1. CARE OF PREMATURE NEWBORNS
Am One in 10 Births
By Dr. Rashmi Gode
Moderator- Dr. Subodh Gupta

2. framework Introduction Definition and terminology Need of special care
Complications of preterm new-born
Long term Impact
Intervention need high coverage
Reducing Burden
NMR in India and interventions
Strategy and Commitment by organizations
References

3. introduction
Every Year-15 million babies are born preterm (1 in 10 babies) it is rising
Prematurity- world’s single biggest cause of newborn death, and 2nd leading cause of all child deaths, after pneumonia
Rate of preterm ---5% to 18% (184 countries)
In low – income group half babies born at 32weeks die due to-lack of feasible ,cost-effective care, and basic care for infections and breathing difficulties.
The high and rising incidence of preterm birth ,with death and disability is a significant Public health impact.

4. Epidemic of prematurity
Since 1990, the worldwide mortality rate of children under- five has declined from 90 to 46 deaths per 1,000 live births in 2013.
Annual reduction rate %
million were preterm births
% of all live births were Preterm ( 14.9 million)
2013- Globally 1 .1million death due to preterm birth complications ( Million)
Preterm mortality rates have declined at only 2.0% annually (WHO global mortality rate for preterm birth in 1990 and 2013).
Prematurity is moving higher up on the global agenda.
“We have an epidemic of preterm and newborn deaths that represents one of the greatest health challenges of the 21st century. Two-thirds of these deaths could be prevented without intensive care.” ( ….born too soon 2012 )

5. The 10 countries with the highest rates of preterm birth rate (% of live births) 2010
India % (% of Global total-23.6%)
China %
Nigeria %
Pakistan % ( % Global total -5.%)
Indonesia %
USA %
Bangladesh %
Philippines %
Democratic Republic of Congo %
Brazil %
*Source-lancet vol.379, June 9,2012

6. Definition
Babies born before 37th week of gestation are considered premature or “preemies”. Are sub-categories
Extremely preterm (<28 weeks)- 5%
Very preterm (28 to <32 weeks)- 10%
Moderate to late preterm-(32 to <37 weeks)- 83%
Post term ≥ 42 weeks
Survive – 24 weeks– 50% ,with Intensive care (HIC)
34 Weeks- 50% , (LMIC)
Many survive with lifetime disability, including learning disability and visual and hearing impairment
75% deaths from preterm birth can be prevented without intensive care

7. Terminology Low birth weight < 2.5 kg
Very Low Birth Weight < 1.5 kg
Extremely Low birth Weight < 1.0 kg
Early still birth (ICD)- Wt ≥500gm or ≥22weeks
Late still birth Wt ≥1000gm or ≥28weeks
Survive - Weight gm, 85%-90%
Weight gm, 20% survival
ELGAN: Extremely Low Gestational Age Newborn < 26 weeks

8. Types of preterm birth and risk factors
Spontaneous Preterm-birth
Age at pregnancy and pregnancy spacing
Multiple Pregnancy
Infection
Underlying Maternal chronic medical conditions
Nutritional
Lifestyle/work related /stress
Maternal psychological health
Genetic and other
Provider-initiated preterm birth
Medical induction or caesarean
Obstetric indication-cervical incompetence
Fetal Indication

9. Four settings -15 million preterm babies receive care
High Income Countries
Access to full intensive care (1.2 M)
Middle-income countries
Neonatal care units ( 3.8 M)
Low-income countries
Home Birth and care
at home(5.6M)
Low-income countries
Facility births but limited
space, staff and equipment
(4.4M)
Source-Born too soon, 2012,chapter 5

10. Survival gap 60 % -Africa and South Asia
12% are premature in poorest countries
9% -High income countries
High income countries- <10%
Low income countries -90%
Eg- Antenatal screening, High risk ANC enlisting, ANC steroids
Kangaroo Mother Acre

11. Need of special care Premature new-borns have underdeveloped systems
(Lungs. Digestive system, Immune system And skin
Inadequate respiration
Inadequate thermoregulation
Fluid and electrolyte imbalance – dehydration sunken fontanels <1ml/kg/hr or over hydration bulging, edema and urine output >3ml/kg/hr
PDA and Hypotension
Acid –Base disorders
CNS developmental issues

12. Long term Impact of Preterm birth on survivors
Long term Outcomes
Impact
Example
Frequency in survivors
specific physical effects
▪Visual impact
▪Hearing Impairment
▪Chronic lung disease of prematurity
Blindness
Increased hypermetropia and myopia
▪25% affect
▪ 5-10% in extremely preterm
▪40% of extremely preterm
Neuro-development/behaviour effects
▪Mild disorders of executive functioning
▪Specific learning impairments ,dyslexia,
▪Motor Impairment
Cerebral palsy
▪Affected by quality of care dependant
Family ,economic and social effects
▪Impact on family ,on health service
▪Psychosocial ,emotional, and economic
▪Risk of preterm birth in offspring
▪ medical risk factors ,disability,.

13. Five Intervention Needs high coverage
High Income countries
Smoking Cessation
Decreasing Multiple embryo transfers during assisted reproductive technologies
Cervical cerclage
Use of progesterone agents
And reduction of elective labour induction or caesarean delivery without medical indication
Low and middle income countries
Family planning;
Prevention and management of STIs
Use of insecticide treated bednets and
Intermittent preventive treatment for malaria
Identification and treatment of preeclampsia
Reduction of physical workload

14. Reducing the burden of Preterm Birth –A Dual track
Prevention of Preterm Birth
Premature baby care
Preconception care package
Antenatal care
Effective childbirth care
Policy support- No smoking, Employment safety for Pregnant women
Essential and extra newborn care, mainly feeding support
Kangaroo mother care
Neonatal resuscitation
Management of RDS ,Infections and Jaundice
Comprehensive neonatal Intensive Care
Preterm Labour Management
*Tocolytics to slow down labour
*Steroids
*Prevention of PROM by antibiotics
Preterm Birth reduction
Mortality reduction

15. who recommendations to intervention to improve preterm outcomes
Antenatal corticosteroids to improve new born outcomes
Tocolytics for inhibiting preterm labour
Magnesium sulphate for Fetal protection against neurological complications
Antibiotics for preterm labour
Optimal mode of delivery
Thermal care for preterm newborn- KMC
Continuous positive airway pressure for newborn with RDS
Surfactant administration for newborn with RDS
Oxygen therapy and concentration

16. nmr --India Neonatal deaths as % of
Infants death
India’s contribution to global neonatal deaths burden
Neonatal
Source- SRS 2012

17. Rural-urban nmr of india.

18. Difference Across the country
Source: SRS 2012 Statistical Report

19. Causes of neonatal mortality

20. Distribution of deaths due to prematurity
Source- Sanskar MJ 2014 ( Systematic Review under Publication)

21. Integrated service Delivery for maternal ,newborn and child health
Outreach/outpatient
Reproductive health care
Antenatal care
Postnatal care
Child health care
Clinical
Reproductive care
Childbirth care
Emergency newborn care
Emergency child care
Eg- KMC

22. Continued-- Family /community Adolescent and pre-pregnancy nutrition
Gender violence prevention
Education
Prevention of STIs and HIV
Optimise pre-pregnancy maternal conditions
Counselling and birth preparedness
Healthy Home care
Intersectoral
Improved living and working condition .

23. Kangaroo Mother Care KMC- a simple and cost effective technique
introduced in India in 1994
KMC and optimal feeding –a step
By GOI as a part of routine care.
In 2003, WHO formally endorsed KMC
and published KMC practice guidelines.
Improvement in gas exchange and
temperature in premature infants
Improvement in lactation
outcomes in mothers wishing to
breastfeed premature infants
Positive impact on the parenting
process

24. Milestones in India for child survival
1992 – Child Survival and Safe Motherhood Programme (CSSM)
1997 – RCH I
2005 – RCH II
2005 – National Rural Health Mission
2013 – RMNCH+A Strategy
2013 – National Health Mission
2014 – India Newborn Action Plan (INAP) to achieve
“Single Digit NMR” by 2030,

25. Intervention under nhm for newborn
Programme Year
Objectives
Status
JSY 2005
Safe motherhood to increase institutional delivery through demand-side-financing and conditional cash transfer
▪Implemented in all states and UT
▪Special focus on Low-performing States
IMNCI at community level and F-IMNCI at health facility 2008
Standard case management of major neonatal and childhood morbidity and mortality
▪Operational in ore than 500 districts
▪5.9 lakhs health and other functions,
26800MO and specialists at CHC/FRU
NSSK 2009
Basic newborn care and resuscitation training programme
▪1.3 lakh health provider trained to date
JSSK 2011
Zero out of pocket expenditure for maternal and infant health services
▪Benefit extended to sick children upto age 1yr

26. Intervention under nhm for newborn continued….
Programme Year
Objectives
Status
FBNC 2011
New born care corner
NBSUs at CHC/ FRUs SNCUs at DH/SDH
( All types of care except assisted ventilation and major surgeries)
▪14,135 NBCCs at delivery point
▪1810NBSUs at CHC/FRUs
▪548 SNCUs at DH/ SDH or Medical college
▪>6300 persons got FBNC training
▪Online reporting in 7 states with 245 SNCUs
▪>2.5lakhs newborns registered in data base
HBNC 2011
Essential care to NB, special care to preterm-al LBW newborns, family support for healthy practices by ASHA
▪Implemented in all states and UTs
▪Most ASHA trained in NBC
▪ASHAs visited .12 lakhs newborn in 2013
RBSK-2013
Screening children with birthdefects,diseases,
deficiency and developmental delays
All children ages 0 to 18 yrs.
> 8 crore children screened and >10lakhs identified for FRUs in 2013
New born stabilization unit

27. Current coverage levels for 8 indicators Globally
75 priority countries-90% of maternal newborn and child deaths.
Essential care reaches only half of the people in need
Sorce-Born Too Soon –WHO 2013

28. Evidence based study
Article: Incidence and risk factors of preterm birth in a rural Bangladesh cohort
Period- June september2009
Method-:CHW collected data from32,126 Mother-live born baby pairs on household Socio demographic status ,pregnancy history ,ANC seeking and Newborn Gestational age (LMP) and intervention of delivery package kit
Results: Out of 22.3%-Preterm(<37wks)12.3%:35-36wks, 7.1% wks & 2.9% wks.
Lower risk- In primary and higher educated females.(RR 0.92;95%CI ),*BNCP (RR 0.32:95% CI )
Higher risk- h/o child death under nutrition, antenatal complications and IFA only for 2-6 months
Conclusion- In minimum resource with High burden ,Preterm birth risk is reduce by close monitoring and/or frequent follow up ,encouraging women to seek ANC& to adopt BNCP
*Birth and new born care Preparedness
Source -Journal :BMC Peds 2014

29. Evidence based data for reduction in NMR –UK US
Phase 1- NMR reduction associated with public Health approaches
Phase 2– improved individual patient management associated with a further halving of NMR reduction prior to NICUs
Phase 3- Neonatal intensive care introduction and scale up 10
Source-Born Too Soon –WHO 2013

30. Strategy
United Nation’s Strategy – “Every Women Every Child” Strategy-target was set for 50% reduction in preterm deaths by 2025
Mobilized 200 commitments from national governments, NGO’s and private sectors.
World prematurity day- 17th November
Celebrated throughout the world, involving more than 60 countries globally, reaching nearly 1.5 billion people.

31. Commitments by organizations
WHO- to regularly providing analysis of global birth levels and trends
University of Malawi-improving care for new borns by introducing technology and enhancing Kangaroo Mother care
Save the children- to catalysing scale up of effective interventions such as kangaroo mother care, in highest burden countries
The bill & Melinda gates Foundation- to reducing preterm birth with grants of $ 1.5 billion (from )
The Home for Premature babies- to establish a branch in every province in china to support families affected by preterm

32. UNFPA-to strengthening mid wifery in 40 countries with emergency obstetric and new born care in 30 countries
The council of Neonatal nurses-to rising awareness about the dangers of premature birth
The March of Dimes- to prematurity Campaign through devoting 420 million annually to research
GAPPS- to Expanding collaborative efforts for global campaign for investment in research and catalyse funding for it.
The Johns Hopkins Bloomberg school of Public health- Strengthening evidence and causes of preterm births globally and developing culturally and economically appropriate interventions.

33. References
Baby,Joy E Lawn,Ruth Davidge.Born too soon ,The Global Action Report on preterm Birth,2012.
Born Too Soon: The global epidemiology of 15 million preterm births, Reproductive Health 2013,10(Suppl1)
India newborn action plan, MHFW, GOI, September 2014
State of India’s New-borns, Public Health Foundation Of India, Save the Children ,2014
WHO recommendations on interventions to improve preterm birth outcomes, WHO 2015.