TRENDS IN NEWBORN CARE

Presentor: Moderator: Dr. Ramkesh Prasad Dr. (Mrs) Chinmayee Barthakur PG, 2nd year Assistant Professor

Department of Community Medicine

Gauhati Medical College

WHERE DO NEWBORN DIE?

Contribution to global NMR

India 27.8% (34)* Nigeria 7.2% (39)* Pakistan 6.9% (42)* China 6.4% (11)* DRC 4.6% (51)*

* NMR

PROBLEM STATEMENT - INDIA

27 million infants are born each year 0.88 million die in the neonatal period

(which constitutes to about 68% of the total IMR

Neonatal mortality has fallen at a lower rate than post-neonatal or early child mortality

Relatively greater progress has been made in some regions and countries e.g. neonatal mortality is now 58% lower

in high income countries than in 1983, compared to 14% reduction in low/ middle income countries

Large variations in mortality rates exist even within the same country

WHEN DO NEWBORNS DIE?

- About half of child deaths occur in the neonatal period

DISTRIBUTION OF NEONATAL DEATHS - DAY 1 TO 7

Day1 Day2 Day3 Day4 Day5 Day6 Day70

5

10

15

20

25

30

35

40

45

39.3

7.3

10.2

6.2 5.5

2.8 2.8

Based on ICMR study on HBNC

DISTRIBUTION OF NEWBORN DEATHS IN THE FIRST WEEKS

Week 1 Week 2 Week 3 Week 40

10

20

30

40

50

60

70

80

74.1

12.610

3.1

Based on ICMR study on HBNC

WHAT DO NEWBORN DIE OF ?

CAUSE OF NEONATAL & CHILD MORTALITY IN INDIA

Source: Lancet Million Death Study, 2010

FIVE YEAR TRENDS IN OVERALL IMR, NNMR & PNMR

1980 1985 1990 1995 2000 2005 20090

20

40

60

80

100

120

114

97

80

74

68

58

50

69

60

5348

44

3734

45

37

27 26 2421

16

IMRNNMRPNMR

NATIONAL GOALS FOR NEONATAL, INFANT AND U5M

Indicators

Goals Target Status

U5M MDG – 4 for 2015 38 64

IMR NPP, NRHM, RCH for 2010XI Plan goal for 2012

<3028

50

NMR National Plan for Action for Children goal for 2010

Enabling goal for RCH II program for 2010

18

<20

34

EFFECTIVE TECHNICAL INTERVENTIONS TO REDUCE NEONATAL MORTALITY

Continuum of Care : Spans both maternal and neonatal care and encompass interventions for appropriate care during pregnancy, care for the mother and newborn during and immediately after delivery, and care for the newborn during the first weeks of life. e.g. Sri Lanka (IMR – 15, NMR - 9)*

*WHS 2011

MILESTONES IN NEWBORN CARE

1985 - UIP 1992 - CSSM 1995 - NMBS 1997 - RCH I 2004 - IMNCI 2005 - RCH II 2005 – JSY 2005 – NRHM 2009 - NSSK 2011 - JSSK 2011 - HBNC

Other programmes

UNIVERSAL IMMUNISATION PROGRAM

Universal Immunisation of Pregnant mothers with Tetanus Toxoid

To prevent Neonatal Tetanus

CHILD SURVIVAL & SAFE MOTHERHOODThe first public health initiative in India that covered the health of newborns

Strategies for improved neonatal survival

Antenatal care to all pregnant women Promote safe delivery Assist establishment of breathing at birth Maintain newborn’s warmth Promote early exclusive breastfeeding Prevention of infection Early detection and referral of high risk newborns Promote birth spacing

NATIONAL MATERNITY BENEFIT SCHEME National Social Assistance Programme. To ensure all BPL women get cash

assistance 8-12 weeks prior to delivery Rs. 500 per birth irrespective of no. of

children and age of the women* Focus – Provision of nutrition support

during pregnancy

* SC Ruling April 2010

REPRODUCTIVE & CHILD HEALTH I

Integration of

CSSM Family welfare program Adolescent Health Prevention of RTI & STI

IMNCIWHO/UNICEF developed a new approach to tackling the major diseases of early childhood called the Integrated Management of Childhood Illnesses IMNCI is an Indian adaptation of the Integrated Management of Childhood Illness approach, a globally accepted model which has been tested in several countries. The IMNCI strategy, piloted by UNICEF in six districts in 2003–2004, has now been taken up by several state governments,

Major highlights of the Indian Adaptation are:

Inclusion of 0-7 days age Malaria, anemia, Vit. A and Immunizations Training of health personnel begins with sick young infants

upto 2 month

REPRODUCTIVE & CHILD HEALTH II

To reduce maternal and child morbidity and mortality with emphasis on rural health care

Integrated with NRHM Major strategies

Essential Obstetric Care Emergency obstetric care Strengthening referral system

JANANI SURAKSHA YOJNA

Launched on 12th April 2005 Modification of National Maternity

Benefit scheme Objective

Reducing IMR & MMR through increased delivery at health institutions

NAVAJAT SISHU SURAKSHA KARYKRAM

Navjat Shishu Suraksha Karykram (NSSK) Launched on September 15, 2009

Focuses on: Prevention of Hypothermia Prevention of Infection Early initiation of Breast feeding Basic Newborn Resuscitation

Objectives: To train healthcare providers at DH, CHCs and PHCs

JANANI SISHU SURAKSHA KARYKRAM

JSSK supplements the cash assistance given to a pregnant woman under Janani Suraksha Yojana and is aimed at mitigating the burden of out of pocket expenses incurred for pregnant women and sick newborns.

Aims to offer completely free and cashless services, including normal or caesarian delivery in all the government hospitals.

The scheme also envisages free treatment for a sick new born (up to 30 days after birth) in any government health institution in rural or urban areas & transportation facilities

F-IMNCI

From November 2009 IMNCI has been re -baptized as F-IMNCI, (F -Facility) with added component of: Asphyxia Management and Care of Sick new born at facility level, besides all other components included under IMNCI

It focuses on providing appropriate inpatient management of the major causes of neonatal and childhood mortality.

Acts as referral support to IMNCI To help meet the shortage of Pediatrician in the

country.

HOME BASED NEWBORN CARE (HBNC)

RATIONALE OF HBNC

Despite the increasing no. of institutional deliveries a substantial proportion of neonatal deaths occur at home ranging from 25 to 50%.

In case of institutional delivery, where the baby and the mother are discharged after 48 hours.

A significant proportion of mothers prefer to return home within a few hours after delivery.

By 2015 a major proportion of rural population will shift to city slums

Gadchiroli Project, SEARCH

SEARCH, Gadchiroli

ANKUR Project in Mahatashtra

HBNC Replication sites

ICMR Study: Government of India, five states.

Other NGOs

Africa

Other Countries

Total 49 Sites

SEARCH, Gadchiroli

Other States

4 countries

OBJECTIVE OF HBNC

Provision of essential new born care to all newborns and prevention of complications

Early detection and special care of preterm and LBW newborns

Early identification of illness in the newborn and provision of appropriate care and referral

Support the family for adoption of healthy practices and build confidence and skill of the mothers to safeguard her and the newborn health

KEY ACTIVITIES IN HBNC

Care for every newborn through a series of home visits in the first 6 weeks of life.

Information and skill to the mother Examination of every newborn for prematurity Extra home visits for preterm and LBW babies Early identification of illness Follow up of sick newborns after they are

discharged from facilities Counseling the mother on postpartum care Counseling on family planning

HBNC

Home visits Home deliveries: 1st, 3rd,7th, 21st, 28th and 42nd day Institutional deliveries: 3rd, 7th, 14th, 21st, 28th and 42nd

Services offered: Essential care of the newborn Examination of the newborn Early recognition of danger sign Stabilization % Referral Counseling of mother for Breastfeeding Warmth Care of the baby Immunisation Postpartum care & Use of family planning methods

CAPACITY BUILDING OF ASHA

Activities to be provided in HBNC and skills are taught in Module 6 & 7

Through 4 rounds of training of five days each by ASHA trainer, all 4 rounds to be completed within 1 year

After each round, ASHA is evaluated for knowledge and skills

Certification process

SUPPORT TO THE ASHA Incentive of Rs. 250/- for conducting

home visits. Ensuring field level support: by facilitator Paid on the 45th day

Birth weight is recorded in MCP card Newborn is immunized Birth registration Mother and newborn are safe until 42nd

days of delivery

WHO WILL PROVIDE HBNC

ASHA ANM AWW Medical officer

The main vehicle to provide HBNC is the ASHA (as envisaged in XI plan)

Thank You

INDIA- REGIONAL VARIATION

Assam MP Gujarat Rajasthan J&K HP Kerela Tamil Nadu0

10

20

30

40

50

60

70

80

60

67

48

63

45 45

12

28

33

47

34

41

37 36

7

18

IMRNNMR

WHEN DO NEWBORNS DIE? - ABOUT HALF OF CHILD DEATHS OCCUR IN THE NEONATAL PERIOD

Day % U5 deaths

1st day 20

By 3rd day 25

By 7th day 37

By 28th day 503.1

10

12.6

2.8

2.8

5.5

6.2

10.2

7.3

39.3

74.1

0 10 20 30 40 50 60 70 80

Week 4

Week 3

Week 2

D7

D6

D5

D4

D3

D2

D1

Week 1

Percent (%)

When do neonates die?