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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Epidemiology of newborn transport in India - The reality check
Tanushree Mondal1, Moksuda Khatun2, SK Md Habibulla2, Somosri Ray3, Avijit Hazra4, M Ivan D5, Rakesh Mondal6
1 Department of Community Medicine, Medical College, Kolkata, West Bengal, India
2 Department of Pediatrics, Medical College, Kolkata, West Bengal, India
3 Department of Neonatology, Medical College, Kolkata, West Bengal, India
4 Department of Pharmacology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
5 Department of Biotechnology, DTU, Delhi, India
6 Department of Pediatric, Medical College, Kolkata, West Bengal, India
| Date of Submission | 05-Dec-2019 |
| Date of Decision | 20-Jan-2020 |
| Date of Acceptance | 25-Jun-2020 |
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Correspondence Address:
Rakesh Mondal,
Department of Pediatrics, Medical College, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjdrdypu.mjdrdypu_336_19
Background: Transporting sick neonates from the periphery to a tertiary care unit is a challenge and transport-related factors can have a bearing on their survival. These factors influence ultimate survival in resource poor settings. Objectives: The objective is to evaluate the transport characteristics for sick newborns from peripheral centers to tertiary care referral hospital. Methods: A prospective study was done with sick newborns transported to our tertiary care teaching hospital over a period of 1 year. The transport logistics were recorded in detail and analyzed. The analyses were repeated for preterm and term babies separately. Results: There were 36.32% preterm babies in the study cohort of 961 newborns. The descriptive profile of the newborns enrolled in the study has been presented along with descriptive summary of the newborn transport logistics. Approximately 23% of babies were born to teen age mothers. Some prereferral counseling was done for only about 20% babies and <1% had vitals monitored during transport. Prereferral stabilization was scarce and around 41% babies had labored breathing or gasping at admission. As many as, 47% babies had no prereferral intervention and 31% had no referral notes; in only 3.3% instances, there was clear prior intimation to the referral unit. Conclusion: Sick newborn transport logistics are to be improved for reducing neonatal mortality in resource poor settings.
Keywords: Mortality, neonatal transport, neonate, newborn
How to cite this URL:
Mondal T, Khatun M, Md Habibulla S K, Ray S, Hazra A, D M I, Mondal R. Epidemiology of newborn transport in India - The reality check. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Feb 26]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=308722 |
| Introduction | |  |
India contributes 20% to global births with 27 million live births every year. It also contributes 25% of neonatal deaths worldwide, accounting for 1 million newborn deaths each year, with prematurity, sepsis, and birth asphyxia being the major factors behind this huge mortality burden.[1],[2],[3] The treatment of sick neonates under intensive or specialized care can reduce mortality and morbidity and the infrastructure of neonatal intensive care units and sick newborn care units is gradually expanding in India. The development of an effective transport system for transportation of sick or preterm babies to a center with expertise and facilities for round-the-clock intensive care is also crucial. In the early 1960s, neonatal transport was first used to make intensive care accessible.[4] The current scenario regarding neonatal transport in India is not encouraging and a streamlined system does not exist.[5] Sometimes, transfers are organized by the source hospital utilizing private ambulances and semi-trained personnel. More often, parents and family members have to make their own arrangements for transport without pretransport stabilization and trained care during transport. This imposes risks.[6],[7] Many of these babies become cold, hypoxic, hypoglycemic and up to 75% of them develop serious complications.[8] Mortality rate of 25%–35% among neonates transferred to tertiary care from distant locations has been reported in previous Indian studies.[7],[8],[9]
| Methods | | |
This prospective observational study was performed at a tertiary care teaching hospital between January 1 and December 31, 2015 on all extramural newborns admitted under the Neonatal Unit of the Pediatric Medicine Department. Institutional ethics committee clearance was obtained beforehand (Memo no MC/KOL/IEC//NON-SPON/54/05-2015, dated-23/05/2015), and written informed consent was provided by the accompanying parent or a legally acceptable representative. Sampling was purposive – newborns for whom consent could not be obtained, those having gross congenital anomaly (like anencephaly) or disease requiring surgical intervention (like congenital cyanotic heart disease) were excluded.
Relevant demographic, delivery and referral details, such as address, place of delivery, delivery mode, gestational age, birth weight, age of mother, Apgar score at 5 min, prereferral interventions, referral center, and reasons for referral, were noted down from the referral card or notes, hospital delivery certificate or by questioning the parents and near relatives. Clinical condition of baby before transport, pretransport stabilization and transport details like type of vehicle, distance and duration of travel, whether supported by medical or paramedical personnel and resuscitation equipment during transport, number of individuals accompanying, and care provided during transport were also captured.
All the babies were managed and investigated based on existing protocols of our institute. Final diagnosis and outcome were recorded.
Data have been summarized by routine descriptive statistics. The correlation and ROC analysis were repeatedly separately for preterm and term babies in the study cohort. The 95% confidence interval (CI) values have been presented where deemed relevant and P < 0.05 has been considered statistically significant. Statistica version 6 (Tulsa, Oklahoma: StatSoft Inc.; 2001) and MedCalc version 11.6 (Mariakerke, Belgium: MedCalc Software; 2011) software have been used for statistical analysis.
| Results | | |
Among 1103 neonates considered for the study, 961 satisfied inclusion criteria. Of these 577 were male (60.04%), 502 (52.24%) hailed from rural areas while the rest from urban areas or slums; 305 (31.74%) were from cesarean births and the mothers were mostly (722; 75.13%) aged between 18 and 35 years and primi-para (697; 72.53%). However, 218 (22.68%) mothers were below 18 years while 21 (2.19%) were above 35 years. [Table 1] presents further baseline demographic, delivery, and referral details of the study participants, while [Table 2] and [Table 3] present summaries of the transport-related details and in-hospital management respectively. There were 349 (36.32%) preterm babies in the study cohort of 961 newborns. | Table 1: Baseline clinical and referral details of the study participants (n=961)
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 | Table 3: Details related to in-hospital care on arrival of the study participants (n=961)
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Transportation time in our series was >1 h were for 80% babies. Approximately 23% of babies were born to teen age mothers. Some prereferral counseling was done for approximately 20% babies and <1% had vitals monitored during transport. This indicates a sorry state of affairs in newborn transportation. Prereferral stabilization was scarce and around 41% babies had labored breathing or gasping at admission. As many as 47% babies had no prereferral intervention and 31% had no referral notes; in only 3.3% instances, there was clear prior intimation to the referral unit.
In this study, total in-hospital deaths numbered 185 (19.25%; 95% CI 16.76%–21.74%), of which 91 deaths (26.07%; 95% CI 21.47%–30.68%) occurred in preterm neonates and the rest 94 (15.36%; 95% CI 12.50%–18.22%) in term newborns.
| Discussion | | |
In a study conducted in West Bengal, India, improved survival was shown in a sick neonatal care unit set up at a strategic location (district level). This underscores the fact that sick neonates managed in well-equipped units by expert hands have better outcome and therefore should be referred to such units despite the hazards of transport.[10],[11] A study by Narang et al.,[12] on neonatal transport revealed that birth weight <1 kg and transportation time >1 h were significant predictors of mortality among the transported neonates. Mori et al.[13] showed that neonates undergoing a longer duration of transport had 79% higher odds of death than those transported for a short duration after adjusting for confounding effects.[13]
In our study, we considered only out-born neonates all of whom had been transported over some distance. Lengthy transportation times, limited prereferral counseling, and virtually nonexistent monitoring of vital signs during transport indicate a sorry state of affairs in newborn transportation. Prereferral stabilization was also scarce. This denotes that peripheral caregiver personnel require to be trained regarding standard prereferral stabilization practices for better neonatal survival.
Many factors influence survival and well-being in sick neonates referred to specialized centers.[11],12],[13],[14] These include low birth weight (particularly <1.5 kg), prematurity (particularly gestational age <28 weeks), home rather than institutional delivery, birth asphyxia, later hypoxia, poor perfusion, and sepsis. In addition, factors related to transport logistics, such as transport in well-equipped ambulance, accompaniment by trained health-care personnel providing stabilization care during transport, effective communication, and referral documentation are important. These are the essential components of effective transport systems. Neonates transported by a medical team have better survival as compared to those who come on their own.[15]
We captured details to generate a detailed profile of referral of our study participants. Almost half had no prereferral intervention and one-third lacked referral notes. Clear prior intimation to the referral unit was almost nonexistent. These facts emphasize the importance of sensitizing referral units to both the technical and documentation requirements of referring newborns to specialized centers. Various neonatal referral stabilization models are available such as STABLE[16] (Sugar, temperature, airway, blood pressure, laboratory workup, and emotional support), SAFER[17] (Sugar, arterial circulatory support, family support, environment, respiratory support), and TOPS[18] (Temperature, oxygenation [airway and breathing], perfusion, and sugar) and these need to be adapted to local circumstances for the sake of improving the sick baby's chance of survival.
The need for developing standardized models for perinatal transport has prompted efforts in this direction in developed countries.[19] Innovative models for sick newborn transport have been tried in some states in India like Tamil Nadu, Kerala, Andhra Pradesh, and Madhya Pradesh. In a retrospective analysis of data over 33 months, from regionalized transport in and around 250 km of Hyderabad, biochemical and temperature disturbances were more common in babies transported on their own as compared to specialized neonatal transport service.[20] However, despite improvements with time, a uniform and effective nationwide system is lacking. The existing evidence from developed countries indicates that better regionalization of neonatal care is associated with better outcome.[21],[22]
The study have fair share of limitation including small sample sizes as well as purposive sampling used in recruiting the babies in hospital setting. The purposive sampling is a nonprobability sampling strategy may introduce bias and the results may be less generalizable.
The Government of India launched the “Janani Shishu Suraksha Karyakaram” on June 1, 2011 for the benefit of pregnant women and sick infants.[23] The aim was to eliminate out-of-pocket expenses for institutional delivery of pregnant women and treatment of sick infants. In 2014, the program was extended to all antenatal and postnatal complications of pregnancy and all sick children (up to 1 year of age) accessing public health institutions for treatment. Nationwide, the scheme is helping neonatal transport from home to nearby health-care facility, from health facility to referral center and back to home on discharge, with other facilities such as treatment and laboratory services free of cost. Dedicated ambulances for sick newborn transport are being provided. However, penetration and accessibility of this facility are still patchy, and in many regions, even after some form of state-sponsored transport system being in use, including some community-based vehicles, many families still depends on private vehicles at the hour of need.
| Conclusion | | |
Strengthening public schemes for sick newborn transport, with proper workforce and training, can greatly help the cause of improving newborn survival in India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Table 1], [Table 2], [Table 3]
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