Neonatal Near Miss Cases of Different Health Facilities

Address for correspondence: Dr. Sunil Raja Manandhar, Assistant Professor, Department of Paediatrics Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal E-mail: drsunilraja@gmail.com Mobile: 9803812218 1Dr. Sunil Raja Manandhar, MBBS, MD, Assistant Professor, Department of Paediatrics, Kathmandu Medical College Teaching Hospital (KMCTH), 2Prof. Dr. Dharma S Manandhar, MBBS, DCH, MRCP (UK), FRCP Lon & Edin, FNAMS, FIAP, Head, Department of Paediatrics, KMCTH & President and Executive Director, MIRA, 3Mr. Dhruba Adhikari, Research Officer, Mother and Infant Research Activities (MIRA), 4Mr Jyoti Raj Shrestha, Research Coordinator, Mother and Infant Research Activities (MIRA), 5Ms Chandra Rai, Project Director and Country Representative, Health Right International, 6Mr. Hari Rana, Training and Operation Coordinator, Health Right International. 7Mr. Mohan Paudel, Monitoring and Evaluation Coordinator, Health Right International. Abstract


Introduction
T he near miss concept and the criterion-based clinical audit are proposed as useful approaches for obtaining such informa on in newborn health care.Neonates with severe complica ons at birth or during the neonatal period who nearly died but survived cons tute neonatal near miss cases.There is however, no standard WHO defi ni on or interna onally agreed iden fi ca on criteria for neonatal near miss cases.Development of such criteria would facilitate the use of neonatal near miss as a measure of quality of newborn care tool 1 .There is currently no standard defi ni on and criteria for neonatal near miss especially for the community level interven on.
Pileggi C et al 2 described neonatal near miss cases as severe life threatening condi on at birth, e.g.gesta onal age of < 30 weeks, birth weight <1.5kg and Apgar score at 5 minutes <7.Souza JP et al 3 described neonatal near miss as consis ng of clinical organ dysfunc on criteria, e.g.tachypnea, bradycardia, etc. and laboratory marker of organ dysfunc on, e.g.SPO 2 less than 80%, serum pH <7.1, etc.Similarly, Knijf AD et al described neonatal near miss cases as the babies with signs of respiratory failure/dysfunc on, cardiac failure/dysfunc on, CNS failure/dysfunc on, etc 4 .
But in developing countries like Nepal, the above men oned criteria may not be followed properly in the community se ng as most of the health facili es in the community are providing level I and partly level II newborn care.Thus, life-saving interven ons could be an entry point to ini ate the development of the neonatal near-miss defi ni on; together with other indicators of increased risk of death, e.g.infants who survived extreme preterm birth, very low birth weight, severe birth asphyxia, severe birth trauma, and neonatal sepsis could be considered as neonatal near miss cases.MIRA and HealthRight developed a new tool for assessing neonatal near miss cases based on the CB-NCP programme.This is a part of opera onal research (OR) programme by Mother and Infant Research Ac vi es (MIRA) and HealthRight Interna onal (HRI) on strengthening the health facili es of electoral cons tuency No; 2 (EC 2) of Arghakhanchi district in Nepal.One part of opera onal research is to train health facility staff on newborn care and se ng up neonatal corners at health facili es and conduc ng neonatal near miss analysis in the health facili es to improve neonatal quality care.The opera onal research study was started on 1 st October 2010 ll 14 th April 2013 (Chaitra 2069).
The objec ve of this study were to iden fy and analyze neonatal near miss cases at diff erent health facili es of EC 2 of Arghakhanchi district, Nepal.

Material and Methods
As a part of opera onal research for strengthening the health facili es of EC 2, one day training on iden fying neonatal near miss cases was given at Arghakhanchi district hospital to the staff of health facili es EC no.2 of Arghakhanchi district for two days, for two groups.37 health staff including doctor, staff nurse, Health Assistant (HA), and Auxiliary nurse midwives (ANM) of diff erent health facili es were trained on comple ng the modifi ed neonatal near miss case forms.Neonatal near miss cases were documented for nine months dura on.

Criteria determined for neonatal near miss cases:
Any one of the following condi ons was taken as a neonatal near miss case in this study:

Results
There were a total of 28 cases of neonatal near miss reported from diff erent health facili es of EC No.2 cons tuency of Arghakhanchi district.Among them, 18 cases were reported from Arghakhanchi district hospital, fi ve cases from Thada PHC, two cases each from Subarnakhal HP and Pokharathok HP.
While analyzing 28 babies with neonatal near miss condi on, 90% (25) babies were delivered at health facility whereas three babies (10%) were delivered at home depicted in Fig. 1.According to birth weight category, most of the babies 72% (20) were of normal weight, 21% (6) babies were low birth weight and 7% (2) babies were very low birth weight, which were depicted in Fig 2 .While analyzing resuscita ve procedures applied in 28 near miss cases, 60% (17) were provided ini al steps including suc on and tac le s mula on and 40% (11) did not required any form of resuscita on.Among those 17 asphyxiated babies, 65% (11) received bag and mask ven la on by health workers which were depicted in Fig. 3.While analyzing the outcome of neonatal near miss babies 57% (16) were discharged from health facili es a er treatment by health personnel whereas 43% (12) were referred to higher ter ary centre depicted in Fig. 4.Among 12 referred cases, three cases each were of sep cemia, birth asphyxia and high fever.Two babies were of very lowbirth weight and one baby had pneumonia.
Analysis of near miss cases showed Possible severe bacterial infec on (PSBI)/severe infec on 47% (13), Birth asphyxia in 43% (12), very lowbirth weight 7% (2) and meconium aspira on 3% (1) which are depicted in Fig. 5 and Table 1.Among six PSBI cases, three cases with high fever, two cases are hypothermia and one case is of umbilical sepsis.

Discussion
Possible severe bacterial infec on (PSBI)/ severe infec on were the commonest cause (47%) of neonatal near miss followed by birth asphyxia (43%).Among 60% (17) of the asphyxiated babies, some form of neonatal resuscita on procedures were provided.Avenant T 6 also postulated intrapartum asphyxia as a commonest cause (12.9%) of neonatal near miss which is also resembled in this study.
A social prac ce of wrapping babies with dirty clothes in the community and improper hand washing before touching babies could be important contribu ng factors for neonatal sepsis as severe infec on was the commonest cause (47%) of neonatal near miss.Similarly, it was seen that 57% (16) near miss cases were treated successfully by health personnel.This could be due to impact of proper neonatal near miss iden fi ca on and treatment a er neonatal near miss training.
In a study done by Pileggi Castro C et al 7 defi ned one of the neonatal near miss criteria as birth weight < 1.5 kg with a sensi vity of 72.6% (70.6-74.5)and specifi city of 97.4% (97.4-97.5),which is included in this study also as one of the criteria for neonatal near miss.So, such studies will help to postulate defi nite criteria for diagnosing neonatal near miss per culalrly in community se ng.

Conclusions
Severe infec on/ PSBI and birth asphyxia were the two most common causes of neonatal near miss in the health facili es of Arghakhanchi district.

Recommendations
There is a need to improve the quality of antenatal care and intrapartum management to reduce asphyxia in the health facili es.There is s ll need to improve the quality of neonatal care at the health facili es to properly manage these neonatal near miss cases which were referred to higher centre.There is a need of regular training to health staff and regular supply of essen al equipments like warm cot, Resuscitaire, Ambu bag at least in district hospital for improving the quality of neonatal care in health facili es in order to manage these neonatal near miss cases which were referred to higher centres.The training on neonatal near miss could have a good impact on managing high risk babies.For development of proper guideline for neonatal near miss tool, such more studies on neonatal near miss are required.
Acknowledgement: Our sincere thanks go to Dr. Yam Bahadur Basnet, DHO Arghakhanchi district, Mr. Lila Ram Gautam, DPHO and the Arghakhanchi district public health offi ce team for their kind support and coopera on during this opera onal research process.We are acknowledging to the health staff including medical offi cers, nurses and paramedical staff of the Arghakhanchi District Hospital, Thada PHC, Narpani HP, Pokharathok HP, Subarnakhal HP and Siddhara HP.At last but not the least, thanks are due to the mothers and rela ves who agreed to be interviewed and other.

Funding:
Health Right Interna onal with support from USAID Confl ict of Interest: This study was done with technical support from Mother and Infant Research Ac vi es (MIRA).Permission from IRB: Yes

Table 1 :
Causes of neonatal near miss cases