LOW COST LEVEL II NEWBORN CARE SERVICE : EXPERIENCE OF KATHMANDU MEDICAL COLLEGE TEACHING HOSPITAL

* Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal. Address for correspondence : Prof. D. S. Manandhar Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu Email: dsm@healthnet.org.np


INTRODUCTION
Newborn infants require special care when they become sick.They have limited capability of maintaining temperature and are prone to get infections very easily.Deaths within four weeks of birth (neonatal deaths) account for 60% of infant mortality 1 .
Though there has been significant reduction in IMR in last 30 years due to various public health programmes, reduction of infants death has been seen only in postneonatal period.Nearly 831,000 babies are born every year in the country 2 and 10-15% develop problems requiring hospital care 3 .About 1-3% will require intensive care.Facilities for care of sick newborns are very limited in Nepal and outside Kathmandu, it is available in few hospitals only.Lack of knowledge on the care of the newborns and the feeling that newborn care requires costly and sophisticated equipment have inhibited expansion of even basic newborn care facilities in the district hospitals.The special care baby unit (SCBU) of Kathmandu Medical College Teaching Hospital (KMCTH) is using low cost locally made equipment in the care of sick newborns.Experience of using such equipment in the care of sick newborns is presented here.

METHODOLOGY
Prospective study of babies admitted in the SCBU in the period of 28 months ( 2 nd July 2001 to 17 th Oct. 2003).Locally made low cost equipment -DSM Resuscitaire (fig. 1) and DSM Warm Cot (fig.2) were used to keep the baby warm.DSM Phototherapy Unit (fig.3) was used to treat hyperbilirubinaemia.Locally made oxygen hood is used to provide oxygen.Autoclaved newspapers (Fig. 4) were used to wipe the hands after washing.In KMCTH delivery service was started from 29th May, 2001 and SCBU was started on 2nd July, 2001.In KMCTH, all deliveries are attended by a medical officer from the department of Paediatrics and 2 nd on call is also available at delivery whenever needed.All   babies are examined within 24 hours in postnatal ward and all babies are examined everyday and before discharge.Babies requiring observation and special care are transferred to SCBU.All the newborns are being followed up in the well baby clinic on Tuesdays.Those with special problems are advised to come earlier.
There is a "Resuscitation corner" in the Labour Room and Special Care baby Unit.Resuscitation corner in labour room is supplied with a locally made resucitaire, suction machine, oxygen, resuscitation equipment (self-inflating resuscitation bag, laryngoscope, ET tubes), essential drugs and disposables.
The Special Care Baby Unit (SCBU) has 10 beds.It has two rooms.The inner room with monitors is for the care of very sick babies and the outer room for less sick babies not requiring monitors.A separate room nearby is kept for the mothers for easy access and promotion of exclusive breastfeeding.Equipment used are designed by Prof D.S.Manandhar and are locally made low cost equipment: "DSM" Resuscitaire, "DSM" Warm cot, "DSM" Phototherapy Unit and of Oxygen hood.Those requiring warmth are initially kept in a resuscitaire then transferred to a warm cot.Room temperature is maintained at 28 0 C by using air conditioners and fan heaters.Phototherapy is started whenever serum bilirubin goes above 15 mg/dl.Oxygen is administered by oxygen hood when it is required.12 nurses, 6 medical officers, supervised by lecturers, senior registrar and consultants look after sick newborns and other general pediatrics patients.

RESULTS
In the period of 28 months, 882 babies were delivered in KMCTH.Out of 882 babies delivered in KMCTH, 859 were live births.3 babies died before admission in the SCBU.A total 201 babies were admitted in SCBU which included 28 babies born outside the hospital.Out of 859 live births in KMCTH, 173 babies (20.1%) were admitted in SCBU.The main causes of admission in SCBU were low birth weight, neonatal jaundice, birth asphyxia, septicemia, and others.The tables given below give data on 201 newborns admitted during the study period.Among the admitted babies 44.2% were of low birth weight and 8.45% were of very low birth weight as shown in Table I.Most low birth weight infants were therefore in the weight group of 1500-2499 gms.Majority of the babies (70.6%) were also term infants, with less than 10% below 32weeks gestation.Among low birth weight babies 53% were small for dates and 47% were preterm.
Among the admitted babies 61.1% were male and 38.3% were female.Regarding causes of admission, most admission were for low birth weight (37.3%), 18.9% for neonatal jaundice, 6.9% for birth asphyxia, 5.9% for respiratory problems, 2.4% for septicaemia and 28.3% for miscellaneous causes which include poor feeding, vomiting, fever, hypothermia, meconium stained liquor, etc.The average duration of stay was 1-3 days (46.7%).Of the babies admitted from outside the hospital, 50% were born at Prasuti Griha, 25% at home, 14% at Patan Hospital, 7% at Nursing homes and 4% outside Kathmandu.The commonest cause for admission among the babies born outside the hospital was neonatal jaundice.
Out of 201 babies 89% were discharged in good condition, 4% left against medical advice, 5% expired and 1% transferred to Kanti Children Hospital.The main causes of death of the babies were extreme prematurity (53.8%), septicaemia (23%), birth asphyxia (15.2%) and congenital anomalies (7.6%).The survival of babies by birth weight and gestation is shown in table V and VI.Babies with birth weight below 1000 gms did not survive.The survival of babies with birth weight between 1000 gms to 1499 gm was 67%.The survival of babies with birth weight between 1500 gms to 1999 gms, between 2000 gms to 2499 gms and above 2500 gms were 86%, 98% and 99% respectively.By gestation also, those with less than 28 weeks of gestation did not survive.80% of babies with gestation between 28 weeks to 31 weeks survived.89% of babies with gestation 32 weeks to 36 weeks survived and 99.5% of babies with gestation above 37 weeks survived.Among the admitted babies, 4 of them were kept on a ventilator but they did not survive.3 babies were admitted for hyaline membrane disease and one baby for multiple congenital anomalies.
The perinatal mortality rate (PMR), extended perinatal mortality rate (EPMR), neonatal mortality rate (NMR) and NMR excluding <1kg during this period were 26.4/100 births 39/1000 births, 15.1/1000 live births and 10.5/1000 live births respectively, which are quite satisfactory.The equipment are comparatively very cheap, easy to operate and maintain.Any local electrician could repair and maintain it.The nurses have found these equipment to be very user friendly and there was no problem in using them.
There is a misconception that newborn care depends upon interventions, which are too costly or technological for high coverage in poor countries.This attitude has been aggravated by the exposure of professionals to neonatal intensive care units.Majority of newborn care requires only minimal care i.e. feeding, warmth and cleanliness, which are generally provided by the mother.But, in fact, mothers, health professionals and policymakers all seems to lack education about simple, low cost principles of newborn care laid down by the French obstetrician Pierre Budin in his classic work "The Nursling". 4Nearly 15% newborn babies develop problems requiring hospital care. 4Only 1-3% will require intensive care.In Nepal common neonatal problems requiring care in hospital are-birth asphyxia, low birth weight, infection, jaundice, feeding problems and respiratory distress.Most of these problems could be managed using low cost locally made equipment.For proper management of birth asphyxia, there should be a resuscitation corner in the labour room with essential drugs and equipment.Most of the babies require thermal control for which the incubators used are very costly in comparison to the locally made warm cot and resucitaire.In our experience, we found that temperature of the babies has been well maintained throughout the hospital stay by using locally made resuscitaire and warm cot.Neonatal hyperbilirubinaemia was managed by using locally made phototherapy unit.
Most infants are born at home, so mother is the prime care provider during newborn period.With increasing urbanization, significant proportions of infants in urban areas are born in hospital.In Kathmandu valley, it has been estimated that nearly 65% births occur in the hospitals. 5Neonatal care services outside Kathmandu is very limited and is available in few hospitals only.The main obstacle for expanding neonatal care services in district, zonal and regional hospitals has been the feeling that imported costly and sophisticated equipments like incubators, ventilators and highly skilled personnel are required.The present study has shown that most of the sick newborns could be managed using locally made low cost equipment.Such equipment are being used in the care of the newborns in eight district hospitals where Safer Motherhood Programme has been implemented by Nepal Safer Motherhood Programme.

CONCLUSION
Nearly 15% of newborn babies develop problems requiring care in a hospital.Most of these problems could be managed by using locally made low cost equipment as has been shown by our experience.Locally made low cost equipment are affordable and easy to operate and maintain.Providing such facilities in district hospitals will help in reducing the present high neonatal mortality which constitutes over 60% of infant mortality rate of the country.

Table VI : Survival of babies born at KMCTH by gestation
In our special care baby unit, we have managed 201 babies with different problems.Babies with birth weight of 1020 gms and gestational age as low as 28 weeks have survived.The problems ranging from respiratory distress, birth asphyxia, septicemia and others were managed with the use of low cost locally made equipment and this service was provided at fairly low cost which is affordable by majority of the people.Majority of neonatal deaths in KMCTH was due to extreme prematurity, for whom intensive care with ventilator support is required.NMR of this hospital is 15.1/1000 live births which is quite low in comparison to national NMR of 38.4/1000 live births.Excluding the babies weighing <1kg, NMR comes to 10.3/ 1000 live births.Facilities available in SCBU are affordable, as locally made low cost equipment are used in this unit.Equipment for care of sick newborn constitutes a large proportion of cost of a neonatal unit.