|Year : 2016 | Volume
| Issue : 5 | Page : 566-569
Neonatal transport in India: From public health perspective
Manas Pratim Roy, Ratan Gupta, Rachna Sehgal
Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Web Publication||13-Oct-2016|
Manas Pratim Roy
Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Transport of sick newborns is undergoing massive changes in India. Over past few years, specialized transport has been activated in most of the states although out of pocket expenditure and absence of health personnel in the ambulance are still posing hurdles. With gradual expansion of all-weather roads to the furthest corner of the country and introduction of free transport for all neonates, it brings opportunities for us to reach all the sick newborns to the nearest equipped hospital at the earliest. Telecommunication and presence of health personnel during transport and training on life support are other initiatives boosting health care of the neonates during transport. Thus, improved transport could be a solution for reduction of stagnant neonatal mortality in India.
Keywords: Mortality, newborn, transport
|How to cite this article:|
Roy MP, Gupta R, Sehgal R. Neonatal transport in India: From public health perspective. Med J DY Patil Univ 2016;9:566-9
| Introduction|| |
Neonatal transport remains a neglected topic so far, particularly in the context of developing countries. Evidence suggests that mortality in transported newborns is much higher than inborn babies, but there are lack of robust data on neonatal deaths that could be ascribed to transport. Although concerned literature repeatedly suggested the need for regionalization of newborn care, with stress on specialized transport, we were still far away from implementing a uniform strategy in India. In this system, all the high-risk cases are referred in utero to equipped higher center. With an efficient, rapid response retrieval system in place, the mechanism could avoid most of the deaths attributable to referral and transport.
The concept on transport of sick neonates is gradually expanding in the country. With most of the deliveries being conducted at the district level and below, there was a felt need to establish standalone transport system for the newborns. Over time, realizing the fact that wretched transport of unstable moribund neonates to higher center could kill all sincere efforts, some form of transport system has been established in most of the states. Comparing with development of technologies India has witnessed for newborn care, the progress in setting up transport has been minuscule.
| Role of Transport for Neonates|| |
India has a network of 2.7 million km rural roads. Pradhan Mantri Gram Sadak Yojana was launched in 2000, with an aim to connect all villages with >1000 population by all-weather roads. A total of 100,000 km roads have been constructed till 2007, serving 45 million people.
With only 60% habitations of the target made in 2005 for entire country being connected till 2011 by all-weather roads, this is not even possible to get a ride to the nearest hospital always as evident from >20% home deliveries. In fact, studies have earlier elicited the fact that distance and lack of transportation play roles in not seeking care, even when the need is evident. When it is within reach, factors such as limited working hours, overcrowding, and unavailability of essential medicines at health facilities compel parents to seek care from unqualified fellows, thus adding further misery to the health of the young children.
India, with more than 25 million live births per year, has witnessed a slow decline in neonatal mortality rate (NMR) (from 52/1000 in 1990 to 29/1000 in 2013) in last few years. With this sluggish advancement, the country is unlikely to achieve its millennium development goal (MDG) of NMR (17/1000 live birth) by 2015.
Here, thanks to hierarchical referral system, clients, when condition of newborn gets critical, need to rush to tertiary hospital as most of the centers below that level are not equipped with sufficient manpower or equipment. In the absence of any dedicated transport system for referred children, a major chunk of them succumbs to death within 24 h after reaching higher centers, let alone those dying during transportation without any documentation.
As a result, more than 40% of neonatal deaths occur within first 24 h of admission. With the current preference being referral of sick newborns to the higher center without prior stabilization, referral note, or accompanying trained personnel, this is probably not a wonder., In spite of repeated stress on safety and superiority of in utero transfer for neonates, this is hardly in practice. For overcoming the shortcomings, development of infrastructure around the need of population and referring hospital could be an option.
After the evolution of the concept of regionalization of care, transport seems to play an integral role in reducing maternal and child deaths. It has been seen that most of the deaths could have been avoided had there been ideal interventions, including transport, everywhere. For neonatal mortality, absence/inadequate transport may cost dear, particularly for preterm ones with critical illness, as evident from the extent of post-transport mortality (15-36%) in our country.,
Realizing the same for national perspective, Janani Shishu Suraksha Karyakram was launched for providing referral transport, with other facilities such as surgical/medical treatment and laboratory services at free of cost. Under this scheme, pregnant mothers and sick babies could use hospital services for free, thus curtailing out of pocket expenditures. With the use of this facility being patchy, even after some form of transport system being in place in 28 states of the country, including some community-based models, many households still depend on private vehicles for getting hospital care.,
In an existing system in India, few states have implemented National Ambulance Service (NAS) while Emergency Management and Research Unit (EMRI), a public-private partnership, is working in some other states. As an example of local innovation, boat clinics have also been introduced in Assam. In fact, states have been given flexibility to establish their own transport system. For betterment, it has been proposed to set Geographic Positioning System facility in all the ambulances dedicated for transfer of sick neonates. Geographic Information System has been used successfully in monitoring emergency obstetric services. This could be also used for identifying areas for future improvements. Lack of concept of return transport of stable neonates is another issue in this regard which should be addressed with due importance.
When the parents are left with a tedious job of referral of newborn about which they are clueless about, out of pocket expenditures ensue. Studies carried out in Burkina Faso and Northeast Brazil suggested transport cost as high as one-quarter of the total patient costs of using hospital services. In Bangladesh, transport was the second most expensive item for patients after medicines. Other developing countries suggest transport to consume as high as 25% of total expenditure for hospital stay. Related review in India has found NAS to be cheaper than EMRI. A study from Madhya Pradesh pointed out that system users face more delay in waiting for ambulances than their counterparts who lose time in arranging for the ambulance.
In fact, when transport is uncertain, particularly in rural area, time spent for waiting for transport is another major cost we do not count. Norms have been set for the transport system to respond and reach the clients to the nearest hospital within stipulated time in our country, but it is rarely the case., It has been stressed that transport system should respond within stipulated time period to ensure intervention at the golden hour and guide caretakers from referring hospital to apply treatment until it reaches a tertiary hospital.
Arranging transport usually poses a greater challenge than providing manpower. Mere presence of an ambulance without resuscitation kit may prove futile, particularly when condition of the newborn is critical and higher center is situated at a distance requiring journey for 1 h or more. The provision for maintaining temperature, oxygenation, perfusion, blood sugar (TOPS) must exist to ensure neonatal survival during transport. Use of thermocol box, plastic wrap, and insulating blankets could be helpful for preventing hypothermia. For providing oxygenation, hood, nasal prongs, laryngoscope, endotracheal tube of appropriate size, pulse oximeter, and continuous positive airway apparatus are to be kept inside the ambulance along with oxygen cylinder. Intravenous cannula, syringes, and three-way stopcocks should be present during transport. Instruments such as glucometer, infusion pump with long battery life, suction machine, electrocardiogram monitor, defibrillator, nasogastric tube, nebulizer, intraosseous needles, bag and tube, and mucous aspirator could prove assets when situation arises. Medications such as calcium gluconate (10%), inotropes, adrenaline, hydrocortisone, surfactants, sodium bicarbonates, and anticonvulsants may be required in certain cases. More important is the presence of a member who could decide the need of intubation or inotropes and act accordingly.
The transport team
In rest of the cases, i.e., where transportation is available, lack of emergency care on the way to higher centers put many a lives to death as evident by high mortality within 24 h of admission. In India, the trend for utilizing ambulance for referral of sick newborn was found to be only 30% or less., The presence of medical staff on board or knowledge of drivers about the position of patients or operating equipment, as evident from the past, could be helpful in saving lives of newborns. Transport of neonates is important as it may influence homeostasis in different ways. Even in developed countries, it may pose a challenge, as evident from studies revealing deterioration of such children, completely unrelated to the severity of the condition they are suffering from., Training of the concerned fellows, including ambulance driver, on basic and advanced life support, has been stressed in the previous review. A limited number of transport teams in each region may be countered by the provision of reserved team equally equipped with all modern amenities.
In the absence of data from all over the country, it is not surprising that peripheral hospitals might have a poorer picture. Before setting up top-notch specialty clinics for pediatric care, it is essential to ensure optimal neonatal care and presence of health personnel during transport. To bring down the mortality among referred neonates, it is necessary to develop a strong transport system, which could also impact demand for health care services, due to its substantial effect on time costs.
| Other Communications|| |
As of now, there is no system of informing higher hospital even at the age of mobile revolution. In a study conducted in Delhi, less than 8% of babies were sent to referred hospital after prior communication. Prior communication is vital for ensuring optimal management of the referred newborns. Many times, accepting referred babies is not possible because of lack of space in nursery/Neonatal Intensive Care Unit. Unnecessarily, the parents need to rush from one hospital to another, instead of getting intervention for the baby, at the crucial hours only to pay the price with lives. The harassments go unnoticed, the death being reported neither by referring hospital nor by referred one. In addition, telecommunication to a senior pediatrician for seeking advice might be fruitful in saving lives.
| Conclusion|| |
In India, little research has been carried away to know the process of transport and the fate of referred neonates. Far less documentation is there on deterioration in neonatal condition during transport. Standing in the last year for achieving MDG, we are still in the phase of implementing diverse policies in different states and yet to ensure referral for all the newborns that are in dying need, with sole responsibility left to the discretion of parents/guardians in many places.
In this perspective, this paper puts focus on neonatal transport to tertiary centers, a topic neglected so far in a country where the difference between secondary and tertiary care is so huge that the cost is usually paid by numerous preventable deaths. There is need to strengthen community-level physicians in resuscitation activities and maintain their theoretical and practical competency, at least for the sake of avoiding overload at tertiary hospitals and transport by family. Key barriers and bottlenecks of the proxy transport system needs to be identified until some dedicated system comes to place. Among the claim that as in utero transfer is better than neonatal transfer, there remains sufficient scope for conducting pragmatic randomized controlled trial in India for exploring the issue in future as a potential solution to address the “second delay.” It will reveal those weak hinges in neonatal health where we should underscore our efforts to bring down IMR further, thus curbing the pile of 1 million deaths and promising life to more number of children in days to come.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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