Research Article: Care practices and neonatal survival in 52 neonatal intensive care units in Telangana and Andhra Pradesh, India: A cross-sectional study

Date Published: July 23, 2019

Publisher: Public Library of Science

Author(s): Claudia Hanson, Samiksha Singh, Karen Zamboni, Mukta Tyagi, Swecha Chamarty, Rajan Shukla, Joanna Schellenberg, Usha Ram

Abstract: BackgroundThe Indian government supports both public- and private-sector provision of hospital care for neonates: neonatal intensive care is offered in public facilities alongside a rising number of private-for-profit providers. However, there are few published reports about mortality levels and care practices in these facilities. We aimed to assess care practices, causes of admission, and outcomes from neonatal intensive care units (NICUs) in public secondary and private tertiary hospitals and both public and private medical colleges enrolled in a quality improvement collaborative in Telangana and Andhra Pradesh—2 Indian states with a respective population of 35 and 50 million.Methods and findingsWe conducted a cross-sectional study between 30 May and 26 August 2016 as part of a baseline evaluation in 52 consenting hospitals (26 public secondary hospitals, 5 public medical colleges, 15 private tertiary hospitals, and 6 private medical colleges) offering neonatal intensive care. We assessed the availability of staff and services, adherence to evidence-based practices at admission, and case fatality after admission to the NICU using a range of tools, including facility assessment, observations of admission, and abstraction of registers and telephone interviews after discharge. Our analysis is adjusted for clustering and weighted for caseload at the hospital level and presents findings stratified by type and ownership of hospitals. In total, the NICUs included just over 3,000 admissions per month. Staffing and infrastructure provision were largely according to government guidelines, except that only a mean of 1 but not the recommended 4 paediatricians were working in public secondary NICUs per 10 beds. On admission, all neonates admitted to private hospitals had auscultation (100%, 19 of 19 observations) but only 42% (95% confidence interval [CI] 25%–62%, p-value for difference is 0.361) in public secondary hospitals. The most common single cause of admission was preterm birth (25%) followed by jaundice (23%). Case-fatality rates at age 28 days after admission to a NICU were 4% (95% CI 2%–8%), 15% (9%–24%), 4% (2%–8%) and 2% (1%–5%) (Chi-squared p = 0.001) in public secondary hospitals, public medical colleges, private tertiary hospitals, and private medical colleges, respectively, according to facility registers. Case fatality according to postdischarge telephone interviews found rates of 12% (95% CI 7%–18%) for public secondary hospitals. Roughly 6% of admitted neonates were referred to another facility. Outcome data were missing for 27% and 8% of admissions to private tertiary hospitals and private medical colleges. Our study faced the limitation of missing data due to incomplete documentation. Further generalizability was limited due to the small sample size among private facilities.ConclusionsOur findings suggest differences in quality of neonatal intensive care and 28-day survival between the different types of hospitals, although comparison of outcomes is complicated by differences in the case mix and referral practices between hospitals. Uniform reporting of outcomes and risk factors across the private and public sectors is required to assess the benefits for the population of mixed-care provision.

Partial Text: The neonatal period—the first 28 days of life—is the most vulnerable period of childhood, and almost half of all neonatal deaths are in the first 24 hours of life. With improvements in basic neonatal care such as thermoregulation and breastfeeding, the provision of advanced care for neonates in need of hospital care is increasingly important for the reduction of neonatal mortality in low- and middle-income countries [1].

This cross-sectional study uses data from 52 consenting hospitals from Andhra Pradesh and Telangana that were included in the baseline evaluation (30 May to 26 August 2016) of the Safe Care Saving Lives quality improvement collaborative programme, implemented by Access Health International, an international nongovernmental organisation. The evaluation was carried out independently by the Public Health Foundation of India together with London School of Hygiene and Tropical Medicine, UK.

Of the 60 hospitals contacted for the study (28 public secondary, 6 public medical colleges, 20 private tertiary, and 6 private medical colleges), the facility heads from 8 refused participation of their hospital (2 public secondary hospitals, 1 medical college, and 5 private tertiary; Fig 1). Facility readiness assessments were conducted in 49 hospitals (25 public secondary, 5 public colleges, 14 tertiary hospitals, and 5 private medical colleges), and observation of admission to the NICU was conducted in 35 hospitals (21 public secondary, 5 private colleges, 6 private tertiary hospitals, and 3 private medical colleges). The assessment of register data was available from 47 hospitals (24 public secondary, 4 public medical colleges, 14 private tertiary hospitals, and 5 private medical colleges). Information from a total of 979 telephone interviews with mothers (54% of intended interviews) were linked with their newborns’ outcome information from the registers to estimate overall outcome including postdischarge period.

Our study spanned inputs, processes, and case fatality at 7 and 28 days of age, comparing public secondary hospitals, public medical colleges, and private hospitals and private medical colleges and indicates suboptimal and a high 28-day case fatality of 5.9% after admission to a NICU. Although prematurity is, as expected, the most common admission diagnosis (25% of admissions), we were surprised to find that jaundice was the second most common, accounting for 23% of admissions. Case fatality was highest in medical colleges, particularly for prematurely born neonates, of whom 25% died within the first 28 days of life. Our telephone interviews with mothers whose newborn was admitted to a NICU suggest that hospital registers substantially underestimate the 28-day case fatality. Whereas 28-day case fatality was 5.9% (95% CI 3.6%–9.7%) across registers from the 4 types of hospitals, case fatality was 11.6% (95% CI 8.1%–16.3%) according to postdischarge telephone interviews. Differences may be explained both by registers being incomplete and by a high mortality in neonates discharged against medical advice.



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