Nigerian Journal of Paediatrics

1Challenges and opportunities for neonatal respiratory support in Nigeria a case for regionalisation of care

Niger J Paediatr 2016; 43 (2):64 – 69

REVIEW

Okolo AA

Challenges and opportunities for

Okonkwo IR

Ideh RC

neonatal respiratory support in

Nigeria: a case for regionalisation of

care

DOI:http://dx.doi.org/10.4314/njp.v43i2.1

Accepted: 7th December 2015

Abstract : Background: Neonatal

Results: In the 1974-1976 era, the

health appears not to have re-

major cause of neonatal mortality

Okolo AA

(

)

ceived the deserved attention in

at the University of Benin Teach-

Okonkwo IR, Ideh RC

the context of the Child Survival

ing Hospital (UBTH), Benin City,

Department of Child Health,

University Benin Teaching Hospital

Strategies and this must have con-

Nigeria, was birth asphyxia with

Benin-City, Nigeria.

tributed to the non-attainment of

an attendant perinatal mortality of

Email: angelneneo@yahoo.com

the MDG-4 in Nigeria. Neonatal

80.9/1000 births. The decline in

mortality contributes 40% or more

the

perinatal

mortality

to the current rate of child deaths

33.4/1000 births between 1976 and

globally, with birth asphyxia, pre-

1980 was linked to the introduc-

maturity and its complications and

tion of delivery room resuscitation

severe infections as the leading

with a reciprocal decline in the

causes. This emphasises the need

incidence of birth asphyxia. There-

to re-focus on neonatal health.

after, neonatal mortality rate has

Given the state of the economy in

continued to increase. This

the low- and middle-income coun-

increase could be attributed to a

tries, Nigeria, like most of the

three-fold rise in the proportion of

other countries lack the resources

very preterm admissions from

required for efficient neonatal

6.5% in 1985 to 19.3% in 2013.

health care with minimal attention

This population of babies is predis-

on the strategies needed to ad-

posed to Respiratory Distress Syn-

dress the major causes of newborn

drome and respiratory failure.

death.

Neonatal intensive care did not

Objectives: To assess the contem-

include respiratory supports until

porary situation of neonatal care

very recently (2013) when the fa-

in Benin City, Nigeria and exam-

cilities were provided but at high

ine diverse approaches to be

cost to the patient and the health

adopted to provide high level neo-

system.

natal care services aimed at im-

Conclusion: The strategies re-

proving neonatal survival rates.

quired to address reduction in neo-

Methods: The trends of neonatal

natal mortality rates should neces-

morbidities and mortality over the

sarily include neonatal resuscita-

period between 1974 and 2014

tion and mechanical ventilation, all

were studied by reviewing the

within the context of Neonatal

hospital records covering admis-

Intensive Care. In order to provide

sions and weekly mortality

the full range of neonatal intensive

records. The pattern of categories

care services in a resource- con-

of babies and the causes of death

strained setting such as Benin City,

were recorded. The information

Nigeria, regionalisation of care in

gathered identified the gaps in the

a stepwise manner is recom-

management strategies for new-

mended, both for improved medi-

borns over the years. Electronic

cal outcomes and economic reali-

databases such as the Medline and

ties.

Pubmed were searched for rele-

vant literatures published between

Key words: Challenges, Neonatal

1960 and 2015 which might pro-

ventilatory support, Regionalisa-

vide ideas required to fill the

tion of care

gaps.

Introduction

The Benin-City Case study

Several studies have highlighted the high rates of infant

Birth asphyxia has been the leading cause of perinatal

8-10

and young child mortalities in sub-Saharan Africa

1-4

mortality since 1974

. Between 1976 and 1980, neona-

Indeed this is clearly reflected by the fact that majority

tal mortality trends significantly declined with a recipro-

of these countries did not meet the MDG 4.

5,6

In an at-

cal drop in perinatal mortality rate (PMR) and a decline

tempt to meet the MDGs, resources were directed into

in cause-specific mortality in birth asphyxia. This ob-

improving maternal and child health in the last decade.

served decline in PMR rates could be attributed to the

This action contributed to a significant decline in mater-

introduction of basic perinatal health measures in late

nal and child mortality rates but the decline was less for

1975. In the 1980s and the 1990s, neonatal mortality

newborn deaths which also declined but at a very slow

declined due to a decrease in the loss of bigger babies.

pace as maternal health and child survival programs

Specialized teams were available for care in the delivery

room

8-10

received greater attention . Neonatal mortality contrib-

4-6

. Early use of assisted ventilation was available

utes 40% or more to the current rate of child deaths

in the mid-1980s but it was not sustained over time.

globally . This emphasises the need to re-focus on neo-

5,6

However, a few babies weighing less than 1000gm were

natal health.

salvaged. The mortality rate for the crop of babies

weighing less than 1000gm was greater than 90% while

Given the state of the economy in the low- and middle-

the mortality rates for babies less than 1500gm was

income countries, Nigeria, like most of other countries,

greater than 60%. Therefore, these group of babies con-

tributed the bulk of neonatal mortalities .

lack the resources (material, manpower and financial)

require for optimal newborn care services. Therefore,

the newborn care physicians in Nigeria need to be inno-

Fig 1: Bar chart showing the trends of the incidence of birth

vative, learn to apply the basic principles of child health

asphyxiain Benin City, Nigeria

and adopt a holistic approach in their practices. This

group of practitioners cannot rely too much on the avail-

ability of equipment and other facilities, as it obtains in

the high-income parts of the world, to impact on new-

born care in their setting.

In the efforts to improve the quality of routine newborn

care, the standard of care provided for sick newborn

infants and improve neonatal survival rates, several new

approaches need to be adopted and adapted to boost the

basic principles of paediatrics and child health. The high

rates of mortality and morbidity among infants and

under-five children accrue from the very high neonatal

By 1990, it was realized that further reductions in neo-

mortality rate (NMR) . The major causes of neonatal

2,5

natal mortality could not be achieved unless attention

morbidities and mortality in Nigeria have not changed

was shifted to the care of the Extremely Low Birth

over time. Birth asphyxia (27%), prematurity and its

Weight (ELBW) infants using intensive care facilities,

particularly, respiratory support

10,11

complications (25%), severe infections (23%) including

. This management

diarrhoeal diseases (4%), Tetanus (8%) and Jaundice

strategy was instituted in 2013 and small babies are

(8%) are largely responsible for early neonatal deaths in

now ventilated in the context of neonatal intensive care

Nigeria . Efforts to address some of these underlying

unit.

causes of mortality among infants and young children

through the Child Survival Strategies (CSS) gave less

Mechanical Ventilation

attention to neonatal health . Other contributory factors

like the poor health-seeking behaviour of women , low

This form of newborn care often requires other ad-

hospital delivery rate with a low skilled attendance at

vanced modalities of care in the context of neonatal in-

tensive care, which makes it quite expensive . This

birth (ranging from 35% to 40%), were not directly ad-

dressed by the CSS.

6,7

form of care is capital intensive both to the health sys-

tem and to the individual patients. The neonatal inten-

In the past, in Nigeria, only major teaching hospitals

sive care requires ancillary supportive care and efficient

provided neonatal care services including routine care of

team work. Such care, rudimentary as it may be, should

well newborn infants. Although sick babies were cared

be provided in the context of a minimum standard of

for in the neonatal ward, sophisticated and highly-

care at a Level-II facility. At this level of neonatal care,

specialized neonatal care facilities were not available. In

not only increasing technology is required but also me-

addition, delivery room resuscitation of the newborn

ticulous nursing services, new professional techniques

and team approach . Ideally, oxygen saturation and

was not routinely done. Therefore, birth asphyxia, pre-

maturity, sepsis, respiratory disorders and jaundice were

other multiple parameters should be monitored when

the major killers of newborn babies.

humidified oxygen is administered to babies, even when

arterial blood gas (ABG) measurement is impossible.

The neonatal intensive care unit team must have the

skills to intubate babies rapidly and provide

endotracheal toileting and other supportive care as re-

The scope of neonatal care services in Nigeria: How do

quired. More importantly, skills for the safe and effec-

we meet our needs?

tive use of infant ventilators without causing lung injury

and oxygen toxicity are essential .

In most centres, the care for babies referred from other

health facilities (out-born) is provided largely by differ-

What is Neonatal Intensive care Unit (NICU) and what

ent nurses in a unit that is entirely different from what is

types of Neonatal Units are available?

provided for in-born babies. These units are manned by

nurses with less experience in the care of the newborn

The NICU is an intensive care unit specialized in the

babies thus, high mortality rates in such units may not

care of ill newborns within the first 28days of life. The

be surprising.

first official Intensive Care Unit (ICU) for neonates was

The rudiments of efficient neonatal care were not avail-

established by Professor Mildred Stahlman at the Van-

able in major centres until about the mid-1960s. In 1974

derbilt University in 1961 . At the same time in the US,

precisely, in UBTH, Benin City, the training of paediat-

the first NICU was established and was so recognised

ric resident doctors in neonatal resuscitation and manda-

while Stahlman was the first to use a ventilator to assist

tory attendance at high risk deliveries was instituted.

a baby with breathing difficulties .

This development made significant impact on the New-

In addition to trained neonatologists, other cadres of

born Mortality Rate (NMR) in the hospital. Newborn

specialist doctors and nurses also work in the NICU as

care was centralised in the same area of the hospital,

necessary. In the least, this group of health workers must

though in different wards. This development was also

be able to provide neonatal resuscitation. Following the

extended to include the training of nurses to provide

introduction of intensive care into newborn care in the

specialized neonatal care. Today, paediatric residents

US, neonatal mortality has fallen more than four-fold

perform delivery room resuscitation of high risk neo-

from 18.73 per 1000 live births to 4.04 per 1000 live

nates as the standard of care and this has been shown to

15,16

births in 2012

. Much of this decline can be attributed

have contributed to the decline in the morbidities associ-

to the highly specialised care provided for preterm and

ated with birth asphyxia at some point. These efforts

sick newborn babies by the neonatologists and the mul-

need to be improved upon to achieve further reduction in

8-10

tidisciplinary teams in the NICU

17,18

the incidence rates of birth asphyxia

NICUs are categorised according to the scope of care

What do we have in the other parts of Nigeria?

available in such units. For example, Level-I facility

provides and supports basic care needs of newborn babi-

A present day challenge is coping with the increasing

es . While Level-II facility provides special care needs,

number of preterm admissions with the decline in the

number of bigger babies requiring admission

8,23

Levels III and IV are more demanding as more material

. The

and human resources are required to function . These

various reasons advanced for the increase in preterm

levels provide comprehensive on-site access to sub-

admissions include increasing use of assisted conception

specialty consultants, performance and interpretation of

and in-vitro fertilisation with high rates of multiple ges-

advanced imaging tests such as computed tomography,

tation, general increase in birth rates, urbanisation,

magnetic resonance imaging and echocardiography on

increase health care-seeking awareness and better utili-

zation of health services for high risk situations

24-27

urgent basis. Other procedures in NICUs include extra-

corporeal membrane oxygenation, haemofiltration and

Majority of these babies, as high as 85 to 90%, present

haemodialysis, or surgical repair of major congenital

with varying degrees of respiratory distress culminating

cardiac malformations which require cardiopulmonary

in respiratory failure and death in more than 50% of

by-pass .

such cases.

In high-income countries, most NICUs now concentrate

How have we met the needs for respiratory support?

on the care of critically-ill neonates and the very small

infants . Premature labour, and its prevention, remain a

How many of the neonatal units in Nigeria provide basic

major challenge for doctors . Even though medical ad-

respiratory support using the least device for bubble

vances have made the survival of low birth weight ba-

continuous positive airway pressure (bCPAP)? There are

bies more possible, it is better to delay such premature

currently very few of our care units equipped to provide

births . No doubt, the use of NICUs have greatly in-

basic respiratory support for the newborn. Indeed, the

creased the survival of very low birth weight and ex-

use of the bubble Continuous Positive Airway Pressure

tremely premature infants . In the era preceding the use

(bCPAP) as the least respiratory support device is highly

of NICUs, infants with birth weight less than

limited. There are currently very few neonatal units in

1400 grams rarely survived. Today, infants weighing

Nigeria which use exogenous surfactant for respiratory

500 grams at 24 weeks are known to have a fair chance

distress syndrome among very immature babies despite

of survival in the more technologically-advanced coun-

the global acceptance of this therapy.The characteristics

tries. Indeed, the NICU environment provides

of babies in newborn units keep changing; currently, it is

challenges as well as benefits

21, 22

usual to have a mixed population of large sick babies as

well as ELBW babies whose morbidities are variable .

The constraints to the provision of Respiratory Support

Level-III facilities are available; such NICU should pro-

A major constrain in the provision of neonatal respira-

vide mechanical ventilation beyond CPAP by nasal

prongs .

tory supports is the low level of resources required to

sustain and support such care

17,11

Unfavourable Policy environment

Material resources may be insufficient or not available.

The material resources and equipment required, aside

Policy and management issues are a challenge as rele-

the ventilators and CPAP machines, include infant incu-

vant policies are almost non-existence. Neonatal care is

bators, infusion pumps syringe drivers, multi- parameter

capital intensive. Both the overhead cost and mainte-

monitors and ABG monitors. These equipment are very

nance cost are quite high and the returns to service are

expensive . Ventilators, depending on the make, cost on

not commensurate with the level of investment made.

the average between five and nine million Naira while

The cost of care is high both to the system and to the

the CPAP machine costs between two and four million

individual patient’s family who often have to pay out -of-

Naira . Where the ventilators are available, use may be

pocket.

hindered by incomplete accessories and lack of concrete

Financial Resources are lacking

arrangements for after-sales supports and maintenance.

The equipment may be unsuitable for the environmental

peculiarities in Nigeria, hence they may be damaged by

Financial resources are lacking but resources can be

power outages. On the other hand, the model of equip-

committed, in all its ramifications, to provide the need-

ment may be obsolete and thus, may not be serviceable

ful for ventilator support and care in the context of the

when the need arises.

NICU in Nigeria.

Resources are needed for the development of infrastruc-

Infrastructural arrangements are inadequate

ture, procurement and maintenance of equipment, capac-

ity building and the strengthening of human resources

Most newborn units are not purpose-built and may not

management. Policy and management challenges should

be in close proximity to the delivery suites in the mater-

be addressed and social support services should be pro-

nity units. The neonatal units may be space constrained

vided for the users.

and thus, may not have the capacity for mechanical ven-

tilation. Infection control measures may also be difficult

Proposed Solutions include

to implement. There may also be lack of piped oxygen

or air or other sources of oxygen supply to the neonatal

The centralisation of care and investment in a concerted

unit. The ambiance may be non-conducive and the unit

effort and approach is desired. This will enable the im-

may have poor air conditioning/ cooling system which is

plementation of a phase approach to the introduction of

unsuitable for the temperature- and humidity-sensitive

change in practices. Regionalisation of such essential

care

12,18

machines and equipment. Some of the equipment are not

which may not be made available at all the cen-

conditioned for harsh tropical climatic conditions and

tres may be a way of reducing costs at the Federal level.

may deteriorate with hot and humid weather conditions.

The States may wish to develop Private-Public Partner-

The incessant power outages affect the electrical compo-

ships to grant the immediate catchment population ac-

nents of machines and indicate the need for back-up

cess to such care. In addition, the state governments may

power sources.

provide Level-II neonatal care.

Un-met human resource needs

The foreseen benefits of the provision of highly special-

ized neonatal care in Nigeria are numerous. In the eco-

Manpower resources are in short supply as there are

nomically advanced countries, investments are made in

insufficient numbers of doctors adequately trained in

the development of care and research. Significant mor-

highly specialised neonatal care to provide the needed

tality from respiratory disorders impaired the attainment

services.

of the Fourth MDG for most countries of Sub-Saharan

Africa, including Nigeria .

Similarly, there is the dearth of nurses trained in neona-

tal intensive care services. This implies inability to meet

If neonatal mortality must decline considerably, health

the recommended nurse-to-patient ratio for efficient

planners and administrators must invest in the provision

nursing care at the Levels II and III settings .

of ventilator care in the critical care of high-risk new-

born babies . The loss of vulnerable newborns trans-

In addition, there is a dearth of biomedical engineers in

most institutions hence, maintenance services for the

lates to huge economic losses as the nation, by exten-

equipment in the NICU may be difficult to come by.

sion, is deprived of potential manpower for workforce

and economic development .

1,2

When these equipment breakdown, NICU activities

maybe disrupted. This renders support services for ven-

At the family level, such losses also translate to the im-

tilator care precarious, not prompt, or unavailable. Even

poverishment of the family and a health risk for the

breathing circuits became available in Nigeria, only re-

mothers who would desire another pregnancy to replace

cently, as most centres have been highly dependent on

the lost babies.

the importation of such materials. Indeed, the available

These issues imply increased utilisation of the health

ancillary services are rudimentary. Capacity should be

resources and depletion of economy, which in turn

developed for all level of personnel particularly where

translates to high mortality indicators for the country

and shifts the country lower down in the global ranking

there is a cogent need to address the quality of the man-

of healthy nations. In the Nigerian setting, now is the

agement of respiratory morbidities to reduce the mortal-

time to focus on how the need for ventilator support as a

ity arising from them. This can be achieved by providing

crucial part of neonatal care services, could be met and

efficient respiratory support care. The regionalisation of

be made appropriate for the identified level of care

such highly specialized care at specific tertiary regional

centres may reduce costs whilst secondary level centres

could offer basic respiratory support with the bCPAP. In

the same vein, it is attractive to propose the regionalisa-

Conclusion

tion of full intensive care support for the Nigerian new-

born babies.

The number of preterm babies admitted to neonatal care

units is on the rise coupled with a decline in the number

Conflict of interest: None

of larger babies requiring hospitalisation. Therefore,

Funding: None

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