Neonatology in developed and developing nations
http://www.100md.com
《美国医学杂志》
1 Department of Pediatrics, Central Hospital, Sector 20A, Faridabad, India
2 Department of Newborn Care, Royal Hospital for Women, Randwick, NSW 2031, Australia
Neonatal care has made tremendous improvements in developing countries. However there are number of challenges to be met and neonatal mortality remains unacceptably high. In contrast to this neonatal care in developed nations have moved ahead of a pre-occupation to reducing the neonatal mortality only. The main reasons for this gap are poor infrastructure, resource limitations and lack of systems developed by neonatal units in the developed nations. Though this communication we explore the possibilities of application of health policies in the Australian neonatal units n developing countries.
Keywords: Neonatology; Developed; Developing; Nations
Neonatal and perinatal mortality rates are the major indicators of the health status of the nations.[1] Many developing nations especially India has an increasing focus on the neonatal care with tertiary level centers being established to provide neonatal training programs.[2],[3] But despite remarkable progress in urban areas, neonatal and perinatal mortality and morbidity remains high (rural and urban neonatal mortality rates being 46.7 and 31.7 respectively).[4] This is in stark contrast to developed nations such as Australia where the neonatal and perinatal mortality stands at only 3.4 and 8.5 per 1000 live births respectively.[5] The major factors limiting progress in neonatology in India have been addressed by Dr Bhargava.[6]
The authors briefly discuss Australian health policies and strategies that had kept their neonatal and perinatal rates to the best minimum possible. Through this communication the authors explore the applicability of these policies for better delivery of the antenatal, perinatal and neonatal services in developing countries, particularly India. These centre discuss on the following issues:
Community Neonatology
More than half of the deliveries in India still happen in a non-institutional area [4]. This is largely responsible for increased neonatal and perinatal mortality. Delivery by the untrained dais in unfavorable environment continues to be an unending saga. In Australia secondary and community level hospitals have link-ups with designated tertiary hospitals resulting in referral of the sick neonate at the earliest. Good care with available resources at secondary and community level hospitals can serve the purpose of a large number of neonates in developing nations [7],[8]. Community interventions are the most cost effective method to reduce mortality and morbidity. This has recently been shown in research done in rural areas of Gadchiroli [9]. Large number of preterm neonates can now be managed with gentler ways of ventilation such as CPAP [10]. It seems to be a feasible option to develop NICU's at low cost which can provide care to a large number of preterm neonates with gentle non-invasive ventilation.
Neonatal and Nursing Training
Concentrated efforts of pioneers in India with a strong backing of the National Neonatology forum and support from the governmental and international agencies has helped most tertiary level centers to equip themselves with the state of art equipment required for the neonatal care.[3] There also has been a laudable improvement in the training of doctors in the field of neonatology and a DM course in Neonatology has been initiated. However, a MEDLINE search and search of the two major journals of Pediatrics in India (1999-2004) did not reveal any article on Neonatal nursing. The potential for nursing education in the field of neonatology remain untapped and unexplored with little focus on it during the basic nursing training courses. It now seems quite a possible task for post graduate institutes with large number of trained and experienced nurses to start formal training courses in neonatal nursing. This will fill the long felt void of advanced neonatal nurse practitioners and also facilitate research in areas related to neonatal nursing. This will at the same time better highlight the nursing perspectives for developing countries. Logically enough with more trained nurses available the gap in the nursing care norms for the level II and III neonatal care would be bridged.
Neonatal Emergency Transport Services (NETS)
NETS linked with the regional and tertiary perinatal services has gone a long way in reducing mortality and morbidity in developed nations. In Australia, each state has a well developed network of emergency transport services with separate retrieval teams consisting of a doctor and a trained nurse. They coordinate with the secondary and tertiary NICU's in the states.[11] These services are mostly run by the funds collected from the charity work or other private organizations as donations. As most neonates in developing countries are transported without any medical aid an unestimated number dies either before reaching the nursery or are brought in much advanced morbidity. India has a large number of non- governmental organizations and formulation of public trusts dedicated for developing the neonatal emergency transport services on a regional basis seems be a feasible option. Embarking on such an initiative will save lives of large number of neonates.
Research in Neonatology
Research and development are integral entities for development of any field of science. Most research in developed world is well funded. Research in neonatology remains far from satisfactory in nations like India.[12],[13] Recent retrospective survey of the various studies published in four indexed Indian journals revealed striking gaps in the type and quality of research needed for developing nations.[12] There were no experimental studies on perinatal asphyxia. Majority of the descriptive studies were on subjects of no national importance. There were only 5.6% studies which were community based. There were only two long term studies on development of high risk neonates. Most analytical studies were poorly designed. Such a scenario calls for urgent introspection as has been aptly addressed by Prof. Narang.[12] More recognition and availability of funds for researchers by the governmental, non-governmental bodies will help more doctors to conduct research in the relevant areas of concerns for developing nations.
Drug Dispensing (Pharmacy) Aspects
Drug dispensing is an important area in neonatology as the dosage required by neonates is fraction of that required by adults. Also neonates do not have the buffer many times to withstand medication errors.[14] A well researched hospital pharmacy, providing prepared total parenteral nutrition, antibiotics and other medications in suitable formulations with clear instructions to avoid any administration errors, is necessary for advanced care of sick neonates. There exists a two tier checking system for the medication errors in most units in Australia (Neonatal nurse checks the dose before administering, and medication of all charts are rechecked by a senior pharmacist) and incidents are reported for any error on part of the pharmacy. Such a system decreases the errors to a significantly low level. Pneumatic system for sending urgent blood investigations as well as receiving blood products from the laboratory help prompt availability of pathology and biochemical results. Results are linked up with the computers in the units giving an easy access to the users.
Feto-maternal Medicine
This has grown itself as a fully specialized independent field in the western world.[15] There have been significant advances in the antenatal diagnosis and management of the complex congenital fetal malformations. This results in a better comprehensive management of the surgical and genetic problems of the neonates. Our hospital has a well developed maternal-fetal unit involved in antenatal diagnosis and management of complex fetal genetic, surgical and medical conditions. Though there has been a steady progress in this field in the developing nations it has been hampered by poor awareness in the people and is limited to only few centers. A large number of neonates in primary and secondary levels of care in developing world with congenital, genetic and surgical malformations are born in an unprepared, chaotic facility. This results in uninformed and unsatisfactory management of babies needing surgical correction or genetic counselling for the future pregnancies. Public awareness programmes, better antenatal services and referral and follow-up will lead to a better care.
Newborn Screening Programme
Is the most modern public health preventive population-screening programme in all the developed countries. With the advances in technology and knowledge in genetics, much attention has been focused on screening for preventable causes of disability and death in the newborn babies. This has been a routine now in all developed nations. In Australia, all newborn babies are screened on the third day of life for metabolic disorders.[16] In developing nations like India such programs are yet to be undertaken. Studies carried out recently in Hyderabad have shown an unusually high prevalence of inborn errors of metabolism to the extent of 1 per thousand newborns.[17] This study reveals the importance of screening in India, necessitating nation wide large-scale screening.
Follow up Care
Neonatal care poses complex psychosocial problems to the family. Some of the areas in which social support is needed are critically sick neonates admitted in NICU's for months, neonates of methadone dependent mothers, depressed mothers etc. Developing nation has its own concerns with poverty and illiteracy as the most pressing problems in mothers. Formulation of special multidisciplinary teams at secondary and tertiary centers involving social workers and home visits to enquire into problems relating to mothers and neonates especially for the high risk mothers would help in the detection of the problems at the earliest.[18]
Data collection and analysis
Is an important aspect for giving future directions to the care of neonates. Australia and New Zealand have an excellent data collection system. The neonatal, maternal and perinatal data that comprise the Australia and New Zealand neonatal network Data Collection, are prospectively collected and collated within each neonatal intensive care unit by a designated Clinical Audit Officer. These data are compiled into a central database where they undergo rigorous quality control procedures.[19]
National Neonatal perinatal database (only large national database in the developing nation) is already generating important data on large number of neonates from many centers across India.[20] The efforts are commendable and praiseworthy. Linking follow up data on high risk neonates from practicing pediatricians to bigger private tertiary hospitals and medical schools will generate better long term data. All of these regional data can then be linked to the National Neonatal and Perinatal database (NNPD). This would give a larger picture of the neonatal concerns and thus help in further research.
Incorporation of some of these suggestions in a phased manner with concentrated efforts of the government, NGO's, professional bodies and people alike should help bridge the gap between the neonatal care of developed and developing nations.
Acknowledgement
Authors express their sincere thanks to Prof NB Mathur, President National Neonatology forum (NNF), New Delhi, India for critically appraising the paper.
References
1.Satyanarayana L, Indrayan A. Measures of mortality and morbidity in children. Indian Pediatrics 2000; 37(17): 515-521.
2.Costello AML, Singh M. Recent developments for neonatal health in developing nations. Seminars Neonatol 1999; 4(3): 131-139.
3.Paul VK. Newborn care in India: A promising beginning, but a long way to go. Seminars in Neonatol 1999; 4(3) : 141-149.
4.National family health survey (NFHS 2), India, 1998-99. International Institute for Population Sciences, Mumbai, India, and ORC macro, Maryland, USA, October 2000
5.Reproductive health indicators Australia, 2002. Available from http://www.npsu.unsw.edu.au/publications. Accessed 23 April 2005
6.Bhargava SK. The challenge of Neonatal mortality in India. Indian Pediatr 2004; 41(7): 657-664
7.Garg P, Krishak R, Shukla DK. NICU in a community level hospital. Indian J Pediatr 2005; 72 : 27-30. [PUBMED] [FULLTEXT]
8.Bose A, Sinha S, Choudhary M, Aruldas K, Moses PD, Joseph A. Experiences of neonatal care in a secondary level hospital. Indian Pediatr 1999; 35(6) : 803-807.
9.Bang TA, Reddy HM, Deshmukh MD, Baitule SB, Bang AR. Neonatal and infant mortality in the ten years (1993 to 2003) of the Gadchiroli field trial: Effect of home based Neonatal care. J Perinatol 2005; 25: S92-S107.
10.Upadhyay A, Deorari AK. Continuous positive airway pressure- A gentler approach to ventilation. Indian Pediatric 2004; 41(5) : 459-469.
11.Neonatal emergency transport services. Available http:// www.nets.org.au. Accessed 3 May 2005
12.Narang A, Srinivas Murki. Research for neonatology: Need for Introspection. Indian Pediatr 2004; 41 : 170-174.
13.Bhutta ZA, Darmstadt G L, Hasan BS, Haws RA. Community-based interventions for improving Perinatal and Neonatal health outcomes in developing countries: A review of the evidence. Pediatrics 2005; 115(2) : 519-617.
14.Simpson JH, Lynch R, Grant J, Alroomi L. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2004 Nov; 89(6):F480-2.
15.Norwitz ER, Bahtiyar MO, Sibai BM. Defining standards of care in maternal-fetal medicine. Am J Obstet Gynecol 2004; 191(4) : 1491-1496.
16.NSW Newborn screening programme. The Children's Hospital at Westmead. Available from http://www.chw.edu.au/prof/services/newborn Accessed 1 July 2005
17.Verma I C, Bijarnia S. The Burden of Genetic Disorders in India and a Framework for Community Control. Community Genetics 2002; 5 : 192-196.
18.Bang AT, Bang RA, Reddy HM, Deshmukh MD, Baitule SB. Reduced incidence of Neonatal morbidities: Effect of home -based Neonatal care in rural Gadchiroli, India. J Perinatol 2005; 25: S62-S71
19.Australia's mothers and babies 2002. Available http:// www.npsu.unsw.edu.au/. Accessed 15 March 2005
20.National Neonatology Forum. Report of the neonatal-perinatal database (2000). Available http://www.nnfi.org/Nnpd.pdf. Accessed 2 Feb 2005.(Garg Pankaj, Bolisetty Srinivas)
2 Department of Newborn Care, Royal Hospital for Women, Randwick, NSW 2031, Australia
Neonatal care has made tremendous improvements in developing countries. However there are number of challenges to be met and neonatal mortality remains unacceptably high. In contrast to this neonatal care in developed nations have moved ahead of a pre-occupation to reducing the neonatal mortality only. The main reasons for this gap are poor infrastructure, resource limitations and lack of systems developed by neonatal units in the developed nations. Though this communication we explore the possibilities of application of health policies in the Australian neonatal units n developing countries.
Keywords: Neonatology; Developed; Developing; Nations
Neonatal and perinatal mortality rates are the major indicators of the health status of the nations.[1] Many developing nations especially India has an increasing focus on the neonatal care with tertiary level centers being established to provide neonatal training programs.[2],[3] But despite remarkable progress in urban areas, neonatal and perinatal mortality and morbidity remains high (rural and urban neonatal mortality rates being 46.7 and 31.7 respectively).[4] This is in stark contrast to developed nations such as Australia where the neonatal and perinatal mortality stands at only 3.4 and 8.5 per 1000 live births respectively.[5] The major factors limiting progress in neonatology in India have been addressed by Dr Bhargava.[6]
The authors briefly discuss Australian health policies and strategies that had kept their neonatal and perinatal rates to the best minimum possible. Through this communication the authors explore the applicability of these policies for better delivery of the antenatal, perinatal and neonatal services in developing countries, particularly India. These centre discuss on the following issues:
Community Neonatology
More than half of the deliveries in India still happen in a non-institutional area [4]. This is largely responsible for increased neonatal and perinatal mortality. Delivery by the untrained dais in unfavorable environment continues to be an unending saga. In Australia secondary and community level hospitals have link-ups with designated tertiary hospitals resulting in referral of the sick neonate at the earliest. Good care with available resources at secondary and community level hospitals can serve the purpose of a large number of neonates in developing nations [7],[8]. Community interventions are the most cost effective method to reduce mortality and morbidity. This has recently been shown in research done in rural areas of Gadchiroli [9]. Large number of preterm neonates can now be managed with gentler ways of ventilation such as CPAP [10]. It seems to be a feasible option to develop NICU's at low cost which can provide care to a large number of preterm neonates with gentle non-invasive ventilation.
Neonatal and Nursing Training
Concentrated efforts of pioneers in India with a strong backing of the National Neonatology forum and support from the governmental and international agencies has helped most tertiary level centers to equip themselves with the state of art equipment required for the neonatal care.[3] There also has been a laudable improvement in the training of doctors in the field of neonatology and a DM course in Neonatology has been initiated. However, a MEDLINE search and search of the two major journals of Pediatrics in India (1999-2004) did not reveal any article on Neonatal nursing. The potential for nursing education in the field of neonatology remain untapped and unexplored with little focus on it during the basic nursing training courses. It now seems quite a possible task for post graduate institutes with large number of trained and experienced nurses to start formal training courses in neonatal nursing. This will fill the long felt void of advanced neonatal nurse practitioners and also facilitate research in areas related to neonatal nursing. This will at the same time better highlight the nursing perspectives for developing countries. Logically enough with more trained nurses available the gap in the nursing care norms for the level II and III neonatal care would be bridged.
Neonatal Emergency Transport Services (NETS)
NETS linked with the regional and tertiary perinatal services has gone a long way in reducing mortality and morbidity in developed nations. In Australia, each state has a well developed network of emergency transport services with separate retrieval teams consisting of a doctor and a trained nurse. They coordinate with the secondary and tertiary NICU's in the states.[11] These services are mostly run by the funds collected from the charity work or other private organizations as donations. As most neonates in developing countries are transported without any medical aid an unestimated number dies either before reaching the nursery or are brought in much advanced morbidity. India has a large number of non- governmental organizations and formulation of public trusts dedicated for developing the neonatal emergency transport services on a regional basis seems be a feasible option. Embarking on such an initiative will save lives of large number of neonates.
Research in Neonatology
Research and development are integral entities for development of any field of science. Most research in developed world is well funded. Research in neonatology remains far from satisfactory in nations like India.[12],[13] Recent retrospective survey of the various studies published in four indexed Indian journals revealed striking gaps in the type and quality of research needed for developing nations.[12] There were no experimental studies on perinatal asphyxia. Majority of the descriptive studies were on subjects of no national importance. There were only 5.6% studies which were community based. There were only two long term studies on development of high risk neonates. Most analytical studies were poorly designed. Such a scenario calls for urgent introspection as has been aptly addressed by Prof. Narang.[12] More recognition and availability of funds for researchers by the governmental, non-governmental bodies will help more doctors to conduct research in the relevant areas of concerns for developing nations.
Drug Dispensing (Pharmacy) Aspects
Drug dispensing is an important area in neonatology as the dosage required by neonates is fraction of that required by adults. Also neonates do not have the buffer many times to withstand medication errors.[14] A well researched hospital pharmacy, providing prepared total parenteral nutrition, antibiotics and other medications in suitable formulations with clear instructions to avoid any administration errors, is necessary for advanced care of sick neonates. There exists a two tier checking system for the medication errors in most units in Australia (Neonatal nurse checks the dose before administering, and medication of all charts are rechecked by a senior pharmacist) and incidents are reported for any error on part of the pharmacy. Such a system decreases the errors to a significantly low level. Pneumatic system for sending urgent blood investigations as well as receiving blood products from the laboratory help prompt availability of pathology and biochemical results. Results are linked up with the computers in the units giving an easy access to the users.
Feto-maternal Medicine
This has grown itself as a fully specialized independent field in the western world.[15] There have been significant advances in the antenatal diagnosis and management of the complex congenital fetal malformations. This results in a better comprehensive management of the surgical and genetic problems of the neonates. Our hospital has a well developed maternal-fetal unit involved in antenatal diagnosis and management of complex fetal genetic, surgical and medical conditions. Though there has been a steady progress in this field in the developing nations it has been hampered by poor awareness in the people and is limited to only few centers. A large number of neonates in primary and secondary levels of care in developing world with congenital, genetic and surgical malformations are born in an unprepared, chaotic facility. This results in uninformed and unsatisfactory management of babies needing surgical correction or genetic counselling for the future pregnancies. Public awareness programmes, better antenatal services and referral and follow-up will lead to a better care.
Newborn Screening Programme
Is the most modern public health preventive population-screening programme in all the developed countries. With the advances in technology and knowledge in genetics, much attention has been focused on screening for preventable causes of disability and death in the newborn babies. This has been a routine now in all developed nations. In Australia, all newborn babies are screened on the third day of life for metabolic disorders.[16] In developing nations like India such programs are yet to be undertaken. Studies carried out recently in Hyderabad have shown an unusually high prevalence of inborn errors of metabolism to the extent of 1 per thousand newborns.[17] This study reveals the importance of screening in India, necessitating nation wide large-scale screening.
Follow up Care
Neonatal care poses complex psychosocial problems to the family. Some of the areas in which social support is needed are critically sick neonates admitted in NICU's for months, neonates of methadone dependent mothers, depressed mothers etc. Developing nation has its own concerns with poverty and illiteracy as the most pressing problems in mothers. Formulation of special multidisciplinary teams at secondary and tertiary centers involving social workers and home visits to enquire into problems relating to mothers and neonates especially for the high risk mothers would help in the detection of the problems at the earliest.[18]
Data collection and analysis
Is an important aspect for giving future directions to the care of neonates. Australia and New Zealand have an excellent data collection system. The neonatal, maternal and perinatal data that comprise the Australia and New Zealand neonatal network Data Collection, are prospectively collected and collated within each neonatal intensive care unit by a designated Clinical Audit Officer. These data are compiled into a central database where they undergo rigorous quality control procedures.[19]
National Neonatal perinatal database (only large national database in the developing nation) is already generating important data on large number of neonates from many centers across India.[20] The efforts are commendable and praiseworthy. Linking follow up data on high risk neonates from practicing pediatricians to bigger private tertiary hospitals and medical schools will generate better long term data. All of these regional data can then be linked to the National Neonatal and Perinatal database (NNPD). This would give a larger picture of the neonatal concerns and thus help in further research.
Incorporation of some of these suggestions in a phased manner with concentrated efforts of the government, NGO's, professional bodies and people alike should help bridge the gap between the neonatal care of developed and developing nations.
Acknowledgement
Authors express their sincere thanks to Prof NB Mathur, President National Neonatology forum (NNF), New Delhi, India for critically appraising the paper.
References
1.Satyanarayana L, Indrayan A. Measures of mortality and morbidity in children. Indian Pediatrics 2000; 37(17): 515-521.
2.Costello AML, Singh M. Recent developments for neonatal health in developing nations. Seminars Neonatol 1999; 4(3): 131-139.
3.Paul VK. Newborn care in India: A promising beginning, but a long way to go. Seminars in Neonatol 1999; 4(3) : 141-149.
4.National family health survey (NFHS 2), India, 1998-99. International Institute for Population Sciences, Mumbai, India, and ORC macro, Maryland, USA, October 2000
5.Reproductive health indicators Australia, 2002. Available from http://www.npsu.unsw.edu.au/publications. Accessed 23 April 2005
6.Bhargava SK. The challenge of Neonatal mortality in India. Indian Pediatr 2004; 41(7): 657-664
7.Garg P, Krishak R, Shukla DK. NICU in a community level hospital. Indian J Pediatr 2005; 72 : 27-30. [PUBMED] [FULLTEXT]
8.Bose A, Sinha S, Choudhary M, Aruldas K, Moses PD, Joseph A. Experiences of neonatal care in a secondary level hospital. Indian Pediatr 1999; 35(6) : 803-807.
9.Bang TA, Reddy HM, Deshmukh MD, Baitule SB, Bang AR. Neonatal and infant mortality in the ten years (1993 to 2003) of the Gadchiroli field trial: Effect of home based Neonatal care. J Perinatol 2005; 25: S92-S107.
10.Upadhyay A, Deorari AK. Continuous positive airway pressure- A gentler approach to ventilation. Indian Pediatric 2004; 41(5) : 459-469.
11.Neonatal emergency transport services. Available http:// www.nets.org.au. Accessed 3 May 2005
12.Narang A, Srinivas Murki. Research for neonatology: Need for Introspection. Indian Pediatr 2004; 41 : 170-174.
13.Bhutta ZA, Darmstadt G L, Hasan BS, Haws RA. Community-based interventions for improving Perinatal and Neonatal health outcomes in developing countries: A review of the evidence. Pediatrics 2005; 115(2) : 519-617.
14.Simpson JH, Lynch R, Grant J, Alroomi L. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2004 Nov; 89(6):F480-2.
15.Norwitz ER, Bahtiyar MO, Sibai BM. Defining standards of care in maternal-fetal medicine. Am J Obstet Gynecol 2004; 191(4) : 1491-1496.
16.NSW Newborn screening programme. The Children's Hospital at Westmead. Available from http://www.chw.edu.au/prof/services/newborn Accessed 1 July 2005
17.Verma I C, Bijarnia S. The Burden of Genetic Disorders in India and a Framework for Community Control. Community Genetics 2002; 5 : 192-196.
18.Bang AT, Bang RA, Reddy HM, Deshmukh MD, Baitule SB. Reduced incidence of Neonatal morbidities: Effect of home -based Neonatal care in rural Gadchiroli, India. J Perinatol 2005; 25: S62-S71
19.Australia's mothers and babies 2002. Available http:// www.npsu.unsw.edu.au/. Accessed 15 March 2005
20.National Neonatology Forum. Report of the neonatal-perinatal database (2000). Available http://www.nnfi.org/Nnpd.pdf. Accessed 2 Feb 2005.(Garg Pankaj, Bolisetty Srinivas)