The global impact of neonatal infection.

One of the greatest challenges to global public health is to eliminate the gaps between rich and poor countries in health care resources, in access to preventive and curative services, and in health outcomes. Although infant mortality has declined by more than 50% since 1955, 1 neonatal mortality has changed little in some of the world’s poorest countries. Worldwide, neonatal mortality accounts for a substantial proportion of deaths of both infants and children younger than 5 years. 1, 2, 3 The World Health Organization (WHO) estimates that more than 4 million neonates die each year and that 98% of these deaths occur in developing countries. 2, 3 Causes of neonatal mortality, especially in developing countries, are difficult to ascertain, partly because many of these deaths occur at home, unattended by medical personnel, and partly because critically ill neonates often present with nondiagnostic signs and symptoms of disease. Infectious diseases, birth asphyxia, and complications of prematurity are thought to be the major causes of neonatal death worldwide. 2, 3, 4, 5

Neonatal Infections: A Global Perspective

A comparative study of perinatal mortality patterns over a period was conducted at a teaching hospital of South India. Among the 6,048 babies born from January 1984 to December 1985 (Group A), there were 265 (43.8/1000) still births and 127 (22.0/1000) early neonatal deaths. Three hundred and thirty seven (41/1000) babies were still born and 235 (29.8/1000) early neonatal deaths out of 8,215 deliveries during 1992–93 (Group B). The perinatal mortality rate (PMR) in Group A and B were 57.9/1000 and 57.7/1000 respectively. Unbooked cases accounted for the majority (> 75%) of perinatal deaths during both the periods. The overall mortality rates in unbooked cases were three to four times higher than booked cases. Among the various causes of still births, antepartum haemorrhage and uterine rupture had increased. Septicaemia was the major cause of early neonatal deaths in Group A, but in Group B birth asphyxia and prematurity were the leading causes. Effective interventions like creating awareness among the target population to utilise maternal and child health services and early referral of high risk cases with improved intranatal and perinatal care can decrease the perinatal mortality.

Perinatal mortality trends in a referral hospital.

At Christian Medical College Hospital, Vellore, there were 21,585 consecutive births during a five year period of 1979–1983. The overall perinatal mortality rate was 40·7, stillbirth rate was 23·6 and early neonatal mortality rate was 17·5. Although the perinatal mortality rate was only half that reported from other teaching hospitals in India, it is three times the rate reported for Avon area hospitals providing special and intensive care. The highest perinatal mortality rate 45·5 was noted in 1979; the lowest 38·6 in 1982. The highest stillbirth rate 26·6 was noted in 1980, the lowest 19·3 in 1981 (p<·05). Throughout it was consistently higher than early neonatal mortality rate. The highest early neonatal mortality rate 20·8 was noted in 1979 the lowest 13·9 in 1980 with 33 per cent reduction; (p<·05) however in 1983 it was 17·1. At the end of five years perinatal mortality rate, stillbirth and early neonatal mortality rates were not reduced significantly. If 223 unsalvagable infants, 131 with congenital lethal malformation and 92 others with birth weight below 1000 gm were excluded, then all the three rates for 21,360 normally formed infants weighing above 1000 gm would be statistically significantly lower (perinatal mortality rate 30·7, stillbirth rate 18·4 and early neonatal rate 12·5 (p<·01).

Perinatal mortality in Vellore Part I: A study of 21,585 infants

The neonatal mortality rate (per 1000 live births) dropped from 36.6 in 1985 to 23.9 in 1986. Neonatal sepsis ranked as number 2 as a cause of neonatal mortality in 1985, while it dropped to rank 4 (even lower than major malformations) in 1986. The decline in the sepsis-related neonatal mortality was due to reduced incidence of sepsis (38.2 and 18.8 per 1000 live births during 1985 and 1986 respectively) and improved survival (case fatality rates of 24.6% vs 17.7% in 1985 and 1986 respectively). The strategies which reduced the incidence of nosocomial infections included decongestion of use of the nursery, discontinuation of use of heparinised saline for flushing intravenous lines and routine use of intravenous cannulas instead of metallic scalp vein needles.

Strategies which reduced sepsis-related neonatal mortality.

Study on 2500 consecutive deliveries revealed a perinatal mortality rate of 82.4/1000 births a stillbirth rate of 48/1000 births and a neonatal death rate of 36.1/1000 live births. Perinatal loss was found to be significantly higher in twin deliveries mothers with a poor obstetric history abnormal presentation and in cases where there is an extreme in maternal age or parity. Similarly perinatal mortality was found to increase with decreasing birth weight and gestational age. Asphyxia (32.5%) infections (11%) maternal diseases (8.7%) and congenital anomalies (8.7%) were found to be the major causes of perinatal deaths. Autopsy revealed anoxia (48%) and pulmonary lesions (28%) as the most common causes of death. (authors)

Some observations on perinatal mortality.

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Some observations on perinatal mortality.