Geography determines survival of babies with birth defects

A global study involving 74 countries has found that the survival rate of babies born with a birth defect is heavily dependent on where the child is born, sparking calls for Australia to play a role in improving surgical care for children in other countries.

Published in The Lancet, the study examined the risk of mortality for nearly 4000 babies born with birth defects in 264 hospitals around the world. Babies born with birth defects involving the intestinal tract had a two in five chance of dying in a low-income country, compared to one in five in a middle-income country and one in 20 in a high-income country.

2019 John Monash Scholar Dr Brendan Jones — together with Associate Professor Sebastian King and Dr Damir Ljuhar — was the co-country lead for Australia and New Zealand in what is reported to be the largest international study of outcomes for babies born with major congenital diseases.

“Associate Professor Sebastian King, Dr Damir Ljuhar and I coordinated the study in Australia and New Zealand and are saddened, but unfortunately not surprised, by the incredible disparities between high-income nations like Australia and New Zealand and low-income nations,” Dr Jones said.

“In Australia and New Zealand, we routinely care for children with diseases like gastroschisis with a full expectation that the baby will not only survive but go on to thrive and live a full life. Australia and New Zealand should be proud that we can offer this expectation to our children and their parents.

“Following our participation in this study, we encourage Australia and New Zealand to play a leading role in improving surgical care for children beyond our borders.”

Gastroschisis — a birth defect where a baby’s intestines protrude through a hole by the umbilicus — had the greatest difference in mortality rates, with 90% of babies dying in low-income countries compared with 1% in high-income countries. In high-income countries, most of these babies will be able to live a full life without disability.

Principal Investigator Dr Naomi Wright has devoted the last four years to studying these disparities in outcome. She said, “Geography should not determine outcomes for babies who have correctable surgical conditions. The Sustainable Development Goal to end preventable deaths in newborns and children under five years old by 2030 is unachievable without urgent action to improve surgical care for babies in low- and middle-income countries.”

The researchers stress the need for a focus on improving surgical care for newborns in low- and middle-income countries globally. Over the last 25 years, while there has been great success in reducing deaths in children under five years by preventing and treating infectious diseases, there has been little focus on improving surgical care for babies and children, and indeed the proportion of deaths related to surgical diseases continues to rise.

Birth defects are now the fifth leading cause of death in children under five years of age globally, with most deaths occurring in the newborn period. Birth defects involving the intestinal tract have a particularly high mortality in low- and middle-income countries as many are not compatible with life without emergency surgical care after birth.

In high-income countries, most women receive an antenatal ultrasound scan to assess for birth defects. If identified, this enables the woman to give birth in a hospital with children’s surgical care so the baby can receive help as soon as it is born. In low- and middle-income countries, babies with these conditions often arrive late to the children’s surgical centre in a poor clinical condition. The study shows that babies who present to the children’s surgical centre already septic with infection have a higher chance of dying.

The study also highlights the importance of perioperative care — the care received either side of the corrective operation or procedure — at the children’s surgical centre. Babies treated at hospitals without access to ventilation and intravenous nutrition when needed had a higher chance of dying. Furthermore, not having skilled anaesthetic support and not using a surgical safety checklist at the time of operation were associated with a higher chance of death.

The researchers found that improving survival from these conditions in low- and middle-income countries involves three key elements:

1. Improving antenatal diagnosis and delivery at a hospital with children’s surgical care.
2. Improving surgical care for babies born in district hospitals, with safe and quick transfer to the children’s surgical centre.
3. Improved perioperative care for babies at the children’s surgical centre.

The team acknowledge that this requires strong teamwork and planning between midwifery and obstetric teams, newborn and paediatric teams, and children’s surgical teams at the children’s surgical centre, alongside outreach education and networking with referring hospitals.

The researchers urge that alongside local initiatives, surgical care for newborns and children needs to be integrated into national and international child health policy and should no longer be neglected within global child health.

Image credit: ©stock.adobe.com/au/mocker_bat