Background
Decades of supportive policies and program focused on reducing maternal and neonatal deaths led to declines in Indonesia’s neonatal mortality ratio (NMR) from the early 1990s. Data show declines in NMR from 30 deaths per 1000 births in 1994 to 19 deaths per 1000 by 2007. Yet, further reductions since this time have not materialized. The most recent Indonesia Demographic and Health Survey (2012) indicates that the NMR has remained stagnant at 19 deaths per 1000 live births, with 60% of all infant deaths and nearly 50% of all under 5 deaths occurring during the first month life. The Challenges of delivering adequate neonatal health care in Indonesia include limited access to quality facilities, limited availability of health staff capable of managing complications, lack of awareness and cultural constraints regarding newborn care, low nutritional and health status of women, and frail system for recording neonatal deaths.
The limited availability of data has made it challenging to fully understand the reasons behind persistently high neonatal death rates. In April 2015, EMAS collaborated with Perinatology Working Group of the Indonesian Pediatricians Society (Ikatan Dokter Anak Indonesia or IDAI UKK Perinatologi) to undertake a review of neonatal deaths in selected EMAS-supported facilities. In Indonesia, WHO estimates that prematurity is the leading cause of neonatal death, accounting for 44% of deaths, followed by birth asphyxia and birth trauma (21%), congenital abnormalities (13%) and sepsis and other infections (11%). Data from EMAS supported hospitals generally reflects this pattern. In the period reviewed, neonatal deaths in phase 1 and 2 hospitals, were most commonly associated with low birth weight (43%), and followed by asphyxia (24,5%) and sepsis (12%). A relatively large proportion of neonatal deaths (20%) were also associated with “other” cause.
Purpose and Process of Review
The objective of the retrospective review of individual charts in selected EMAS-Supported hospitals was to better understand the causes of death among neonates greater than 2000 gram who die in the first week of life, including the associated contextual factors such as the source of referral and pre hospital care, the quality of care provided at the facility and related barriers that may have contributed to neonatal death (e.g. timeliness of care, availability of personnel or equipment, or appropriate administration of treatment and monitoring) and to determine whether or not the deaths may have been preventable, the review also sought to inform future research and interventions to reduce preventable deaths.
In total six district hospital in five EMAS-supported provinces took part in the review process. Cases selected for review were neonates weighing over 2000 grams at birth who died within the first seven days of life. These criteria were established in order to review the cases that had the strongest likelihood of survival, and yet did not survive. Cases with major congenital anomalies were excluded. The neonatologists reviewed individual case level medical records for neonatal deaths that occurred in the six selected hospitals from January to June 2015. Newborn nursery and newborn intensive care (NICU) environments were also assessed through observation and general review of documentation.
The review is limited in that it was retrospective and based on a single source of data-the available chart documentation varied in completeness, with numerous examples of missing documentation and data. Which limited the ability of the reviewers to draw definitive conclusions regarding all factors with each death.
Main Findings
- 30% of cases had an incorrect diagnosis.
- In 43% of the deaths, the neonates had received inadequate clinical management, with a number of clinical interventions not performed as per SOP.
- There were significant information gaps in the medical record for a number of variables reviewed, and incomplete daily medical records for 42% of cases.
- In 33% of cases, delays in the provision of care in the hospital were found to have contributed to death.
- In 25% of cases, there was a delay in handling an emergency.
- Delays in initially seeking care were seen in 27% of referral cases.
- The majority 84% of referred cases were referred by a midwife or doctor, yet 30% were not adequately stabilized prior to referral.
- The decision to refer was made too late in 31% of the cases.
- Expert opinion determined that 70% of the deaths could have been prevented with more accurate diagnose and more appropriate clinical and referral management.
This report has been presented at UKK perinatology in front of the Perinatology Working Group The Indonesian Pediatricians Society at IDAI Board Meeting In Jakarta in July 2015, and at GKIA’s Workshop in September 2016, supported by USAID through the EMAS Program and AT&T through Jhpiego.