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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 15-19

Levels of neonatal care services in Kaduna state


Neonatal Unit Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Ahmadu Bello University Zaria, Kaduna, Nigeria

Date of Web Publication20-Jun-2018

Correspondence Address:
Dr. Abdulkadir Isa
Neonatal Unit Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Ahmadu Bello University Zaria, Kaduna
Nigeria
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DOI: 10.4103/ssajm.ssajm_8_18

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  Abstract 


Introduction: Neonatal medicine is a specialized aspect of pediatrics. The availability and accessibility of efficient newborn units are essential for improved newborn health and survival. In the structure of our healthcare system in Nigeria, neonatal units are meant to be the component units of secondary and tertiary healthcare facilities.
Aims: The study aimed at determining the availability of neonatal units and the levels of care services in Kaduna state, Northwestern Nigeria.
Settings and Design: This was a cross-sectional, descriptive study.
Materials and Methods: The study was a survey of all hospitals in Kaduna state including public and nongovernment healthcare facilities. Information on the availability of newborn unit, staffing, and equipment was obtained and units were categorized into the levels of care.
Statistical Analysis Used: Data obtained were summarized and presented in proportions and simple percentages.
Results: A total of 33 public nonprimary healthcare facilities and 25 nongovernment specialist facilities operated in the state. Only two (one each state and federal owned) of these 33 public facilities, both of which were tertiary healthcare facilities, had an operational neonatal unit while 15 of the 25 specialist nongovernment facilities operated a neonatal unit. All the neonatal units were of level I category except for the state-owned tertiary facility, which was of level II category and the federal-owned tertiary facility, which was of level III category.
Conclusions: The number of neonatal units and levels of care in both public and private health facilities in the state are grossly inadequate. Improving these may result in improved neonatal care in the state.

Keywords: Levels of neonatal care, neonatal intensive care, neonatal medicine, neonatal unit


How to cite this article:
Isa A, Mustapha AN, Gbemiga A, William ON. Levels of neonatal care services in Kaduna state. Sub-Saharan Afr J Med 2018;5:15-9

How to cite this URL:
Isa A, Mustapha AN, Gbemiga A, William ON. Levels of neonatal care services in Kaduna state. Sub-Saharan Afr J Med [serial online] 2018 [cited 2018 Sep 25];5:15-9. Available from: http://www.ssajm.org/text.asp?2018/5/1/15/234760




  Introduction Top


Neonatal medicine is a specialized aspect of pediatrics. The availability of newborn units which provide comprehensive neonatal care services are an essential integral component of hospital services which ensures improved newborn health and survival.[1] The extent to which this is achieved depends on the specialized care provided, which in turn is determined by the staffing, available/quality specialty and subspecialty services, and structure of and equipment in the unit. The setting up of neonatal units is guided by policies which define basic or minimum standard requirements for efficiency.[2] Although differences exist in categorizing neonatal units into levels, generally however, the complexity of available services and technology and the severity of cases managed in units advance across levels of care from level I to level III or even IV such that complex and severe neonatal conditions are likely to survive at the higher levels of care compared to lower levels.[3],[4],[5],[6] In the structure of our healthcare system in Nigeria, neonatal units are meant to be the component units of secondary and tertiary health facilities.[7] Policies guiding standards for newborn care units are lacking and units may therefore operate without any target standard and thus not positioned to provide the much desired neonatal services capable of reducing neonatal deaths and improving newborn survival and health.[7]

The study aimed at determining the availability of neonatal units and level of care services in Kaduna state, Northwestern Nigeria.


  Materials and methods Top


The study was a cross-sectional, observational descriptive study of healthcare facilities in Kaduna state conducted over an 18-month period from January 2016 to June 2017. The state has a population of over 6.5 million people living across its 23 local government areas (LGAs) and an annual birth of 262,000.[8] The state operates at least one secondary healthcare facility in each of its LGAs.

Public facilities providing secondary and tertiary health care were identified from the health management information system (HMIS) from the ministry of health while nongovernment private facilities were itemized using information from both the state HMIS and from the guild of private medical practitioners. From the database of facilities obtained, all facilities offering neonatal care were then identified and contacted. The neonatal unit of each of the facilities identified from the database was included in the research and visited. A predesigned proforma was administered to a senior staff in the neonatal unit and available equipment noted. Information on the staffing of the unit including the availability of separate staff for the unit and the availability of a pediatrician/neonatologist was obtained. Other information sourced for include the category of neonates cared for and the severity of illnesses handled, referral hospital, and the mode of transport to referral centre. The newborn units were then defined and classified into the levels of care based on the complexity of functional capabilities of units as follows: level I (basic neonatal care), level II (specialty care), or level III (subspecialty care) in accordance with a constellation of characteristics extracted from the American Academy of Pediatrics policy statement on the levels of neonatal care [Table 1].
Table 1: American Academy of Pediatrics policy statement on levels of neonatal care

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  Results Top


A total of 33 public nonprimary healthcare facilities operated as secondary or tertiary healthcare facilities while 25 (5.4%) of the 466 nongovernment, private facilities in the state operated as specialist facilities. Only 2 (6%) of the 33 public facilities (one each state and federal owned), both of which were tertiary healthcare facilities, had operational neonatal units while 15 (60%) of the 25 specialist nongovernment, private facilities operated neonatal units. None of the 31 public secondary healthcare facilities in the state operated a functional neonatal unit. The majority [15 (88.3%)] of the total 17 operational neonatal units were nongovernment private units and were all located in three LGAs around the state capital. Of the 15 private facilities operating neonatal units, all had a staff either a nurse/midwife or doctor who could resuscitate a baby, 4 (26.7%) had a pediatrician to attend to babies while the remaining 11 (73.3%) suggested a pediatrician visited when services were requested. None of the 15 nongovernment private facilities had dedicated and separate neonatal unit staff. All the private facilities offered varying degrees of services within level I care; all managed babies that were term or late preterm while 2 (13.3%) will in addition manage moderately preterm who were stable or mildly ill. Twenty percent (3/15) could provide supplemental oxygen using cylinders while 1 (6.6%) had piped oxygen. None of the private facilities could offer continuous positive airway pressure (CPAP) or mechanical ventilator support. Three (20%) of the private facilities could provide ambulance for the transfer of referred patients.

The two public neonatal care facilities provided services above level I care. The state-owned tertiary facility had dedicated and separate neonatal unit staff, managed all categories of babies, and offered limited surgeries. It did not offer CPAP or mechanical ventilation but had transport facility for the transfer of referred cases. The federal-owned tertiary facility offered similar services and in addition offered more subspecialty services including neurosurgeries, cardiothoracic, and more complex pediatric surgeries but does not offer open heart surgeries. The unit provides CPAP and is capable of providing mechanical ventilator support but not at all times.

All the neonatal units in the state were of level I category except for the state-owned tertiary facility, which was of level II category and the federal-owned facility, which was of level III category. There was no policy on minimum benchmark and standard for the levels of neonatal care.


  Discussion Top


The majority (88.3%) of overall specialized neonatal care were obtainable in nongovernment, private facilities, all of which were able to provide only level I care. It is encouraging to note that as expected more facilities provided level I care services; however, the study did not assess the quality of the care as the availability of care does not equate to quality and/or efficiency. On the other hand, it is worrisome that none of the public secondary healthcare facilities operated a neonatal care unit. Public secondary healthcare facilities by distribution are widely spread and provide services to certain areas of the state such that this ensures the entire coverage of the state as against the specialist private facilities which were narrowly spread and often more expensive. This suggests that newborns who will require level I care, who are usually the majority, will have no or limited access to care and thus have an increased risk of worsened morbidity and poor outcome. Similarly, affordability may also further limit access to level I care even among those within the perimeter of facilities providing such services. This may be attributed to the high cost of neonatal care and the fact that private facilities are profit driven vis-a-vis the high poverty level[9] and out-of-pocket payments,[10] which exposes parents to catastrophic health expenditure. The sole (100%) provision of level I care by private facilities dictates that government should identify and encourage these facilities by providing them with appropriate policies and guidelines to support such services. The need to also engage these facilities in government-designed programs targeted at improving knowledge and skills toward standardizing and improving this level of care becomes imperative.

The outcomes of referred newborn cases to the higher levels of care have been shown to depend also on the mode of transport in addition to, of course, other factors which include the primary condition and the initial care received or stabilization attained.[11] One-fifth of the private facilities which provided level I care could provide ambulance for patient transfer to the higher level of care. This suggests that the majority of neonates who receive care in level I neonatal units are disadvantaged and at an increased risk of instability and poor outcome during transfer, as transfer entails maintaining and sustaining achieved stabilization as well as preventing and treating any evolving challenge or morbidity en route, all of which are not available in the absence of appropriate transport.[11]

Levels II and III neonatal care were each provided by a state-owned and federal tertiary hospital, respectively. The hospital providing level II care could neither provide CPAP nor mechanical ventilation. The reason was not elicited by this study but could be due to the lack of equipment, manpower, and/or skill. This level of care should be equipped and primed to provide CPAP to all patients and mechanical ventilator support to the limited category of patients. This will provide more access to neonates requiring such services and reduce the overburdening of level III facility. The level III care should be strengthened and empowered to provide mechanical ventilator support at all time to all category of patients.[12],[13]The absence of a policy on minimum standard for the neonatal levels of care leaves room for the provision of suboptimal and inefficient newborn services. Such document provides guidelines and stipulates minimum requirements and benchmark of care that should be provided by every level and at the same time enables appropriate and efficient vertical referral or transfer of patients. Overall, a properly implemented well-articulated policy will guarantee efficient and optimal neonatal care services.


  Conclusion Top


Neonatal care services in Kaduna state are limited and inadequate and there is no policy on minimum standard for the levels of neonatal care services. The current healthcare structure provides an opportunity to appropriately key in the levels of neonatal care and at the same time to provide relatively wide coverage.

Recommendations:
  1. Government should have partnership and support private facilities which provide neonatal care services to ensure standard and affordability.
  2. The setting up of an efficient neonatal transport service with well-trained staff to provide or sustain established stability of newborns that require transportation to a higher level of care.
  3. A policy to categorize, characterize, and recommend minimum standard requirements for the levels of neonatal care services be provided and disseminated.
  4. The current health structure should be maintained but further reorganized to assign level I care to secondary healthcare facilities, while level II care should be assigned to strategically identified and upgraded secondary healthcare facilities to serve as referrals to a grouped number of other secondary healthcare facilities. The tertiary healthcare facilities should be upgraded and fully equipped to serve as level III neonatal care centers.


Acknowledgements

The authors wish to acknowledge Dr. Bhuttawa of the Kaduna State Ministry of Health and Human Services, the guild of private medical practitioners, and all the participating facilities for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Okonkwo IR, Abhulimhen-Iyoha BI, Okolo AA. Scope of neonatal care services in major Nigerian hospitals. Niger J Paediatr 2016;43:8-13.  Back to cited text no. 1
    
2.
Federal Ministry of Health. Nigeria Every Newborn Action Plan: A Plan to End Preventable Newborn Deaths in Nigeria. Abuja: Federal Ministry of Health; 2016.  Back to cited text no. 2
    
3.
American Academy of Pediatrics. Policy statement levels of neonatal care. Pediatrics 2004;114:1341-7.  Back to cited text no. 3
    
4.
Committee on Fetus and Newborn. Policy statement: Levels of neonatal care. Pediatrics 2012;130:587-97.  Back to cited text no. 4
[PUBMED]    
5.
Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 2007;356:2165-75.  Back to cited text no. 5
[PUBMED]    
6.
The Swiss Society of Neonatology. Standards of Levels of Care in Switzerland; 2012. Available from: http://www.neonet.ch. [Last accessed on 2017 Mar 3].  Back to cited text no. 6
    
7.
Nigeria Federal Ministry of Health. Health Management Information System Department of Health Planning and Research. Revised Policy Programme and Strategic Plan of Action 2006; 2014. Available from: http://cheld.org/wp-content/uploads/2012/04. [Last accessed on 2017 Jan 5].  Back to cited text no. 7
    
8.
Federal Ministry of Health. Saving Newborn Lives in Nigeria: Newborn Health in the Context of the Integrated Maternal, Newborn and Child Health Strategy. 2nd ed. Abuja: Federal Ministry of Health, Save the Children, Jhpiego; 2011. Available from: http://countdown2030.org/documents/countdown-news/nigeria-full-report. [Last accessed on 2018 Mar 27].  Back to cited text no. 8
    
9.
National Bureau of Statistics. Nigeria Poverty Profile Report; 2016. Available from: http://www.nigeriastat.gov.ng. [Last accessed on 2016 Apr 4].  Back to cited text no. 9
    
10.
Out-of-Pocket Health Expenditure (% of Total Expenditure on Health) World Health Organization Global Health Expenditure Database; 2017. Available from: https://data.worldbank.org/indicator. [Last accessed on 2017 Feb 2].  Back to cited text no. 10
    
11.
Nandiran R. Evaluating and improving neonatal transport services. Early Hum Dev 2013;89:851-3.  Back to cited text no. 11
    
12.
Provider Standards. California Children’s Services Manual of Procedures; 1999. Available from: http://www.dhcs.ca.gov/services/ccs/Pages/ProviderStandards.aspx. [Last accessed on 2017 Feb 18].  Back to cited text no. 12
    
13.
White RD. Recommended standards for newborn ICU design. J Perinatol 2006;26:2-18.  Back to cited text no. 13
    



 
 
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