Initiatives for Strengthening Newborn

Care

EPIDEMIOLOGY• In India 26 million babies born every year & 9,40,000 babies dies before 1 month.

• Neonatal period is of 28 days with current (2010) Neonatal mortality rate is 33/1000 live birth.

• Neonatal mortality contributes to two third of all infant death (47/1000 live birth) & half of all under 5 death.

• IMR in India steadily declined 58/1000 in 2004 to 47/1000 in 2010 but NMR declined from 37 in 2004 to 33 in 2010.

• About 40% of neonatal deaths occur on the first day of life, almost half within three days and nearly three-fourth in the first week.

Five year trends in in overall infant mortality rate & neonatal mortality

1980 1985 1990 1995 2000 2005 20100

20

40

60

80

100

120114

97

8074

6858

47

6960

5348 44

37 33

infant mortalityneonatal mortality

Causes of neonatal & child mortality in India (nationally representative mortality survey lancet Million death study

NOV 2010)

14%

8%

12%

1%7%

13%17%

11%

16%prematurity & lowbirt wt birth asphyxia & birth

traumaneonatal infection tetanusothers diarrhoeal diseasesothers other infectious diseasespneumonia

Distribution of newborn death in the first 4 weeks (ICMR STUDY)

week 1

DAY 1

DAY 2

DAY 3

DAY 4

DAY 5

DAY 6

DAY 7

week 2

week 3

week 4

0

10

20

30

40

50

60

70

8074.1

39.3

7.3 10.26.2 5.5 2.8 2.8

12.6 103.1

Series 1

Series 1

Wealth index & Neonatal mortality ( NFHS 3 ,2005-06)

LOWEST SECOND MIDDLE FOURTH HIGHEST0

10

20

30

40

50

60

44.8 44.941.2

32.4

24.3

RURALURBANTOTAL NEONATAL DEATH

Comparison of wealth index with Neonatal & Post neonatal mortality

Wealth index Rural UrbanTotal Neonatal death

total Postneonatal death

lowest 44.8 39.4 48.4 22second 44.9 40.8 44.6 24middle 41.2 32 39.3 19.1fourth 32.4 31.3 31.9 12.1highest 24.3 21.1 22 7.2

Neo-natal mortality rates and percentage share of Neo-natal deaths to Infant deaths by residence, India and bigger States (SRS 2010 )

INDIA

ASSAM

CHHATISGARH

GUJRAT

HIMACHAL P

RADESH

JHARKHAND

KERALA

MAHARASHTRA

PUNJAB

TAMILNADU

WEST BENGAL

0102030405060708090

NEONATL MORTALITY RATE% OF NMR TO INFANT DEATH

Neonatal, Post neonatal & infant mortality rates , NFHS - 3 ,NFHS-2 and NFHS-1 India

NFHS 1 NFHS 2 NFHS 30

10

20

30

40

50

60

70

80

90

48.643.2

39

29.924.2

18

78.5

67.6

57neonatal mortalitypostneonatal mortalityinfant mortality

National goals for neonatal , infant & under 5 mortality

Indicator Goal Target Status

U5 mortality rate MDG 4 for 2015 38 64

Infant mortality rate National population policy, NRHM, RCH 2 For 2010X1 Plan goal for 2012

<30

28

47 (SRS 2011)

Neonatal mortality rate

National plan of action for children goal for 2010Enabling goal for RCH2 programme for 2010

18

<20

33(SRS 2011)

Programme Milestone:• NPP programme launched in 1951 & the earliest child health initiative consisted of

immunisation with Small Pox & BCG.

• The EPI is started in 1978 to protect against six vaccine preventable diseases.

• In 1980 primary health operationalize in Alma Ata declaration. the goal for Health for All by 2000 articulated , MCH goal to bring down IMR <60/1000 live birth, PMR 35 /1000 live birth.

• The first NHP formulated in 1983. Universal immunisation programme (UIP ) launched in

1985-86

• CSSM launched in 1992.

• RCH -1 in 1997.

• RCH -2 in 2005.

CSSM Program• Newborn health is recognised as priority in 1990.

• Essential newborn care(ENC) introduced as a part of CSSM in 1992 at conclusion of UIP.

• ENC Package: Resuscitation of asphyxiated newborn. Prevention of hypothermia & infection. Exclusive Breastfeeding. Referral of sick newborn.

RCH PHASE 1• On the recommendation of ICPD , RCH -1 launched in 1997.

• RCH -1 programme integrate the SM & CS component of CSSM, but separate FP program & added RTI /STD intervention. The services are client centred, demand driven ,high quality & based on need of the community.

• ENC is continued to be part of programme.

• During implementation Govt of India approached NNF to operationalize district for newborn care.

RCH PHASE 2 (2005-10)• RCH -2 launched in 2005.

• Goal : to reduce NMR < 20 BY 2010.

• CHILD HEALTH COMPONENT: Home Based Newborn Care: for the use of ASHA. In UP it is integrate with

IMNCI for the training of ASHAs & ANM & named it comprehensive child survival programme.

Pre service IMNCI: it is included in curriculums of medical college of country.

IMNCI: it is the intervention under RCH-2 , to prevent & manage commonest childhood illness.

RCH PHASE 2 (2005-10) CONTD....• F-IMNCI: it is facility base care with IMNCI package, to

empower the skill of health personnel. It focus on providing appropriate inpatient M/M of major causes of Neonatal & childhood mortality.

• Sick new born care unit: to provide specialised services to sick new born.

• As of JAN 2010 : 267 SNCU, 1,772 NBSU, 5892 NBCC are

operational in the country.

Major stakeholder & partners• National Neonatology Forum• Indian academy of Paediatrics• FOGSI• BPNI• ICMR• UNICEF• WHO • UNFPA• DFID• USAID• INDIAclen• PATH

Continuum of care for Maternal & Newborn survival

Antenatal care Immediate newborn care

TT immunisation M/ m of anaemia & hypertension, maternal infection, maternal nutrition, danger sign identification & prompt referral .

Newborn resuscitation Prevention of Hypothermia & Hypoglycaemia, Eye care birth weight recording & referral when indicated .

Intrapartum care Home Based Newborn care

Clean deliverySkilled care at deliveryTimely access to emergency care .

Exclusive breastfeedingCord care Maintenance of temperature Early detection of pneumonia & sepsis Promoting hygiene practices .

Objective of HBNC• Essential newborn care & prevention of complication..

• Early detection & special care of preterm & low birth weight newborn.

• Early detection of illnesses in newborn babies & provision of appropriate care & referral.

• Support of family to adopt healthy practices & build confidence & of the mother to safeguard her newborn.

Key activities in HBNC• Care of every newborn through series of home visit up to 6 weeks of life.

• Skill to the mother & family for better outcome.

• Examination of every newborn for preterm & LBW.

• Extra home visit to preterm & LBW by ASHA & ANM.

• Early identification of illness & follow up illness of sick New born.

• Follow up mother for postpartum care & family planning methods.

Capacity building & support• ASHA is expected to acquire the skill listed in module 6& 7.

• There will 4 rounds of training of 5 days each, all round expected to complete within 1 year ,there is gap of 10-12 week b/w each round.

• Support : Rs 250 Paid for 6 home visit (3,7,14,21,28 &42), payment given on 45 days for following if :

• Birth wt is recorded.• Ensuring birth registration• Both mother & child are safe till 42 days • Newborn is immunised for BCG, FIRST DOSE OF OPV & DPT COMPLETED &

entered in the card .

Skill needed by ASHA in provision of HBNC

• Mobilize the women for full ANC package.

• Birth planning & preparedness.

• Newborn care through series of home visit include skill for measuring weight, temperature, exclusive breastfeeding, warmth, hand washing promotion providing skin , eye & cord care.

• Detect sign symptoms of sepsis & prompt referral.

• Recognise postpartum complication.

• Use the check list for first visit to newborn.

• Immediate newborn care in case of home delivary

FACILITY BASED NEWBORN CARE

Newborn care facility at different level

Terminology

• Newborn care corner (NBCC): is mandatory for all the health facility where delivery is conducted.

• Newborn stabilization unit (NBSU): close to maternity ward where sick & LBW newborn kept for short period. All FRUs/CHC need to have a NBSU in addition to NBCC.

• Special newborn care unit (SCNU): is a neonatal unit which provide special care to sick newborn. (all care except assisted ventilation & major surgery)

• Any facility with more than 3000 delivery / year should have SNCU.

Expected services provided at newborn facility:

Expected services provided at newborn facility contd..:

Cost of setting newborn care facility :

Indication for admission to NBSU

• Apnoea or gasping

• Respiratory distress ( rate >70/min with severe retraction/ grant)

• Hypothermia <35.4 c

• Hyperthermia >37.5c

• Central cyanosis

• Shock (CFT >3 second)

• Significant bleeding

Criteria for admission to SNCU

• Birth weight <1800gm or gestation <34 weeks

• Large baby(4.0kg)

• Perinatal asphyxia

• Apnoea or gasping

• Refusal to feed

• Respiratory distress (rate >60/min)

• Severe jaundice

• HYPOTERMIA

• Central cynosis

• Shock (CFT>3 Sec)

• Coma, convulsion, encephalopathy

• Abdominal distension

• Diarrhoea / dysentery

• Bleeding

• Major malformation

Setting, Human resources & training for newborn care services

NBCC NBSU SNCU

Floor area 20-30sqft 200 sqft 1200 sqft

Beds --- 4 12 + 4 beds to step down

MANPOWER 1 DOCTOR + 1 ANM

1 DOCTOR + 4 NURSE ( 1 nurse / shift)

1 Paediatrician + 3-4 medical officer + 9 nurse ( 3/ shift)

LEVEL OF TRAINING

NSSK F-IMNCI FBNC

Nawjaat shishu suraksha karyakaram

is equips the staff with appropriate knowledge & skill to provide essential newborn care.

NSSK addresses newborn resuscitation , prevention of hypothermia, infection & early initiation of breast feeding

Facility based IMNCI(F-IMNCI)• it is recommended that All NBSU staff at FRUs is trained in

F-IMNCI which includes “Facility base care of new born. • Is skill based training based on participatory approach

combining classroom session with hand on clinical session.

Facility Based Newborn Care :• All doctors & nurses posted in SNCU need to undergo a more intensive training

programme , including observership at a recognised centre.

Training Facility based newborn care

Trainees Medical officer & staff nurse posted in SNCU

Trainers National Facilitators from NNF, Faculty member , dept of Neonatology of National & Regional SNCU collaborative centre.

Venue Training in district hospital (SNCU) followed by observership in an SNCU collaborative centre or a medical college with level -3 neonatology unit

Duration 4 days of training & followed by 2 weeks of observership .

Batch size 20- 24 participant per batch of training & 4 participant per batch of observership.

• Facility for newborn care in a district having one district hospital with more than 3000 delivery per year, 5 FRUs & twenty 24x 7 PHCs.

Operational status of Special newborn care unit in INDIA( Fourth Quarterly Technical Report Oct –Dec 2011)

Distribution of SNCU according to bed strength

Average no of bed per SNCU

Percentage of SNCU with bed strength12 & above 7-11 4-6 <4

13.8 69.4 16.7 12.2 1.7

Availability /adequacy & training status of Doctor & Nurses

HR status

% of SNCU with Training status

Avg no of doctor / SNCU

Avg no of doctor / SNCU

Adequate no of Doctor

Adequate no of of Nurses

% of Doctor FBNC trained

% of Nurses FBNC trained

04 8.3 53.2 38.6 61.8 59.9

Operational status of Special newborn care unit in INDIA( Fourth Quarterly Technical Report Oct –Dec 2011)

Adequacy of bed strength according to delivery load

Bed strength % of SNCU % of SNCU with bed strength

More than adequate

Adequate Less than adequate

4-6 14.1 29.4 5.9 64.7

7-11 19.2 15.2 10.9 73.8

>12 66.7 26.9 15 58.1

References

1. Home Based Newborn Care, operational guidelines,2011 MOHFW, GOI .

2. Facility based newborn care operational guidelines,2011 MOHFW , GOI .

3. Status of India’s Newborn ,2004, National Neonatology Forum, MOHFW, WHO .

4. Fourth Quarterly Technical Report , operational status of special Newborn Care unit in India Oct-Dec 2011, MOHFW, NCHRC-NIHFW .

5. The million death study collaborators, LANCET;2010: 1853-60