Neonatal Asphyxia in Egypt Where we stand ?

8/14/2019 Neonatal Asphyxia in Egypt Where we stand ?

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Neonatal Asphyxia in EgyptNeonatal Asphyxia in Egypt

Where we stand ?Where we stand ?

Mohamed Khashaba,MDMohamed Khashaba,MD Professor of Pediatrics/NeonatologyProfessor of Pediatrics/Neonatology

Head of NICU, MUCHHead of NICU, MUCH

Mansoura, EgyptMansoura, Egypt


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A healthy newborn infant is the bestA healthy newborn infant is the best

promise for the futurepromise for the future


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The Millennium Development GoalsThe Millennium Development Goals

(MDG)(MDG)

To create an environment at the nationalTo create an environment at the national

and global levels alike-which is conductiveand global levels alike-which is conductive

to development and to elimination ofto development and to elimination of

poverty.poverty.( UN General Assembly)( UN General Assembly)


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Goals 4 and 5Goals 4 and 5

Aim to reduce maternal and child mortality.Aim to reduce maternal and child mortality.

Investment in maternal, newborn, and child healthInvestment in maternal, newborn, and child health

is not only a priority for saving lives, but is alsois not only a priority for saving lives, but is also

critical in advancing other goals related to humancritical in advancing other goals related to human

welfare, equity and poverty reductionwelfare, equity and poverty reduction..


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Over 9 million deaths occureach year in the perinataland neonatal periods;

98% of these deaths takeplace in the developingworld;

Most of these deaths arecaused by infectiousdiseases; pregnancy-related

complications; or delivery-


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In most of the world,under-5 year and infant

(under-1 year) mortalityrates have declinedsubstantially in the past

three decades.


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Neonatal mortality hasdeclined less rapidly than

other child mortality;

Neonatal deaths nowaccount for 40 -70% of all

infant mortality;


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20

40

60

80

100

120

140

1975 1980 1985 1990 1995

Year

Rateper

100

0

Comparison of Infant andNeonatal Mortality Decline in

Turkey 1975 -1995

Infant Mortality

Neonatal Mortality


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20

40

60

80

100

120

140

1975 1980 1985 1990 1995

Year

Rateper

1000

Comparison of Infant andNeonatal Mortality Decline in

Egypt 1975 -1995

Infant Mortality

Neonatal Mortality


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Medium-Term Trends in Neonatal Mortalit

in the Middle East and North Africa

NeonatalMortalityRa

te

Year

1975 1980 1985 1990 1995

0

25

50

75

YemenMorocco

E tTunisia

ordan


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Many neonatal deaths are unseen andMany neonatal deaths are unseen and

undocumentedundocumented


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Most epidemiological and other researchMost epidemiological and other research

focuses on 1% of deathsfocuses on 1% of deaths


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Neonatal

Tetanus

14%

Asphyxia

21%

Injuries

11% Congential

abnormalities

11%

Sepsis

7%

Prematurity

10%

Other

5%

Diarrhea

2%

Pneumonia

19%

Direct Causes of Neonatal Mortality

HO Mother and Baby Package, 1993


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Causes of perinatal death in EgyptCauses of perinatal death in Egypt

Congenital

malformations

7%

Asphyxial conditions

developing in labor

28%

Deaths before start of

labor

7%Unclassified

11%

Other specific causes

3%

Conditions associated

w ith preterm birth or

immaturity

21%

Time of intrauterine

death unclear,

possibly asphyxial

conditions developing

in labor or deaths

before the start of

labor

23%


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In developing countries, 3% ofIn developing countries, 3% of

all newborn babies (3.6 million)all newborn babies (3.6 million)

develop moderate or severedevelop moderate or severe

asphyxia. Of these, aboutasphyxia. Of these, about840000 die . Same number840000 die . Same number

develop severe sequelae,develop severe sequelae, WHO,WHO,

1996Mother-baby package1996Mother-baby packageWHO1996:Implementing safeWHO1996:Implementing safe

motherhood in countries,motherhood in countries,


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Statistically, asphyxia claims theStatistically, asphyxia claims the

lives of eight to ten per 1,000lives of eight to ten per 1,000

infants worldwideinfants worldwide.. Sherman et al,Sherman et al,

20022002

Most common diagnoses forMost common diagnoses for

admission of critically illadmission of critically ill

neonates in the developingneonates in the developing

countries is peripartum asphyxiacountries is peripartum asphyxia

with its numerous complicationswith its numerous complications


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The neonatal mortality of 24.7%amongThe neonatal mortality of 24.7%amongasphyxiated neonates was 34.5-timesasphyxiated neonates was 34.5-timescompared to that of the non-asphyxiatedcompared to that of the non-asphyxiated

population .population .

The mortality rates in preterm-and term-The mortality rates in preterm-and term-asphyxiated neonates were 47.8% and 6%,asphyxiated neonates were 47.8% and 6%,respectively .respectively .

Mortality: 7.5% of HIE among all bornMortality: 7.5% of HIE among all born

infants Bose et al, 1998infants Bose et al, 1998


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HIE is an important cause of mortalityHIE is an important cause of mortality

and morbidity in full-term newborns,and morbidity in full-term newborns,

and neurologic handicaps occur inand neurologic handicaps occur inabout 25% to 28% of these infantsabout 25% to 28% of these infants

with devastating human, social andwith devastating human, social and

economic consequences.economic consequences.

(Freeman & Nelson, 1988)(Freeman & Nelson, 1988)


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Asphyxia burden inAsphyxia burden in

EgyptEgypt

Total population: 74,033,000Total population: 74,033,000 Child mortality 36per 1000Child mortality 36per 1000 HIE Rate: 4.5-5.5 cases per 1000 term birthsHIE Rate: 4.5-5.5 cases per 1000 term births

(MOH, 2006)(MOH, 2006) Cairo: 3.6% admission recorded and up toCairo: 3.6% admission recorded and up to

4.4 % Diagnosis at discharge4.4 % Diagnosis at discharge

Alex: HIE: 4.2%,Alex: HIE: 4.2%, Mortality: 6.5% (FT: 7.7%)(MOH, , 2005)Mortality: 6.5% (FT: 7.7%)(MOH, , 2005)


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El Shatby Children Hospital, Jan, 2005,El Shatby Children Hospital, Jan, 2005,March, 2006-17 years : 156 (114 males, 41March, 2006-17 years : 156 (114 males, 41females) cases, [132 cases < 5 years].females) cases, [132 cases < 5 years].

(National Health Insurance, MOH, 2006)(National Health Insurance, MOH, 2006) Neurodevelopmental delay among HIENeurodevelopmental delay among HIE

infants: 39.6%infants: 39.6% CP rate 23% of HIE infants (referral fromCP rate 23% of HIE infants (referral from

Suez Canal Area, 90% outborn transferredSuez Canal Area, 90% outborn transferredcases)El Metwally, et al, 2006cases)El Metwally, et al, 2006


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Birth AsphyxiaBirth Asphyxia

Data information systems are not availableData information systems are not available

and the burden of disease is likely to beand the burden of disease is likely to be

higher.higher.

Intrapartum factors are likely to representIntrapartum factors are likely to represent

important cause of asphyxiaimportant cause of asphyxia


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Birth AsphyxiaBirth Asphyxia

Data on long term disability due to birthData on long term disability due to birth

asphyxia are lacking .asphyxia are lacking .

Lack of a common definition of birthLack of a common definition of birth

asphyxia for accurate epidemiologic dataasphyxia for accurate epidemiologic data


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Birth asphyxia does not featureBirth asphyxia does not feature

on most lists of childhoodon most lists of childhood

"killers" and is not a policy or"killers" and is not a policy or

funding priority.funding priority.


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Cause-specific effect of intervention packagesCause-specific effect of intervention packages

delivered at different periodsdelivered at different periods

Antenatal/intrapartum/post natal

(10-50%) Preconception (Folic acid)( neural tube defects 40-85%)

Intranatal

( 10-20%)

Intrapartum:Skilled care (20-30%)

Antibiotics for PROM

( infection 15-45%)Antenatal steroids(25-50%)

Postnatal:

Extracare for LBWT(20-40%)

Management of serious neonatal

illeness ( 10-50%)


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Tackling the problemsTackling the problems

Antenatal CareAntenatal Care The general lack of antenatal care isThe general lack of antenatal care is

responsible not only for most maternalresponsible not only for most maternal

deaths but also for high neonatal morbiditydeaths but also for high neonatal morbidityand mortality rates (Dnser et al, 2006)and mortality rates (Dnser et al, 2006)

Antenatal missed opportunity for referralAntenatal missed opportunity for referral

for high risk pregnancy as high as 81.3%for high risk pregnancy as high as 81.3%Awad et al, 2005Awad et al, 2005

Lack of etiological factor in approximatelyLack of etiological factor in approximately50% of pregnancies yielding HIE50% of pregnancies yielding HIEinfantsSerdaro Gcaron Lu et al, 2006infantsSerdaro Gcaron Lu et al, 2006


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Neonatal ResuscitationNeonatal Resuscitation

6% to 42%of neonatal mortality or6% to 42%of neonatal mortality or

morbidity in the developing worldmorbidity in the developing world

could be decreased by neonatalcould be decreased by neonatal

resuscitationresuscitation (Darmstadt(Darmstadt,,

2005)2005)


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Health workers should be periodicallyHealth workers should be periodically

trained in the assessment andtrained in the assessment and

management of birth asphyxia.management of birth asphyxia. Necessary equipment forNecessary equipment for

resuscitation should be available andresuscitation should be available and

health care providers trained in itshealth care providers trained in itsuseuse..


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Community Reach.Community Reach.

Tailoring NRP to primary healthTailoring NRP to primary healthcare personnel (Nurses,care personnel (Nurses,

Midwifes, EMS).Midwifes, EMS).

Midwives and community healthworkers must be authorized and

trained to give bag and mask


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SpecializedCentersSpecializedCenters

High risk infants, neurodevelopmentalHigh risk infants, neurodevelopmentalclinics:clinics:

Follow-upFollow-up Management of complicationsManagement of complications

Physiotherapy/RehabilitationPhysiotherapy/Rehabilitation ReferralReferral Health educationHealth education Data-baseData-base


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;

Improvements in transportationservices for referral.

Education campaigns specificallytargeted at newly married couplesand their families, and the generalpublic through television and

radio messages. Institution of perinatal andneonatal audits at hospitals andhealth centers


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Crucial to the success of programsis:

national ownership, and public-private partnerships to

ensure long-term funding.


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Research Priorities forCommunity-Based

Health Services

Community-based studies to determineexisting obstetric practices, neonatal

care, and health-seeking behavior forperinatal asphyxia. Training of traditional birth attendants

and community health workers toimplement the package of basic

neonatal care resuscitation. Strategies to improve access to

emergency obstetric care, and methodsto increase referral rates for

complicated pregnancies, and


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An ongoing dialogue must beestablished between governmentand researchers to combatperinatal asphyxia.

Research results must be used toformulate national programs andpolicies.


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Documents

Neonatal Asphyxia in Egypt Where we stand ?