1. Status of Newborn Health in India and Community-based Newborn Care
Framework of presentation
Global status of newborns
Causes of neonatal deaths
Significance of newborn deaths
Status of newborn in SEAR
Status of newborn in India
Determinants of newborn health
Essential newborn care
Community practices
NFHS III findings on newborn care practices
Example: Gadchiroli model
GOI initiatives
References

2. Global status of newborns
Perinatal and neonatal ill health in 2000 consisted of 7 million perinatal deaths (4 million still births and 3 million early neonatal deaths) and 1 million late neonatal deaths
Globally burden of LBW infants- 16% of all births; while in developed countries (5-7%)
Challenges in addition to this are bad practices in the community.
Reductions in perinatal mortality
preventive care before pregnancy,
improved ANC that includes birth plans and emergency preparedness,
skilled attendance during childbirth and
refocused postpartum care for the mother and the baby.

4. Significance of newborn deaths: India
Day
Under 5 child deaths %
Day 1 20
Day 3 25
Day 7 37
Day 28 50
ICMR Data:2003

5. Status of Neonatal Health in SEAR
Sr. No.
Country
NMR 2000
NMR 2004 1
Bangladesh 36 2
Bhutan 38 30 3
Democratic peoples of Korea 22 4
India 43 39 5
Indonesia 18 17 6
Maldives 37 24 7
Myanmar 49 8
Nepal 40 32 9
Shri Lanka 11 10
Thailand 13
Timor East 29
Source:

6. Early Childhood Mortality Rates
Sr. no.
Type of mortality
Mortality rate
India
Maharashtra 1
Neonatal mortality 39
31.8 2
Post Neonatal mortality rate 18
5.7 3
Pere natal mortality rate
48.5
35.8 4
Infant mortality rate 57
37.5 5
Child mortality rate
9.5 6
Under 5 mortality 74
46.7
Source: NFHS III

7. Early Childhood Mortality Rates for the Five-Year Period preceding the Survey, NFHS-1, NFHS-2, and NFHS-3

8. Neonatal and post neonatal mortality
Year preceding the survey
Neonatal mortality
Post neonatal mortality
Urban
0-4
28.5
13.0
5-9
35.9
18.8
10-14
34.6
18.1
Rural
42.5
19.7
53.9
24.2
57.5
28.1
Total
39.0
18.0
49.3
22.8
51.3
25.3
Neonatal mortality rate has decreased by 12 deaths per 1,000 live births (from 51 to 39),
Post neonatal mortality rate has decreased by 7 deaths per 1,000 live births (from 25 to 18),

9. it is possible to stratify states and divisions –
In both the neonatal and post neonatal periods, mortality in rural areas is about 50 percent higher than mortality in urban areas.
In the neonatal period, the decline in mortality was slightly faster in rural areas (26 percent) than in urban areas (18 percent).
it is possible to stratify states and divisions –
with very high (above 50/1000 NMR)
high (35-50/1000 NMR)
moderate (20-34/1000 NMR)
low (less than 20/1000 NMR

10. Socioeconomic Determinants
Back ground characteristics
Neonatal mortality
Post neonatal mortality
Education of mother
No education
45.7
24.0
12th or more
19.6
6.3
Religion
Hindu
40.3
18.2
Muslim
34.1
Christian
31.5
10.1
Buddhist/neo Buddhist
43.0
9.8
Caste -SC
46.3
20.1 ST
39.9
22.3
OBC
38.3
18.3
Other
34.5
14.5
Wealth index-lowest
48.4
22.0
Middle
39.3
19.1
Highest
7.2

11. Demographic Determinants
Demographic characteristics
Neonatal mortality
Post neonatal mortality
Child’s sex
Male
33.0
10.7
Female
23.4
15.7
Mother’s age at birth
<20
30.5
13.8
20-29
28.4
12.6
Birth size
Very small
91.4
37.2
Small
42.1
19.8
Average or Larger
32.3
16.2
It was found that as the birth interval decreases , both neonatal and post neonatal mortality increases.
While, it is less in first order child than the child having order more.

12. Essential newborn care
Ante natal care (providers contact/visits)
TT immunization
IFA
t/t of RTIs/STIs
Malaria prophylaxis
Birth preparedness
Labour & delivery care (Skilled attendance)
Clean delivery
Prevention of hypothermia
Immediate breast feeding
Prophylactic eye care
Postnatal care (providers contact/visits)
Exclusive breast feeding
Warmth
Hygiene, Cord care
Immunization

13. Special care Maternal and fetal complications
Prevention of mother to child transmission of HIV
M/M or referral of obstetrics & neonatal complications
Birth Asphyxia
Resuscitation
Post resuscitation care
Referral if necessary
Special care
Infection, malformation, and other problems
Antibiotics
Supportive care
ART if in need
Referral if necessary
Low birth weight
Special warmth , KMC
Hygiene, Cord care
Assisted feeding, if necessary

14. Intervention Packages
Skilled obstetric and immediate newborn care including resuscitation
Emergency obstetric care to manage complications such as obstructed labour and hemorrhage
Antibiotics for preterm rupture of membranes#
Corticosteroids for preterm labour#
Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies
Clinical
care %
NMR
effect
4-visit antenatal package including
tetanus immunization,
detection & management of syphilis, other infections, pre-eclampsia, etc
Malaria intermittent presumptive therapy*
Detection and treatment
of bacteriuria#
Outreach
services
Postnatal care to support healthy practices
Early detection and referral of complications
6 - 9%
Folic acid #
Counseling and preparation for newborn care and breastfeeding, emergency preparedness
Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care
Extra care of low birth weight babies
Case management for pneumonia
Family-community
Clean home delivery
Simple early newborn care %
Infancy
Neonatal period
Pre- pregnancy
Pregnancy
Birth

15. Ante natal check ups NFHS III
Type of Ante Natal care
India MH
% of women had at least one ANC
76.4
90.8
% of women had ≥ 3 ANC
52.0
75.1
% of women received ≥ 2 TT injection during Pregnancy
76.3
85.1
% of women received 1 booster TT injection during 2nd or Pregnancy after 3 years or more yr
1.5
1.7
% women received IFA tabs
65.1
80.9
% of women consumed 90 or more IFA tabs
23.1
31.4

16. Timings of Post natal check ups NFHS III
Back ground characteristics
Time between delivery & first Post natal check up %
No post natal check up
< 4 hrs
4-23 hrs
1-2 days
3-41 days
Urban
45.2
8.1
7.7
2.7
34.3
Rural
20.8
3.7
4.4
66.1
Type of health care provider for PNC
Residence
Doctor
ANM/ Nurse
Other health provider
TBA
Urban
53.0
8.1
0.2
2.3
Rural
20.9
7.8
0.8
3.4

17. Initiation of breast feeding NFHS III
Characteristic
Timings of initiation of breast feeding
% of babies received prelacteal feeds
Residence
With in ½ hr
With in 1 hr
With in 1 day
Urban
29.4
30.3
64.5
50.2
Rural
21.4
22.4
51.9
59.8
Sex
Male
23.7
24.7
55.5
57.3
Female
23.4
24.3
55.0
57.0
Mother’s Edu
No Education
15.9
16.7
43.1
67.5
≥ 12th std
33.5
34.6
71.6
43.4

18. Morbidity pattern NFHS III
Characteristic
% ARI
% fever
% diarrhea
% diarrhea with blood in stool
Age < 6 months
6.2
11.6
10.6
0.2
Urban
5.1
14.0
8.9
0.6
Rural
6.0
15.1
9.0
1.0
Treatment sought
69.0
71.0
57.1 -

19. Do we have Solution ?
A mix of community and facility-based interventions
A mix of integrated child health approaches
Integrated management of neonatal and child hood illnesses is proven tool

20. Evidence-based Interventions to Reduce Newborn Deaths
Syphilis Control
Folate Supplementation
Tetanus Toxoid Immunization of Mother
Clean Delivery
Cord Care
Early & Exclusive
Breastfeeding
Antibiotics for mother and baby
Cong.
Anom 7%
Infection
36%
Sepsis/Pneumonia
Tetanus
Diarrhea
Malaria Control
Antenatal Corticosteriod
Treatment of Bacteriuria
Complications of Prematurity
27%
Other 7%
Asphyxia
23%
Kangaroo Mother Care
Birth Spacing
Maternal Nutrition
Warming
Resuscitation
Skilled Birth Attendants
Low birth weight is a significant
contributor in 40–70% of neonatal deaths.
Adapted from Lancet 2005

21. Deaths among infants under 7 days are decreasing more slowly than among older infants
100
Developing Regions
Post-neonatal mortality 80
Late neonatal mortality
Early neonatal mortality 60 40
Developed Regions 20
1983
2000
1983
2000
Source: RHR/WHO, 2003

22. Goals of IMNCI
Standardized case management of sick newborns and children
Focus on the most common causes of mortality
Nutrition assessment and counselling for all sick infants and children
Home care for newborns to
promote exclusive breastfeeding
prevent hypothermia
improve illness recognition & timely care seeking

23. IMNCI-INDIA-Major Adaptations
The entire 0-5 year period covered including the first week of life
50% of training time for management of young infants (0-2 months)
The order of training reversed; now begins with management of young infants
Reduced training duration (8 days), separate training materials for physicians & health workers
Management now consistent with current policies of MoHFW, DWCD,IYCF,PD & NAMP
Home-based care of young infants by health workers added

24. What does IMNCI not provide at all or fully
Antenatal care
Skilled birth attendance
Birth asphyxia management
Inpatient care modules for first level referral hospitals
A way forwards
SBA is a newer strategy adopted by GOI in addition to IMNCI
Inclusion of care at birth

25. Where to start?
Build policy commitment & Develop a national strategy
Interlinking the strategies to reduce neonatal mortality with related fields like Reproductive health, safe motherhood and child survival
Improve newborn health services & household practices
Plan based on maternal and newborn health status, existing services, newborn care practices to be developed
Create demand of services
As most of the deliveries are taking place at home so, research into attitudes and dynamics of decision making at family level to be considered and appropriate plan for corrective measures

26. Dahanu Experience
Under the Rural neonatal care project, started by Govt of Maharashtra, in Dahanu Block TBA played important role for caring the newborn
Maintence of warm chain and resuscitation of newborn recognized as a most important intervention besides detection of LBW/ preterm baby and safe transport of such baby
Foot length by foot print was used as indicator for referral
Neonatal mortality rate dropped from 57.1 to 33.6
Perinatal mortality rate dropped from 74.8 to 28.7
Conclusion: domiciliary neonatal care by TBAs supported by facilities for neonatal care at PHCs and community hospitals can influence neonatal survival in our country

27. Gadchiroli Newborn Case Study
SEARCH introduced home-based neonatal care.
VHW are trained –
provide prenatal care,
resuscitate asphyxiated babies,
prevent and treat hypothermia,
support breastfeeding, and
recognize and treat infections.
TBA are given training and basic supplies (clean delivery kits, IFA pills, condoms).
By the third year, there was a 62% decline in neonatal mortality, and significant declines in neonatal and maternal morbidities.
RCH II is supporting this home-based model for rural communities.

28. Other studies Bangladesh study: Nepal study:
Effect of topical treatment with skin barrier-enhancing emollients on nosocomial
infections in preterm infants in Bangladesh: a randomized controlled trial
Use of sunflower oil or Aquaphor (petrolatum, mineral oil, mineral wax, lanolin alcohol daily for massage and found infants treated with sunflower seed oil were 41% less likely to develop nosocomial infections than controls
Lancet: Volume 365, Number 9464     19 March 2005
Nepal study:
Randomized trial of the effect on birth weight of a daily multiple-micronutrient
supplement given to Nepalese women during pregnancy.
The investigators found an average increase in birth weight of 77 g and a 25% reduction in the rate of low birth weight compared with the controls who received iron and folate.
Lancet: Volume 365, Number 9463     12 March 2005