IMR on par with developed countries, but gaps need to be filled - Health Ministry
While Sri Lanka’s impressive low Infant Mortality Rates (IMR) at 8.2 is commendable there is still room for improvement. Health officials have already put strategies to this end in place with Special Care Baby Units and Neonatal Intensive Care Units and Mother- Baby centres to care for sick babies and mothers.
Consultant Community Physician, President, Perinatal Society of Sri Lanka and National Program Manager, Maternal & Child Mortality Surveillance, Dr Kapila Jayaratne , tells the Sunday Observer why babies die, and how these deaths can be prevented.
Excerpts…
Q. Last week we discussed why new mothers die and how these deaths could be prevented.
This week I want to ask why babies die. Even though our infant mortality rate is low since most deliveries are in hospitals what causes them to die?
A. Every year around 2,800 infants die before they reach their first birthday. Out of this nearly 70% die within 28 days of birth -they are called neonatal deaths. Out of neonatal deaths, 60% die in the first seven days and 30% in the first 24 hours.
Our death rates are low, as 99.9% of births take place in hospitals. Now we face highly complex situations which necessitate sophisticated care for survival.
Q. What is the current incidence rate of infant mortality? How do these figures compare to a decade ago?
A. For infant mortality data we depend on the Registrar General’s Department. They are based on death registration. The latest available infant mortality rate (IMR) is for the year 2013 -8.2 per 1,000 live births.
The graph shows how the infant and neonatal mortality reduced in the country over the years. During the era that we obtained independence, Sri Lanka’s IMR was 140, by 1980 it dropped to 35. In 2000 IMR was 13 per 1,000 live births.
Another category is perinatal deaths (PND)-deaths in utero after 28 weeks and early neonatal deaths (END). In the year 2015, there were 1,728 stillbirths and 1,555 ENDs (Total 3,283 PNDs).
Stillbirth and early neonatal mortality rates were 5.3 per 1,000 total births and 4.8 per 1,000 live births, respectively. The perinatal mortality rate was 10.1 per 1,000 total births. This translates that for every 1,000 pregnant women, one of them experiences the death of her baby during pregnancy or immediately after delivery.
However, the current IMR of 8.2 is a remarkable achievement when compared with the IMR of developed regions of the world which is 6 per 1,000 live births.
While a few countries like Japan and Finland report only 2 infant deaths per 1,000 live births, even in USA the rate is 6.
Q. Are these infants born pre-term or largely full term?
A. A significant proportion is due to prematurity. Every year around 26,000 babies are born before term. Only about 500 – 600 babies die due to complications of prematurity. Our service delivery can save even 24 week foetuses in our best centres.
Q. Is it because of some physical deformity in the foetus? Or poor nourishment in the womb?
A. Congenital abnormalities or birth defects, account for 1/5 of infant deaths. A majority of them are heart disease and nervous system abnormalities. Intra-uterine growth retardation due to multiple causes and low birth weight also contribute to infant mortality.
Q. Have they occurred during delivery? Or after delivery?
A. For almost two thirds of these deaths, the causes originate either prior to or during pregnancy. Birth asphyxia, infections and respiratory distress may be considered as appearing after delivery. But their root causes may be linked to pregnancy and delivery period.
Q. What is the percentage of surgical errors that has contributed to infant mortality?
A. Nearly zero. Only a few babies need surgical care after birth and their survival afterwards due to the good standard of our surgeons.
Q. What are the early indications that the baby may not survive?
A. Every baby born alive is cared for by a qualified doctor in the hospital. Nearly 95% of births take place in a hospital where a paediatrician or a neonatologist is available.
For every newborn, an Apgar score is calculated based on the examination. It is a measure of the physical condition of a newborn infant.
It is obtained by adding points (2, 1, or 0) for heart rate, respiratory effort, muscle tone, response to stimulation, and skin coloration; a score of ten represents the best possible condition. With Apgar score we can predict prognosis of the baby. With a low Apgar score, the survival is usually not good.
Q. What are the commonest causes for infant deaths in Sri Lanka?
A. The causality of a majority of infant deaths originate from the pregnancy period and around delivery. Therefore, perinatal complications such as growth retardation in the womb, prematurity and low birth weight, account for about 50% of infant deaths.
Congenital abnormalities, as the second leading cause, contribute to 20% of infant deaths. Birth asphyxia, respiratory distress after birth, infections and pneumonia are the next leading causes.
Q. Has there been a national survey on the causes of these deaths?
A. We have issues on the timeliness and quality of the cause of death in data on infant mortality from the civil death registration system. The Ministry of Health took steps to address this. In 2016, a systematic infant death surveillance and response mechanism was launched at both institutional and field levels, where each and every infant death occurring at field level and hospital should be notified within 24 hours to the Family Health Bureau.
An in-depth review should be conducted with a view to identify service gaps and translate lessons learnt into action within 14 days. Individual infant death investigation formats were formulated and distributed to all MOH offices and health facilities. Data are being analysed.
Q. Who are the most vulnerable?
A. Babies born to women with complicated pregnancies are at highest risk of dying. Pregnancies in extremes of age of the mother, teenage pregnancies as well as pregnancies in elderly women (above 35 yrs) can be considered vulnerable.
Around 5% of pregnant mothers are under the age of 20 and 15% are above the age 35. Babies born to underweight (prevalence is around 20%) as well as obese women (prevalence 18%) suffer many illnesses after delivery. Pregnancies complicated with heart disease, hypertension, diabetes and other chronic illnesses are at high risk of complications.
Q. Which areas in the country do you see the highest rate of infant mortality? Why?
A. Kilinochchi, Jaffna and Matale districts reported high infant mortality rates. Immediate and distant causes of infant mortality are multiple and complex.
Root causes originate before pregnancy due to socio-economic backgrounds, education, cultural practices and geographical location. Access to quality healthcare may also be an issue.
Q. Has there been any new studies regarding infant mortality?
A. We have collected data on infant deaths from household and hospital level in the year 2016. We are now analysing nearly 6,000 data formats. We may be able to give preliminary results in the coming months.
Q. Does nutritious diets and healthy lifestyles by the mother count where infant morbidity and mortality is concerned?
A. Anaemia, low body weight and obesity causes multiple complications to the foetus and the newborn. Therefore, a pregnancy should be a carefully planned one with ideal body weight and nutritional status.
We expect an adequate weight gain based on the BMI at booking visit of pregnancy. To achieve this a nutritious diet during pregnancy is crucial.
Q..Are there special wards for emergency cases for babies? Where? Are there enough facilities like ICUs etc?
A. For sick newborns Special Care Baby Units and Neonatal Intensive Care Units are available throughout the country.
In these facilities, highly sophisticated care for the sick babies are provided with modern treatment modalities. Mother- Baby centres to care for sick babies and mothers are also available in several specialist hospitals.
Q. What is your current focus?
A. Now, we are focusing on patient-centered care. With quality newborn care, the survival of our newborns has increased over the years.
We want a country in which there are no preventable deaths of newborns or stillbirths, where every pregnancy is wanted, every birth celebrated, and women, babies and children survive, thrive and reach their full potential.
Q. Do you have a back up when the mother is unable to feed her new born baby?
A. Usually a majority of mothers can initiate breastfeeding within half an hour after birth. In some cases there may be issues.
Hospital staff is adequately trained to tackle such cases. Lactation Management Centres to support mothers with breastfeeding problems are available in many of the specialized hospitals.
Q. How many qualified obstetricians and paediatricians are there in the country? Are they all qualified?
A. There are 140 fully-qualified obstetricians and 170 paediatricians in the government hospitals and a significant number in the private sector. Yes, they are well qualified.
Q. What is the training like? For how long does a person have to study to be a fully fledged obstetrician?
A. All specialist doctors should have the basic degree of MBBS. Then they have to sit a qualifying examination followed by post-graduate training in the field of study, usually for 3 years.
After they pass the specialist exam (MD or MS), there is a mandatory overseas training at a Best Center for 1 – 2 years. Only after they have undergone all this training will they will be board-certified to practice as a specialist in the country.
Q. What are the present gaps in the health system that should be overcome for safe delivery and care of a baby?
A. We have obstetricians and paediatricians spread all over the country providing access to care. They are placed in 81 specialized hospitals. There is an MBBS doctor within a 5Km radius in the country.
Despite all these, we need to improve the quality of care. Not all hospitals are equally manned or equipped with all resources.
There are issues in human resources. Not only doctors, we need other categories of health staff, midwives, nurses, radiographers, physiotherapists, MLTs etc to provide optimal care. Furthermore, the survival of a newborn still depends on where it is born based on facilities or the quality of care it was able to receive.
Another pressing need we have is modern technologies to care for sick newborns e.g:. Therapeutic cooling machines, nitrous oxide, caffeine citrate, neonatal retrieval systems, etc.
Q. Plans for the future?
A. Our focus has shifted. Now we focus not merely on mortality rates. We have already achieved best rates in infant and neonatal mortality, in the region and are on par with highly developed countries.
So we now target reducing the number of deaths and giving quality care for morbidity. Quality assessment tools for quality assurance in maternal and newborn care are finalised and used in 10 hospitals in the country.
In addition, a Bottle Neck Analysis was carried out to identify gaps in the current newborn care program in 2015 to facilitate development of Every Newborn Action Plan. This plan will address many gaps in the service delivery system.
Q. Any advice to mothers regarding their role in newborn survival?
A. We want every pregnancy to be planned. Have an ideal weight, go for pre-pregnancy counselling. Attend to existing illnesses.
Take peri-conceptional medications, e.g. Folic acid, register one’s pregnancy, be compliant with medication and clinic follow up. Pay close attention to any danger features during pregnancy.
Deliver at a suitable hospital. And most importantly, exclusively breastfeed your baby.
Return immediately to the hospital if you observe any abnormal features in the newborn baby.