Introduction:
Preterm birth is a major cause of mortality and morbidity for newborns and impose a considerable burden on limited health care resources. (1) Even though the incidence of preterm birth is rising worldwide due to the continued innovation in Neonatal Intensive care unit facilities, the survival of preterm neonates has significantly increased. (2) Over the years, the success of neonatology is measured in terms of birth weight of the survivors. A more proactive approach to antenatal and postnatal care has led to encouraging results in the management of preterm neonates. The better medical care, good resuscitation practices, surfactant therapy, gentle ventilation have contributed to the survival rate. (3)
The sequelae of preterm birth pose a significant public health problem. Children born before 37 weeks of gestational age are at increasing risk of repeated respiratory illness, neurodevelopmental disabilities like cerebral palsy, mental retardation, cognitive impairment, visual and hearing impairments, behavioral problems, and more subtle disorders of central nervous system function. (4, 5)
The global incidence of preterm birth accounts for 12.9 million (9.6%), of which 85% is concentrated in Asia and Africa. This marks the preterm birth as a significant perinatal problem across the globe, which is associated with mortality and short term and long term morbidity. (6) The neonatal mortality rate in India is 28 per 1000 live births. The rate of decline of neonatal mortality is very slow, contributing to the burden. (7)
A cross sectional study carried out in Pune, India during the year 2008 to 2010 showed an overall perinatal mortality among preterm births as 426.4 per 1000 preterm births. (8) One year prospective study carried out in Belgaum, India reported the incidence of late preterm births as 61.68%. (9) A prospective cohort study conducted in Lucknow, India reported an incidence of 20.9% preterm deliveries. (10) The community based study conducted in villages of Kaiwara, Bangalore showed that the proportion of preterm births in the study area was 20.5%. (11) The incidence of preterm births varies across different states and districts in the country.
Despite of interventions and programs focusing on reducing the preterm births and the associated morbidity, these studies exemplify the burden of preterm births in different parts of the country. The present study intended to find the mortality and morbidity patterns in a tertiary care hospital of Udupi District, Karnataka, South India.
Material and Methods:
This cross sectional study was conducted among the preterm neonates admitted in the Neonatal Intensive Care Unit (NICU) of a tertiary care hospital of Udupi District during the year 2014 and 2015. This NICU was a 32 bedded unit with level IIIB facilities and trained neonatologists and nurses. The unit serves as a referral unit for the neighbouring taluks and districts of Udupi like Shimoga, Chikkamagaluru, Dakshina Kannada, Davanagere, Dharwad, Uttara Kannada. A total of 589 preterms born in the year 2014 and 605 preterms born in the year 2015 were included. All the preterms neonates <37 weeks of gestation admitted in the NICU of the hospital during January 2014 to December 2015 were included.
The outcomes of the study were the mortality and morbidity of the preterm neonates. Ethical clearance was taken from the Institutional Ethical Committee.
The data was collected from the medical records of preterm neonates admitted in NICU using valid, reliable questionnaires which includes the demographic proforma and the clinical outcomes of preterm neonates. The demographic proforma comprised of details of the preterm neonate such as gestational age, gender, birth weight, presence of disease. The clinical proforma was used to collect the clinical data. The data were analysed using SPSS version 16.0
Results:
A total of 1194 preterm neonates were included in this study. During the study period, a total of 2468 neonates were admitted in NICU, of which 1216 neonates were admitted in the year 2014 and 1252 neonates were admitted in 2015. Out of a total of 2468 cases, 1221 (49.5%) were inborn and 1247 (50.5%) were out born. Among the 1216 neonates admitted in 2014, 579 (47.6 %) were inborn and 637(52.4 %) were out born. Among the 1252 neonates admitted in 2015, 642 (51.3 %) were inborn and 610 (48.7 %) were out born.
Of the total 2468 neonates admitted in NICU during the study period, 1194 (48.4 %) were preterm neonates. In the year 2014, of the 1216 admissions in NICU, 589 (48.4%) were preterms. Of the 1252 admissions in the year 2015, 605 (48.3%) were preterm neonates.
The sample characteristics of preterm neonates is presented in Table 1.
| Table 1: Sample Characteristics of Preterm Neonates |
Demographics of participants |
2014 (n= 589) |
2015 (n= 605) |
Total (n= 1194) |
n (%) |
n (%) |
n (%) |
Gestational age (in weeks) |
Less than 30 |
99 (16.8) |
102 (16.9) |
201 (16.83) |
30 -34 |
298 (50.6) |
314 (51.9) |
612 (51.3) |
34- 36 |
192 (32.6) |
189 (31.2) |
381 (31.9) |
Gender |
Male |
326 (55.3) |
322 (53.2) |
648 (54.3) |
Female |
263 (44.7) |
283 (46.8) |
546 (45.7) |
Birth weight (in grams) |
Less than 1000 |
59 (10) |
65 (10.7) |
124 (10.4) |
1000 - 1500 |
164 (27.8) |
146 (24.1) |
310 (25.9) |
1501 - 2000 |
187 (31.75) |
205 (33.9) |
392 (32.8) |
More than 2000 |
179 (30.4) |
189 (31.2) |
368 (30.8) |
Place of birth |
Inborn |
374 (63.5) |
406 (67.1) |
780 (65.3) |
Out-born |
215 (36.5) |
199 (32.9) |
414 (34.7) |
Birth weight categorization according to gestational age |
Appropriate for gestational age (AGA) |
463 (78.6) |
506 (83.6) |
969 (81.2) |
Small for gestational age (SGA) |
110 (9.2) |
91 (15.04) |
201 (16.83) |
Large for gestational age (LGA) |
16 (1.3) |
8 (1.3) |
24 (2) |
The data presented in Table 1 shows that majority of the 612 (51.3%) preterm neonates had the gestational age between 30 and 34 weeks and 648 (54.3%) were males. The survival rate of the preterm neonates admitted in NICU during the study period was 92.5 %.
The mortality rate of the preterms admitted in NICU was 90 (7.5 %) during the study period. In the year 2014, the mortality rate of preterms admitted in NICU was 36 (6.11%) and in the year 2015 it was 54 (8.92%). The total mortality of neonates admitted in the NICU was 161 (6.5 %), of which in the year 2014 it was 68 (5.59%) and in 2015, it was 93 (7.4%). The morbidity pattern of the preterm neonates is presented in Table 2.
Table 2: Morbidity profile of preterms admitted to NICU |
Morbidity profile ( n = 1194 ) |
n (%) |
Respiratory Distress Syndrome (RDS) 446 (37.4) |
Mild Respiratory distress syndrome |
229 (19.2) |
Moderate Respiratory distress syndrome |
96 (8.1) |
Severe Respiratory distress syndrome |
121 (10.1) |
Other medical conditions |
Hyperbilirubenemia |
285 (23.9) |
Pneumonia |
54 (4.5) |
Pneumothorax |
7 (0.6) |
Perinatal asphyxia |
89 (7.45) |
Apnoea of prematurity |
35 (2.93) |
Transient Tachypnea of Newborn |
9 (0.7) |
Anaemia of prematurity |
18 (1.5) |
Congenital heart disease |
52 (4.4) |
GI anomalies |
44 (3.7) |
Early onset Sepsis |
50 (4.2) |
Late onset Sepsis |
72 (6.03) |
Other Congenital anomalies |
41 (3.4) |
Renal conditions |
41 (3.4) |
Hydrocephalus |
20 (1.7) |
Meningitis |
30 (2.5) |
Intraventricular haemorrhage |
21 (1.8) |
Seizures |
9 (0.7) |
Necrotising entero-colitis |
33 (2.8) |
Polycythaemia |
27 (2.3) |
Thrombocytopenia |
20 (1.8) |
ROP |
37 (3.0) |
Hypoglycaemia |
69 (6.0) |
Meconium Stained Aspiration Syndrome |
28 (2.3) |
Others |
125 (10.5) |
Table 2 describes the morbidity pattern of the preterm neonates. Among the 1194 preterm neonates, 102 (8.5%) of preterms received surfactant therapy. In 2014, 212 (35.9%) and in 2015, 234 (38.7%) had Respiratory Distress Syndrome (RDS). The illness in the other category included hearing loss, vitamin D deficiency, septic arthritis, PVL, Pulmonary haemorrhage, hyperglycaemia, hypocalcaemia, hyponatremia, hyperthyroidism, hypernatremia, metabolic acidosis, failure to thrive, Inborn Error of Metabolism, feed intolerance, neonatal cholestasis, galactosemia, congenital rubella, fracture etc. Sepsis was found among 122 (10.2%) of preterms. The organisms isolated and responsible for sepsis were : Klebsiella (2.5%), Coagulase negative Staphylococcus (2.7%), Escherichia coli (1.2%), Candida (1%), Acinetobacter (1%); Serratia marcescens (1%), Stenotrophomonas (1%), Pseudomonas (1.3%), Enterobacter (0.6%), group B streptococcus (0.6%), Fungal (0.4%), Staphylococcus aureus (0.3%), Toxoplasmosis (0.3%).
Discussion:
Prematurity is one of the leading cause of neonatal deaths in India. (7) This study showed that majority of the preterm neonates were in the gestational age of 30-34 weeks and had birth weight between 1500 and 2000 grams. The present study is supported by another cross sectional study which showed that the gestational age of preterms between 31 to 34 weeks was 44% and 23% of preterms had birth weight between 1500 and 2000 grams. (12) A study conducted by Karegoudar in 2014 in Belgaum showed that the birth weight of 41.61% premature babies was between 1501 and 2000 grams. (9) In a study conducted in Ethiopia, the prevalence of preterm birth was 25.9%, whereas in the present study the proportion of preterm birth among the NICU admissions was higher. (13)
Preterm births contribute to a major burden of mortality and morbidity in the early neonatal period. Even though there is a disparity in the rate of neonatal mortality within the states and districts of India, there is a huge decline in the neonatal mortality rates in the past two decades. The neonatal mortality rate decreased from 52 per 1000 live births in 1990 to 28 per 1000 live births in 2013. (7) In a tertiary care hospital in Tanzania, the neonatal mortality was 19% which is higher than our present study. (14) In contrast, a similar study conducted in a tertiary care hospital in Mandya supports the present study findings which showed the mortality rate among the neonates admitted in NICU as 7.1%. The major morbidities identified were neonatal sepsis (28.8%), respiratory distress syndrome (RDS) (23.85%) and birth asphyxia (17.72%). (15)
In the present study, RDS, hyperbilirubinemia, perinatal asphyxia and sepsis were the major morbidities identified. The morbidities presented in this study correlates with the studies carried out in different parts of India and abroad. The present study is supported by a study conducted in Nigeria on the morbidity and mortality pattern among 261 neonates which showed that, 24.5% had low birth weight, 16.9% had neonatal sepsis and 0.06% had neonatal jaundice. The death rate was 14.2% among the included sample. The rate of perinatal asphyxia 30.7% was higher compared to the present study. (16) Similar findings were observed in a study conducted in the NICU of rural Uganda on the neonatal outcomes, which showed a survival rate of 78% at discharge. The morbidity which were most common included: infections 30%, prematurity 30%, respiratory distress 28%, asphyxia 22%. The focus on facility based neonatal care has increased the survival rates in low and middle income countries. (17)
A case control study conducted by Soumya Patil on the neonatal outcome showed that 25% of neonates had sepsis, RDS was found in 19%, 21.9 % had hyperbilirubinemia, and 9% had transient tachypnea of newborn which supports the present study. (18)
Although the survival rates of preterm neonates has increased in the last decade due to the advancement in the technology, ventilator support, surfactant etc, the outcomes with regard to the survival is still not satisfactory. These preterms are at increased risk of developing neurological and behavioural problems in the long run which has to be addressed. (19) Comprehensive educational programmes can be planned to improve the neonatal outcomes and reduce the mortality rate.
Conclusion:
Preterm births are a significant public health concern posing considerable burden of mortality and morbidity among the population. The sequelae of morbidity among the preterms and the admissions to NICU can have long term impact in the outcomes, which in turn can affect the neurodevelopment. The results provide a baseline data targeting future research to provide facility based and home based newborn care programmes for empowering mothers of preterms before discharge from the hospital. Follow up programs for the preterms helps to early identify the associated long term impact of the morbidities and plan early intervention programme to minimize the infant mortality and morbidity.
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