Preplanned Studies: Analysis of Early Essential Newborn Care Capacities of Rural Health Facilities — Four Provinces in Western China, 2016

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.

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).

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).