At-Risk Newborns: Overlooked in Expansion From Essential Newborn Care to Small and Sick Newborn Care in Low- and Middle-Income Countries

AN EVOLVING APPROACH TO NEWBORN CARE

Between 1990 and 2017, the global under-5 mortality rate declined by 58% and the neonatal mortality rate by 51%,¹ but both measures remain well above the Sustainable Development Goal targets for 2030.² In many low- and middle-income countries (LMICs), major challenges persist, hindering the achievement of Sustainable Development Goal 3.2, in particular, of reducing preventable deaths of newborns to at least 12 deaths per 1,000 live births by the year 2030.²

Newborn care in LMICs has varied based on factors such as the low availability of funds and the competing priorities of country governments, various stakeholders, and the private sector. Newborn care was initially viewed as a high-tech intervention, and resources were consequently focused on level III neonatal intensive care units (NICUs) and level II special neonatal care units (SNCUs) in hospitals, even when home deliveries were common. Community-based newborn care was positioned under the larger umbrella of maternal and child health, with the newborn components often slipping between the 2 pillars of maternal health and child health.

Over the last 2 decades, a more coordinated attempt to address newborn care has been implemented in LMICs through programs such as Basic Support for Institutionalization of Child Survival (BASICS),³ Maternal and Newborn Health Program,⁴ Saving Newborn Lives,⁵ Every Preemie–SCALE (Scaling, Catalyzing, Advocating, Learning, Evidence-Driven),⁶ and Every Newborn Action Plan.⁷ Unlike maternal health that focused primarily on skilled birth attendance at deliveries, newborn care programs began with community-based care, centering around the concept of essential newborn care (ENC) for all babies. This was to a considerable extent influenced by the seminal study on home-based care of the newborn by Bang et al. in 1999.⁸ ENC comprised (1) basic care, including clean delivery practices, temperature maintenance with immediate drying, skin-to-skin contact, early initiation of breastfeeding, clean cord care, eye care, basic resuscitation; and (2) identification of and referral for common problems/danger signs.⁹ ENC later expanded to include other components, such as kangaroo mother care and the detection and treatment of infections. The content of ENC varies in different countries and regions, with basic clinical components at the community level and additional elements, including investigations, in health facilities. ENC has become a fundamental requirement, and nearly all national health authorities have adopted it as their standard of basic care.^10,11

When prematurity was identified as the leading cause of under-5 mortality in 2015, the need to provide appropriate facility-based care for the small and sick newborns was renewed,¹² as was the need to provide 3-tiered care, appropriate to resources in the community, at first and second level facilities, and finally referral/tertiary level hospitals.¹³

THE NEED FOR AN INTERMEDIATE NEWBORN CATEGORY

The label “small and sick newborn” has served well for early identification of infants who require a higher acuity of monitoring and care, including intensive interventions, and for differentiation from the “well newborn.” This clear demarcation allows infants who fall outside the small and sick category to remain with their mothers to bond and establish breastfeeding with minimal concerns for deterioration. The approach addresses hospital-based care, as many primary health care facilities/centers below district-level hospitals lack the resources for providing more than basic care and can keep mother-baby dyads only for a few hours or at most a day and thus refer babies with potential or actual problems to district, regional, or tertiary hospitals.¹⁴

In several LMICs, notably in sub-Saharan Africa, mothers and their well babies are provided care in postnatal wards only by midwives whose primary expertise and focus is maternal care. Training in the care of newborns is minimal, and newborn care does not always extend to periodic monitoring. Newborns in the postnatal wards are also not routinely examined by the neonatal unit physicians because regular physician/pediatrician rounds do not take place in such postnatal wards, and doctors assess a baby only when referred by the midwife (Ashura Bakari, personal communication, 2021). A study of facility-based newborn care in India noted concerns with the quality of care with respect to rounding by midwives and availability of attending physicians.¹⁵ In the global shift from ENC provided at home/community and at peripheral centers by midwives to care of small and sick newborns at the SNCU/NICU in hospitals, insufficient attention has been directed to the quality of care in upper-level hospital postnatal wards. This relates, in particular, to suitable training of midwives and supply of relevant basic resources, with, ideally, routine physician rounding to identify and manage newborns with higher acuity problems. As a result, at birth, newborns with risk factors requiring some additional monitoring and even low-acuity interventions are grouped with the small and sick newborns and, although clinically stable, are admitted to the SNCU/NICU. In single-center reports of NICUs in Jordan and Nepal, the authors noted a substantial percentage of admissions for maternal premature rupture of membranes of more than 18 hours (Jordan 21%; Nepal 12%) and for physiologic jaundice (Jordan 10.7%; Nepal 7%).^16,17

This dichotomous newborn care model of intensive/special care versus minimal to no physician-level care in many facilities in LMICs, particularly in sub-Saharan Africa, may ensure better monitoring and avoid deterioration going unrecognized in minimally staffed postnatal wards. In our opinion, this also has the potential for overmedicalization of care of babies who require only some additional observation and minimal extra care and can add considerably to the workload of the already crowded and understaffed advanced neonatal units. A study of care in 16 referral hospitals in Uganda, Indonesia, and India described the nurse-to-patient ratio in some hospitals in LMICs can be as high as 1:15 during the day and 1:30 at night, with some units having more than 1 baby sharing a cot, radiant warmer, or incubator.¹⁸ Transfers to the neonatal unit thus have the potential to expose babies to hospital-acquired infections, especially in understaffed, crowded units. This practice also needlessly separates newborns from their families, with adverse impacts on both babies and mothers, including on establishing breastfeeding and bonding in this vulnerable subgroup.

DEFINING THE AT-RISK NEWBORN

We propose the term “at-risk newborn” to describe a neonate with an increased risk of morbidity and/or mortality but who is currently maintaining homeostasis and does not require a special or intensive care level of monitoring or medical intervention. Such at-risk babies require close monitoring with simple technology for a period of time, which can be provided by a few additional health caregivers with some additional newborn care training above ENC but not to the level of nurses in level II or III neonatal units. This allows these newborns to continue to adapt well to extrauterine life without separation from their mothers and provides for the timely recognition of conditions that require transfer to the SNCU/NICU. Some of these at-risk babies may also merit subsequent closer evaluation at home during follow-up.

Although there is an existing 3-tiered approach of basic/essential newborn care at home or a primary care facility, with transfer to level II care and level III care at a different facility when needed, the system used only consists of 2 newborn categories, “well” and “small and sick.”^12,13 Our concept of “at-risk” babies focuses on the delivery of care to this special group of babies in individual hospitals that already have either level II or level III/IV care. In both the latter types of care, there often appears to be a 2-tiered approach of either essential newborn care or special/intensive care. Our opinion is that, especially for care strategies for babies delivered in higher-level facilities, identifying and adding a group of babies with a specific label of the “at-risk” newborn will help promote a 3-tiered approach in each hospital of (1) basic care, (2) care of the at-risk babies, and (3) special/intensive care. This proposed framework not only formalizes the existing tiering of newborn care between primary, district, and tertiary care facilities but also clarifies and systematizes strategies for care delivery within the latter 2 levels of facilities, thus promoting nonseparation from mothers for more babies.

The Box lists examples of at-risk newborns who appear well at birth but are at higher risk for developing problems than well babies with no identifiable risk factors. Some small newborns who currently fit into the small and sick newborn category may also not immediately need the interventions traditionally available in level II or level III neonatal care units and may be better grouped as at-risk newborns. Monitoring of these at-risk newborns with early identification and timely management of problems is necessary for better outcomes, and it is important that the resources and training are appropriate.¹⁹ However, this at-risk group has not always been clearly delineated in national action plans. The Ghana Health Service National Newborn Health Strategy and Action Plan is one that does at least identify this at-risk group of babies as a specific entity that needs to be addressed, although it does not outline separate care strategies.²⁰

It is important to differentiate this categorization of an at-risk newborn from the at-risk approach related to maternal health.²¹ The aim is not to have a targeted at-risk approach to only identify babies with risk factors and provide necessary care but to promote (1) essential care for all newborns, (2) additional monitoring and support in an appropriate manner for more vulnerable at-risk babies, and (3) special/level II and intensive/level III/IV care reserved for overtly unstable newborns requiring advanced care. Central to this concept is the promotion of nonseparation of the mother and baby, ideally for all categories, but at a minimum for the well newborns and the at-risk group.

Although data from LMICs are lacking, in high-income countries (HICs), late preterm infants constitute about 60% of all preterm babies and 4%–7% of all live births.^22,23 These babies represent a prime example of an at-risk category with increased risk of morbidity and mortality as compared with full-term newborns.²⁴ Too early discharge may result in rehospitalization of these babies with problems such as poor feeding, hypothermia, hypoglycemia, and significant jaundice.²⁵ At-risk categorization could facilitate the extension of closer monitoring of late preterm infants for the few days required to ensure that homeostasis is achieved before discharge, while maintaining the mother-baby dyad. Other at-risk newborns will similarly need extra monitoring to identify potential clinical problem(s) and institute the necessary interventions within the capacity of the nonintensive setting to treat and halt progression. This can also facilitate early identification of deterioration to permit timely transfer to the higher level of care in the SNCU/NICU.

APPROACHES FOR NEWBORN CARE

The Table lists suggested levels of care for the 3 categories of newborns. Besides the necessary infrastructure, human resources, and supplies, the family-centered care approach would be an ideal overarching requirement for all options.²⁷

Postnatal/postpartum units may exist as wards or single rooms, the latter being more common in HICs and in some private facilities in LMICs. Where these units are used for at-risk newborns, a special demarcated area or room, preferably located near the nursing station, would permit easy identification for providing the extra required nursing care and additional visits by the physicians, as well as ensure that such mother-baby dyads are not inadvertently discharged too early. Ideally, the inclusion of nursing staff with additional training in this section would be very beneficial, though competence to the extent of the SNCU/NICU nursing staff may not be necessary. Equal emphasis on the care of the mother and the baby by trained staff, including physicians and nurses, should be promoted in these units.²⁸ Also, as noted in the Table, the adapted postnatal mother-baby unit may be linked with the postnatal ward²⁹ (Sushma Nangia, personal communication) or with the SNCU/NICU.³⁰ In their review of the tiered approach in India, Neogi et al. describe an approach of 3 levels of newborn care (though the at-risk group is not named) that includes observation in a newborn stabilization unit for vulnerable babies that are in need of transfer to a special care unit.¹⁵ The at-risk approach we describe has some similarities to the newborn stabilization units in India. However, these units are usually in lower-level centers, where babies brought from home are stabilized and kept until they are ready for discharge or to be transferred to a higher-level hospital for more advanced care. In contrast, the at-risk babies we focus on in this article are those babies who are delivered in hospitals that already have the level II, III, or IV neonatal unit.

In some district-level hospital SNCUs in sub-Saharan African countries, provision of level II care may also be implemented in a mother-baby unit. These units are distinct from postnatal/postpartum wards in both staffing and admission criteria (Ashura Bakari, personal communication). There is now evidence to suggest that the ideal option for all categories of care may be the mother-baby unit with no separation, using kangaroo mother care and family-centered care wherever feasible for low birthweight infants, beginning at birth.^27,31 However, this requires careful planning, appropriate infrastructure, beds, equipment, supplies, and suitably trained, motivated administrative staff and health care providers, as well as, most importantly, a shift in the culture of care.