Review Of Neonatal Deaths Research Articles

Global Stillbirth Policy Review - Outcomes And Implications Ahead of the 2030 Sustainable Development Goal Agenda.

Globally, data on stillbirth is limited. A call to action has been issued to governments to address the data gap by strengthening national policies and strategies to drive urgent action on stillbirth reduction. This study aims to understand the policy environment for stillbirths to advance stillbirth recording and reporting in data systems. A systematic three-step process (survey tool examination, identifying relevant study questions, and reviewing country responses to the survey and national documents) was taken to review country responses to the global 2018-2019 World Health Organization (WHO) Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy Survey. Policy Survey responses were reviewed to identify if and how stillbirths were included in national documents. This paper uses descriptive analyses to identify and describe the relationship between multiple variables. Responses from 155 countries to the survey were analysed, and over 800 national policy documents submitted by countries in English reviewed. Fewer than one-fifth of countries have an established stillbirth rate (SBR) target, with higher percentages reported for under-5 (71.0%) and neonatal mortality (68.5%). Two-thirds (65.8%) of countries reported a national maternal death review panel. Less than half (43.9%) of countries have a national policy that requires stillbirths to be reviewed. Two-thirds of countries have a national policy requiring review of neonatal deaths. WHO websites and national health statistics reports are the common data sources for stillbirth estimates. Countries that are signatories to global initiatives on stillbirth reduction have established national targets. Globally, nearly all countries (94.8%) have a national policy that requires every death to be registered. However, 45.5% of reviewed national policy documents made mention of registering stillbirths. Only 5 countries had national policy documents recommending training of health workers in filling out death certificates using the International Classification of Diseases (ICD)-10 for stillbirths. The current policy environment in countries is not supportive for identifying stillbirths and recording causes of death. This is likely to contribute to slow progress in stillbirth reduction. The paper proposes policy recommendations to make every baby count.

Implementation of a neonatal donation protocol in the neonatal intensive care unit: A single-center experience.

Lack of specific protocols for neonatal donation contributes to the rarity of neonatal donors. In this study, we evaluate the impact of the implementation of a neonatal donation protocol in our NICU. In this single-center study, we conducted a retrospective chart review of neonatal deaths in our NICU from January 2013 to January 2022. The study was divided into two periods: before and after the implementation of a neonatal donation protocol. The referral rates of potential neonatal donors to the OPO in the two periods were compared using the chi-square test. A p value < .05 was considered statistically significant. Sixty-four infants were reviewed. Seven (10.9%) met the inclusion criteria for potential neonatal donors after DCC. The referral rate of potential neonatal donors increased from 2.5% to 16.7% after the implementation of this protocol (p = .041), and one infant (4.1%) became an effective heart-valve donor. The implementation of a local neonatal donation protocol could have contributed to increase the referral rate of potential neonatal donors in our NICU. Following the implementation of a local neonatal donation protocol, we were able to perform a heart-valve donation for the first time in our unit.

Maternal and neonatal death surveillance and response in Liberia: An assessment of the implementation process in five counties.

To evaluate the implementation of the maternal and neonatal death surveillance and response (MNDSR) system at county level in Liberia. Secondary analysis of data from a cross-sectional study carried out in March 2016, using both quantitative and qualitative methods to collect data in five counties based on set criteria. Three health facilities were selected in each county through the Health Management Information System (HMIS) by random sampling. The evaluation was also carried out in one catchment community per health facility and at the county referral hospital. Primary data were collected through individual interviews and a review of MNDSR tools and structure. Data were analyzed using thematic analysis. Implementation of the MNDSR system was very low in the five counties. Only two out of the five counties were currently conducting MNDSR. MNDSR guidelines and standard operating procedures were not available at the county level. Only 12 (23.5%) health facilities had a maternal and neonatal death review committee. Less than a quarter of the assessed community members could correctly give the definition of a maternal or neonatal death. The MNDSR system is weak in Liberia, at county, health facility, and community levels. Strong national commitment is needed in collaboration with diverse partners for successful implementation of the system.

Maternal and neonatal death surveillance and response is implemented in Burundi but needs improvement.

To analyze implementation of the maternal and neonatal death surveillance and response (MNDSR) strategy in Burundi. Secondary data analysis using a qualitative approach and document review. The qualitative approach consisted of semistructured interviews with decision-makers at central, regional, and district levels, health providers, and technical and financial partners using four interview guides and a data extraction tool. Document review utilized maternal death review reports and policy documents. Interviews and hospital visits took place from July 16-26, 2017, in Bujumbura and Gitega, Burundi. Notification of maternal deaths is incorporated into the Integrated Disease Surveillance and Response (IDSR) system. Maternal death review committees existed in the five visited hospitals (Prince Regent Charles Hospital and Kamenge University Hospital in Bujumbura, Gitega Regional Hospital, Kibimba District Hospital, and Kibuye District Hospital) but not at subnational level (provincial or district levels). Since the beginning of 2017, maternal death review has been effective and regular in some district and regional hospitals due to integration of quality-of-care criteria for the performance-based financing strategy; review has been less effective at national hospital level. Implementation of review recommendations is heterogeneous and varies from one health facility to another. No formal follow-up mechanism on review recommendations was identified. Notification and review of neonatal deaths does not occur, nor does notification of maternal or neonatal deaths at community level. Despite integration of notification of maternal deaths into IDSR, efforts must be undertaken to scale up MNDSR to include neonatal deaths and maternal and neonatal deaths at community level.

The Jordan Stillbirth and Neonatal Mortality Surveillance (JSANDS) System: Evaluation Study.

BackgroundThe Jordan Stillbirth and Neonatal Mortality Surveillance (JSANDS) is an electronic surveillance system that automatically transfers the data on births, stillbirths, and neonatal deaths to the concerned authorities in the Ministry of Health. JSANDS was implemented and tested in 5 maternity hospitals during the period spanning May 2019 through December 2020.ObjectiveThis study aimed to evaluate the usefulness and performance of JSANDS to register births, stillbirths, and neonatal deaths, and determine their causes. Specifically, this study examined the JSANDS attributes of acceptability, simplicity, flexibility, stability, representativeness, sustainability, penetration, data quality, sensitivity, and adoption.MethodsAn evaluation study was conducted after 18 months of the JSANDS implementation using the Updated Guidelines for Evaluating Public Health Surveillance Systems. The evaluation focused on how well the system operated to meet its purpose and objectives. The indicators assessing the system attributes were scored on a Likert scale. Each indicator and overall attribute percentage score was represented as score rank and interpreted as excellent (score ≥80%), good (score ≥60 and <80%), average (score ≥40 and <60%), and poor (score <40%).ResultsA total of 270 health care professionals participated in this study and evaluated the system performance. The system users rated the usefulness of JSANDS as excellent (percentage score=85.6%). The overall acceptability (percentage score=82.3%), flexibility (percentage score=80.2%), stability (percentage score=80.0%), and representativeness (percentage score=86.6%) were also rated excellent. The overall simplicity was scored good (percentage score=75.4%). All participants were trained on JSANDS and used it in the past 12 months. Of the 270 respondents, 219 (86.2%) reported that they intend to continue using the JSANDS system to register neonatal deaths and stillbirths in the future. All variables in JSANDS had complete data with no missing values.ConclusionsThe performance of JSANDS in registering all stillbirths and neonatal deaths as well as their causes was excellent. Almost all attributes and indicators of JSANDS functionality were rated excellent. JSANDS can be scaled up to cover all maternity hospitals in Jordan. The potential for scaling up the system is very high for many reasons, including its usefulness, simplified stillbirth and neonatal death review tools, and ease of the reporting process.

Walk the Talk: The Transforming Journey of Facility-Based Death Review Committee from Stillbirths to Neonates.

Background Facility-based death review committee (DRC) of neonatal deaths and stillbirths can encourage stakeholders to enhance the quality of care during the antenatal period and labour to improve birth outcomes. To understand the benefits and impact of the DRCs, this study was aimed at exploring the DRC members' perception about the role and benefits of the newly developed facility-based DRCs in five pilot hospitals in Jordan, to assess women empowerment, decision-making process, power dynamics, culture and genderism as contributing factors for deaths, and impact of COVID-19 lockdown on births. Methods A descriptive study of a qualitative design—using focus group discussions—was conducted after one year of establishing DRCs in 5 pilot large hospitals. The number of participants in each focus group ranged from 8 to10, and the total number of participants was 45 HCPs (nurses and doctors). Questions were consecutively asked in each focus group. The moderator asked the main questions from the guide and then used probing as needed. A second researcher observed the conversation and took field notes. Results Overall, there was an agreement among the majority of DRC members across all hospitals that the DRC was successful in identifying the exact cause of neonatal deaths and stillbirths as well as associated modifiable factors. There was also a consensus that the DRC contributed to an improvement in health services provided for pregnant women and newborns as well as protecting human rights and enabling women to be more interdependent in taking decisions related to family planning. Moreover, the DRC agreed that a proportion of the neonatal deaths and stillbirths occurring in the hospitals could have been prevented if adequate antenatal care was provided and some traditional harmful practices were avoided. Conclusions Facility-based neonatal death review audit is practical and can be used to identify exact causes of maternal and neonatal deaths and is a valuable tool for hospital quality indicators. It can also change the perception and practice of health care providers, which may be reflected in improving the quality of provided healthcare services.

Early neonatal death review from two provinces in Papua New Guinea: A retrospective analysis.

To determine the causes of early neonatal death and the avoidable factors associated with these deaths among women participating in a cluster-randomised crossover trial in Papua New Guinea. Early neonatal deaths were identified by retrospective chart review of the Women and Newborn Trial of Antenatal Interventions and Management study participants between July 2017 and January 2020. Causes of death and avoidable factors were identified using the Perinatal Problem Identification Program system. There were 35 early neonatal deaths among 2499 livebirths (14 per 1000 births). Fifty-seven percent (20/35) of deaths occurred on the first day of life. Idiopathic preterm birth was the leading obstetric cause of perinatal death (29%; 10/35). Extreme multi-organ immaturity (23%; 8/35) and hypoxic ischaemic encephalopathy (17%; 6/35) were the most common final causes of neonatal death. Forty-six avoidable factors were identified among 26 deaths, including delays in care-seeking, insufficient resources at health facilities, poor intrapartum care and immediate care of the newborn, including neonatal resuscitation. In this study, potentially preventable causes and avoidable factors were identified in the majority of early neonatal deaths. Addressing these factors will require health system strengthening, particularly the upskilling of primary level health staff, as well as targeted health education of women and the community.

Registration, documentation, and auditing of stillbirths and neonatal deaths in Jordan from healthcare professionals’ perspectives: reality, challenges and suggestions

Objectives: The current study aimed to explore healthcare professionals’ (HCPs) perceptions towards the registration and reporting process of stillbirth and neonatal mortality and their causes. Another aim is to explore HCPs’ perceived importance of registering stillbirths and neonatal deaths as well as the perceived challenges and suggestions of building a new surveillance and auditing system to report stillbirths and neonatal deaths in Jordan.Methods: A descriptive qualitative approach using an in-depth focus group discussion was used. A total of 16 focus groups were conducted in four major representative hospitals that cover different geographical areas in Jordan. An average of five healthcare providers (HCPs) was interviewed in each focus group with a total of 80 HCPs. All recorded focus group interviews were transcribed in a full verbatim, which was checked for accuracy by the project team. The whole content thematic analysis process was conducted in its original Arabic language to conserve credibility of the findings. Healthcare providers’ perceptions were derived from the group discussions using a group-interview guide.Results: Overall, the majority of HCPs across all hospitals agreed that it is important to document neonatal deaths and stillbirths in the hospital records mainly for statistical purposes. HCPs usually document neonatal deaths but not stillbirths. The causes of stillbirths and neonatal deaths are inaccurately recorded and not usually completed by the attending physician. Surprisingly, only neonates who live more than 4 h after delivery are registered as neonatal deaths but any neonate who dies before 4 h after delivery is not registered or registered as stillbirth. The majority of HCPs said that they were not aware of having neonatal death review committee in their hospitals. Importantly, the majority of HCPs in the four hospitals were enthusiastic about the development of a new surveillance system to register neonatal deaths and stillbirths in Jordan. Several suggestions were conveyed by the HCPs to better build, develop, implement, and sustain the proposed surveillance system.Conclusions: Electronic health information system and centralized database for compiling audit, registering births and deaths, and assigning causes of deaths should be developed and implemented. Designing and implementing an electronic registry or surveillance system that adopts ICD-10 codes is expected not only improve the completeness and timeliness of registration but also results in accurate recording of the causes of deaths.

Burn Injury of a Pregnant Mother in Rural Bangladesh: A Case Report

Introduction: This paper describes a case of pregnant mother who died of burn injury in order to understand the societal factors related to the event. We reviewed the case in the rural community. Initially, the case was reported as a maternal death to maternal and neonatal death review (MNDR) system being conducted in Bangladesh within exiting health system to explore the medical and social causes of maternal and newborn deaths. However, during the verbal autopsy, it was found that the mother died of bun injury. Therefore, we performed detailed case study. Case Presentation: A woman aged 18 years was nine months pregnant in a rural community in Moheskhali upazila of Cox’s Bazar district. During the wintertime, the mother feels cold and goes near to the oven in the yard to be warm. Suddenly, part of her clothing (Anchal of Sari) catches fire; she does not recognized and starts to walk towards her room. A neighbor notices and starts to shout. The woman scars and tries to run. The neighbors come with a bucket of water. By this time, the fire spreads over whole body and cloths. Immediately after the event, she is transferred to a medical college hospital. Conclusions: Doctors tried to do immediate cesarean section; however, they could not save the life of the baby inside. The mother who was severely burnt also died after 10 days. Rural community in Bangladesh still does not have adequate awareness and knowledge about risk of burn. The scarce knowledge of appropriate steps immediately after burn was explored. Moreover, delays in decision-making and transferring the patient to the facility were identified. Specific interventions need to be taken to increase knowledge and awareness in the community, which could save thousands of lives.

The Economic Cost of Implementing Maternal and Neonatal Death Review in a District of Bangladesh.

IntroductionMaternal and neonatal death review (MNDR) introduced in Bangladesh and initially piloted in a district during 2010. MNDR is able to capture each of the maternal, neonatal deaths and stillbirths from the community and government facilities (hospitals). This study aimed to estimate the cost required to implement MNDR in a district of Bangladesh during 2010-2012.Materials and methodsMNDR was implemented in Thakurgaon district in 2010 and later gradually extended until 2015. MNDR implementation framework, guidelines, tools and manual were developed at the national level with national level stakeholders including government health and family planning staff at different cadre for piloting at Thakurgaon. Programme implementation costs were calculated by year of costing and costing as per component of MNDR in 2013. The purchasing power parity conversion rate was 1 $INT = 24.46 BDT, as of 31st Dec 2012.ResultsOverall programme implementation costs required to run MNDR were 109,02,754 BDT (445,738 $INT $INT) in the first year (2010). In the following years cost reduced to 8,208,995 BDT (335,609 $INT, during 2011) and 6,622,166 BDT (270,735 $INT, during 2012). The average cost per activity required was 3070 BDT in 2010, 1887 BDT and 2207 BDT required in 2011 and 2012 respectively. Each death notification cost 4.09 $INT, verbal autopsy cost 8.18 $INT, and social autopsy cost 16.35 $INT. Facility death notification cost 2.04 $INT and facility death review meetings cost 20.44 $INT. One death saved by MNDR costs 53,654 BDT (2193 $INT).ConclusionsProgrammatic implementation cost of conducting MPDR give an idea on how much cost will be required to run a death review system for a low income country settings using government health system.Significance for public healthMaternal and neonatal death review (MNDR) system in a low income county is one of the key indicators to improve quality of health care services. The MNDR also support in the reduction of maternal and newborn deaths. However, to run a comprehensive death review system need to know costs associated with the system. This is crucial in low income countries for planning and designing a public health intervention. Very few studies yet perform to look at the costs to run a death review system. This paper describes health economic cost of death review system in Bangladesh for future public health research in low income countries

G528(P) To transfer or not transfer – the ethical and resources implications for transferring infants with a high risk of early death

BackgroundOver the last decade neonatal transport services (TS) have developed significantly as networks have been established. The responsibility of the TS is to transfer sick neonates for specialist care usually...

Maternal and Neonatal Death Review (MNDR): A Useful Approach to Identifying Appropriate and Effective Maternal and Neonatal Health Initiatives in Bangladesh

Objectives: To identify the effects of Maternal and Neonatal Death Review (MNDR) in terms of improving maternal and neonatal health at the community level in Bangladesh. Methods: Both quantitative and qualitative methods were undertaken for collecting data in Kashipur Union, Bangladesh. Death notifications from households, subsequent data collections from a focus-group discussion (FGD), a group discussion (GD) and in-depth interviews (IDIs) were obtained using structured tools and guidelines. Results: A total of four maternal deaths, 21 neonatal deaths and 15 still births were reported in the MNDR death notification system at Kashipur Union in 2010. Data were presented to local programme managers, who took various initiatives including awareness programmes, pregnancy registration, antenatal care, birth planning, and also the revitalization of a community clinic. The coverage of antenatal care, delivery in clinics, postnatal care and referral of complications increased through the active participation of the community. Community healthcare providers, care recipients and members of the community expressed satisfaction with the quality of maternal and neonatal services. In the preceding two years, maternal and neonatal deaths substantially reduced in Kashipur (in 2011 maternal death = 1, neonatal death = 20, still birth = 8; in 2012 maternal death = 1, neonatal death = 8, still birth = 13). Conclusions: The MNDR system successfully delivered notification of all maternal and neonatal deaths in the defined area and collected information for the formulation and implementation of specific interventions, which resulted in visible and tangible changes in care-seeking and client satisfaction.

Community Notification of Maternal, Neonatal Deaths and Still Births in Maternal and Neonatal Death Review (MNDR) System: Experiences in Bangladesh

Objectives: The aim of the study was to examine the process of community maternal, neonatal deaths and still births notification within the Bangladesh government health structure using the Maternal and Neonatal Death Review (MNDR) system. The study also explored the feasibility and acceptance of community death notification in the MNDR system. Methods: The study was under-taken in the Thakurgaon district of Bangladesh during 2010. During the study a mix of both qualitative and quantitative information was collected. A review of the documentation process of community death notification was undertaken and focus group discussions (FGDs) with community members, health care providers and managers in a sub-district were conducted, with in-depth interviews (IDIs) with district heath and family planning managers. Quantitative data were collected from community death notifications in the district during January to December 2010. Results: The death notification process was implemented by the government health care system within the Thakurgaon district. Field level health and family planning staff collected maternal and neonatal death information, recorded the death on the notification form and reported back to the Upazila (sub-district of the district) focal point at the Upazila health complex (primary health care centre). Community people were encouraged to share their death information to field level health staff. The health and family planning managers in the district periodically discussed the maternal and neonatal deaths and prepared remedial action plans in high death notified areas. In 2010, 59 maternal deaths, 739 neonatal deaths and 633 still births were reported in Thakurgaon district. District health and family planning departments performed community death notification as part of their routine daily work and integrated these procedures with other field level activities. Conclusion: Community death notification under the MNDR system was found to be achievable and acceptable at the district level using the existing government health system. The simple death notification process used to capture community level maternal, neonatal deaths and still births provides a guide for planning corrective actions for better health outcomes for the community.

Fim de Vida em Neonatologia: Integração dos Cuidados Paliativos

Today the limitation of therapeutic effort and the neonatal palliative care are extremely important and had been increasingly done by several countries. Nevertheless, in Portugal, studies and guidelines regarding end of life attitudes are still a shortage. We analyzed 49 files in a retrospective review of neonatal deaths between 2010 and 2012; the results were compared with those from a previous study made in the same NICU that included the neonatal deaths of 1992-1995 and 2002-2005. The results show that congenital anomalies were the cause of death for 57.1% newborns, extreme prematurity for 18.4% and 16.3% died with infection. Regarding to the mode of death, 57.1% of newborns died after cardiopulmonary resuscitation failure, 20.4% after withholding treatment and 22.4% of deaths followed therapy withdrawal. Differences were found between the three groups classified according to the 'mode of death', length of stay and parental presence during death. Therapeutic limitation practices and palliative care were reported in 28.6% of the files and a Do-Not-Resuscitate Order was included in 16.3%. The former two increased during the three periods analyzed. The use of a neonatal pain scale, opioids and sedatives administration, parental presence during death, clinical meetings with neonatologists, interdisciplinary meetings and psychological support for parents also increased. This study shows a trend towards an increase in therapeutic limitation practices and palliative care in this NICU in the last three decades. However, there is still a lot to do regarding the clinical research, medical education and ethical discussion.

Twelve‐year review of neonatal deaths in the delivery room in a perinatal tertiary centre

To describe decisions made for babies who died in the delivery room as a result of clinical practice of non-resuscitation or unsuccessful resuscitation. A retrospective study was conducted of neonatal deaths (NNDs) ≥ 400 g and/or ≥20 weeks' gestation born at Mater Mothers' Hospitals 1998-2009 who were not admitted to a neonatal nursery. Deaths were divided into not resuscitated and unsuccessful resuscitation and subdivided by cause of death as extremely preterm, congenital abnormality or 'other'. Of all 539 NNDs, 217 (40.3%) were not admitted to a neonatal nursery, comprising 174 (80.2%) not resuscitated and 41 (18.9%) unsuccessful resuscitation, while in a further two newborn infants resuscitation was not required. Only 13 of 123 (10.6%) extremely preterm infants who died in the delivery room had resuscitation attempted. Of 77 infants who died from congenital abnormalities in the delivery room 18 (23.3%) had resuscitation attempted. Fifteen babies with other diagnoses died in the delivery room; five with severe intrapartum asphyxia without resuscitation and a further 10 (8 preterm) with Apgar scores of 0-1 at 1 min and ≤3 at 5 min who did not respond to extensive resuscitation. A large proportion of NNDs occurred outside the neonatal nurseries involving end-of-life decision-making. Review of the circumstances of these NNDs in the subcategories of extreme prematurity, congenital abnormalities and 'other' raises different management dilemmas with the potential for clinical practice improvement in compassionate care and transparency in decision-making.

End of life in the neonatal intensive care unit

PURPOSE:Death at the beginning of life is tragic but not uncommon in neonatal intensive care units. In Portugal, few studies have examined the circumstances surrounding the final moments of neonates. We evaluated the care given to neonates and their families in terminal situations and the changes that had occurred one decade later.DESIGN AND METHODS:We analyzed 256 charts in a retrospective chart review of neonatal deaths between two periods (1992-1995 and 2002-2005) in a level III neonatal intensive care unit.RESULTS:Our results show differences in the care of dying infants between the two periods. The analysis of the 2002-2005 cohort four years revealed more withholding and withdrawing of therapeutic activities and more effective pain and distress relief; however, on the final day of life, 95.7% of the infants received invasive ventilatory support, 76.3% received antibiotics, 58.1% received inotropics, and 25.8% received no opioid or sedative administration. The 2002-2005 cohort had more spiritual advisor solicitation, a higher number of relatives with permission to freely visit and more clinical meetings with neonatologists. Interventions by parents, healthcare providers and ethics committees during decision-making were not documented in any of the charts. Only eight written orders regarding therapeutic limitations and the adoption of palliative care were documented; seven (87.5%) were from the 2002-2005 cohort. Parental presence during death was more frequent in the latter four years (2002-2005 cohort), but only 21.5% of the parents wanted to be present at that moment.CONCLUSION:Despite an increase in the withholding and withdrawing of therapeutic activities and improvements in pain management and family support, many neonates still receive curative and aggressive practices at the end of life.

Preventing Child Deaths

Preventing Child Deaths

A ten-year review of neonatal deaths in the special care baby unit at the University College Hospital, Ibadan

A ten-year review of neonatal deaths in the special care baby unit at the University College Hospital, Ibadan

Structured review of neonatal deaths in a managed care organisation.

We sought to quantify neonatal mortality (< 28 days) in a 10-hospital system, determine what proportion was associated with suboptimal neonatal care and make recommendations on how neonatal mortality rates (NMRs) could be used in quality improvement efforts. Deaths were identified using electronic linkage to the State of California Death Certificate Tapes. Individual fatalities were reviewed by a minimum of two physicians who did not care for the infant. Deaths were classified as either being associated with suboptimal care or not. For deaths where suboptimal care was an issue, emphasis was on delineating the process involved in the death. Subjects were all neonatal deaths among 64,469 babies born in 1990-91 in the 10 birth facilities of the Kaiser Permanente Medical Care Program, Northern California Region. A total of 241 neonatal deaths were identified. Adjusting for prematurity by increasing the follow-up period in preterm babies (included as neonatal deaths if they died up to 40 weeks corrected gestational age + 27.9 days) increased overall mortality rates by 5%. Birthweight-specific NMRs in Kaiser Permanente are similar to those of other published reports. Among the 198 deaths in babies weighing > or = 500 g at birth, only 14 (7%) were possibly associated with suboptimal care. In populations with access to health insurance, reporting only aggregate NMRs is of limited use. The number of deaths that could be ascribed to suboptimal neonatal care is very small and measuring variations in rates of such deaths is difficult. Future measurements of quality of care will require more sophisticated measures, database systems, review strategies and dissemination methods.

Contribution of Genetic Disorders to Neonatal Mortality in a Regional Intensive Care Setting

We examined the contribution of chromosomal abnormalities, mendelian disorders, and birth defects to mortality in a regional neonatal intensive care unit by medical record review of neonatal deaths in that unit. Of a total of 296 infant deaths during the 5-year period June 1986 to May 1991, 69 (23.3%) had a genetic disorder. By diagnostic category, 18.8% had a chromosomal abnormality, 10.1% had a mendelian condition, 42% had a single primary defect in development, and 29% had an unrecognized pattern of malformation. The rate of autopsy and genetic evaluation differed markedly between these diagnostic categories. A comparison was made of underlying cause of death determined from medical records with underlying cause as classified by vital statistics nosologic procedures. No death certificate was on file for two of the deaths; for the remaining 67, 27 (40.3%) had an erroneous or misleading underlying cause of death as determined from vital statistics. The important contribution of genetic disorders to neonatal mortality in this high-risk population and the relative underrecognition of these disorders by vital statistics sources indicate that efforts aimed at reducing neonatal mortality will require a full range of preventive health activities, including preconception, prenatal and perinatal assessment, and counseling. Improved data collection techniques need to be developed to understand the contribution of this group of conditions to total neonatal mortality.