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BACKGROUND: Mothers with babies in the neonatal intensive care unit (NICU) face a host of challenges following childbirth. Limited information is available on these mothers' postpartum health needs and access to services. OBJECTIVE: To identify health needs of NICU mothers, access to services, and potential service improvements. DESIGN: A mixed-methods study including a retrospective cohort study, in-depth interviews, and focus groups. SETTING: Large, Level IV, regional referral, university-affiliated hospital in the United States. PARTICIPANTS: Mothers of live-born infants born from 1 July 2014 to 30 June 2016 (n = 6849). Interviews included 50 NICU mothers and 59 stakeholders who provide services to these mothers or their infants. MEASUREMENTS: Severe maternal morbidity, chronic health conditions, health care encounters from discharge through 12 weeks postpartum, maternal health needs, care access, and system improvements. RESULTS: Compared with mothers of well babies, NICU mothers had more chronic diseases, experienced more perinatal complications, and utilized more acute care postpartum. Qualitative analyses revealed the desire to be at the baby's bedside as a driver of maternal health-seeking behaviors, with women not seeking or delaying medical care so as to stay by their infant. Stakeholders acknowledged the unique needs of NICU mothers and cited system challenges, lack of clarity about provider roles, and reimbursement policies as barriers to meeting needs. LIMITATIONS: The study was conducted within a single health care system, which may limit generalizability. Qualitative analyses did not explore the influence of fathers, other children in the home, or length of NICU stay. CONCLUSION: Universal screening and convenient access to maternal health services for NICU mothers should be explored to reduce adverse maternal health outcomes. PRIMARY FUNDING SOURCE: Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services.

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BACKGROUND: With the rapid development of economy in recent two decades, neonatology has been progressing quickly in China. However, there is little knowledge about the exact developmental status of neonatal departments in China. The aim of this study was to assess resources available for care of sick newborns in mainland China. METHODS: Questionnaires were sent to the membership of the Chinese Neonatologist Association (CNA) and used to survey the scale, facilities, staff, technologies, transport systems and preterm infants' outcomes of neonatal departments (NDs) in different areas of China from June 2012 to December 2012. RESULTS: The result of this survey including a total of 117 questionnaires showed that investigated ND had a mean of 65 (median 47; range 5-450) beds, including 19.59 (median 15, range 0-100) NICU beds. The overall doctor/bed and nurse/bed ratio was 1:3.84 and 1:1.43, respectively. Lack of medical equipment was one of the main problems in most NDs surveyed, and only 26 NDs (22.2%) had more than one neonatal incubator per bed. Only 70.1, 30.6, 30.8 and 4.3% NDs carried out high-frequency ventilation, hypothermia, nitric oxide inhalation, and ECMO respectively. The capacity to provide advanced therapies increased with the size of the NDs (P < .01). A total of 81 NDs (69.2%) carried out neonatal transport, but only 70 NDs (86.4%) were equipped with transport incubators, 36 NDs (44.4%) had the ability of performing intrauterine transport of the preterm infants, and 3 NDs (3.7%) had the ability of performing air transport. The survival rate of extremely preterm infants (Gestational age less than 28w) to discharge home was 47.8% in 2011. CONCLUSION: NDs in mainland China are not well distributed and still face many problems, such as staff shortage, inadequate facilities, and imperfect transport. It is urgent to set up a classification of neonatal care to enhance the utilization rate of medical resources and improve the prognosis of critically ill infants.

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BACKGROUND: WHO MCS in 2011 evaluated the incidence and management strategies linked with maternal and neonatal mortality in facilities across 26 countries including Pakistan. This study, a sub-analysis assessed the availability of essential obstetric and newborn care at referral level facilities of Pakistan that were selected for WHO MCS to correlate it with maternal and neonatal outcomes. METHODS: This cross-sectional study assessed the infrastructure, equipment and services in 16 referral level government hospitals participating in WHO MCS from 1st March to 30th May, 2011. The association was found between this data and maternal & neonatal outcomes of each facility using chi square test. RESULTS: The studied facilities had basic infrastructure, most components of Essential Maternal and Neonatal Obstetric Care services with part time/full time availability of obstetricians, anaesthetists and paediatricians. Adult intensive care unit was available in 68%, and neonatal intensive care unit was available in half of the facilities. The incidence of severe maternal outcomes had a positive correlation with presence of adult intensive care unit, mechanical ventilator and twenty-four hours (24/7) availability of anaesthesiologist, nurses & paramedics. The neonatal mortality was also higher in facilities with neonatal intensive care unit facility. CONCLUSIONS: Most components of Essential Maternal and Neonatal Obstetric Care were present in the studied facilities. Tertiary level facilities even with availability of Adult and neonatal intensive care units had more adverse maternal and new-born outcomes perhaps due to more disease burden.

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BACKGROUND: Free choice of hospital has been introduced in many healthcare systems to accommodate patient preferences and incentivize hospitals to compete; however, little is known about what patients actually prefer. OBJECTIVES: This study assessed women's preferences for birthing hospital in Denmark by quantifying the utility and trade-offs of hospital attributes. METHODS: We conducted a discrete-choice experiment survey with 12 hypothetical scenarios in which women had to choose between three hospitals characterized by five attributes: continuity of midwifery care, availability of a neonatal intensive care unit (NICU), hospital services offered, level of specialization to handle rare events, and travel time. A random parameter logit model was used to estimate the utility and marginal willingness to travel (WTT) for improvements in other hospital attributes. RESULTS: A total of 517 women completed the survey. Significant preferences were expressed for all attributes (p < 0.01), with the availability of a NICU being the most important driver of women's preferences; women were willing to travel 30 more minutes (95% confidence interval 28-32) to reach a hospital with a highly specialized NICU. The subgroup analyses revealed differences in WTT, with substantial heterogeneity due to prior experience with giving birth and regarding risk attitude and health literacy. CONCLUSION: A high specialization level was the most influential factor for women without previous birth experience and for risk-averse individuals but not for women with a high health literacy score. Hence, more information about the woman's risk profile and services required could play a role in affecting hospital choice.

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OBJECTIVE: This article assesses the effect of reducing consecutive hours worked by residents from 24 to 16 hours on yearly total hours worked per resident in the neonatal intensive care unit (NICU) and evaluates the association of resident duty hour reform, level of trainee, and the number of residents present at admission with mortality in the NICU. STUDY DESIGN: This is a 6-year retrospective cohort study including all pediatric residents working in a Level 3 NICU (N = 185) and infants admitted to the NICU (N = 8,159). Adjusted odds ratios (aOR) were estimated for mortality with respect to Epoch (2008-2011 [24-hour shifts] versus 2011-2014 [16-hour shifts]), level of trainee, and the number of residents present at admission. RESULTS: The reduction in maximum consecutive hours worked was associated with a significant reduction of the median yearly total hours worked per resident in the NICU (381 hour vs. 276 hour, p < 0.01). Early mortality rate was 1.2% (50/4,107) before the resident duty hour reform and 0.8% (33/4,052) after the reform (aOR, 0.57; 95% confidence interval [CI], 0.33-0.98). Neither level of trainee (aOR, 1.22; 95% CI, 0.71-2.10; junior vs. senior) nor the number of residents present at admission (aOR, 2.08; 95% CI, 0.43-10.02, 5-8 residents vs. 0-2 residents) were associated with early mortality. Resident duty hour reform was not associated with hospital mortality (aOR, 0.73; 95% CI, 0.50-1.07; after vs. before resident duty hour reform). CONCLUSION: Resident duty hour restrictions were associated with a reduction in the number of yearly hours worked by residents in the NICU as well as a significant decrease in adjusted odds of early mortality but not of hospital mortality in admitted neonates.

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OBJECTIVE: To characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. STUDY DESIGN: This was a population-based, cross-sectional study. 2013 US birth certificate and 2012 American Hospital Association data were used to assign newborns and NICU beds to neonatal intensive care regions. Descriptive statistics of admission rates were calculated across neonatal intensive care regions. Multilevel logistic regression was used to examine the relationship between bed supply and individual odds of admission, with adjustment for maternal and newborn characteristics. RESULTS: Among 3 304 364 study newborns, the NICU admission rate was 7.2 per 100 births and varied across regions for all birth weight categories. IQRs in admission rates were 84.5-93.2 per 100 births for 500-1499 g, 35.3-46.1 for 1500-2499 g, and 3.5-5.5 for ≥2500 g. Adjusted odds of admission for newborns of very low birth weight were unrelated to regional bed supply; however, newborns ≥2500 g in regions with the highest NICU bed supply were significantly more likely to be admitted to a NICU than those in regions with the lowest (aOR 1.20 [1.03-1.40]). CONCLUSIONS: There is persistent underuse of NICU care for newborns of very low birth weight that is not associated with regional bed supply. Among larger newborns, we find evidence of supply-sensitive care, raising concerns about the potential overuse of expensive and unnecessary care. Rather than improving access to needed care, NICU expansion may instead further deregionalize neonatal care, exacerbating underuse.

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Neonates who require additional care, be it in a special care baby unit, neonatal intensive care unit or just on the labour ward, may need specific equipment to allow the team to care for them accurately and safely. This article outlines some of the specific types of equipment which may be needed.

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ABSTRACT This study was designed to investigate the use of off-label and unlicensed drugs in a Neonatal Care Unit (NCU) and to compare the frequency of use of off-label drugs according to the drug regulatory agencies in Brazil (Agência Nacional de Vigilância Sanitária-ANVISA) and the United States Food and Drug Administration (FDA). A prospective observational study was carried out in the NCU. Prescriptions were classified as off-label and unlicensed using both ANVISA and FDA criteria. A total of 157 newborns and 1187 prescriptions were analyzed. The most prescribed drug was fentanyl (9.3%), followed by multivitamin (8.4%) and gentamicin (7.9%). According to ANVISA criteria, there were 665 (56.0%) off-label prescriptions and 86 (7.2%) unlicensed prescriptions and 95.5% of newborns received at least one drug off-label. By contrast, according to FDA criteria, there were 592 (49.9%) off-label prescriptions and 84 (7.1%) unlicensed prescriptions, and 72.0% of newborns received at least one drug off-label. The off-label use of drugs registered by ANVISA differed significantly from that of drugs registered by the FDA. There was a high frequency of off-label and unlicensed drug use in the investigated NCU, and there was an inverse relationship between off-label and unlicensed usage and the gestational age of the newborns.

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In Mongolia, a Central Asian lower-middle income country, intensive care medicine is an under-resourced and-developed medical specialty. The burden of critical illness and capacity of intensive care unit (ICU) services in the country is unknown. In this nationwide census, we collected data on adult and pediatric/neonatal ICU capacities and the number of ICU admissions in 2014. All hospitals registered to run an ICU service in Mongolia were surveyed. Data on the availability of an adult and/or pediatric/neonatal ICU service, the number of available ICU beds, the number of available functional mechanical ventilators, the number of patients admitted to the ICU, and the number of patients admitted to the study hospital were collected. In total, 70 ICUs with 349 ICU beds were counted in Mongolia (11.7 ICU beds/100,000 inhabitants; 1.7 ICU beds/100 hospital beds). Of these, 241 (69%) were adult and 108 (31%) pediatric/neonatal ICU beds. Functional mechanical ventilators were available for approximately half of the ICU beds (5.1 mechanical ventilators/100,000 inhabitants). While all provincial hospitals ran a pediatric/neonatal ICU, only dedicated pediatric hospitals in Ulaanbaatar did so. The number of adult and pediatric/neonatal ICU admissions varied between provinces. The number of adult ICU beds and adult ICU admissions per 100,000 inhabitants correlated (r = 0.5; p = 0.02), while the number of pediatric/neonatal ICU beds and pediatric/neonatal ICU admissions per 100,000 inhabitants did not (r = 0.25; p = 0.26). In conclusion, with 11.7 ICU beds per 100,000 inhabitants the ICU capacity in Mongolia is higher than in other low- and lower-middle-income countries. Substantial heterogeneities in the standardized ICU capacity and ICU admissions exist between Mongolian provinces. Functional mechanical ventilators are available for only half of the ICU beds. Pediatric/neonatal ICU beds make up one third of the national ICU capacity and appear to meet or even exceed the demand of pediatric/neonatal critical care.

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BACKGROUND: Respiratory distress is a leading cause of neonatal death in low-income and middle-income countries. CPAP is a simple and effective respiratory support modality used to support neonates with respiratory failure and can be used in low-income and middle-income countries. The goal of this study was to describe implementation of the Silverman-Andersen respiratory severity score (RSS) and bubble CPAP in a rural Ugandan neonatal NICU. We sought to determine whether physicians and nurses in a low-income/middle-income setting would assign similar RSS in neonates after an initial training period and over time. METHODS: We describe the process of training NICU staff to use the RSS to assist in decision making regarding initiation, titration, and termination of bubble CPAP for neonates with respiratory distress. Characteristics of all neonates with respiratory failure treated with bubble CPAP in a rural Ugandan NICU from January to June 2012 are provided. RESULTS: Nineteen NICU staff members (4 doctors and 15 nurses) received RSS training. After this, the Spearman correlation coefficient for respiratory severity scoring between doctor and nurse was 0.73. Twenty-one infants, all < 3 d of age, were treated with CPAP, with 17 infants starting on the day of birth. The majority of infants (16/21, 76%) were preterm, 10 (48%) were <1,500 g (birthweight), and 13 (62%) were outborn. The most common diagnoses were respiratory distress syndrome (16/21, 76%) and birth asphyxia (5/21, 24%). The average RSS was 7.4 ± 1.3 before starting CPAP, 5.2 ± 2.3 after 2-4 h of CPAP, 4.9 ± 2.7 after 12-24 h of CPAP, and 3.5 ± 1.9 before CPAP was discontinued. Duration of treatment with CPAP averaged 79 ± 43 h. Approximately half (11/21, 52%) of infants treated with CPAP survived to discharge. CONCLUSIONS: Implementing bubble CPAP in a low-income/middle-income setting is feasible. The RSS may be a simple and useful tool for monitoring a neonate's respiratory status and for guiding CPAP management.

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BACKGROUND: Several new generation neonatal ventilators that incorporate conventional as well as high frequency ventilation (HFOV) have appeared on the market. Most of them offer the possibility to use HFOV in a volume-targeted mode, despite absence of any preclinical data. With a bench test, we evaluated the performances of 4 new neonatal HFOV devices and compared them to the SensorMedics HFOV device. METHODS: Expiratory tidal volumes (V(T)) were measured for various ventilator settings and lung characteristics (ie, modifications of compliance and resistance of the system), to mimic several clinical conditions of pre-term and term infants. RESULTS: Increasing the frequency proportionally decreased the V(T) for all the ventilators, although the magnitude of the decrease was highly variable between ventilators. At 15 Hz and a pressure amplitude of 60 cm H2O, the delivered V(T) ranged from 3.5 to 5.9 mL between devices while simulating pre-term infant conditions and from 2.6 to 6.3 mL while simulating term infant conditions. Activating the volume-targeted mode in the 3 machines that offer this mode allowed the V(T) to remain constant over the range of frequencies and with changes of lung mechanical properties, for pre-term infant settings only while targeting a V(T) of 1 mL. CONCLUSIONS: These new generation neonatal ventilators were able to deliver adequate V(T) under pre-term infant, but not term infant respiratory system conditions. The clinical relevance of these findings will need to be determined by further studies.

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Objetivo: descrever intervenção em surto de Klebsiella pneumoniae produtora de betalactamase de espectro expandido (ESBL) em unidade de terapia intensiva neonatal (UTIN) no município de Teresina, estado do Piauí, Brasil, 2010-2011. Métodos: exame micológico direto de fragmentos de unhas e cultura com antibiograma; os funcionários da UTIN com resultado positivo para K. pneumoniae ESBL submeteram-se a tratamento medicamentoso específico; adotaram-se medidas de prevenção de infecção relacionada à assistência à saúde (IRAS) como implantação de protocolos assistenciais e estímulo à adequada higienização das mãos. Resultados: foram notificados 21 casos de K. pneumoniae ESBL, as notificações diminuíram após a intervenção; a frequência de IRAS pelo bacilo passou de 67 por cento (julho/2010) a zero (maio/2011). Conclusão: a implantação de medidas preventivas de IRAS mostrou-se efetiva na redução de casos de infecção por K. pneumoniae ESBL na UTI neonatal, contribuindo para a melhoria dos indicadores epidemiológicos e da qualidade da assistência prestada.

Objective: to describe an intervention in an outbreak of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in a neonatal intensive care unit (NICU) in Teresina, Piauí state, Brazil, 2010-2011. Methods: mycological examination was conducted using fingernail fragments and culture antibiogram. NICU Staff (2 nurses, 3 physicians and 6 nursing technicians) testing positive for ESBL-producing K. pneumoniae underwent specific drug-based treatment. Healthcare-associated infection (HCAI) prevention measures such as implementing care protocols and encouraging proper hand washing were adopted. Results: notifications of cases of ESBL-producing K. pneumoniae (n=21) decreased after the intervention. The frequency of HCAI due to ESBL-producing K. pneumoniae reduced from 67 per cent in July 2010 to zero in May 2011. Conclusion: the implementation HCAI prevention actions was shown to be effective in reducing cases of infection related to ESBL-producing K. pneumoniae in the neonatal ICU, contributing to the improvement of epidemiological indicators and quality of care.

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OBJECTIVES: To identify the resources related to the care of critically ill patients in Spain, which are available in the units dependent of the Services of Intensive Care Medicine (ICM) or other services/specialties, analyzing their distribution according to characteristics of the hospitals and by autonomous communities. DESIGN: Prospective observational study. SETTING: Spanish hospitals. PARTICIPANTS: Heads of the Services of ICM. MAIN OUTCOME VARIABLES: Number of units and beds for critically ill patients and functional dependence. RESULTS: The total number of registries obtained with at least one Service of ICM was 237, with a total of 100,198 hospital beds. Level iii (43.5%) and level ii (35%) hospitals predominated. A total of 73% were public hospitals and 55.3% were non-university centers. The total number of beds for adult critically ill patients, was 4,738 (10.3/100,000 inhabitants). The services of ICM registered had available 258 intensive are units (ICUs), with 3,363 beds, mainly polyvalent ICUs (81%) and 43 intermediate care units. The number of patients attended in the Services of ICM in 2008 was 174,904, with a percentage of occupation of 79.5% A total of 228 units attending critically ill patients, which are dependent of other services with 2,233 beds, 772 for pediatric patients or neonates, were registered. When these last specialized units are excluded, there was a marked predominance of postsurgical units followed by coronary and cardiac units. CONCLUSIONS: Seventy one per cent of beds available in the Critical Care Units in Spain are characterized by attending severe adult patients, are dependent of the services of ICM, and most of them are polyvalent.

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BACKGROUND AND OBJECTIVE: Nasal continuous positive airway pressure (NCPAP) plus intubation, surfactant, and extubation (InSurE) with the option of back-up ventilation for those infants for whom noninvasive ventilatory support failed resulted in a significant increase in survival in extremely low birth weight (ELBW) infants. The authors sought to determine the outcome of ELBW infants treated with NCPAP and InSurE in a neonatal high care ward with limited back-up ventilation. METHODS: Three hundred eighteen inborn infants with birth weight 500-1000 g and gestational age ≥25 weeks who were admitted to the neonatal high care ward were included in this observational study. InSurE was administered to infants with respiratory distress syndrome on NCPAP who had severe in-drawing and recession, apneic spells, or an Fio(2) >0.4 within 1 hour of birth. RESULTS: Two hundred twelve (68.6%) infants could be treated with NCPAP only and 97 (31.4%) required InSurE. Seventeen infants were admitted to the NICU; 90%, 87%, and 74.8% of the infants survived until day 3, 7, and discharge, respectively. Only 2 infants developed a pneumothorax and 2 had chronic lung disease. Seventy-nine percent of the infants of ≥750 g or >26 weeks' gestation survived to discharge compared with 56% and 60% of the infants of <750 g or ≤26 weeks' gestation, respectively. Maternal antenatal steroid administration contributed significantly to the survival of the infants (P = 0.0017, odds ratio 2.7, 95% confidence interval 1.44-5.07). CONCLUSIONS: The use of NCPAP and InSurE in a neonatal high care ward with limited resources can improve the survival of ELBW infants. Maternal antenatal steroid administration contributed significantly to survival.

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OBJECTIVE: To describe the practice of pediatric intensive care in Latin America and compare it with two European countries. DESIGN: Analysis of data presented by member countries of the Sociedad Latinoamericana de Cuidado Intensivo Pediátrico (SLACIP), Spain and Portugal, in the context of a Symposium of Spanish and Portuguese - speaking pediatric intensivists during the Fifth World Congress on Pediatric Intensive Care. SETTING: Pediatric intensive care units (PICUs). PARTICIPANTS: Pediatric intensivists in representation of each member country of the SLACIP, Spain and Portugal. INTERVENTIONS: None. VARIABLES OF INTEREST: Each country presented its data on child health, medical facilities for children, pediatric intensive care units, pediatric intensivists, certification procedures, equipment, morbidity, mortality, and issues requiring intervention in each participating country. RESULTS: Data from 11 countries was analyzed. Nine countries were from Latin America (Argentina, Colombia, Cuba, Chile, Ecuador, Honduras, México, Dominican Republic and Uruguay), and two from Europe (Spain and Portugal). Data from Bolivia and Guatemala were partially considered. Populational, institutional, and operative differences were identified. Mean PICU mortality was 13.29% in Latin America and 5% in the European countries (P=0.005). There was an inverse relationship between mortality and availability of pediatric intensive care units, pediatric intensivists, number of beds, and number of pediatric specialty centers. Financial and logistic limitations, as well as deficiencies in support disciplines, severity of diseases, malnutrition, late admissions, and inadequate initial treatments could be important contributors to mortality at least in some of these countries. CONCLUSION: There are important differences in population, morbidity and mortality in critically ill children among the participating countries. Mortality shows an inverse correlation to the availability of pediatric intensive care units, intensive care beds, pediatric intensivists, and pediatric subspecialty centers.

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OBJECTIVE: In centers electing to offer therapeutic hypothermia for treating hypoxic-ischemic encephalopathy (HIE), determining the optimal number of cooling devices is not straightforward. The authors used computer-based modeling to determine the level of service as a function of local HIE caseload and number of cooling devices available. METHODS: The authors used discrete event simulation to create a model that varied the number of HIE cases and number of cooling devices available. Outcomes of interest were percentage of HIE-affected infants not cooled, number of infants not cooled, and percentage of time that all cooling devices were in use. RESULTS: With 1 cooling device, even the smallest perinatal center did not achieve a cooling rate of 99% of eligible infants. In contrast, 2 devices ensured 99% service in centers treating as many as 20 infants annually. In centers averaging no more than 1 HIE infant monthly, the addition of a third cooling device did not result in a substantial reduction in the number of infants who would not be cooled. CONCLUSION: Centers electing to offer therapeutic hypothermia with only a single cooling device are at significant risk of being unable to provide treatment to eligible infants, whereas 2 devices appear to suffice for most institutions treating as many as 20 annual HIE cases. Three devices would rarely be needed given current caseloads seen at individual institutions. The quantitative nature of this analysis allows decision makers to determine the number of devices necessary to ensure adequate availability of therapeutic hypothermia given the HIE caseload of a particular institution.

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The objective of this study was to describe the characteristics of neonatal and pediatric intensive care units (ICU) and beds in Rio de Janeiro, correlating with population demands in 1997 and 2007. All neonatal and pediatric ICUs were visited, identifying the availability and type of beds. Comparisons were made between: supply and demand using projected need for beds for the population; public and private ICUs; and geographical regions. In 2007, 95 units were included totaling 1,094 beds (74 units and 1,080 beds in 1997): 51% public and 48% private (47% and 52% in 1997); 47% neonatal, 18% pediatric and 35% mixed units. Most units were located in the metropolitan area. The distribution of public and private beds was similar in the metropolitan area in both periods; in the interior, public beds tripled. Access has improved, mainly in the interior, but there is still no equity in the distribution of and accessibility to the available beds, with a shortage in the public sector, an excess in the private sector, and a great concentration in the metropolitan area.

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INTRODUCTION: The only way to characterize the Mexican problem related to congenital heart disease care is promoting the creation of a national database for registering the organization, resources, and related activities. MATERIAL AND METHODS: The Health Secretary of Mexico adopted a Spanish registration model to design a survey for obtaining a national Mexican reference in congenital heart disease. This survey was distributed to all directors of medical and/or surgical health care centers for congenital heart disease in Mexico. This communication presents the results obtained in relation to organization, resources and activities performed during the last year 2009. RESULTS: From the 22 health care centers which answered the survey 10 were reference centers (45%) and 12 were assistant centers (55%). All of them are provided with cardiologic auxiliary diagnostic methods. Except one, all centers have at least one bidimentional echocardiography apparatus. There is a general deficit between material and human resources detected in our study. Therapeutic actions for congenital heart disease (70% surgical and 30% therapeutical interventionism) show a clear centralization tendency for this kind of health care in Mexico City, Monterrey and finally Guadalajara. CONCLUSIONS: Due to the participation of almost all cardiac health centers in Mexico, our study provides an important information related to organization, resources, and medical and/or surgical activities for congenital heart disease. The data presented not only show Mexican reality, but allows us to identify better the national problematic for establishing priorities and propose solution alternatives.

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Neonatal mortality rate in India is high and stagnant. Special Care Newborn Units (SCNUs) are being set up to provide quality level II newborn care services in district hospitals of several districts to meet this challenge. The units are located in some of the remotest districts where the burden of neonatal deaths and accessibility to special care is a concern. A recently concluded evaluation of these units indicates that it is possible to provide quality level II newborn care in district hospitals. However, there are critical constraints such as availability and skills of human resources, maintenance of equipment and bed occupancy. It is not the SCNU alone but an active network of SCNU (level II care), neonatal stabilization units (level I care) and newborn care corners can impact neonatal mortality rate reduction higher. Number of beds is also not sufficient to cater to the increasing demand of such services. Available number of nurses is a problem in many such units. An effective and sustainable system to maintain and repair the equipment is essential. Scaling up these units would require squarely addressing these issues.

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