| In the past ten years, woman and child health care, especially maternal-fetal-neonatal care improved dramatically in China. However, information of vital statistics based on birth population, or disease incidence and mortality from the epidemiologic studies with regard to the neonatal birth data, incidence of various neonatal diseases, and neonatal transportation, are scant. There are fewer perinatal-neonatal epidemiologic studies mainly based on hospital chronological surveys. No prospective population-based perinatal-neonatal study has been conducted yet. This hampers the development of perinatal-neonatal care with regard to advanced strategy and technology implementation, and cost-effectiveness assessment, In view of this limitation, we conducted a population-based perinatal-neonatal epidemiologic study in Huai’an city, Jiangsu province in2010.Huai’an city is a prefectural region, located in the eastern part of China with a population of5,340,000and58,000live births in2009. There were few migrant people in this city. The proportions of residents in both urban and rural areas were close to that of the national situation (rural resident accounted for50.3%of all the population in China in2011). The GDP per capita was23,000Chinese Yuan (CNY) in this region, close to that of the national level at24,000CNY. We assumed a perinatal-neonatal survey in Huai’an city should represent the situation in most part of China as intermediate development in both economics and woman and child health care, which accounted for a population of600,000,000, or40%of the total population (1.34billion).The first part of the dissertation investigated the population-based ratios and proportions in gender at birth, birth weight (BW), gestational age (GA), birth defect, multiple pregnancy, cesarean section, and the perinatal mortality and neonatal mortality. The second part of the dissertation investigated the local neonatal medical resource, the incidence of various neonatal diseases, neonatal respiratory failure, and function of the neonatal transport system. By analysing the status of perinatal-neonatal care, incidence and outcome of neonatal diseases, a good use of the limited medcal resources and development of service may be achieved.Part I A prospective, birth population-based epidemiologic study for the vital statistics of newborns in Huai’an city in2010Background The neonatal birth data are the basis for the analysis of the population health care. The aim of the study was to obtain birth data from all the births in the area. The normal gender ratio at birth is generally at103-107:100, but it increased dramatically in China since1990’s. In2000by the fifth national census it reported to be117:100. We performed current survey to verify whether this ratio has changed substantially, and what the neonatal birth related statistics would be that reflects perinatal-neonatal care in regions with intermediate levels of economics and woman and child health care. As BW of the newborns increased in the recent years, we first try to figure out average BW for all the newborns in Huai’an city. The Neonatal Assembly of Chinese Pediatric Society carried out a survey for preterm births in77hospitals in2002-2003, and reported a rate of7.8%. As the participating hospitals were all tertiary centers and received many high risk pregnancies, this rate is biased, and the preterm rate for all the newborns may be lower than that level, especially in rural areas. Another important feature is the increasing cesarean section rate in major city hospitals, which may be higher than60%of all the deliveries. This may cause adverse effects on both pregnancy women and newborns, and measures were taken to alter this trend. We try to find out whether these measures have effectively implemented at rural deliveries. Birth defect (BD), perinatal and neonatal mortalities are all important figures to evaluate the socio-economic development and health care level. In this study we described the BD, perinatal and neonatal mortality and the causes of deaths, so as to delineate approaches and effects in elimination of BD and maintenance of health care quality of the newborns.Objective This study was aimed to provide a profile of the demographic characteristics of live births, including ratios and proportions of gender at birth, LBW, preterm birth, cesarean section, BD and its consitutes, perinatal and neonatal mortality.Methods A collaborative study group for perinatal-neonatal care was established and epidemiologic appoaches adopted. Information for all the newborns was prospectively collected from Jan1,2010to Dec31,2010with the aid of regional perinatal-neonatal information network system. Children’s Hospital of Fudan University designed and initiated this study. Coordination center for this study was based at Huai’an Women and Children’s Hospital. Center staffs were in charge of the administration and communication work in the collaborative group. Data analysis was conducted using software SPSS version16.0.Results Over the12-month study period, a total of60,615newborns were enrolled in the151participating hospitals, including32,406males and27,874females, a ratio of116:100at birth. When the hospitalized (6,872) cases were deleted, the remaining healthy newborns showed a ratio of111:100. Mean BW was3,441±491g, mean BW in boys was3,494±496g vs.3,379±477g in girls. Low BW infant accounted for2.80%(1,691/60,372) with a mortality of8.83%. The preterm rate was3.72%(2,239/60,264) with a mortality of7.61%. Multiple pregnancy rate was1.80%(1,088/60,567). Birth defects were found in0.67%(411/60,986). The mean age for the pregnancy mother was25.9±5.1years old. Delayed child-bearing (mother age≥35years old) accounted for8.41%(5,065/60,209).10.0%deliveries had significant prenatal risk factors such as premature rupture of membrane (5.43%), gestational hypertension (1.68%), and anemia (1.23%). The Cesarean section rate was52.9%(31,964/60,445). The grade Ⅰ,Ⅱ and Ⅲ amniotic fluid contamination was5.4%,4.6%and4.2%, respectively.1-and5-min Apgar score≤7accounted for3.8%and0.9%, respectively. There were97.4%newborns were discharged with normal health and2.2%required care in neonatal ward. There were241stillbirths and106died immediately after birth. The perinatal mortality was0.77%, and neonatal mortality was0.44%.Conclusions This prospective, birth population-based survey described the basic demographic characteristics for all the newborns in the area. The sex ratio at birth was equal to the number found in the fifth national census in2000. The preterm birth rate and LBW rate were lower than previously reported studies. The cesarean section rate was52.9%. Not only the tertiarial hospitals, but also lever I and II hospitals had a high cesarean section rate. The perinatal and neonatal mortality was first reported, and may be higher than that in the developed areas in China. Part Ⅱ A prospective, birth-population-based epidemiologic study for the hospitalized neonates in Huai’an city.Background With the development of neonatology in China, the neonatal medical resources, such as neonatal ward area, number of neonatal ward beds, specialized physicians and nurses increased as well. It may meet the demand of increasing perinatal-neonatal care of patients. There was no report yet about the neonatal medical resources in a prefectural region. We conducted this study to find out the medical resources distribution in rural area and the ways to make better use of it. The Neonatal Assembly of Chinese Pediatric Society conducted a clinical epidemiologic survey for the hospitalized neonates in2005that included80hospitals and enrolled43,289neonates. It reported a male-to-female ratio at1.73:1,26.2%of all the hospitalized neonates as premature born, and65.7%hospitalized in the first7days after birth. The leading diseases for the hospitalized neonates were jaundice, pneumonia and hypoxic-ischemic encephalopathy. Other major diseases included asphyxia, intraventricular hemorrhage (IVH), omphalitis, congenital heart disease and sepsis. There were63.9%infants recovered,27.3%improved after treatment, and7.6%requested own discharge, and1.2%as clinical death. About46.4%died within the first24hours after admission. Though this survey described the neonatal diseases spectrum from the hospitalized, it was not population-based, therefore it did not report the incidence and mortality of these major neonatal diseases, neither for those requiring critical care. We include all the hospitals in Huai’an that provided neonatal care, which ensured determination of the incidence of neonatal diseases. Neonatal respiratory failure (NRF) was one of the most common neonatal critical diseases, and a major cause of neonatal deaths. The Collaborative Study Group for neonatal Respiratory Diseases reported a13.2%NRF in23NICU admissions in2004. Primary causes of NRF were respiratory distress syndrome (RDS,34.8%), pulmonary infection (pneumonia and/or sepsis) developed before or during delivery (14.7%), amniotic fluid aspiration syndrome (10.3%), meconium aspiration syndrome (MAS,9.9%) and transient tachypnea (7.1%). The mortality of NRF was31.7%which is much higher than that of the developed countries in early90’s. The Hebei Collaborative Study Group further did an identical survey in14provincial and sub-provincial NICUs and found similar results. Our current investigation of NRF in a city as prefecural region complemented the previous study findings. The neonatal emergency transport system in China developed quickly in the past decade. It has effectively reduced neonatal mortality and disability due to birth related disorders. We described the basic information about the local neonatal emergency transport system and analyzed the prognosis of the transported neonates.Objective This survey was to delineate the local neonatal medical resources distribution, to derive incidences of the major neonatal diseases, along with disease spectrum of the critically illneses and mortalities, with special emphases on the diagnosis, treatment and prognosis of NRF. This survey also report the local neonatal emergency transport system, its efficacy and limitation in reduction of the mortality of critically ill neonates born from lower level hospitals.Methods All the11hospitals as level II and III regional centers that provided neonatal care took prat in the survey. We prospectively collected hospitalized neonate information from Jan1,2010to Dec31,2010. For patiented referred to the Nanjing Children’s Hospital and Nanjing Maternity and Child Health Care Hospital, their clinical data were also included so as to provide nearly complete hospitalized neonates information. After training, staffs from the collaborative centers executed the study by filling up all the record forms for the hospitalized neonates, including those with NRF and transport survey table. Coordination center for this study was based at Huai’an Women and Children’s Hospital.Results There was a total neonatal ward area of2,935m2in these hospitals, with172neonatal beds and17NICU beds,69specialized physicians and119neonatal nurses,7ventilators for conventional mechanical ventilations (CMV),2high frequency oscillatory ventilators, and11CPAP ventilators. There were153incubators,50phototherapy boxes,18laryngoscopes,28recovery capsules and57face masks. Three level III hospitals could provide neonatal surgery. No hospital in this area had neonatal cardiac surgery. Oxygen therapy, blood culture, electrolyte analysis and CT examination were provided in all these11hospitals.There were6,872neonates admitted to the ward including4,332male and2,540female, the male to female ratio was1.71:1. The mortality for the male and female were both2.4%.43.0%were admitted in the first24hours after birth.75%of the neonates came from the rural area. The mean BW for all the hospitalized neonates was3,092±706g, the median BW was3,200g. Preterm infants accounted for24.5%, LBW infants19.4%. BD was found in9.0%.18.8%deliveries had significant prenatal risk factors such as premature rupture of membrane. The Cesarean section rate was54.2%. The incidence of pneumonia, jaundice, sepsis, HIE, IVH was6.35%,2.92%,2.56%,2.08%,2.07%respectively. The incidence of asphyxia, congenital heart disease (CHD), RDS, impetigo, omphalitis was1.33%,0.86%,0.61%,0.46%and0.45%, respectively. The critical diseases included septic shock, pulmonary hemorrhage, cardiac failure, RDS, DIC, pneumothorax, NEC.26.8%of the hospitalized neonates received oxygen therapy,99.2%with antibiotic therapy,9.3%corticosteroids, and1.3%surfactant therapy. In all the hospitalized neonates34.9% had recovered,56.2%improved,4.8%requested own discharge,2.4%were given up or died,1.7%transferred to other hospitals. The average length of hospital stay was8.53±6.31d, the average cost of hospital stay was4,182±4,033Yuan.There were556NRF diagnosed, corresponding to an incidence of0.91%of all the admissions, with a male to female ratio of2.52:1,38.5%admitted in the first hour after birth, and88.3%in the first day. The mean BW was2,433±789g, with53.8%as LBW and64.1%as preterm. The primary diseases for NRF were RDS, pulmonary infection, asphyxia, sepsis and pulmonary hemorrahage. The complications of NRF were ventilation associated pneumonia (VAP), pneumotharox, IVH and sepsis. Surfactant was provided to14.0%of NRF, at a mean age of9.23±10.63h for the first dose. CPAP was used in67.9%, CMV in33.3%and HFV in13.7%. The mortality of NRF was22.5%. Mean length of stay in hospital and costs were14.7±11.8days and10,904±7,554CNY, respectively.There were498neonates transported, in which male accounted for68.1%. LBW and preterm infants accounted for28.7%and35.6%, respectively.67.4%were transported on the first day after birth, The most common diseases for the transport were pneumonia, IVH, HIE, RDS, asphyxia, sepsis, CHD and hyperbilirubinemia. No neonates died on transport while routine medical measures were performed on the road including nasal oxygen, artificial respiration, cardiac massage, intravenous rehydration. The transport equipments included CPAP ventilator, ECG monitor, recovery capsule, oxygen bag, transport incubator, etc. The mortality of the transported neonates was11.2%. Length of stay in hospital and costs were11.0±8.0days and7,516±5,701CNY, respectively.Conclusion This survey revealed the medical resources for neonatal care, and respiratory support with mechanical ventilation and surfactant were used frequently in the level Ⅲ hospitals. The most common neonatal diseases were pneumonia, jaundice, sepsis, HIE, IVH, asphyxia whereas the critical neonatal diseases included septic shock, pulmonary hemorrhage, cardiac failure, RDS, DIC, pneumonthorax, CHD and NEC. The mortality of NRF was22.5%. The neonatal emergency transport system was effectively running in the area. |
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