Indian J Pediatr (January 2013) 80(1):39–49 DOI 10.1007/s12098-012-0952-0

SPECIAL ARTICLE

Current Challenges and Future Prospects of Neonatal Care in India O. N. Bhakoo & Praveen Kumar

Received: 7 December 2012 / Accepted: 7 December 2012 / Published online: 22 December 2012 # Dr. K C Chaudhuri Foundation 2012

Keywords District committee . Levels of care . Neonate . Neonatal Mortality Rate . Special Neonatal Care Unit

Abstract Maternal and neonatal health is the current focus of central and state governments as well as various funding organizations. There is a lot happening in terms of expansion of secondary healthcare facilities and training of the healthcare personnel. This offers an exciting opportunity like never before, for those interested in the welfare of the newborns. Although infant and neonatal mortality rates in our country have been falling progressively, the pace has been much slower than expected, especially for neonatal mortality and we are likely to miss the Millennium Development Goals. In this article, the authors critically review the current status of neonatal health, infrastructure for neonatal care, the current national programs, the peculiar challenges we face and offer suggestions for alternative approaches to the way forward. The authors propose that neonatal care should be delivered as a continuum through an integrated district based model run by empowered District Coordination Committees with a smooth flow of referral and back-referrals between different levels of care. The prioritization and planning should be based on local data, needs and geopolitical scenario rather than a single national plan, which can provide a broad guideline. The need of the hour is to revive and make the primary care system functional and accountable while expanding and ensuring quality of special care services.

Perinatal-neonatal period carries the highest risk of mortality and morbidity in the entire lifespan of a human being. It lays the foundations of the future health of individuals and determines the health and development of the nation as a whole. Poor neonatal care leads to high incidence of disabilities in the survivors. In fact, death and disease in the first month of life results in 126 million disability adjusted life years (DALYs) lost annually, or 8.3 % of the global disease burden, compared to 63 million DALYs for ischemic heart disease [1]. The most important non-communicable diseases afflicting the world today- diabetes mellitus, hypertension, coronary artery disease and many renal and endocrine disorders have their origins in fetal and neonatal period [2, 3]. This problem is of much bigger magnitude in our country because of the high incidence of low birth weight (LBW) and intrauterine growth restriction (IUGR) [4].

Based on Dr K C Chaudhuri Oration delivered by Prof. O. N. Bhakoo on September 9, 2012

The Challenge for India

O. N. Bhakoo (*) 356, Sector 6, Panchkula, Haryana 134102, India e-mail: [email protected] P. Kumar Neonatal Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Why Neonatal Care?

Because of our huge population and high mortality and morbidity rates, India holds the dubious record of highest number of neonatal deaths in the world. Of the global burden of 4 million annual neonatal deaths, India contributes to more than 25 % [5]. The LBW rate in India has not declined much for last several decades. Currently, about 28 % of babies are born LBW, thereby contributing 7.5

40

million LBW babies annually [6]. Premature delivery occurs in 13 % of pregnancies in our country, accounting for 3.5 million preterm births per annum [7]. The neonatal mortality rate (NMR) in our country is 7 to 8 times higher as compared to the developed nations. The infant mortality rate (IMR) in the country has declined steadily from 165 per 1000 live births in 1950s to 44 in 2011. On the other hand, NMR has shown a much slower fall in-spite of a surge of government interest in neonatal survival (Fig. 1). As a result, the NMR has been forming an increasing proportion of IMR over the years and currently accounts for two-thirds of the infant deaths and more than half of under-5 mortality [8]. Two-thirds of neonatal mortality occurs within first week of life and is related to perinatal and birth events. The specific programs of maternal and child health focusing on reduction of neonatal mortality have been launched only in the recent years. Apart from the mega numbers to deal with, there is a huge variation within the country between different regions and states. The NMR in rural areas is nearly twice that of urban areas. Within the urban population, neonates born to the poor have a NMR nearly double as compared to the economically better off. Some of the states have infant and neonatal mortality rates similar to that of developed countries but the gap between states with lowest and highest NMR is still very wide (Table 1) [9]. Poorly performing states are a drag on national NMR. Health is a state subject and we are aware of the enormous cultural, social and economic diversity in our country. This poses a big challenge for planners, but at the same time offers an exciting opportunity to learn from each other within the country. It can be seen from Table 1 that states with lower NMR have higher female literacy, higher institutional delivery rate, lower total fertility rate and higher mean age at marriage [10–12]. However, the relationship between social and economic determinants and infant and neonatal mortality rates is not that straightforward [13]. This is exemplified by Punjab and Himachal Pradesh which have a low percentage Fig. 1 Infant and neonatal mortality rate in India over the years

Indian J Pediatr (January 2013) 80(1):39–49

of population below poverty line, yet have intermediate NMRs. This may be reflective of poorly functioning healthcare infrastructure and poor governance. Therefore, different strategies and priorities are required for different regions and states rather than a single plan for the whole country.

Improving the Survival and Quality of Neonatal Care The advanced countries launched neonatal intensive care programs in late sixties and early seventies which have resulted in the survival of fetuses of very low gestation previously considered not viable. The neonatal care in these countries progressed through 3 phases: first phase of high mortality and high incidence of brain damage, second phase of low mortality and high incidence of brain damage, and the current third phase of low mortality and low incidence of brain damage. In many parts of our country we have moved or are moving from first phase to the second phase. The wisdom lies in learning from the experience of developed countries and bypassing the second phase. While we are expanding perinatal -neonatal care to improve survival, the quality has to be tackled simultaneously so that we move to the phase of low mortality and low incidence of brain damage rather than create a large burden of disabilities. This requires an understanding of what causes neonatal deaths as well as the causes of preventable brain damage. The broad categories of causes of neonatal mortality are similar in the hospitals as well as community but their proportional contributions are different and hence different approaches are required in community and hospitals to decrease mortality (Table 2) [14–16]. Overall, asphyxia and sepsis account for more than half of the deaths. Prematurity is the third important cause and LBW is a significant underlying contributor in more than 75 % of the deaths. The contribution of different causes of neonatal deaths also varies according to NMR. In areas with high NMR, birth asphyxia and sepsis are the dominant causes and a significant proportion of

Indian J Pediatr (January 2013) 80(1):39–49

41

Table 1 Socioeconomic factors and mortality in selected states [9–13] IMR NMR PNMR Population below Female literacy Institutional deliveries (SRS Dec 2011) (SRS 2010) (SRS 2010) poverty line (%) (%) (Census 2011) (%) (NFHS – 3) (Planning (2005–06) commission India 2009–10) Low NMR states (<20) Goa 11 Kerala 13 Tamil Nadu 24 Delhi 30 Intermediate NMR states (20–32) Maharashtra 28 W. Bengal 31 Punjab 34 Karnataka 38 Jharkhand 42 Andhra Pradesh 46 Gujarat 44 Himachal 40 Pradesh Bihar 48 High NMR states(>32) Haryana 48 Assam 58 Jammu & 43 Kashmir Chhattisgarh 51 Rajasthan 55 Odisha 61 Uttar Pradesh 61 Madhya Pradesh 62

6 7 16 19

5 6 8 11

8.7 12 17.1 14.2

81.8 91.9 73.8 80.9

93 100 90 70

20.5 20.8 18.9 19.2

1.77 1.93 1.80 2.13

22 23 25 25 29 30 31 31

6 8 9 13 13 16 13 9

24.5 26.7 15.9 23.6 39.1 21.1 23 9.5

75.4 71.1 71.3 68.1 56.2 59.7 76.6 70.7

66 53 43 67 19 69 55 45

18.0 17.5 19.7 17.6 17.4 15.9 18.1 18.5

2.11 2.27 1.99 2.07 3.31 1.79 2.42 1.94

31

17

53.5

53.3

22

15.1

4.00

33 33 35

15 25 8

20.1 37.9 9.4

66.7 67.2 58.0

39 23 54

17.4 19.4 18.9

2.69 2.42 2.38

37 40 42 42 44

14 15 19 19 18

48.7 24.8 37 37.7 36.7

60.5 52.6 64.3 59.2 60.0

16 32 39 22 30

15.9 15.8 17.8 16.1 15.9

2.62 3.21 2.37 3.82 3.12

deaths occur in normal birth weight infants. In areas having low NMR, prematurity, respiratory distress syndrome and congenital malformations are more important causes and most of the deaths occur in low and very low birth weight infants. The importance of the high prevalence of LBW in our country is evident from Table 3 which shows that though only one-third of the neonates in community as well as hospitals are LBW, the mortality in them is several fold higher as compared to normal birth weight babies. Of all the LBW infants, 90 % are between 1500 to 2500 g and 95 % of Table 2 Major causes of neonatal mortality [14–16]

NNPD National NeonatalPerinatal Database

Mean age at Total fertility rate marriage (y) (NFHS — 3) (Demography (2005–06) 2010)

Birth asphyxia Sepsis Prematurity + RDS Congenital malformations Others Feeding problems Hypothermia

them will do well if special care is provided. Only 2 to 3 % are less than 1500 g and need intensive care for survival [14, 16]. One of the important concerns of neonatal care is whether the infant would be neurologically and developmentally normal in the long run. Though some proportion of neonates may have inherently poor outcomes due to developmental malformations, a substantial proportion of brain damage is preventable. This includes sequelae due to asphyxia, sepsis, hyperbilirubinemia, hypoglycemia, inadequate nutrition, unregulated use of oxygen, intraventricular and cerebral

Hospitals NNPD (2002–03)

Field Lancet (2010)

Field Bang (1996)

29 19 26 9

19 33** 33 3

20 53 15 –

17 Important contributors Underlying LBW075 %

12 **Neonatal tetanus 03.3 %

12

42 Table 3 Incidence and neonatal mortality in relation to birth weight groups [14, 16]

2500 g037 wk; 2000 g035 wk; 1500 g032 wk; 1000 g028 wk NNPD National NeonatalPerinatal Database

Indian J Pediatr (January 2013) 80(1):39–49

Birth weight group (in g)

≥2500 2000–2499 1500–1999 <1500

Incidence%

Mortality %

Bang (1996)

NNPD (2002–03)

Bang (1996)

NNPD (2002–03)

58 32 8 2

68 22 7 3

1 4 30 69

0.9 1.7 7.4 34

haemorrhage, hypo and hypertension. In the primary care setting, simple monitoring and appropriate interventions can prevent most of them. These include good quality antenatal and intranatal care, effective and timely resuscitation, meticulous attention to prevention of sepsis in the perinatalneonatal period, monitoring and management of blood glucose and jaundice and early breast milk feeding. For the sicker and smaller infants, in addition to the above, close electronic monitoring and appropriate management of oxygen therapy and blood pressure, providing aggressive enteral or parenteral nutrition and developmentally supportive care can help to reduce the brain damage related to neonatal special care. Developmentally supportive care includes skin to skin contact, nursing babies in nesting position, providing boundaries, minimizing exposure to pain, light and noise and being gentle in handling of the fragile preterm infants.

Components of Neonatal Care Mother’s Status is Central to Neonatal Health Neonatal and infant health is affected by a variety of factors operating before birth, during and soon after birth and in the post-neonatal period. Antenatal factors include maternal health, socio-cultural practices, care during pregnancy, labor and delivery. In fact, mother is the seed, soil as well as farmer for neonatal health. A healthy mother will beget a healthy child. A small mother will produce LBW neonate who is at high risk of morbidities and mortality. Health,

nutrition, education and empowerment of women are long term goals which can improve neonatal outcomes substantially, but this requires sustained social and economic changes which should be possible with the current political will and enthusiastic administrators. Factors operating during neonatal period are quality of resuscitation at birth, thermal control, nutrition, asepsis, care of LBW and sick babies at the facility and during transport. The type of follow-up and rehabilitation services during post-neonatal period also affect the quality of long term outcomes.

Requirements for Neonatal Care Table 4 depicts the different levels of neonatal care, the categories of newborns which can be cared for in these and the costs. In general, smaller and sicker babies need higher levels of care and involve higher costs. More than 70 % of newborns are normal and need minimal care and another 10 % need supervised care at home. Supervised care at Community Health Centre (CHC) and level II hospital care are most cost-effective in terms of intact survival of high risk neonates, who comprise about 16–18 % of all newborns. Intensive care (level III) is required by 2 to 3 % of neonates but will save the lives of the small proportion who cannot survive with level II care. The estimated total numbers of various categories of staff required for a district of 10 lacs population and for the whole country are calculated in Table 5. For districts with higher population, the numbers should be proportionately increased.

Table 4 Levels of care and cost

Refer to Tables 5 and 6 for details of costing

Level of Care

Birth wt. (g)

Severity of illness

Proportion of newborns who need care

Cost of care(Rs)

I(a) Minimal I(b) Supervised

≥2500 2000–2499

Nil Mild

70 %

Nil

10 % 8% 8–10 % 2–3 %

200–500 1500 2500 10,000+

at home at CHC II Special III Intensive

1500–1999 <1500

Moderate Severe

Indian J Pediatr (January 2013) 80(1):39–49

43

Table 5 Staff requirements for neonatal care Per district Population 10 lacs Doctors 50 % Pediatricians Nurses ANMs

All India Population 12,000 lacs 30

36,000

100 200

120,000 240,000

Individual state wise requirement can be calculated according to the population of the state

Current National Programmes for Neonatal Health The importance of neonatal care and survival has been recognized by the policy makers and a series of programs have been launched. In 2003, India was the first country to modify WHO’s Integrated Management of Childhood Illnesses (IMCI) program to include newborn as an important component and it was rechristened as Integrated Management of Neonatal and Childhood Illnesses (IMNCI) [17] . The National Rural Health Mission (NRHM) was launched in 2005 to provide effective healthcare delivery which is affordable and accessible [18]. This was proposed to be achieved by planning at village level, strengthening the primary and secondary care and promoting public-private partnership. Janani SurakshaYojana (JSY) was promoted to encourage institutional delivery by utilizing Accredited Social Health Activists (ASHAs) as the link. Cash incentives are offered to the delivering woman as well as the health worker if the woman delivers in a hospital [19]. On the lines of NRHM, National Urban Health Mission (NUHM) is being launched in near future [20]. The NUHM envisages USHAs (Urban Social Health Activists) similar to ASHAs in villages. In 2009, Navjat Shishu Suraksha Karyakram (NSSK) was launched with a three pronged strategy to decrease the NMR- skill development of ASHAs and skilled birth attendants; to provide basic newborn care and resuscitation; and, creation of Neonatal Stabilization Units (NSU) at CHCs and Newborn Resuscitation Corners(NRC) at Primary Health Centres (PHCs) and Special Neonatal Care Units (SNCUs) at district level [21]. The SNCUs have also been described as Sick Newborn Care Units but it is important to realize that all preterm or LBW infants are not ‘sick’ but do need special care. The NSSK aims to utilize the IMNCI model by expanding it to cover Facility Based Newborn Care (FIMNCI) [22]. Some of the states have gone further and implemented enhanced schemes for maternal and newborn care e.g., Chiranjeevi Yojana in Gujarat, Thai BhagyaYojana in Karnataka which have given even better results. To make sure that cash incentives are extended beyond hospital delivery to neonatal care and families are willing to stay for treatment of the newborn, the government

launched an integrated program for maternal and newborn care—Janani Shishu Suraksha Karyakram (JSSK) in 2011 [23]. The JSSK provides free and cashless services to pregnant women including normal delivery and cesarean section and treatment of sick newborn upto 30 d of life in all government health institutions. High out-of-pocket costs pose a barrier to access curative services for a significant proportion of Indian households. Even at public facilities, households have to bear significant costs on account of medicines, laboratory tests and other indirect costs [24]. The JSSK program aims to reduce barriers of financial access to make health care delivery available to all. Neonatal care is particularly costintensive and thus institutionalization of free of cost inpatient neonatal care under JSSK scheme is likely to be beneficial.

Current Blueprint of Primary Care Primary care (level Ia and Ib) implies provision of basic essential care in the form of resuscitation at birth, thermal support, asepsis, breast feeding and simple clinical monitoring. This type of care is required for babies ≥2000 g. For the primary care of the neonate at block level, provision of NRCs in all delivery facilities and NSUs in CHCs has been operationalized to a large extent. All deliveries are to be conducted by a health professional in a PHC or CHC equipped with a NRC to ensure effective resuscitation for all. NSUs are meant for stabilization of sick neonates before transport to a hospital. They are also supposed to provide supervised care to babies ≥2000 g or those with relatively mild illness. They have 4 beds, are located in CHC or an upgraded PHC and are manned round the clock by specially trained paramedical professionals and are supervised by a doctor with special training in newborn care. A sub-centre caters to a population of 5000 and hence 120 births per year. Of these, 25 neonates need supervised care at home or at CHC and 8 to 10 need hospitalization. In a block of 100,000 population (2500 births per year), 250 babies need supervised care at home and 200 neonates require supervised care at CHC, while 180 neonates need hospital care in a SNCU (level II). One NSU at CHC can handle all this at the block level by supervising home care, providing supervised care at CHC and stabilizing neonates before transfer to SNCU (level II). In the urban areas, the upper and middle class population usually goes to private maternity homes and hospitals. The poor and lower middle class, who forms two-thirds of the urban population, utilizes government hospitals which are overcrowded. Hence, there is a need to create child birth and neonatal care facilities (by the government) close to all urban poor areas. This could be similar to CHC, and of variable size depending upon the size of local population. In other words, child birth and neonatal care facilities must be provided in urban areas for providing

44

Indian J Pediatr (January 2013) 80(1):39–49

supervised neonatal care like in a CHC. In this way, district hospital facilities will be more effectively utilized for providing level II care. This may also decrease overcrowding at district hospitals.

Current Blueprint of Secondary Care Secondary care (level II) is provided in SNCUs for infants between 1500 and 1999 g with moderate illness. Such care is required only for 8–10 % of neonates, provided supervised primary care is being effectively carried out by the CHCs in rural areas and urban slums. SNCU provides all types of specialized treatment, short of assisted ventilation, to all the sick and premature neonates. This includes incubator/radiant warmer care, gavage feeding, intravenous fluids, asepsis, electronic monitoring, management of hypoglycemia, respiratory distress, jaundice etc. Each unit has 12 neonatal beds manned by 3 doctors and 10 nurses (at least 2 nurses in each shift with leave reserve). According to the present government policy, each district hospital is expected to have one SNCU.

Costs Based on the establishment costs, staff salaries and maintenance costs, the expenses for augmenting neonatal care in a typical district are shown in Table 6 [25]. An amount of Rs 136 lacs is required for initial establishment and Rs 259 lacs annually for the running of primary and secondary care facilities in a district of 10 lacs population. It is rationale that two-thirds of the total budget allocation is for primary care. However, as can be seen from Table 7, the proposed number of SNCUs to provide secondary care is only 20 % of

Table 6 Cost of augmenting neonatal care facilities in a district (population 10 lacs) (Rslacs) Type of unit (numbers)

Nos. needed

Establishment cost

Staff salaries per year

Annual maintenance cost

Resuscitation Corner Stabilization Unit SCNU Total

20

0.8×20016

10

8×10080

15×100150

2×10020

1

40×1040 136

75×1075 225

10×1010 34

0.2×2004

Primary Care096+1740270 lacs Secondary Care040+85 0125lacs Additional expense for 2 SCNUs080+1700250lacs Derived from the costs of level II care in the toolkit for setting up Special Care Newborn Units, Stabilisation Units and Newborn Care Corners [25]

Table 7 District module for hospital care of sick neonates (Level -II) • Population 10 lacs • 20,000 to 25,000 child births per year • 1800 neonates (8 %) require hospital care. i.e., 60 beds for sick, premature and LBW neonates. • Five Special Care Neonatal Units (SCNU) of 12 beds each per district. • At least 36 such beds (60 %) should be in government hospitals and remainder could be in private sector. The numbers may vary according to population served by the unit and administrative feasibility

the requirement of a district. Assuming that private sector may cover 40 % of the population, government still has to provide remainder 60 % of the SNCU beds. A study which analyzed the actual cost of neonatal care at 4 SNCUs in 3 Indian states reported the health system cost of SNCU treatment in 2010 was Rs 4581 per neonate treated and Rs 818 per bed-day treatment [26]. However, the salaries paid to the doctors and nurses in these SNCUs are one of the lowest across different states and the largest proportion of admitted neonates were more than 1800 g. This study also estimated that if 100 % free coverage of sick newborns was to be provided, the scheme outlay of JSSK would have to be doubled from the current Rs 1170 crores and nearly 8 % of current national health budget would have to be allocated for sick newborn care [27].

Where Are We? Although, we now have many dedicated national programs and massive inflow of funds for maternal and newborn care, the ground reality is that most of our objectives are far from fulfilled (Table 8). At the primary level, even basic four antenatal visits are completed in just about half of the pregnancies. In-spite of aggressive promotion of JSY and similar schemes, institutional deliveries are far below targets. As per SRS 2011, 25 % of deliveries still take place without any supervision by a trained person. An impact evaluation of JSY showed that the implementation was highly variable by state — from less than 5 % to 44 % of women giving birth received cash payments from JSY [28]. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and infacility births but neonatal care was suffering as the focus of the delivering women as well as ASHAs was only on the cash incentives related to delivery. The association of increase in hospital deliveries with decline in the perinatal mortality rate in rural India after the launch of NRHM in 2005 was assessed recently using the Sample Registration

Indian J Pediatr (January 2013) 80(1):39–49

System report [26]. It was found that though relative increase in hospital deliveries was 57 % from year 2005 to 2008, the relative decline in perinatal mortality rate was only 2.5 %. This has raised questions about the quality of care at the time of childbirth .A large proportion of delivery facilities are non-functional or function sub-optimally. As a result, the functional institutions are over-loaded and find it very difficult to cope up with the sudden rush because of such schemes promoting hospital delivery. Similarly, there is a lot of variation in the utilization of services in the SNCUs across various states and the overcrowding is also affecting the quality of neonatal care [29]. In the recent years, a modern free ambulance service accessible through central call centers has been introduced in several states and is helping laboring women and sick infants to reach health facility in time. Though this is working very well in some states, a large majority of the population is yet to be reached. However, most of these ambulances are not equipped with specialized neonatal transport equipment and the staff manning them lacks specific training in neonatal transport. Overall, in the country, 60 % of the population is poor or very poor and is completely dependent on governmental facilities. The middle class, which comprises 25 % of the population, utilizes private nursing homes and hospitals for minor ailments but falls back on government institutions for expensive treatments. Only 15 % of population, which belongs to upper and upper middle classes is able to afford private hospitals. As pointed out above, even in the free public sector facilities, the families have to bear significant expenses on account of medicines, investigations and other indirect costs [27]. Hence, the government cannot escape its responsibility of providing optimally functioning facilities in adequate numbers for this majority, which determines the overall health of the nation. The infrastructure of sub-centres, PHCs and CHCs for providing primary care already exists in the districts but is lacking functionality and accountability. The pace of establishment of new SNCUs and training of staff has picked up in recent years but a large number of districts are yet to be covered. Only about a quarter of neonates needing special care actually receive it and even in them, the quality of care is questionable (Table 8). There are a multitude of agencies working to improve perinatalneonatal care. Most prominent ones include UNICEF, NIPPI and NRHM. They are funding and helping to establish SNCUs at a rapid pace all across the country. They are also financing the training of doctors and nurses posted at these units by collaborating with tertiary care institutions. Apart from inadequate number of secondary and tertiary level facilities, there is a problem of inefficient utilization of the existing ones. Although we have sub-centres and PHCs at village level, CHCs at block level, district hospitals, medical colleges and some apex institutions, the

45

coordination between different levels of care(regionalization) and different stakeholders is missing. There is lack of community involvement and accountability. As a result, there is mal-distribution, underutilization of some and overcrowding of other facilities, and a general confusion because of multiple authorities. So, it is essentially a problem of management and coordination with the facilities not reaching the consumer and not a problem of lack of funds, which is often overplayed by people who are responsible for making the systems functional.

What Can We Do? To ensure better maternal and neonatal outcomes and costeffective utilization of resources, positive lessons from the Table 8 Objectives not fulfilled as yet Objectives

Primary care 1. Antenatal care to all 2. All deliveries by trained professionals 3. All deliveries in hospital 4. Neonatal resuscitation facility at birth for all 5. Essential neonatal care to all babies 6. Effective transport for all sick neonates Secondary Care 7. All sick, premature and LBW neonates cared in SNCU 8. Monitoring of BP, Oxygen, Healthcare associated Infections and brain damage in all neonates in SNCU 9. Trained and adequate staff 10. Equipment (a) Availability (b) Maintenance and functionality 11. Coordination between LI and II care facilities 12. Outreach education to all 13. Obstetric — Pediatric coordination Overall 14. Govt. and Private sector coordination 15. Community involvement 16. Audit of quality of care 17. Audit of coverage and cost of neonatal care 18. Periodic accreditation of Level — I, II, III care units 19. Regular collection of Neonatal — Perinatal data from Level — I, II, III units

% already fulfilled

51 to 75 (4 to 1 visits) 75 60 ? 25 ? 50 ? 10 ? 25 ? 25 ? 25 ? 60 ? 20 ? 10 ?5 ? 25 Nil Nil ? 10 ? 25 ? ? 20

There is little objective data published for most of these parameters. The numbers are based on best estimates and discussions with various experts

46

concept of local governance and Panchayati Raj can be adopted. Coordination is required between different levels of care, between government and private sector and between various stakeholders. The ambulance system needs to be strengthened for neonatal transport by ensuring it is equipped with appropriate equipment and manned by staff trained in neonatal transport. A periodic audit of the care provided is a must to improve quality. This should be based on the health outcomes achieved and not only on the number of admissions or procedures performed. Similarly, accreditation of the facilities based on pre-defined and publicized criteria can help to standardize the quality of facilities. Accreditation should be given for a limited duration and re-accreditation should be sought after that. Both accreditation and audit of government as well as private hospitals can be done by teams from government and the professional associations viz. National Neonatology Forum (NNF) and Indian Academy of Pediatrics (IAP). There is a need to form Coordination Committees on PerinatalNeonatal Care in each district. These committees should include local pediatricians, obstetricians, NGOs, community leaders, civil surgeons and district administrators and should have full authority of planning and implementation(Table 9). The committees should decide their own Chairperson and Convener, of whom at least one should be a government official. The district committees should in turn be supervised by state, regional and national level coordination committees. This concept needs to be evaluated in Indian conditions and modified as necessary. To help these committees and functionaries, there is a need to develop a ‘Manual on Neonatal Care’ for the managers. This manual would be for those involved in managing neonatal care viz. civil surgeons, hospital administrators, Directors of Health Services and bureaucrats. This should include important aspects of neonatal care and management problems, audit criteria, training of staff, prioritization of resources, health education, community participation, coordination and principles of good leadership. It should however, be concise, not

Indian J Pediatr (January 2013) 80(1):39–49

exceeding 100 pages. It will be useful to have specialization in health management for bureaucrats and special courses by management institutes. Leadership has to be taken up by different tiers of care not only for themselves but also for supporting lower levels of care in their areas (Fig. 2). Medical colleges and institutions which have often remained disconnected from the national programs, need to provide proactive support to the government programs in the form of technical inputs, training and monitoring. The costs involved for setting up and running SNCUs, are quite high. Geographic targeting can be used as a strategy by focusing implementation of SNCU care in phases starting from districts which have a reasonable level of community-based newborn care and intermediate NMR. In districts with high NMR, the priority should be first on providing and strengthening level I care. This implies that strengthening the community-based newborn care is maintained alongside the pathway to facility based care. The costs of SNCU care to the family however, should not become a burden and should be affordable. Some strategies to reduce the cost of care include full utilization of patient care facilities, reducing the duration of hospital stay, reducing healthcare associated infections, preventing malnutrition by aggressive enteral nutrition and encouraging health insurance for neonatal special care. In addition to these, use of antenatal steroids, avoidance of prolonged intubation and utilization of non-invasive respiratory support by units practicing intensive care can reduce complications and shorten the hospital stay of high risk babies. A model of backtransport wherein the infants are shifted back to lower levels of care once they are stable, can help lower costs and efficiently utilize both SNCU and NSU beds. Keeping bigger and stable babies in SNCU is a waste of resources. For cost-effectiveness, the flow of neonatal care in the district should be a continuum in an integrated manner between different levels of care (Fig. 3). Mothers should be involved in the care of their babies. They can perform simple tasks of baby care and thus free up some of the nursing time. The

Table 9 District coordination committee for perinatal — neonatal care • Co-ordinates perinatal — neonatal care in an area having 20000 to 25000 annual births (Population of 10 lac). Big districts could have 2 or more such committees. • Comprises of representatives from civil surgeon’s office, practicing local pediatricians and obstetricians, local NGOs and local community leadership. • Picks up its own Chairperson and Convener — at least one of these should be a government official • Prioritizes neonatal care according to local NMR and available facilities. • Audits quality and coverage of neonatal care in their area including neonatal transport. • Meets at least once a month and ensures coordination between L-I and L-II care, Government and private health care, and Obstetricians and Pediatricians • Ensures regular outreach education. • Supervised by state, zonal and national committees.

Indian J Pediatr (January 2013) 80(1):39–49

Teaching Hospital

District Hospital

CHC

47

• Leader of tertiary care • Support level II and level I care

Advocacy Giving Voice to the Silent Newborn

• Leader of special care • Support level I care

Have a working plan

• Leader of primary care • Support community health workers

Fig. 2 Leadership for neonatal care

saved time should be utilized by the nurses for education and training of the mothers so that they can continue to provide nursing care for the high risk infants at home after discharge. This strategy has been shown to significantly decrease the incidence of sepsis, improve weight gain, exclusive breast feeding rates and can decrease duration of hospital stay [30, 31]. Neonates are silent and cannot demand for themselves. They are entirely dependent on adults. Advocacy and lobbying for a better deal for the newborns must not be forgotten and is by itself an important role. Professional bodies like NNF and IAP are in a position to give voice to the silent newborn by sensitizing the decision maker politicians directly and through social activists and press, and ensuring that the bureaucrats and professionals provide correct advice (Fig. 4).

Future Prospects While there is a rapid progress in gaining new knowledge, we also need to ensure better and wider application of Care in Tertiary Hospital

• Level III

Care in District Hospital

REFERRAL

• Level II

Supervised care in CHC/PHC BACK-REFERRAL

• Level Ib

Home Care supervised by • Level Ia health worker Home Care by Mother alone

Fig. 3 Flow of integrated neonatal care

Fig. 4 Partnership for neonatal care

existing knowledge. Significant advances are being made in providing better obstetric care and gentler brain protective and lung protective neonatal care. Increasingly, we are moving away from invasive to non-invasive and the technological leaps are helping to achieve this. There is a new focus on preventive care using proven strategies of antenatal steroids, kangaroo care, early and aggressive breast milk feeding, and avoiding healthcare associated infections. Lot of thoughts are going into research for preventing prematurity and intrauterine malnutrition - the root causes of major neonatal morbidities and mortality. Technological advances are helping us to develop good quality equipment at lower costs and in near future, we can hope to get standards and certification systems implemented in our country to ensure its quality and safety. Training of doctors, nurses and other health workers is being scaled up and we are seeing increasing use of innovative technologies and internet to reach large numbers in shortest time and at lower costs [32, 33]. Standardization and quality control of the increasing number of fellowship programs of advanced training is also required urgently. With the ubiquitous and ever increasing penetration of mobile telephones, there is a big opportunity to reach the masses at low cost with preventive, promotive and even diagnostic health services [34]. There is also an increasing awareness and trend to use evidence based care principles and guidelines in the best interests of the newborn [35]. Lastly, as special neonatal care becomes widespread, there will be more debates on ethical aspects linked to long term outcomes and ethical guidelines and committees would have to be increasingly involved in decision making.

Conclusions Our national NMR continues to be very high, especially among 70 % of our population living in rural areas and

48

Indian J Pediatr (January 2013) 80(1):39–49

urban slums. Worldwide, we are the top contributors to neonatal deaths, LBW and prematurity. This situation calls for a major governmental action in a special mission mode. Birth asphyxia and infections are responsible for 50 to 60 % of the high NMR and require simple and affordable interventions. Similarly, 70-80 % of LBW babies also need only low cost care. In view of the widely variable NMR in different parts of our country and even within states, prioritization has to vary from district to district. This requires special managerial skills, social audit and coordination of level I and level II care, between government sector and private sector and involvement of the community. The way to do this is to create empowered District Coordination Committees, produce a managerial document providing broad guidelines and impart specialized training in healthcare delivery. We have to rise up to the task ahead and involve ourselves in strengthening the base of the future health of our nation.

Acknowledgements The authors are grateful to Dr. Rajesh Kumar, Professor and Head, and Dr Shankar Prinja, Assistant Professor of Health Economics, School of Public Health, PGIMER, Chandigarh for their extremely valuable inputs and critical review of the manuscript. They are also obliged to Dr. Gagan Mahajan, Senior Resident, Neonatal Unit, Department of Pediatrics, PGIMER, and Chandigarh for help in collection of data. Conflict of Interest None.

Role of Funding Source

None.

References 1. Global and Regional Burden of Disease Attribution to Selected Major Risk Factors. Comparative Quantification of Health Risks. WHO 2008. 2. Barker DJ. Human growth and chronic disease. Ann Hum Biol. 2012;39:335–41. 3. Barker DJ, McMillen IC, Robinson JS. Developmental origins of the metabolic syndrome: prediction, plasticity, and programming. Physiol Rev. 2005;85:571–633. 4. Maternal anthropometry and pregnancy outcomes. A WHO Collaborative Study. Bull World Health Organ. 1995, 73:S198. 5. State of India’s Newborn 2004. National Neonatology Forum and Save the Children, USA. 6. Low Birth Weight babies—Global Health Facts. US Global Health Policy. Available from : http://www.globalhealthfacts.org/data/topic/ map.aspx?ind047 Accessed on September 1, 2012 7. Howson CP, Kinney MV, Lawn JE, Soon BT. The Global Action Report on Preterm Birth. WHO, March of Dimes, PMNCH, Save the Children. Geneva: World Health Organization; 2012.

8. State of the World’s Children 2012. Available from http:// www.unicef.org/sowc/files/SOWC_2012-Main_Report_EN_ 21Dec2011.pdf. Accessed on October 30,2012 9. Sample Registration System, Government of India. Available at url: http://censusindia.gov.in/Vital_Statistics/SRS/Sample_Registration_ System.aspx Accessed on September 1, 2012 10. Census of India 2011. Available at url:http://censusindia.gov.in/ 2011-prov-results/prov_results_paper1_india.html Accessed on October 13, 2012 11. International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India. 12. Desai S, Andrist L. Mumbai: IIPS. Gender scripts and age at marriage in India. Demography. 2010;47:667–87. 13. Percentage and number of poor in India. Expert group report. Planning Commission, Government of India 2009-10. Available at url: http://planningcommission.nic.in/data/datatable/index.php? data0datatab Accessed on November 5, 2012 14. National Neonatal Perinatal Database 2002-03. NNPD Network. Available at url : http://nnfi.org Accessed on August 31,2012 15. The Million Death Study Collaborators. Causes of neonatal and child mortality in India: a nationally representative mortality survey. Lancet. 2010;376:1853–60. 16. Bang AT, Paul VK, Reddy HM, Baitule SB. Why do neonates die in rural gadchiroli, India? (Part I): primary causes of death assigned by neonatologist based on prospectively observed records. J Perinatol. 2005;25:S29–34. 17. Integrated Management of Neonatal and Childhood Illnesses. WHO and Government of India 2003. 18. National Rural Health Mission. Ministry of Health and Family Welfare. Available at http://www.mohfw.nic.in/NRHM.htm Accessed on August 17, 2012 19. Janani SurakshaY ojana. Government of India. Available at url : http://mohfw.nic.in/NRHM/maternal_health.htm Accessed on August 17,2012 20. National Urban Health Mission. Available at url: http://www.uhrc.in/ downloads/Reports/NUHM-Draft.pdf Accessed on November 1, 2012. 21. Navjat Shishu Suraksha Karyakram. Government of India. available at http://mohfw.nic.in/NRHM/Child_health.htm Accessed on September 15, 2012 22. Facility based Integrated Management of Neonatal and Childhood Illnesses. Government of India.Available at http://mohfw.nic.in/ NRHM/Child_health.htm Accessed on September 15, 2012 23. Janani Shishu Suraksha Karyakram.Government of India 2011. Available at url : http://mohfw.nic.in/NRHM/maternal_health.htm Accessed on August 17,2012 24. Prinja S, Kanavos P, Kumar R. Health care in equities in north India: role of public sector in universalizing health care. Indian J Med Res. 2012;136:421–31. 25. Toolkit for Setting Up Special Care Newborn Units, Stabilisation Units and Newborn Care Corners. Available at url : http://www.unicef.org/ india/SCNU_book1_April_6.pdf Accessed on November 1, 2012 26. Singh SK, Kaur R, Gupta M, Kumar R. Impact of National Rural Health Mission on perinatal mortality in rural India. Indian Pediatr. 2012;49:136–8. 27. Prinja S, Manchanda N, Mohan P, et al. Cost of Neonatal Intensive Care Delivered through District Level Public Hospitals in India (in press-personal communication). 28. Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's JananiSurakshaYojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet. 2010;375:2009–23.

Indian J Pediatr (January 2013) 80(1):39–49 29. Neogi SB, Malhotra S, Zodpey S, Mohan P. Assessment of special care newborn units in India. J Health Popul Nutr. 2011;29:500–9. 30. Mohpal UC, Bhakoo ON. Evaluation of mother’s role in the care of low birth weight babies . Thesis submitted for MD (Pediatrics), Postgraduate Institute of Medical education and Research, Chandigarh 1990. 31. Karan S, Rao SS. Benefits of early maternal participation in care of low birth weight infants leading to early discharge. J Trop Pediatr. 1983;29:115–8. 32. Deorari AK, Thukral A, Aruna V. Online learning in newborn health: A distance learning model. Natl Med J India. 2012;25:31–2.

49 33. Thukral A, Sasi A, Chawla D, et al. Online neonatal training and orientation programme in India (ONTOP-IN)–The way forward for distance education in developing countries. J Trop Pediatr. 2012 Jul 12. [Epub ahead of print] 34. Tamrat T, Kachnowski S. Special delivery: an analysis of Health in maternal and newborn health programs and their outcomes around the world. Matern Child Health J. 2012;16:1092– 101. 35. Kumar P, Jain N, Thakre R, Murki S, Venkataseshan S. Evidence Based Clinical Practice Guidelines. India: National Neonatology Forum; 2010. pp. 1-327.