Neonatal Mortality of De Los Santos Medical Center NICU

(Neonatal Intensive Care Unit) from 2012 to 2016

Members:
Acha, Kea Khaerloe
Alcantara, John Allen
Marcelo, Ma. Theresa Andrea
Moya, Mohanna
Napa, John Michael Joseph
Rey, Cathrina Marie
Yupangco, Maria Monica
 TABLE OF CONTENTS

I. Introduction
i. Objectives
ii. Significance of the Study
iii. Conceptual Framework
II. Review of Related Literature
III. Methodolgy
IV. Results and Discussion
V. Conclusion
I Introduction

Large numbers of children die soon after birth: many of them in the first four weeks of life
(neonatal deaths), and most of those are the newborn babies who died during the first week (early
neonatal deaths). Neonatal deaths stem from poor maternal health, inadequate care during
pregnancy, inappropriate management of complications during pregnancy and delivery, poor
hygiene during delivery and the first critical hours after birth, and lack of newborn care. Several
factors such as womens status in society, their nutritional status at the time of conception, early
childbearing, too many closely spaced pregnancies and harmful practices, such as inadequate cord
care, letting the baby stay wet and cold, discarding colostrum and feeding other food, can be a
contributory factor also.
The neonatal period is one of the most vulnerable periods of life. Neonatal outcome is an
important indicator of obstetric and neonatal health care. Neonates become vulnerable to different
diseases especially the pre-term and low birth weight babies. In most cases, this diseases are
preventable. Neonatal morbidity and mortality are major global public health challenges with
approximately 3.1 million babies worldwide dying each year in the first month of life. This
represents a large proportion of overall under-5 child mortality, with the vast majority of neonatal
deaths occurring in resource-limited settings.
Globally, the neonatal mortality rate is declining. The worldwide neonatal mortality rate
fell by 47% between 1990 and 2015 from 36 to 19 deaths per 1,000 live births. Over the same
period, the number of newborn babies who died within the first 28 days of life declined from 5.1
million to 2.7 million. However, the decline in neonatal mortality in 19902015 has been slower
than that of post-neonatal under-five mortality (1-59 months): 47 percent, compared with 58
percent globally. This pattern applies to most low- and middle-income countries. Of the estimated
5.9 million child deaths in 2015, almost 1 million occur in the first day of life and close to 2 million
take place in the first week.
 In the Philippines, in 2013, although the infant mortality rate slightly increased, the number
of registered infant deaths slightly decreased by more than one percent, from last years 22,254
cases to 21,992 cases. It comprised of 4.1 percent of the total deaths (531,280) reported during the
year. This represented a daily average of 60 infant deaths and was equivalent to an Infant Mortality
Rate (IMR) of 12.5 deaths per thousand live births. The top three leading causes of infant mortality
were Pneumonia (3,146; 14.3%); Bacterial sepsis of newborn (2,731; 12.4%); and Respiratory
distress of newborn (2,347; 10.7%). The listed top ten leading causes of infant mortality in 2013
were the same with what was recorded in 2012 which only differ in ranks.
While there are variations in the healthcare system of the different regions in the
Philippines, this study aims to focus on the mortality of neonates admitted in the NICU of Delos
Santos Medical Center from the years 2012 to 2016.

II Objectives
General Objectives:
To determine the mortality of neonates admitted in the De Los Santos Medical Center
Neonatal Intensive Care Unit from the years 2012 to 2016.

Specific Objectives:
To determine the causes of death of neonates admitted in the De Los Santos Medical Center
Neonatal Intensive Care Unit from the years 2012 to 2016.

To determine the prevalence of diseases in neonates in the De Los Santos Medical Center
Neonatal Intensive Care Unit

III Significance of the Study

To be able to know the epidemiologic trends of cases by mortality in neonates admitted in
the De Los Santos Medical Center Neonatal Intensive Care Unit.

To be able to apply these information in the health care system of the hospital in terms of
prevention and management of these patients for better patient outcomes.
IV Conceptual Framework
 Neonatal Mortality in DLSMC-
NICU from 2012 to 2016

Determine the different direct

causes of neonatal mortality

Determine the underlying causes of

neonatal mortality

2012 to 2016 medical records of

neonatal mortality in DLSMC-NICU

Data gathering and analysis

Chapter II: REVIEW OF RELATED
LITERATURE
WORLDWIDE PERSPECTIVE
Over nine million children in the world die every year during the perinatal and neonatal periods
and nearly all (98%) of these deaths occur in developing countries. Neonatal mortality
contributes between 40-70% of infant mortality. In most developing countries, nearly half of
perinatal deaths occur during the antepartum or intrapartum period, and the rest during the first
week of life. Almost 50% of these deaths are related to severe infection, tetanus and diarrhea in
countries with higher neonatal mortality rates (NMR) (NMR >45). On the other hand, these
causes are less common in countries with low NMR levels (NMR <15). Thus, the causes of
neonatal deaths are observed to vary across countries and geographical locations. Neonatal
deaths in advanced countries are largely due to unpreventable causes like congenital
abnormalities; while in developing countries, newborns die mainly from preventable causes like
infections, birth asphyxia, and prematurity. One of the most striking examples of inequity
between countries is in the area of newborn health. Of the four million neonatal deaths, 98%
belong to the worlds poorest nation.
Worldwide there has been a call for a two thirds reduction in childhood mortality by 2015.
Unfortunately, Millennium Development Goal 4 (MDG4) is unlikely to be reached in years
time. Globally, an estimate of 10.6 million children under five years died in 2000, declining to
8.8 million in 2008 and further to 7.7 million in 2010. At the same time, methods of estimation
and available sources of information for under-five mortality have improved. Of the 130 million
babies born every year, 4 million will die in the first 28 days of life, with the highest risk on the
first day of life. The highest rates are in sub-Saharan Africa, where little progress has been made
in the last 15 years towards reducing the number of deaths.
The relatively larger decline in the post-neonatal period compared to the neonatal period may be
attributable to the relatively high emphasis and global support for Primary Health Care
workforce development and programs such as nutrition, vaccination and health promotion,
relative to hospital-related workforce and infrastructure investments that are necessary for
neonatal mortality reduction, particularly in rural areasThe slow decline in neonatal mortality as
compared to post-neonatal mortality calls for attention and efforts to reverse this trend. Within
the neonatal period an estimated 50% of all deaths are within the first 24 hours while 75% are
within the first week of life. However, in lowincome countries, neonatal mortality rates, trends,
and causes have attracted relatively little attention compared to maternal deaths or deaths among
older children under 5 years, and in international public health policy, neonatal deaths still do not
receive attention commensurate with their burden. Given that a large fraction of these deaths are
preventable, a focus on mortality in the first week of life is important in order to accelerate the
millennium goal.
Information on cause of death is lacking for most neonatal deaths that occur in countries with
inadequate civil registration. Causes of death in neonate have been estimated worldwide by
analyzing the data of vital registration and reports of research studies in 2000. There are
variances of causes in neonate death in different regions, as well as in different countries of
economic development. Given the considerable variations in health systems and individual
countries, national and regional neonatal cause of death estimates are needed and should be a
target for future estimation exercises and data collection

UNDER FIVE MORTALITY

Fetal death is defined as any fetus born without a heartbeat, respiratory effort or movement, or
any other sign of life. It is estimated that globally 2.9 million babies experience fetal death or die
within the first week of life, with 99% of these deaths occurring in developing countries. Studies
have shown that 50% of maternal deaths occur within the first day after childbirth and
approximately 30% of stillbirths occur during labour
Neonatal death is defined as newborn death occurring within the first four weeks after birth. The
perinatal period is recognised as the most dangerous period of life because of various problems
faced by the neonates. There is evidence that there has been no measurable reduction in early
neonatal mortality over the past decade. Most programs addressing childhood mortality focus on
pneumonia, malaria, diarrhea and vaccine preventable conditions, which are geared towards
improving child survival after the first four weeks of life.
Early neonatal death is defined as all deaths of live-born infants occurring on or before the first
seven days of life. Early neonatal deaths account for 75% of all neonatal deaths worldwide, due
mainly to prematurity (40%) and complications of asphyxia (23%). Annually 18 million low-
birth-weight babies are born (14% of all births), but they account for 60 - 80% of neonatal
deaths. The World health organization (WHO) estimates that birth weight below 2500 g
indirectly contributes to about 15% of the neonatal mortality, ranging from 6% in high income
countries to 30% in low income countries, with preterm birth and related complications being the
underlying caus. Late neonatal deaths are principally due to infections (19%) with congenital
abnormalities responsible for 10% of deaths.
For example, Africa has made good progress towards reducing under- 5 mortality, still many
children continue to die from preventable causes. Neonatal deaths account for approximately
40% of all deaths in children >5 years of age in South Africa (SA). In 2009, SA was one of 8
countries in which the neonatal mortality rate (NMR) was higher than the baseline in 1990.
Starting from a rate of 21/1 000 live births in 1998, neonatal mortality needs to be reduced to 7/1
000 live births in 2015 for MDG4 to be attained.

CAUSE SPECIFIC MORTALITY

The Saving Babies 2010 - 2011 report reflects the early neonatal death rate as 21/1 000 live
births, with the majority of these deaths occurring in the 1 000 - 1 499 g weight category. Deaths
due to intrapartum asphyxia were reported as being linked to healthcare provider-associated
avoidable factors in 44% of cases.BA has for a long time been estimated to account for 25% of
neonatal mortality worldwide. However, the definition is imprecise in part because the Apgar
score, often used as an indicator to identify BA, is inaccurate or unreliable. Furthermore, many
affected infants are likely not reported or misclassified as stillbirths. Therefore, considerable
uncertainty surrounds the true estimated proportion of BA-related mortality.
The top 5 health-worker-related factors were: (i) fetal distress monitored but not detected; (ii)
fetal distress not monitored and not detected; (iii) no intervention for prolonged second stage of
labour; (iv) delays in referring the patient and (v) delay in calling for expert assistance.

Deaths due to immaturity had patient-associated avoidable factors in 30% of cases. The top 5
factors identified being: (i) delay in seeking medical attention during labour; (ii) non-initiation of
antenatal care; (iii) booking late in pregnancy; (iv) infrequent visits to antenatal clinics; and (v)
inappropriate response to rupture of membranes.
Administrative problems contributed to deaths due to immaturity in 22% of cases, with
inadequate facilities, no accessible intensive care unit (ICU) bed with ventilator, lack of transport
and inadequate resuscitation equipment reported frequently. Recent research shows that in high
mortality settings, access to emergency obstetric care has the greatest effect in improving
neonatal survival outcomes, and that lack of access to emergency obstetric care services in low-
income countries is a serious constraint in improving pregnancy outcomes.The belief that only
high-level technology can improve neonatal outcome is not appropriate in a developing country.
Cost effective interventions such as resuscitation of the newborn baby, breastfeeding, kangaroo
mother care (KMC) and prevention of hypothermia can dramatically reduce the number of
deaths in resource-limited settings. Neonatal resuscitation training has been reported to reduce
deaths due to intrapartum asphyxia by 30%. Improved obstetric care would also contribute to a
reduced number of neonatal deaths. The majority of deaths occurred at Community Health
Centres (CHCs) or district hospitals, with the poorest quality of care being rendered in district
hospitals.

A retrospective descriptive audit conducted over a 1-year period (1 January - 31 December 2011)
at Steve Biko Academic Hospital (SBAH), offers important insights into causes of neonatal
mortality. The neonatal records of all patients admitted to the Neonatal Intensive Care Unit
(NICU) were surveyed. Cause of death and avoidable factors were collected using the perinatal
death datasheet of the Perinatal Problem Identification Program (PPIP).
The health and survival of newborns has been shown to be closely linked to that of their mothers,
since inadequate maternal care during the pregnancy and postpartum period can also affect the
neonate. The top 5 primary obstetric causes of death at SBAH included spontaneous preterm
labour (38.7%), fetal anomaly (23.2%), hypertensive disorders (12%), intrapartum asphyxia
(9.9%) and antepartum haemorrhage (5.6%). The top 4 causes of neonatal death at SBAH NICU
were immaturity-related (43%), infections (26.8%), congenital abnormalities (17.6%) and
hypoxia (11.3%). Common patient-associated factors included: noninitiation of antenatal care;
attempted termination of pregnancy; and delay in seeking medical attention during labor.
Administrative problems affecting patients born in the tertiary hospital included: inadequate
facilities and equipment; lack of transport; and lack of sufficiently trained personnel. For patients
who died outside of the referral hospital, the most common problem was absence of an
accessible NICU bed with ventilator. Personnel-associated factors identified were diverse and
included hospital-acquired infection, delay in referral, antenatal steroids not given, multiple
pregnancy not diagnosed, inadequate resuscitation and monitoring, and inadequate management
of second stage of labour.
Due to these high mortality rates it is important to understand the risk factors for fetal and
neonatal mortality which are major contributors to high under five deaths globally. Fetal and
neonatal mortality is also a sensitive indicator of maternal health in society because healthy
mothers give birth to healthy babies.

WHAT CAN WE DO
Identification of cause-specific mortality in a particular setting is important to design
interventions directed to improve neonatal survival.
It has been suggested that access to antenatal care and emergency obstetric care could reduce
neonatal mortality by 10-15%. These findings confirm an earlier analysis by Kumar et al. who
report the results of a community-based strategy, where the researchers designed and
implemented a project called Saksham (Empowered) in Uttar Pradesh, Indias largest state which
accounts for a quarter of all newborn deaths in India. The project was supported by a well-
functioning emergency obstetric care system that included dedicated obstetricians,
neonatologists, culturally and technically competent community health workers and nurses who
organized the referral system from communities to respective district hospitals. Their analysis
found that within 18 months of the programs commencement, neonatal deaths dropped by
58%There is evidence that 10% of intrapartum-related and preterm deaths can be reduced by
immediate assessment and stimulation of newborns.
In relation to neonatal mortality prevention, skilled workforce entails adequate quality, quantity
and distribution of neonatologists,mobstetricians, anaesthetists and midwives. Good emergency
obstetric care requires improving the availability, accessibility, quality and use of services for the
treatment of complications that arise during pregnancy and childbirth. The weakest link in
Emergency Obstetric Care Services is the provision of well-functioning and appropriately staffed
district and referral hospitals to provide care for complications that arise during late pregnancy
and at birth. Even in countries where such facilities are provided, delays in obtaining care may
occur at three levels: delay in deciding to seek care; delay in reaching a first referral level
facility, and; delay in actually receiving care after arriving at the facility.
Treatment with antenatal corticosteroids has been associated with a decrease in overall neonatal
deaths, especially for women with premature rupture of membranes (PROM). Darmstadt et al.
report that cost-effective and inexpensive interventions such as antibiotics for preterm premature
rupture of membranes, antenatal corticosteroids, clean delivery practices, resuscitation of the
newborn, breastfeeding, prevention of hypothermia and KMC can reduce neonatal deaths by 41 -
72%. The use of antenatal steroids can reduce the incidence of hyaline membrane disease, intra-
ventricular hemorrhages and necrotizing enterocolitis, and ultimately significantly reduce
neonatal deaths.
Prevention and active management of hypothermia, starting in the delivery room, also reduces
mortality of premature infants significantly. Although hypothermia was documented as an
avoidable cause in only 3 of the SBAH patients, 43.2% of infants <1 500 g were hypothermic on
admission. The simple expedient of covering preterm infants <1 200 g or <28 weeks gestation in
polyethylene or plastic immediately after delivery reduces hypothermia. This should be used in
conjunction with warm delivery rooms and functioning incubators and radiant warmers.
Adequate resuscitation with proper training of health personnel and access to the correct
equipment will reduce deaths due to prematurity and due to asphyxia. Prompt and early referral
for lifesaving treatments, such as surfactant for hyaline membrane disease, and therapeutic
hypothermia for asphyxia, is critical. This is especially crucial for therapeutic hypothermia,
given the specific window of opportunity of just 6 hours.
The responsible use of oxygen should also be promoted at all levels. Adequate monitoring is
essential, especially in the premature infant <32 weeks gestation and <1 500g birth weight, as
these infants are at an increased risk for retinopathy of prematurity (ROP), a leading cause of
blindness in children. The second Benefits of Oxygen Saturation Targeting trial (BOOST II)
recently reported that lower saturations of 85 - 89%, which reduce the risk of ROP, had a
significantly higher rate of death than saturations of 91 - 95%. The unavailability of beds at
referral hospitals needs to be addressed.
III Methodology

Research Design
The researchers utilized the descriptive, retrospective study design using the medical
records of all deceased neonates age 0-28 days between January 2012 to December 2016
admitted in Delos Santos Medical Center Neonatal Intensive Care Unit (NICU). Hand-written
and typewritten patient records, completed routinely by interns and residents, were transcribed to
analyze their respective demographic backgrounds that include: gender, birth weight, gestational
age, APGAR Score, delivery mode, length of stay, maternal disease and leading underlying
cause of death for the neonates.

Inclusion and Exclusion Criteria

In this study, the researchers included late preterm (near term), term, and post term babies
who were born and died from January 2012 to December 2016 in Delos Santos Medical Center.
The neonates are placed in the neonatal intensive care unit for further evaluation and
management. Included are also babies suffering from major congenital anomalies or syndromes
and preterm babies <35 completed weeks upon birth in the hospital who died before the age of
28 days during their stay.
The following were excluded from the present study: 1) neonates who are stable during their
hospital stay and alive upon discharge, 2) deceased neonates with incomplete records, 3)
neonates who died upon arrival in the hospital with no documented diagnoses.

Population and Sampling

Purposive sampling was used to determine neonates who were deceased from January
2012 to December 2016 in the Neonatal Intensive Care Unit in DLSMC. The study came up with
16 deceased neonates out of the 2,547 admissions, in which medical records and death
certificates were transcribed and analyzed if the criteria were met.

Instrumentation
The study used medical records, patient charts and death certificates of neonates born
from January 2012 to December 2016 and were transferred to the Neonatal Intensive Care Unit
of DLSMC. The hand-written and typewritten patient records of the patients, completed
routinely by interns and residents, were retrieved and transcribed to analyze their respective
demographic backgrounds that include: gender, birth weight, gestational age, APGAR Score,
delivery mode, length of stay, maternal disease and leading underlying cause of death for the
neonates.

Data Collection
Participants of this study were deceased neonates age 0-28 days, who were born from
January 2012 to December 2016 in the Neonatal Intensive Care Unit of DLSMC. Out of the
2,579 admissions, there were a total of 16 deceased neonates who were eligible based on the
inclusion criteria. Their medical records and death certificates were transcribed and analyzed
based on their demographic backgrounds that include: gender, birth weight, gestational age,
APGAR Score, delivery mode, length of stay, maternal disease and leading underlying cause of
death for the neonates. Data unavailable in the patient records in the ward were retrieved through
review of patient charts and discharge certificates from the record office. Course in the ward of
these patients were reviewed and analyzed, as well as, management done to better understand the
cause of their deaths.
Ethical Considerations
The research upholds the confidentiality of the participants that are included in this study.
Medical records, patient charts and death certificates are only seen by the members of the
research team and its mentors. The identities were kept anonymous and confidential, as well as,
any information not related to this study were excluded.

Data Analysis
Data was analyzed using descriptive statistics, specifically frequency cumulative
frequencies, mean scores and percentage scores, which described the variables under study
namely: gender, birth weight, gestational age, APGAR Score, delivery mode, length of stay,
maternal disease and leading underlying cause of death for the neonates. Frequency distribution
was utilized in analyzing the scores of variables. This provided the researchers of view of the
general trend in the outcome of the study and the discrepancy of the scores of participants and its
variation from the mean. Creation of contingency tables was also done wherein the variables are
put in a cross-tabulated form for a simpler presentation of data.

Methodological Limitations
The major disadvantage of a non-experimental study is its weakness in revealing the
causal relationships of the variables under study. It is also susceptible to faulty interpretations if
the researcher is not careful with the analysis of data and also because there is a selection bias.
The researcher cannot also assume that the group being presented is similar before the
occurrence of the independent variable. An explanation of the preexisting differences in relation
to the current group differences on the outcome variable may then serve as a likely alternative
explanation for this phenomenon.
There are various critiques in using descriptive statistics. Adequate information, correct
use of indexes, and even presentation of data in a useful, efficient and comprehensible manner
should be taken into consideration.
 RESULTS
Figure 1: Yearly census of live births and deceased neonates in DLSMC-NICU from 2012
to 2016
600

6
1 4

2 3
450
541 543 551

475 469

300
2012 2013 2014 2015 2016
Live births Deceased Neonates
Out of 2,579 live births from 2012-2016, there were 16 recorded deceased neonates (0.6%).
2012: 1 mortality (0.18%) from 541 live births
2013: 2 mortality (0.42%) from 475 live births
2014: 3 mortality (0.64%) from 469 live births
2015: 4 mortality (0.74%) from 543 live births
2016: 6 mortality (1.09%) from 551 live births

Table 1: Demographic Data of Deceased Neonates

VARIABLE NO. (%)
Gender
Male 9 (56.25%)
Female 7 (43.75%)
Birthweight
SGA 2 (12.5%)
AGA 14 (87.5%)
Age of Gestation
Preterm 11 (68.75%)
Term 5 (31.25%)
Mode of Delivery
NSD 2 (12.5%)
CS 14 (87.5%)
 Maternal Disease
UTI 6 (37.5%)
Cervicovaginitis 2 (12.5%)
Placenta Previa 2 (12.5%)
Pre-eclampsia 1 (6.25%)
GDM 1 (6.25%)
Uterine Rupture 1 (6.25%)
Open Cervix 1 (6.25%)
No disease 2 (12.5%)
Length of stay
<24 hours 4 (25%)
7 days 6 (37.5%)
>7days 6 (37.5%)

TOTAL
16 (100%)

Figure 2: Gender Distribution of Deceased Neonates from 2012 to 2016

Gender

Male
Female

Figure 3: Birthweight Distribution of Deceased Neonates from 2012 to 2016

 Birthweight

SGA
AGA

Figure 4: Gestational Age Distribution of Deceased Neonates from 2012 to 2016

Gestational Age

Preterm
Term

Figure 5: Mode of Delivery Distribution of Deceased Neonates from 2012 to 2016

 Mode of Delivery

NSD
CS

Figure 6: Maternal Disease Distribution of Deceased Neonates from 2012 to 2016

Maternal Disease
No disease

Open Cervix

Uterine Rupture

GDM

Pre-eclampsia

Placenta Previa

Cervicovaginitis

UTI

0. 10. 20. 30. 40.

Figure 7: Length of stay Distribution of Deceased Neonates from 2012 to 2016

Length of Stay
> 7 days
7 days
Length of stay <24 hours

0. 9.5 19. 28.5 38. 47.5

Table 3: Neonatal cause of death
CAUSE NO. (%)
Disseminated Intravascular Coagulation 8 (50%)
Septic Shock 2 (12.5%)
Birth Asphyxia 1 (6.52%)
Hypovolemic Shock 1 (6.52%)
Respiratory Failure 1 (6.52%)
Respiratory Insufficiency 1 (6.52%)
Persistent Pulmonary Hypertension of Newborn 1 (6.52%)
Thanatropic Dysplasia 1 (6.52%)

TOTAL
16 (100%)

Figure 8: Distribution of Neonatal Cause of Death

Neonatal Cause of Death

Thanatropic Dysplasia
PPHN
Respiratory Insufficiency
Respiratory Failure Neonatal Cause of Death

Hypovolemic Shock
Birth Asphyxia
Septic Shock
DIC

0. 12.5 25. 37.5 50. 62.5

DISCUSSION

Our findings state that from the year 2012 to 2016, out of 2579 neonates admitted to the newborn
unit, 16 were recorded deceased giving a mortality of 0.6%. 50% out of 16 deaths were due to
Disseminated Intravascular Coagulation followed by Septic Shock at 12.5%. Most of these
mortalities were mainly preterm males, Appropriate for Gestational Age (AGA), delivered via
Cesarean Section correlated with ascending infections from the urinary tract (UTI) of the mother
and had a > 7 days stay in the Neonatal Intensive Care Unit (NICU).

The relatively low number of neonatal mortality in the NICU of De Los Santos Medical Center
can be attributed to the availability of neonatal resources and good access to diagnostic modalities
that are usually covered by a tertiary hospital. In the study of Merlo et al., 2005, decreased neonatal
mortality in low-risk deliveries was seen in larger regional hospitals with full access to neonatal
care as compared to small hospitals. In addition, Lasswell et. Al., 2010 stated that very low birth
weight and very preterm infants born outside a level III hospital is significantly associated with
increased likelihood of neonatal or predischarged death. It is also emphasized by the American
Academy of Pediatrics that facilities that provide hospital care for newborn infants should be
classified on the basis of functional capabilities and that these facilities should be organized within
a regionalized system of perinatal care.

On the other hand, the prognosis and outcome of neonates with DIC are essentially dependent on
the primary disease process. In infants with DIC who experience severe bleeding, mortality rates
are reported to be increased by 60 to 80%. However, other literature now states that the majority
of infants with DIC survive due to the advances in neonatal medicine and its supportive care. DIC
is a secondary process set off by an underlying disease state that results in an imbalance of the
coagulation system and the fibrinolytic system. This disruption in hemostasis leads to
microthrombi distribution throughout the circulation concurrent with systemic hemorrhaging, and
resulting in end organ dysfunction. Male infants have been consistently noted to have a higher
infant mortality rate than female infants. The higher rate of mortality for male infants is present
both in the neonatal and the postneonatal period and persists even after other known risk factors
for mortality are controlled. Prematurity has also been the leading cause of neonatal deaths
reported by WHO. This is mainly due to the inability of the neonate to cope with extrauterine life
due to the immaturity of their organs.

Data specific to elective cesarean delivery in uncomplicated pregnancies are conflicting. Lu &
Johnson, 2014 reported that in order to improve quality and safety of maternal and neonatal care,
early elective deliveries should be reduced. Infants delivered after 37 weeks but before 39 weeks
have significantly greater risks of mortality and morbidities. However, in a meta-analysis of 9
studies including more than 33,000 women, Mozurkewich and colleagues reported a significant
increase in intrapartum and neonatal deaths among term, non-malformed infants who underwent
a trial of labor, compared to those who underwent elective repeat cesarean delivery. Yet, a recent
U.S. population-based study of neonatal and infant mortality by mode of delivery among women
with no indicated risk, however, showed that neonatal mortality was increased more than two-
fold after birth by cesarean, even after excluding infants with congenital anomalies and presumed
intrapartum hypoxic events (Apgar score < 4) and adjusting for demographic and medical
covariates In these studies and others, the reported rates of neonatal death after elective repeat or
no indicated risk cesareans are low, ranging from 0.01 0.17%.

Maternal UTI is the major risk factor identified in our study leading to neonatal DIC secondary to
neonatal sepsis, prematurity, and eventually neonatal death after an elective cesarian section
delivery. Emamghorashi et al., 2012 showed a significant relationship between maternal prenatal
UTI and neonatal infection. It is therefore important to pay attention to the control of maternal
infections prenatally in order to minimize if not totally eradicate neonatal deaths.

Our study is limited by the unavailability of all maternal risk factors and maternal data sheet that
may have helped us correlate the neonatal deaths in the NICU. Also, the availability of how the
neonates were resuscitated in detail were not disclosed. Moreover, most literature related to this
study are coming from third world government hospitals. A thorough comparison from other
tertiary private hospitals especially in the Philippines or Southeast Asia is therefore highly
recommended.

CONCLUSION

The neonatal mortality of the Neonatal Intensive Care Unit in De Los Santos Medical Center from
the year 2012-2016 is 0.6%. This is significantly low and a good indication of the proper and
efficient health care provided by the team of physicians in the pediatric department of the
institution. Neonatal disseminated intravascular coagulation secondary to neonatal sepsis and
prematurity is identified as the leading cause of death. The major risk factor associated with these
deaths is maternal urinary tract infection. Addressing the infection prenatally and preventing
prematurity is therefore crucial in lowering neonatal mortality.

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