Better Data Enables Better Intervention.

Exposure of the fetus to significant intrapartum hypoxia ischaemia may result in a range of adverse outcomes including stillbirth, neonatal encephalopathy (NE) and postnatal death. Indeed, intrapartum-related events are estimated to account for nearly a quarter of neonatal deaths and are second only to prematurity as a cause of neonatal mortality [1]. Furthermore, survivors may develop a variety of important sequelae including cerebral palsy (CP), which is relatively common, and non-motor morbidities such as cognitive dysfunction [2], [3], [4], [5]. In high income countries (HIC), national quality improvement programmes such as Each Baby Counts in UK [6] and NE Task Force in New Zealand [7] are underway and aim to both prevent NE and improve outcomes. In this edition of the journal, Tann et al. [8] describe the follow up of infants with NE, in Uganda, a low income country (LIC) with a neonatal mortality of 27/1000 live births.

It is important to appreciate that the greatest burden from intrapartum related events falls on lower income countries due to their higher prevalence of NE. Indeed, 96% of an estimated 1.15 million babies worldwide who developed NE, associated with intrapartum events, in 2010 were born in low and middle-income countries [ 9]. This number approximates to 8.5 cases per 1000 live births worldwide. However, the distribution is heterogeneous and this averaged rate includes a huge variation. The national rate of NE for New Zealand was reported as 1.0/1000 term births for 2016 [10], a rate approximately 10 times higher has been reported from Nepal [11] and at the upper end of the scale a prevalence of hypoxic ischaemic encephalopathy equal to 10.7% (albeit including preterm infants) was reported from a single centre in Tanzania [12].

Although adverse outcome is a recognised consequence of NE, the nature of the sequelae is both variable and influenced by the health care provided. A composite of outcomes may measure the overall burden, so is often used in interventional trials, but it should be noted that death and long-term impairment are competing outcomes. If there is little or no neonatal intensive care provided the impairment rate is low due to poor survival. However, with increasing provision of neonatal life support (as opposed to neurologically focussed interventions such as cooling) death may be less common but with higher impairment rate. For planning clinical practice improvement (CPI) there is a need to first understand the natural history and outcome following NE, then act to prevent cases and optimise treatment in an equitable and effective manner. Interventions need to be context sensitive and may vary with setting in order to be effective. Until now, data on NE outcome in low income countries has been limited by low numbers and short follow up duration [13], [14]. Furthermore, in low income settings prognostic testing with magnetic resonance imaging or spectroscopy [15], [16] are unlikely to be available so the need to quantify outcome is greater.

In their paper, Tann et al. [8] report the follow-up of 116 infants with NE and 230 control infants in Uganda. Within the maternity system, monitoring of fetal status was typically by intermittent auscultation of heart rate. There were few elective caesarean sections and operative deliveries using ventouse or forceps were not offered. Basic resuscitation was performed by midwives and limited life support provided. In such a setting it is challenging to perform good quality follow up. Nevertheless, a comprehensive program of testing was completed including Griffith and HINE assessments. Mortality was 40.3% by 27–30 months following NE compared with 3.8% in non-NE children. In NE survivors 29.3% had neurodevelopmental impairment (NDI) including 19% CP and 10.3% global developmental delay without CP.

These findings are important and should inform future research, practice improvement and policy making. As with most situations, better data enables better decisions and the insights gained should influence both local and wider practice. Although there are reports of what works to prevent intrapartum related neonatal death with simple, affordable and effective approaches [17], there is still much to be done with respect to other outcomes in LICs. Tann et al. report that half of the children with NDI manifested malnutrition, which is an important area for appropriate intervention. Other valuable findings include the use of simple clinical predictors such as occipital frontal head circumference measurement and requirement for feeding support to predict status at two years. Such information will inform future work on early identification and targeted intervention. Overall a greater knowledge base will assist development of strategies for prevention and appropriate intervention, which is urgently needed to optimise outcomes and quality of life for children affected by NE and their families.