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China has achieved remarkable results in reducing under-five mortality rates, but the proportion of neonatal deaths remains high. In order to explore a pattern of early newborn health care service in China, the National Health Commission of the People’s Republic of China (China NHC) cooperated with the United Nations International Children’s Emergency Fund (UNICEF) to implement the “Safe Neonatal Project” in four western provinces in 2017. The purpose of this study was to understand the gaps between the implementation situation of project areas and the World Health Organization (WHO) recommendations in terms of early newborn health care capacities. A mail survey method was used to collect information of 233 midwifery hospitals in the 21 project counties of 4 western provinces. Descriptive statistical analysis was used to compare the implementation coverage of the 14 core early newborn health care interventions recommended by the WHO. The results indicated that some core interventions were not well implemented, such as using antibiotics for mothers with premature rupture of membranes, immediate skin-to-skin contact between mother and baby, delayed umbilical cord clamping, kangaroo mother care for preterm newborn, and neonatal sepsis and pneumonia management. These results could provide a basis for developing targeted interventions and assessing the project impacts.
In 2017, the national neonatal mortality rate was 4.5‰ in China, accounting for 50% of deaths among children under five years old (1). The time of childbirth and the three days after birth is a critical period for neonatal survival and health. Early interventions in this period can effectively reduce neonatal mortality and improve long-term health outcomes (2). In 2014, the WHO published the “Action plan for healthy newborn infants in the Western Pacific Region (2014−2020)” and set targets for ending preventable neonatal deaths by 2020. Member States are recommended to implement the Early Essential Newborn Care (EENC), a package of evidence-based interventions shown to prevent and treat the leading causes of newborn illness and death (3-4). In 2017, China NHC and UNICEF jointly launched the three-year “Safe Neonatal Project” in four western provinces and introduced EENC. The purpose of this study was to evaluate the baseline situation of project areas in terms of early newborn health care capacities, understand the gaps between existing conditions and the recommendations, and provide a basis for developing targeted interventions.
This study was part of the baseline survey of the “Safe Neonatal Project”. From June 2017 to September 2018, all midwifery hospitals in 21 project counties of Guizhou, Qinghai, and Sichuan provinces and Ningxia Autonomous Region participated in a mail survey to collect data. The questionnaire was focused on the 14-core newborn health care interventions recommended by the WHO EENC guideline (Box 1) (5). Evaluation indicators included: basic information of hospitals, major maternal and child health outcomes, and implementing coverage rates of the core interventions. The questionnaires were issued by NHC through each provincial health authority to the hospitals. Provincial health authorities were responsible for providing training and guiding all counties and township level midwifery hospitals to fill out the questionnaire. All the collected data were the data by the end of 2016. No personal information was collected from individual patients and medical staff.
Maternal health interventions Childbirth interventions Neonatal disease interventions 1. Maternal syphilis detection and treatment 7. Delayed umbilical cord clamping and proper care 11. Neonatal resuscitation 2. Gestational hypertension management 8. Immediate skin-to-skin contact of mother and newborn for at least 90 minutes after birth 12. Neonatal intramuscular injection of vitamin K1 3. Pregnant women take folic acid orally 9. Exclusive breastfeeding 13. Neonatal eye care 4. Antibiotics for management of preterm rupture of membranes 10. Kangaroo mother care for premature newborns 14. Common neonatal diseases diagnosis and treatment 5. Strict control of indications for cesarean section 6. Prevention of obstetric hemorrhage Table Box 1. The 14-core newborn health care interventions recommended by EENC guideline
Data were entered into EpiData database using double-entry method. After the data were checked for quality and cleaned up, SPSS 22.0 (IBM, New York, USA) software was used for data analysis. Descriptive statistical analysis was used to compare the frequency and percentage of indicators among provinces.
There were 21 counties, 417 townships, and 5,352 villages in the project area. State-poverty counties accounted for 85.7% of all counties. There were 59 county-level and 211 township-level midwifery hospitals. A total of 233 midwifery hospitals completed the questionnaire, accounting for 86% of the targeted hospitals. In 2016, the population of 15 to 49 year-old women and 0 to 5 year-old children was 2.44 million and 0.52 million, respectively. The number of pregnant women was 95,430 and the number of live births was 95,764 (Table 1).
Indicator Guizhou Ningxia Qinghai Sichuan Total Number of project counties 5 4 7 5 21 Number of project townships 108 47 101 161 417 Number of villages 1,705 506 1,220 1,921 5,352 Proportion of state-poverty county (%) 100 100 57.1 100 85.7 Number of county-level hospitals 13 6 16 24 59 Number of township-level hospitals 66 24 33 88 211 Total population (ten thousand) 267.8 100.8 167.6 375. 0 911.2 Number of women aged 15−49 years old (ten thousand) 82.0 21.1 44.3 96.9 244.3 Number of children aged 0−5 years old (ten thousand) 16.5 8.4 11.4 16.0 52.3 Number of pregnant women 23,885 15,340 23,979 32,226 95,430 Number of live births 24,813 15,406 23,256 32,289 95,764 Table 1. Basic information and key maternal and child health indicators of the 21 counties in 4 provinces in 2016
Regarding implementation of maternal health interventions, the gestational hypertension management rate (98.3%), maternal syphilis treatment rate (97.9%), and folic acid intake rate (88.8%) in the project area were high. The average cesarean section rate was 30.4%, of which 84.6% had medical indications. Approximately 60.1% of hospitals could implement antibiotics for management of preterm rupture of membranes, but only 77.3% of women with membrane preterm ruptures received this treatment. The average incidence of obstetric hemorrhage was 1.5%, and 70.9% of women received obstetric hemorrhage prevention interventions.
Regarding implementation of childbirth interventions, the proportion of immediate skin-to-skin contact of mother and newborn for at least 90 minutes after birth was 41.8%. Only 17.5% of newborns received delayed umbilical cord clamping, 24.7% of hospitals could implement kangaroo mother care (KMC) for premature newborns, 31.8% of preterm babies received any types of KMC, and 77.7% of newborns completed the first breastfeeding within 1 hour after birth. The exclusive breastfeeding rate at discharge was 83.8%.
Regarding implementation of neonatal disease interventions, the neonatal asphyxia rate was 3.2% in project area. The rate in Guizhou (6.1%) was higher than the other provinces, and the incidence of neonatal sepsis and neonatal pneumonia was 0.1% and 2.9%, respectively. The proportions of hospitals that carried out neonatal sepsis and pneumonia management were 33.5% and 47.8%, respectively. The rate of transferring newborns to neonatal intensive care unit (NICU) was 9.8%, with the rate in Guizhou (21.0%) higher than the other provinces. About 50.9% of hospitals carried out neonatal eye care intervention, and 74.2% of hospitals could implement intramuscular injection of vitamin K1 to prevent intracranial hemorrhage, but only 69.8% newborns received this intervention (Table 2).
Core intervention Indicator Guizhou Ningxia Qinghai Sichuan Total 1. Maternal syphilis detection and treatment Treatment rate of pregnant women with syphilis 83/83 (100) 11/12 (91.7) 132/137 (96.4) 49/49 (100) 275/281 (97.9) 2. Gestational hypertension management Management rate of pregnant women with hypertension 235/235 (100) 355/355 (100) 268/268 (100) 54/70 (77.1) 912/928 (98.3) 3. Pregnant women take folic acid Folic acid intake rate 22,295/24,199 (92.1) 14,143/14,740 (95.9) 15,993/21,598 (74.0) 27,706/29,682 (93.3) 80,137/90,219 (88.8) 4. Strict control of indications for cesarean section Caesarean section rate 8,123/24,153 (33.6) 2,321/14,712 (15.8) 2,695/21,303 (12.7) 14,058/29,395 (47.8) 27,197/89,563 (30.4) Cesarean section with medical indications 6,498/8,123 (80) 2,265/2,321 (97.6) 2,578/2,695 (95.7) 11,673/14,058 (83) 23,014/27,197 (84.6) 5. Antibiotics for management of preterm rupture of membranes Proportion of hospitals implemented 38/60 (63.3) 12/19 (63.2) 14/44 (31.8) 76/110 (69.1) 140/233 (60.1) Proportion of mothers treated 932/1,083 (86.1) 1,571/1,712 (91.8) 1,329/1,636 (81.2) 1,062/1,904 (55.8) 4,894/6,335 (77.3) 6. Prevention of obstetric hemorrhage Incidence of obstetric hemorrhage 581/24,199 (2.4)) 258/14,740 (1.8) 247/21,598 (1.1) 258/29,682 (0.9) 1,344/90,219 (1.5) Obstetric hemorrhage mortality (100 thousand) 0/24,199 (0) 1/14,740 (6.8) 0/21,598 (0) 0/29,682 (0) 1/90,219 (1.1) 7. Neonatal resuscitation Incidence of birth asphyxia 1,474/24,153 (6.1) 293/14,712 (2) 846/21,303 (4) 241/29,395 (0.8) 2,854/89,563 (3.2) NICU transfer rate 5,067/24,153 (21) 1,377/14,712 (9.4) 1,055/21,303 (5) 1,284/29,395 (4.4) 8,783/89,563 (9.8) 8. Immediate skin-to-skin contact of mother and newborn for at least 90 minutes after birth Proportion of hospitals implemented 12/60 (20) 1/19 (5.3) 2/44 (4.5) 5/98 (5.1) 20/221 (9) Proportion of babies skin to skin contact for at least 90 minutes 5,636/24,153 (23.3) 7,927/14,712 (53.9) 7,648/21,303 (35.9) 16,251/29,395 (55.3) 37,462/89,563 (41.8) 9. Exclusive breastfeeding First breastfeeding within 1 hour after birth 17,475/24,153 (72.4) 9,419/14,712 (64) 17,522/214,303 (82.3) 25,147/29,395 (85.5) 69,563/89,563 (77.7) Exclusive breastfeeding at discharge 18,907/24,153 (78.3) 12,474/14,712 (84.8) 17,998/21,303 (84.5) 25,657/29,395 (87.3) 75,036/89,563 (83.8) 10. Delayed umbilical cord clamping and proper care Delayed umbilical cord clamping rate 1,992/24,153 (8.2) 2,101/14,712 (14.3) 3,734/21,303 (17.5) 7,861/29,395 (26.7) 15,688/89,563 (17.5) Neonatal umbilical infection rate 7/24,153 (0) 22/14,712 (0.1) 54/21,303 (0.3) 1/29,395 (0) 84/89,563 (0.1) 11. Neonatal eye care Proportion of hospitals implemented 43/60 (71.7) 6/19 (31.6) 15/44 (34.1) 54/109 (49.5) 118/232 (50.9) Incidence of neonatal eye infection 27/24,153 (0.1) 16/14,712 (0.1) 273/21,303 (1.3) 127/29,395 (0.4) 443/89,563 (0.5) 12. Neonatal intramuscular injection of vitamin K1 Proportion of hospitals implemented 49/60 (81.7) 14/19 (73.7) 21/44 (47.7) 89/110 (80.9) 173/233 (74.2) Vitamin K1 injection rate 19,143/24,153 (79.3) 12,484/14,712 (84.9) 11,538/21,303 (54.2) 19,321/29,395 (65.7) 62,486/89,563 (69.8) 13. Kangaroo mother care for premature newborns Proportion of hospitals implemented 21/60 (35) 6/19 (31.6) 6/44 (13.6) 24/108 (22.2) 57/231 (24.7) Proportion of babies received 36/520 (6.9) 331/626 (52.9) 39/487 (8) 291/556 (52.3) 697/2,189 (31.8) 14. Common neonatal diseases diagnosis and treatment Proportion of hospitals implemented neonatal sepsis management 29/59 (49.2) 6/19 (31.6) 6/43 (14) 36/109 (33) 77/230 (33.5) Proportion of hospitals implemented neonatal pneumonia management 39/60 (65) 9/19 (47.4) 16/44 (36.4) 47/109 (43.1) 111/232 (47.8) Incidence of neonatal sepsis 31/24,153 (0.1) 58/14,712 (0.4) 17/21,303 (0.1) 1/29,395 (0) 107/89,563 (0.1) Incidence of neonatal pneumonia 691/24,153 (2.9) 503/14,712 (3.4) 708/21,303 (3.3) 659/29,395 (2.2) 2,561/89,563 (2.9) Table 2. Comparison of coverage of 14 EENC core interventions of the 21 counties in 4 provinces in 2016 (%)
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