|Year : 2015 | Volume
| Issue : 1 | Page : 1-2
Improving neonatal survival in India
Ballambattu Vishnu Bhat, Bethou Adhisivam
Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
|Date of Web Publication||23-Jun-2015|
Dr. Ballambattu Vishnu Bhat
Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhat BV, Adhisivam B. Improving neonatal survival in India. Int J Adv Med Health Res 2015;2:1-2
Every year an estimated four million babies die in the first 4 weeks of life and 75% of neonatal deaths occur in the first week.  More than a quarter of global neonatal deaths occur in India.  India has achieved significant reduction in the infant mortality rate from 81 deaths per 1,000 live births in 1990 to 47 deaths per 1,000 live births in 2011. However, there is small or no decline in the neonatal mortality rate (NMR), which is still as high as 29 per 1,000 live births. , This stagnation of neonatal mortality in India highlights the importance of improving the quality of perinatal as well as neonatal care. It is very obvious that the Millennium Development Goal 4, which stipulates a two-third reduction in under-five mortality by 2015, cannot be achieved without ensuring a substantial reduction in the NMR.
The NMR is not uniform across India. While Kerala and Tamil Nadu have low NMRs (less than 20 per 1,000 live births), Odisha, Madhya Pradesh, and Uttar Pradesh have very high NMRs (37 or more per 1,000 live births). Uttar Pradesh, Madhya Pradesh, Bihar, and Rajasthan alone contribute to 55% of total neonatal deaths in India.  The model of Tamil Nadu's health care system and its impact on NMR are worth examining. In this state, a skilled birth attendant attends 90% of deliveries, with almost 25% of deliveries taking place in the primary health care facilities, and 81% of the infants being fully immunized. Increased institutional deliveries, enhanced maternal and neonatal transport system, 24/7 delivery service at primary health centers (PHCs), better utilization of the Accredited Social Health Activist (ASHA) workers, implementation of cash incentive schemes, improved human resource management, and monthly auditing of maternal and infant deaths are important National Rural Health Mission (NRHM) strategies, which have made a significant dent in the NMR of Tamil Nadu. 
Prematurity, sepsis, and perinatal asphyxia are the important causes of neonatal mortality in our country. , Treatment strategies like antenatal steroids, surfactant administration, oxygen administration by continuous positive airway pressure (CPAP), surfactant therapy, innovative methods like the intubation-surfactant-extubation (INSURE) technique, newer modes of ventilation, stringent aseptic measures, and improved control of nosocomial sepsis have contributed to significantly improved survival among preterm babies.  The survival of most of the neonates in the community does not require expensive technology or manpower. Ensuring essential newborn care is the cornerstone for decreasing neonatal mortality in India. Appropriate neonatal resuscitation and efforts to make the babies breathe early, exclusive breastfeeding for 6 months, prevention of hypothermia using Kangaroo Mother Care for preterm and low birth weight (LBW) babies, and strategies to prevent sepsis including strict hand hygiene are low cost but effective tools in this context. All health care personnel and caregivers should be trained in essential newborn care.
Preterm and LBW neonates should be given special attention as they form a more vulnerable subgroup. In India, almost eight million LBW infants are born each year that accounts for nearly 40% of the global burden, the highest for any country.  Late preterm neonates also have significantly higher mortality and morbidity compared to term controls. Maternal hypertension and lower gestational age are strong predictors of their morbidity.  Though neonatal transport is an important determinant of clinical outcome among sick neonates, it is often neglected in resource-restricted settings such as India. Stabilization, prior to transport, is essential and the principles of neonatal transportation are independent of distance. Hypothermia and hypoglycemia should be prevented in neonates during transport as they adversely affect the outcome. 
To improve neonatal survival, community-based interventions comprising delivery of packages through home visits and community mobilization should expand. Simultaneously, facility-based newborn care (FBNC) should be strengthened. A nationwide creation of Newborn Care Corners (NBCC) at every point of child birth, new born stabilization units (NBSUs) at community health centers, and special newborn care units (SNCUs) at district hospitals have given a thrust to neonatal care in India. Guidelines and toolkits for standardized infrastructure, human resources, and services at each level have been developed and a system of reporting data on the facility-based newborn care (FBNC) created. Over half a million neonates are being treated each year at SNCUs alone and the number is rising. 
The national neonatology forum (NNF) neonatal week theme for 2013 was "Quality issues and Accreditation in Neonatal Health care delivery system." Accreditation provides a visible commitment by an organization to improve the quality of patient care and/or services, ensure a safe environment, and continually work to reduce risks to both the patients and the staff. It is obviously not a one time process but should be ongoing and continuous. The basic objective of neonatal care accreditation is about improving the way in which care is delivered to neonates and the quality of care they receive. It is the right strategy to audit individual neonatal units to analyze whether the place, personnel, equipment, and protocols are in place, and whether they are maintained as per the specified national/international standards.
The Every Newborn Action Plan (ENAP), which has been recently endorsed by the World Health Assembly, calls for an NMR of less than 10 per 1,000 live births by 2035 in all countries. Following this, the India Newborn Action Plan (INAP) was recently launched by the Government of India with the following key recommendations:
- Ensure that every mother-baby dyad receives quality care during labor, delivery, and thereafter,
- Ensure increased coverage of home-based newborn care (HBNC) and of treatment for neonatal sickness,
- Apply best practices of care at SNCUs on a nationwide level, create mentoring teams, and further increase such units to address the unmet needs,
- Address key social determinants of neonatal health, childbirth after 20 years, and birth spacing,
- Focus on reducing the inequities in maternal-neonatal care,
- Strengthen techno-managerial capacity of the program teams,
- Nurture the neonatal equipment industry,
- Harness the potential of IT in neonatal health education, service delivery, and behavior change,
- Revamp the monitoring of vital neonatal-perinatal data and coverage indicators, and
- Develop a roadmap to end all the preventable neonatal deaths and stillbirths. 
If all these key recommendations are put to practice, neonatal survival is sure to improve in our country.
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