Scaling up of Facility Based Newborn Care in Chhattisgarh

 

Mridula Pandey¹, Tarang Mishra², Vijendra Katre³

¹Research Scholar, Department of Management, Kalinga University, New Raipur, Chhattisgarh,

²Senior Manager, Kalinga University, Naya Raipur, Chhattisgarh,

²Narottam Sekseria Foundation, Mumbai.

³Additional CEO, RSBY, Chhattisgarh

 

ABSTRACT:

Every year, about 3.7 million babies die in the first four weeks of life (2004 estimates). Most of these neonates are born in developing countries and most die at home. Neonatal mortality rate per 1000 live births varies from 1 in developed countries to 52 in the least developed countries. With an NMR of 32 India stands at 29^th position in the world and has the unfortunate distinction of claiming a quarter of the total newborn deaths in the world. The intrastate comparison of NMR shows that Chhattisgarh has a NMR of 38 and is well behind states like Bihar and Jharkhand. Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birth weight is an important indirect cause of death. Coverage of interventions within the state is low due to operational and policy issues. To scale up neonatal care, two interlinked processes are required: a systematic data driven decision making process, and a participatory, rights based policy process. The steps in the process will be to analyze the district wise data to understand the trend of neonatal health in the state and accordingly plan interventions both at community and facility level in areas which contribute much in neonatal mortality.

 

 

 

INTRODUCTION:

Adaptive performance:

Every year, about 3.7 million babies die in the first month of life, 99%¹ in low income and middle income countries. India alone contributes to over 9 lakh ie 28% of neonatal deaths². The complexity of neonatal health is dependent of many factors and the factors which contribute in deciding the fate of neonatal health starts right from the period of conception till the baby is delivered. The factors that contribute on pre conception period are maternal nutrition status, age of mother, parity and other socio economic factors.

 

Due to the high proportion of home deliveries, unwillingness of parents to move sick neonate to health facility and low accessibility to hospitals³ most of these neonatal deaths occur at home. The unwillingness of parents to take sick neonates to health facility is not only because there are lack of facilities in the periphery but also because there is lack of knowledge and awareness among parents to understand the criticality of situation of the neonate. The main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%) (figure-1).

 

MATERIAL:

Low birth weight is associated with the death of many newborn infants, but is not considered a direct cause. Around 15% of neonates weigh less than 2500 g, the proportion ranging from 6% in developed countries to more than 30% in some parts of the world⁴. The state of Chhattisgarh with an NMR of 38⁵ stands at 5^th position in the nation in terms of neonatal mortality rate. The survival of a newborn is affected by the care it receives immediately after birth.

 

Graph 2 – DLHS III -% Home Deliveries

 

The inter district % home deliveries (Graph 2) shows that the majority of births in Chhattisgarh take place at home and a large proportion are assisted by unskilled persons. In such situations, not only the women but also the newborn experiencing life threatening complications may never receive the required life saving emergency services because of several factors including lack of skilled birth attendant and neonatal care at hand. The threat of handling a sick neonate is worsened by its low birth weight. The management of conditions in a low birth weight babies is much more and it increases the chances of neonatal deaths. Chhattisgarh with 27.8⁶ has a comparatively high % of low birth weight babies. With the high percentage of home deliveries and low birth weight babies the vulnerability of neonates born in Chhattisgarh increases. Out of the total estimated 6.1 lakh live births, 9 thousand die within 24 hours of birth, 14 thousand die within 7 days of birth and 22 thousand die within 1 month of birth which implies that NMR contributes 67.9%⁷ of neonatal deaths.

 

The inter district variation (Graph-3) of early and neonatal mortality rate is more or less same across the state. Coverage of interventions to reduce neonatal and early neonatal mortality is low due to operational and policy issues.

 

Graph 3 – NMR,ENMR estimates

 

Table-1

Study	Design	Home visits for new born care on	Other interventions	Neonatal mortality rate in controls	Newborn deats reduction (95% confidence interval
SEARCH, India	One interventrion one control area (new random)	Days 1,2,3, 5,7,14,21 and 28	Care at birth, treatment of newborn infections by village worker, extra care of the LBW, Community mobilization activities	65/1000	61% (44% to 73%)
ANKUR, India	Before-after	Same as SEARCH	Care at birth, treatment of newborn infections by village worker, extra care of the LBW, Community mobilization activities	n/a	51% (36% to 65%)
Sylhet, Bangladesh	Cluster Randomized trial	Days 1, 3, and 7	Treatment of sepsis by village worker, community mobilization activities, health facility strengthening	48/1000	34% (7% to 53%)
Shivgarh, India	Cluster Randomized trial	Days 1 and 7	Birth preparedness, hygienic delivery, skin to skin care for all babies, community mobilization activities	84/1000	53% (42% to 62%)
Hala, Pakistan	4 vs 4 Cluster Random	Days 1,,3,7,14 and 28	Care at birth, extra care of the LBW, community mobilization activities	52/100	30% (10 to 46%)

 

To scale up neonatal care, a participatory, rights based policy process is important. The interventions should be planned as per the target population and service delivery mode. Considering the fact that the institutional delivery is very low across state, interventions to manage newborns at community level and integration of community based process with facility based child health care should be the focus. The Lancet neonatal survival series^8-9 has been important in drawing attention to the fragmentary neonatal survival agenda. It showed that 15-32% of neonatal deaths can be averted through community interventions, 6-9% from outreach interventions and 23-50% through health facility based interventions. It suggested that neonatal deaths could be averted if 16 simple, cost-effective interventions were delivered with universal coverage. Among these are adequate nutrition, improved hygiene, antenatal care, skilled birth attendance, emergency obstetric and newborn care, and postnatal visits for mothers and infants. Aside from the benefits of group-based discursive approaches, a growing number of programs (table-1) have shown that targeted home visits by community-based workers can help reduce newborn mortality.

 

Graph -4 trend of NMR decline

The idea developed over some years in rural Maharashtra, India, where the nongovernment organization (NGO), the Society for Education, Action and Research in Community Health (SEARCH) trained community health workers to conduct group health education, identify pregnant women and make antenatal care visits to their homes, attend delivery, give vitamin K injections, make several further postnatal home visits, identify and manage infants at risk from birth asphyxia, low birth weight and sepsis, and encourage appropriate referral. This seminal model gradually reduced neonatal mortality by 70%¹⁰. Similar program integrated management of neonatal and childhood illnesses, implemented across the nation has shown proven success in capacity building of health care and ICDS functionaries to identify sick new born, classify the degree of sickness and prompt referral of the new born at facility. The impact assessment of IMNCI carried out as cluster randomized controlled trial at 18 clusters in Haryana revealed that the infant mortality rate was significantly lower in the intervention clusters than in the control clusters. The home visit with 24 hours has been 65%¹¹ in the control cluster. Furthermore, neonatal survival was noted to be improved substantially in those born at home in the control cluster. The implementation of IMNCI improved newborn care practices in both home born and facility born infants, but the effect was substantially greater in those born at home. Similar program assessment of IMNCI from 12 districts across nation that had initiated IMNCI before 2005 were carried out. The comparison of the DLHS data provided evidence of the effectiveness of the programme on the coverage of some key newborn and childcare practices, such as care-seeking for ARI, institutional delivery, early initiation of breastfeeding, and exclusive breastfeeding¹². Jug Jug Jiyo Nanheman¹³, the modified IMNCI program implemented in the state of Chhattisgarh through mitanins in the year 2008 had helped in substantial reduction of IMR, however the results were not equally encouraging in terms of NMR reduction(graph 4). The slow pace of reduction of NMR of the state implies that the training of front line workers eg- ANM’s, and RMA’s needs to be strengthened and expedited. The survival of newborns not only depends on how well they are managed at home and community level but also on the availability of care at facility level. According to global reviews and lancet neonatal series, 23-50% of newborns require facility based care. The units has to be established as per set norms and needs at all the delivery points (Table 2).

 

Table-2

Health Facility	Maternal Care	All Newborns at birth	Sick Newborns
Primary Health Center	1.Deliver all low risk 2.Refer high risk	Newborn Corner in labor Room	Prompt Referral
First Referral Unit	1.Stabilize high risk 2.Caesarian section 3.Blood storage 4.Referral facility	Newborn Corner in labor Room and in Operation Theatre (OT)	Neonatal Stabilization Unit Referral Transport Facilities
District Hospital	1.Care of high risk 2.Blood banking 3.Referral facility.	Newborn Corner in labor Room and Newborn Corner in Operation Theatre (OT)	Special Newborn Care Unit (SNCU) Referral Transport Facilities

 

The study conducted at southern India on scaling up of neonatal care showed that neonatal admissions from the district increased by 14.65%¹⁴. The data from the hospitals showed significant decline in stillbirth, early neonatal and perinatal mortality rates among neonates with LBW and those suffering from sepsis and birth asphyxia. Another study conducted at SNCU’s across India showed that the NMR of the patients admitted at SNCU’s reduced by 4-40%¹⁵ across SNCU’s. In the state of Chhattisgarh a total of 12 SNCU’s with 12 beds were planned to be established, however only two could be made operational. As per estimates total 475¹⁶ beds are required at level II for newborn care. Currently the state has 144 beds for newborn care at SNCU level.

 

The estimated number of newborns who will suffer from prematurity, neonatal infections and asphyxia are 219004, 138132 and 74379 respectively¹⁷.State needs to strengthen on the establishment of NBSU’s and NBCC’s at FRU’s and delivery points to provide care to neonates who may suffer from complications. So far identification of 195 NBCC, 38 NBSU and 12 SNCU’s has been done. The centers are identified strategically at DH, MC, FRU’s and 24 *7 PHC’s. There are 1080 delivery points across state however state has planned to scale up facility based new born care at 285 new centers to be developed as NBCC and 54 NBSU (at FRU’s-24*7 PHC’s).

 

ECONOMIC IMPLICATION:

The establishment of facility based newborn care improves survival of newborn, but is associated with high cost. The cost for establishment of Sick new born care unit, Newborn Stabilization Unit and New born care corners requires 41 lakh, 6 lakh and 80,000 Rs respectively.

 

POLICY IMPLICATIONS:

In the current analysis, we have focused on two major health system issues that have a bearing on the performance and outcomes of neonatal health. To address the challenges related to neonatal survival the preparedness of the state should be examined in the light of the availability of its community based interventions along with its preparedness and scaling up of facility based care. Attempts should be made to have a very effective community based strategy to address neonatal needs as well as functional facility based newborn care at every site of delivery. An active network of NBCC, NBSU and SNCU can rationalize admissions of sick newborns in appropriate units. Equal emphasis should be given to up-gradation or creation of tertiary level neonatal units in medical colleges.

 

CONCLUSION:

Provision of care at community and facility level is a prerequisite for ensuring neonatal survival. Scaling up is much needed in addition to addressing the existing constraints of the currently running programmes. Strong ownership and support among the policy makers and program managers who are well versed on the health system efficiency to deliver neonatal interventions is a key to success. Additionally, liaison with international community and researchers will provide a good interface between the researchers and academia with policy makers for formulating evidence based policy. Only then, all these efforts will pay rich dividends in the days to come.

 

ACKNOWLEDGEMENT:

The authors present there sincere gratitude and thanks to the Department of Health and Family Welfare, Government of Chhattisgarh for allowing to conduct study in health department. Special thanks to Director Health Services Dr Kamalpreet Singh .The authors would also like to thank Dr Subhash Pandey, Joint Director RCH for providing necessary support for conducting the study. The study could not had been completed without the immense cooperation of Unicef chhattisgarh.

 

 

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Accepted on 28.06.2017          © A&V Publications all right reserved