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Neonatal Asphyxia in Egypt

Where we stand ?

 Mohamed Khashaba,MD
 Professor of Pediatrics/Neonatology
 Head of NICU, MUCH

 Mansoura, Egypt
A healthy newborn infant is the best
promise for the future
The Millennium Development Goals
(MDG)

 To create an environment – at the national


and global levels alike-which is conductive
to development and to elimination of
poverty.
( UN General Assembly)
Goals 4 and 5

 Aim to reduce maternal and child mortality.


 Investment in maternal, newborn, and child health
is not only a priority for saving lives, but is also
critical in advancing other goals related to human
welfare, equity and poverty reduction.
 Neonatal deaths account for 36% of deaths in children
aged under 5 years (31 per 1000)
 MDG-4 stipulates a reduction of under 5 years mortality
from 95 per 1000 in 1990 to 31 per 1000 in 2015.
 Reduction in neonatal deaths will be required and should
become a major priority.
• Over 9 million deaths occur
each year in the perinatal
and neonatal periods;
• 98% of these deaths take
place in the developing
world;
• Most of these deaths are
caused by infectious
diseases; pregnancy-related
complications; or delivery-
In most of the world,
under-5 year and infant
(under-1 year) mortality
rates have declined
substantially in the past
three decades.
• Neonatal mortality has
declined less rapidly than
other child mortality;
• Neonatal deaths now
account for 40 -70% of all
infant mortality;
Comparison of Infant and
Neonatal Mortality Decline in
Turkey 1975 -1995
140

120

100
Rateper 1000

80

60
Infant Mortality
40
Neonatal Mortality
20
1975 1980 1985 1990 1995

Year
Comparison of Infant and
Neonatal Mortality Decline in
Egypt 1975 -1995
140

120

100
Rateper 1000

80

60
Infant Mortality
40
Neonatal Mortality
20
1975 1980 1985 1990 1995

Year
Medium-Term Trends in Neonatal Mortality
in the Middle East and North Africa

75
Neonatal Mortality Rate

50
Yemen
Morocco

Egypt
25 Tunisia

Jordan

0
1975 1980 1985 1990 1995

Year
Many neonatal deaths are unseen and
undocumented
 Most epidemiological and other research
focuses on 1% of deaths
Direct Causes of Neonatal Mortality
Neonatal
Tetanus
Pneumonia
14%
19%

Diarrhea
2%

Asphyxia Other
21% 5%

Prematurity
10%

Injuries Sepsis
11% Congential 7%
abnormalities
11%
WHO Mother and Baby Package, 1993
Causes of perinatal death in Egypt

Deaths bef ore start of


labor
Unclassif ied 7%
11%

Other specif ic causes


3%

Asphyxial conditions
developing in labor
Conditions associated 28%
w ith preterm birth or
immaturity
21%

Congenital Time of intrauterine


malf ormations death unclear,
7% possibly asphyxial
conditions developing
in labor or deaths
bef ore the start of
labor
23%
 In developing countries, 3% of
all newborn babies (3.6 million)
develop moderate or severe
asphyxia. Of these, about
840000 die . Same number
develop severe sequelae, WHO,
1996Mother-baby package
WHO1996:Implementing safe
motherhood in countries,
 Statistically, asphyxia claims the
lives of eight to ten per 1,000
infants worldwide. Sherman et al,
2002

 Most common diagnoses for


admission of critically ill
neonates in the developing
countries is peripartum asphyxia
with its numerous complications
 The neonatal mortality of 24.7%among
asphyxiated neonates was 34.5-times
compared to that of the non-asphyxiated
population .

 The mortality rates in preterm-and term-


asphyxiated neonates were 47.8% and 6%,
respectively .

 Mortality: 7.5% of HIE among all born
infants Bose et al, 1998
 HIE is an important cause of mortality
and morbidity in full-term newborns,
and neurologic handicaps occur in
about 25% to 28% of these infants
with devastating human, social and
economic consequences.
 (Freeman & Nelson, 1988)
Asphyxia burden in
Egypt
 Total population: 74,033,000
 •Child mortality 36per 1000
 HIE Rate: 4.5-5.5 cases per 1000 term births
(MOH, 2006)
 Cairo: 3.6% admission recorded and up to
4.4 % Diagnosis at discharge

 Alex: HIE: 4.2%,


 Mortality: 6.5% (FT: 7.7%)(MOH, , 2005)
 El Shatby Children Hospital, Jan, 2005,
March, 2006-17 years : 156 (114 males, 41
females) cases, [132 cases < 5 years].
(National Health Insurance, MOH, 2006)
 Neurodevelopmental delay among HIE
infants: 39.6%
 CP rate 23% of HIE infants (referral from
Suez Canal Area, 90% outborn transferred
cases)El Metwally, et al, 2006
Birth Asphyxia

 Data information systems are not available


and the burden of disease is likely to be
higher.
 Intrapartum factors are likely to represent
important cause of asphyxia
Birth Asphyxia

 Data on long term disability due to birth


asphyxia are lacking .
 Lack of a common definition of birth
asphyxia for accurate epidemiologic data
 Birth asphyxia does not feature
on most lists of childhood
"killers" and is not a policy or
funding priority.

Cause-specific effect of intervention packages
delivered at different periods

Antenatal/intrapartum/post natal Preconception (Folic acid)


(↓ 10-50%) (↓ neural tube defects 40-85%)

Intranatal
(↓ 10-20%)

Intrapartum: Postnatal:
Skilled care (20-30%) Extracare for LBWT(20-40%)
Antibiotics for PROM Management of serious neonatal
(↓infection 15-45%)
Antenatal steroids(25-50%) illeness (↓ 10-50%)
Tackling the problems

 Antenatal Care
 The general lack of antenatal care is
responsible not only for most maternal
deaths but also for high neonatal morbidity
and mortality rates (Dünser et al, 2006)

 •Antenatal missed opportunity for referral


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

 •Lack of etiological factor in approximately


50% of pregnancies yielding HIE
infantsSerdaro Gcaron Lu et al, 2006
 Neonatal Resuscitation

 •6% to 42%of neonatal mortality or


morbidity in the developing world
could be decreased by neonatal
resuscitation
 (Darmstadt,
2005)
 Health workers should be periodically
trained in the assessment and
management of birth asphyxia.
 •Necessary equipment for
resuscitation should be available and
health care providers trained in its
use.
 Community Reach.

 •Tailoring NRP to primary health


care personnel (Nurses,
Midwifes, EMS).

Midwives and community health


workers must be authorized and
trained to give bag and mask
 SpecializedCenters

 •High risk infants, neurodevelopmental


clinics:
 –Follow-up
 –Management of complications
 –Physiotherapy/Rehabilitation
 –Referral
 –Health education
 –Data-base
• ;

• Improvements in transportation
services for referral.
• Education campaigns specifically
targeted at newly married couples
and their families, and the general
public through television and
radio messages.
• Institution of perinatal and
neonatal audits at hospitals and
health centers
Crucial to the success of programs
is:
• national ownership, and
• public-private partnerships to
ensure long-term funding.
Research Priorities for
Community-Based
Health Services
• Community-based studies to determine
existing obstetric practices, neonatal
care, and health-seeking behavior for
perinatal asphyxia.
• Training of traditional birth attendants
and community health workers to
implement the package of basic
neonatal care resuscitation.
• Strategies to improve access to
emergency obstetric care, and methods
to increase referral rates for
complicated pregnancies, and

• An ongoing dialogue must be
established between government
and researchers to combat
perinatal asphyxia.

• Research results must be used to


formulate national programs and
policies.

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