Current status of newborn health in India &
newer strategies
Framework:
1. Introduction
2. Trends in neonatal mortality
3. Causes of neonatal Deaths
4. Determinants of neonatal mortality
5. Effective newborn health interventions
6. Strategies for newborn health in India
7. Approaches for improving service utilization and health system
strengthening
– JSY
– JSSK
– Defining standard of maternal and newborn care at
different levels
1.INTRODUCTION:
India is among the countries where child mortality rate is alarmingly high.
The Millennium Development Goal- 4 aims to reduce Child Mortality, targeting
to reduce the under five mortality rate by two thirds between 1990 and 2015.
Infant Mortality rate is one of the indicators to measure the progress of
achievement of this target. The level of mortality is very high in the first few
hours, days and weeks of life. Thereby neonatal deaths contribute to a larger
extent among the infant deaths. The reasons for infant deaths at the earlier
and later stages of infancy differ to a certain extent. So, it’s important to know
about the status of newborn health in India and the interventions.
2.TRENDS IN NEWBORN MORTALITY IN INDIA
• In 2010, the percentage of neo- natal deaths to total infant deaths is
69.3% at national level and varies from 61.9% in urban areas to 70.6% in
rural areas. Among the bigger States, Jammu & Kashmir (82.1%)
registered the highest percentage of neonatal deaths to infant deaths
and the lowest is in Kerala (53.2%).
• In 2010, the neonatal mortality rate (neo- natal deaths per thousand
live births) at national level is at 33 and ranges from 19 in urban areas to
36 in rural areas. Among bigger states, neo-natal mortality rate is highest
in Madhya Pradesh (44) and lowest in Kerala (7).
• At the national level, the early neo –natal mortality rate for the year
2010 has been estimated at 25 and ranges from 28 in rural areas to 15 in
urban areas. Among the bigger States, Kerala (5) and Madhya Pradesh
(34) are at the two extremes.
• The percentage of early neo – natal deaths to the total infant deaths
during the year 2010, at the national level has been 53.9 and it varies
from 54.6 in rural areas to 49.6 in urban areas. Among bigger States, the
percentage of early neo natal deaths for total infant deaths varies from
the lowest level of 38.7% in Kerala to the highest level of 69.4% in
Jammu & Kashmir.
3.CAUSES OF NEONATAL MORTALITY:
• The main causes of newborn deaths are prematurity and low-birthweight, infections, asphyxia (lack of oxygen at birth) and birth trauma.
These causes account for nearly 80% of deaths in this age group.
• Among the 3.1 million deaths that occurred among babies 0-28 days of
life, about one third was due to infections (including pneumonia, sepsis,
neonatal tetanus and diarrhoea).
• Newborn and maternal mortality are closely linked. Therefore, the risk
of dying from neonatal conditions can be mitigated with quality care
during pregnancy, safe and clean delivery by a skilled attendant, and
immediate postnatal care, including resuscitation, extra care of low birth
weight babies, attention to baby warmth, treatment of neonatal sepsis
and early initiation of breastfeeding.
5. EFFECTIVE HEALTH INTERVENTIONS:
6. STRAEGIES FOR IMPROVING NEWBORN HEALTH IN INDIA
1.
2.
3.
4.
5.
NSSK (Navajaat Shishu suraksha karyakram)
Home based new born care
Facility based newborn care
IMNCI
RBSK (Rashtriya bal swasthya karyakram)
1. NSSK(Navajaat Shishu suraksha karyakram)
Navjat Shishu Suraksha Karyakram initiated in 2009.NSSK emphasizes on
Care at birth (Basic new-born care and resuscitation); rationale: 23% of
neonatal death occurs due to asphyxia at birth.
Under NSSK, training on essential newborn care including newborn
resuscitation is being provided to healthcare providers from District
hospitals, Community health centres , Primary health centres
2. Home based new born care
Operational guidelines for home-based newborn care through ASHA was
released in 2011
Objectives of HBNC:
• The provision of essential newborn care to all newborns & the
prevention of complications
• Early detection and special care of preterm & low birth weight newborns
• Early identification of illness in the newborn & provision of appropriate
care & referral
• Support the family for adoption of healthy practices & build confidence
& skills of the mother to safeguard her health & that of newborn.
Key activities in HBNC:
• Care for every newborn through a series of home visits by a trained
health worker in the first six weeks of life.
• Information & skills to the mother & family of every newborn to
ensure better health outcomes.
• An examination of every newborn for prematurity & low birth weight.
• Extra home visits for preterm & low birth weight babies by ASHA or
ANM, & referred for appropriate care as defined in the protocols.
• Early identification of illness in the newborn & provision of
appropriate care at home or referral as defined in the protocols.
• Follow up for sick newborns after they are discharged from facilities.
• Counselling the mother on postpartum care, recognition of
postpartum complications & enabling referral
• Counselling the mother for adoption of an appropriate family
planning method.
3. Facility based newborn care
FBNC has been developed to facilitate planning, establishment,
operationalisation & monitoring of newborn care facilities at various levels of
public health facilities. These are the care provided at various levels.
Health facility
All newborns at birth Sick newborns
Primary
health New born care corner in Prompt referral
centre/sub centre
labor rooms
MCH I
Community
health Newborn care corner in Newborn
centre/ first referral unit labor rooms & in unit
MCH II
operation theatre
District hospital MCH III
stabilization
Newborn care corner in Special newborn care
labor room & in unit
operation theater
These are the expected services to be provided at newborn care facilities
Newborn care corner
Stabilization unit
Care at birth
Care at birth
 Previous infection
 Previous infection
 Provision
of
 Provision
of
warmth
warmth
 Resuscitation
 Resuscitation
 Early initiation of
 Early initiation of
breastfeeding
breastfeeding
 Weighing the new
 Weighing the new
born
born
Care of normal newborn Care of normal newborn
 Breast
feeding
 Breast
feeding
/feeding support
/feeding support
Care of sick newborn
Care of sick newborn
 Identification
&
 Management of
prompt referral of
low birth weight
‘at risk ‘ & ‘sick’
infants > 1800 gms
newborn
with no other
complication
 Phototherapy for
newborns
with
hyperbilirubinemi
a
 Management of
newborn sepsis
 Stabilization
&
referral of sick
newborns & those
with very low
birth
weight
(rooming in)
 Referral services
Immunization
Immunization services
services
Special newborn care
unit
Care at birth
 Previous infection
 Provision
of
warmth
 Resuscitation
 Early initiation of
breastfeeding
 Weighing the new
born
Care of normal newborn
 Breast
feeding
/feeding support
Care of sick newborn
 Managing of low
birh
weight
infants<1800
grams
 Managing all sick
newborns(except
those
requiring
mechanical
ventilation & major
surgical
interventions)
 Follow-up of all
babies discharged
from the unit &
high risk newborns
 Immunization
services
 Referral services
Immunization services
4. IMNCI
In order to address the most common causes of neonatal and child
deaths in India, an integrated strategy that includes both preventive and
curative interventions has been adopted. This is known as the Integrated
Management of Neonatal and Childhood Illnesses (or IMNCI)
It is provided at all levels of care:
• at community (AWW/ASHA package)
• first level care (IMNCI) and
• referral level care (F-IMNCI).
IMNCI addresses various aspects of child nutrition, immunization, and
elements of disease prevention and health promotion.
• Three elements of IMNCI:
- Improvements in the case-management skills of health staff,
- Improvements in the overall health system required for
effective management of neonatal and childhood illnesses,
- Improvements in family and community health practices
5. RBSK(Rashtriya bal swasthya karyakram)
• The ‘Child Health Screening and Early Intervention Services’ Programme
under National Rural Health Mission initiated by the Ministry of Health
and Family Welfare, therefore, aims at early detection and management
of the 4Ds prevalent in children.
• These are Defects at birth, Diseases in children, Deficiency conditions
and Developmental Delays including Disabilities.
• Health screening of children is a known intervention under the School
Health Programme. It is now being expanded to cover all children from
birth to 18 years of age. The Programme has been initiated as significant
progress has already been made in reducing child mortality under the
National Rural Health Mission.
The diseases screened are as follows:
Defects at Birth
1. Neural Tube Defect
2. Down’s Syndrome
3. Cleft Lip & Palate / Cleft Palate alone
4. Talipes (club foot)
5. Developmental Dysplasia of the Hip
6. Congenital Cataract
7. Congenital Deafness
8. Congenital Heart Diseases
9. Retinopathy of Prematurity
Deficiencies
10. Anaemia especially Severe Anaemia
11. Vitamin A De ciency (Bitot spot)
12. Vitamin D De ciency (Rickets)
13. Severe Acute Malnutrition
14. Goiter
Childhood Diseases
15. Skin conditions (Scabies, Fungal Infection and
Eczema)
16. Otitis Media
17. Rheumatic Heart Disease
18. Reactive Airway Disease
19. Dental Caries
20. Convulsive Disorders
Developmental Delays and Disabilities
21. Vision Impairment
22. Hearing Impairment
23. Neuro-Motor Impairment
24. Motor Delay
25. Cognitive Delay
26. Language Delay
27. Behaviour Disorder (Autism)
28. Learning Disorder
29. Attention De cit Hyperactivity Disorder
30. Congenital Hypothyroidism, Sickle Cell Anaemia, Beta Thalassemia
(Optional)
7.APPROACHES FOR IMPROVING SERVICE UTILIZATION & HEALTH SYSTEM
STRENGTHENING IN INDIA
JSY
Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the
National Rural Health Mission (NRHM) being implemented with the objective
of reducing maternal and neo-natal mortality by promoting institutional
delivery among the poor pregnant women.
The Yojana, launched on 12th April 2005, is being implemented in all states and
UTs with special focus on low performing states.JSY is a 100 % centrally
sponsored scheme and it integrates cash assistance with delivery and postdelivery care.
Role of ASHA or other link health worker associated with JSY would be to:
_ Identify pregnant woman as a beneficiary of the scheme and report or
facilitate registration for ANC,
_ Assist the pregnant woman to obtain necessary certifications wherever
necessary,
_ Provide and / or help the women in receiving at least three ANC checkups
including TT injections, IFA tablets,
_ Identify a functional Government health centre or an accredited private
health institution for referral and delivery,
_ Counsel for institutional delivery,
_ Escort the beneficiary women to the pre-determined health center and stay
with her till the woman is discharged,
_ Arrange to immunize the newborn till the age of 14 weeks,
_ Inform about the birth or death of the child or mother to the ANM/MO,
_ Post natal visit within 7 days of delivery to track mother’s health after
delivery and facilitate in obtaining care, wherever necessary,
_ Counsel for initiation of breastfeeding to the newborn within one-hour of
delivery and its continuance till 3-6 months and promote family planning.
LPS States
HPS States
LPS & HPS
All pregnant women delivering in
Government health centres
like Sub-centre, PHC/CHC/ FRU / general
wards of District
and state Hospitals or accredited private
institutions
BPL pregnant women, aged 19 years and
above
All SC and ST women delivering in a
government health
centre like Sub-centre, PHC/CHC/ FRU /
general ward of
District and state Hospitals or accredited
private institutions
JSSK
The new initiative of JSSK would provide completely free and cashless services to pregnant
women including normal deliveries and caesarean operations and sick new born (up to 30
days after birth) in Government health institutions in both rural and urban areas. JSSK
supplements the cash assistance given to a pregnant woman under Janani Suraksha Yojana
and is aimed at mitigating the burden of out of pocket expenses incurred by pregnant women
and sick newborns. Besides it would be a major factor in enhancing access to public health
institutions and help bring down the Maternal Mortality and Infant mortality rates.
The Free Entitlements under JSSK would include: Free and Cashless Delivery, Free CSection, Free treatment of sick-new-born up to 30 days, Exemption from User Charges, Free
Drugs and Consumables, Free Diagnostics, Free Diet during stay in the health institutions
for 3 days in case of normal delivery and 7 days in case of caesarean section, Free Provision
of Blood, Free Transport from Home to Health Institutions, Free Transport between facilities
in case of referral and also Drop Back from Institutions to home after 48hrs stay. Free
Entitlements for Sick newborns till 30 days after birth similarly include free treatment, free
drugs and consumables, Free diagnostics, Free provision of blood, Exemption from user
charges, Free Transport from Home to Health Institutions, Free Transport between facilities
in case of referral and Free drop Back from Institutions to home.
REFERENCES:
UN-IGME. Levels & trends in child mortality. Report 2011
Cousens S et al. Regional and worldwide estimates of stillbirth rates in 2009 with trends
since 1995: a systematic analysis. Lancet 2011; 377:1319-30
WHO. World Health Statistics 2011.
Home based newborn care.operational guidelines,Ministry of health & family welfare
Facility based newborn care,operational guidelines,2011.guidelines for planning &
implementation
Children in India 2012. A statistical appraisal.
A strategic approach to RMNCH+A in India