India needs neonatal transport

India witnessed 25 million births in a year, and has seen a slow decline in neonatal mortality rate in the last few years. With this sluggish advancement, the country has not been able to achieve its millennium development goal of NMR (17 deaths per 1000 live birth). One area that has been neglected by our policymakers, government and industry at large is the neonatal transport, in other words providing transport services and right medical care to pre-term babies who are not getting the required clinical treatment they deserve at the time of their birth due to lack of quality NICU infrastructure.

This is particularly evident in the context of developing countries like India. Evidence suggests that mortality in transported new-borns is much higher than inborn babies, but there is
a lack of robust data on neonatal deaths that could be ascribed to transport.

Although literature repeatedly suggests a need for regionalization of new-born care, with stress on specialized transport, we are still far away from implementing a uniform strategy in India.

In our country, a majority of babies are born in places where appropriate resources to look after babies is not available and therefore would need to be transferred to an appropriate setting. We should aim to bring the NICU to the patient, so that as they arrive we may spend a considerable amount of time at the bedside with the baby. In such a scenario, a Neonatal Emergency Transport Service (NETS) is integral to the delivery of a high-quality neonatal service.

Challenges

Neonatal Transport in India is still in its infancy. With the absence of any dedicated transport system for referred new-borns, a major chunk of critical new-borns, unfortunately, succumb to death soon after reaching tertiary centres. As a result, close to 40% of neonatal deaths occur within the first 24 hrs of admission. Transporting a sick new-born to an equipped health facility is a challenge in India due to scarce and inequitably distributed health facilities and underdeveloped transport network.

Though in utero transport of the new-born and delivery at an adequately equipped canter are ideal, preterm delivery and all the subsequent perinatal problems cannot always be anticipated.

This results in an increased need to transfer such babies after birth. Stabilization of new-born during and before transportation has been shown to improve the condition of new-born in terms of temperature, blood glucose, oxygenation, and blood pressure, thereby improving the outcome of such critically sick neonates. In the developed countries the networking and regionalisation of neonatal emergency transport have evolved from the 1990s onwards and is well developed. Survival rates have improved over the last few years although in utero transfers carry a better prognosis than ex utero transfers. Over the years neonatal services under the National Health Mission have expanded and has led to setting up of tertiary neonatal units and the Special Newborn Care Units (SNCU) in many districts and Newborn Stabilising Units (NBU). The babies who require further intensive care are then referred out to either teaching hospitals where the intensive care facilities are available or to private hospitals.

As there are no dedicated neonatal transport teams parents are forced to arrange for transport themselves or use the inadequately resourced available transport facilities. In over 75% of instances parents brought in the newborn in private vehicles while only about 23% who were brought in an ambulance.

Amongst the babies who were transported in ambulances less than half of them were adequately equipped in terms of resources to provide warmth and oxygen. It is no wonder then that a majority of the babies who were transferred had hypothermia or hypoglycaemia (low blood sugar) or had hypoxia (low oxygen levels in the blood). Little research exists on the impact of transport and the outcome of referred neonates, less documentation further adds to the deterioration in the neonatal condition during transport. As we are evaluating the progress of our SDG’s we are yet to ensure referral for all the new-borns that are in need. The sole responsibility is left to the discretion of parents. 

(The writer is a senior consultant and neonatologist, a paediatrician at Cloudnine group of hospitals, HRBR Layout)