTRIBUTION

32 Mortality with gestational age

33 Early Mortality MEAN 3.6 DAYSMEAN 23 DAYS DAYS

34 Causes of all neonatal death Prematurity < 34wk, MCA multiple cong anomalies, BA+ birth asphyxia The major death determinants were low birth weight (LBW)/prematurity, stillbirth, congenital malformation and birth asphyxia Saudi medical journal, 1998, vol. 19, no6, pp

35 Admission on birth weight B. wtTotal admission DeathsM R(%) ELBW< 1000gm % % > 1500gm % Total Exclude multiple congenital and lethal deaths Corrected M R = 3.4%

36 ELBW Mortality (< 1000gm) Total deaths 85 Average Mortality Rate 36%

37 Mortality by B wt MEAN 670 GM

38 ELBW Deaths (< 1000gm) 77% <750gm Total 85/234 MR 36%

39 Causes of Deaths in ELBW PHE 37% PNX 12%

40 Causes of Deaths in ELBW (<1000gm)

41 Major Risk Factor  Antenatal care  Antenatal Steroid  Growth Retardation  Male Sex  Mode of Delivery  Multiple pregnancy  Ethnic group  In born Vs out born

42 Survival 5min Abgar < 783 (55.7%) Male60 (40.3%) Female89 SVD112 (75%) C section37 (25%) Booked97 (65%) Un-booked52 (35%) Full steroid97 No52 AGA122 (82%) IUGR27 (18%) 5min Abgar <755 (64.7%) Male51 (60%) Female34 P NSVD70 (82%) C. section15 P Booked18 P <0.1 Un booked67 (78.8%) full24 P < No61 (72%) AGA (>10 th 18 P IUGR (<10 th 67 (78%) Deaths Total 149 Total 85

43 Comparison of The Survival Rate of ELBW Infants (500 – 999 gm)

44 Very Low Birth Wt < 1500 gm

45 Mortality in gm B wtTotal adm Deaths% Total

46 Causes of Death in VLBW infant ( gm) CauseNo% Prem2562.5% MCA1537.5% Resp. f PHE 1352% Sepsis936% NEC28% IVH14%

47 Prenatal- Neonatal Death PHE PNEUMX IVH SEPSIS NEC MCA

48 Survival Rate of VLBW Infants RKH Experience

49 Near Term >1500 gm > 34 wks

50 Deaths in Near-term infant Mortality  Total admissions = 3713  85% OF TOTAL ADDMISSION  Deaths = 122 (64 early 58 late)  35 (28.6%) * lethal anomalies  M R = 33 / 1000 live birth (3.3%) ** DNR

51 Near Term Admission

52 Mortality Rate in Near Term infants >1500gm B. WtTotalNo. deaths MR % % > (42.6%) 2.4% Total %

53 B. wt. based Mortality Distribution L A* LA * 35 infant with Lethal Anomalies 40% IUGR

54 Lethal anomalies DNR DiagnosisNO CNS anomalies10 Trisomy 1811 Trisomy 134 thantophoric dysplasia5 Potter Syndromes5 Total35

55 CuasesNo (%) MCA 45 (37%) B. Asp +PPHN 37 (30%) IEM WITH L ACID 13(10.5%) D. hernia 9(7.5%) COMP. CHD 9 (7.5%) Hydropes 4 (3%) Sepsis 4 (3%) AWD 1 (1.5%) Total 122 MCA = Multiple congenital Anomalies

56 Risk Factors  The risk factors independently associated near term death included  low birth weight (IUGR) P value <.001  complications during labour p.001  lethal deformities P value  Infection 0.1

57 2007 Changes  Separate the unit coverage  Isolation  Feeding protocol  Inodomethacine prophylaxis

58 CORRECTED MORTALITY

59 Summary  Total live birth  Total Admission 4352 = 11.6 % of T. Birth  Total Death 229 (5.3%)  Prematrity related is the major cause of mortality(61%) especially ELBE 45%  IVH resposible for early death (45%) while sepsis is the major killer in late death (50%)  Multiple congenital anomalies is the 1 st cause of death in near term infant >34wks of gestation 37%  Followed by Prenatal asphyxia with or with out PPHN 30%  Poor antenatal care, multiple congenital anomalies, multiple pregnancy are major risk factors need to be evaluated

60 Conclusion  The perinatal neonatal services cooperation  National registry  Sepsis and IVH are the major contributing causes for mortality in ELBW infant  Antenatal steroid  Prematurity 15.5%  Congenital anomalies is very high (6 -8/1000 Live Birth)  Need revaluation of the service annually

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