Thursday, 13 November 2014

Concentration of Neonatal Deaths and Role of Community Newborn Care Practices

Neonatal Mortality and its Concentration in India

Every year about 0.76 million neonatal deaths (death within one month of the birth) occur in India, which accounts for 28 percent of such death in the world, the greatest for any country. About two-thirds of infant deaths and half of under-five child deaths are during the neonatal period.  India’s Neonatal Mortality Rate (NMR) stands at 29 deaths per 1000 live birth, and the states at high risk include Madhya Pradesh (39), Odhisa (39), Uttar Pradesh (37), Rajasthan (35) and Chhattisgarh (31).  Though the Neonatal Mortality Rate (NMR) has declined from 52 per 1000 live births in 1990 to 29 per 1000 live births in 2012 (SRS 2012) the declining rate has been very slow as compared to many other developing countries and emerging economic states.

A latest report ‘State of India’s Newborn 2014’ released by Public Health Foundation of India (PHFI) reveals the health disparities among newborns of various communities in India. According to the report, health outcomes are shaped not just by biological factors but also by the social, economic, and cultural environment. Social hierarchies and inequitable distribution of resources produce significant inequalities in the health and well being of people.

Considering the health inequality and social inequality interface, the poorest and most disadvantaged have a higher risk for diseases. This includes the urban and rural poor, female children, specially-abled persons, and traditionally marginalized and excluded communities like Scheduled Tribes (STs), Scheduled Castes (SCs), and ethnic and religious minorities. They also have a higher probability of being excluded from the health services. The PHFI report states that the newborn in these populations are expected to be the most vulnerable to morbidity and mortality. It is evident from the empirical data on Indian neonatal and child mortality that mortality is high among children of these socially disadvantaged and economically deprived communities. The report by Public Health Foundation of India has also emphasized on identifying such communities. The report says that doing this will help in identifying entry points for action and setting priorities for long-term improvement in neonatal survival.

High Risk Communities

High Risk Communities
Status of Neonatal Deaths
Rural Population
In rural areas, neonates are at two times more risk of dying, as compared to their urban counterparts. Data has recorded Neonatal Mortality Rate as high as 33 deaths per 1000 live birth in rural India as compared to 16 for urban areas.
Source: SRS
As children get older, probability of female mortality becomes higher than the males. Females have 36 percent higher mortality than males in the post neonatal period, but a 61 percent higher mortality than males at age 1-4 years.
Source: NFHS-3
Dalits and Adivasis
Child born in a SC family has 13 per cent higher risk of dying in the neonatal period and 18 percent higher risk of dying in the post-neonatal period, as compared to others. Similarly, a child born in a ST family has 19 per cent higher risk of dying in the neonatal period and 54 percent risk of dying in the post neonatal period. 
Source: UNICEF
Educationally Disadvantage Section
Children born to a mother with at least eight years of schooling have 32 percent lesser chance of dying in neonatal period and 52 per cent lesser chances in the postnatal period, as compared to illiterate mothers.
Source: UNICEF

Newborn Care Practices among High-risk Communities

Given the diversity of India, each community and region have their own local newborn care practices. Most of these practices are strong and legitimate, since they originate from local culture, environment and religion. Some of them are also based on traditional medical knowledge of the community regarding pregnancy and neonatal care. Traditional Birth Attendants (TBAs) are the key stakeholders in practicing and delivering traditional neonatal for the disadvantaged population in villages, slums, tribal areas etc. Various studies on this issue have identified many practices that are healthy for the survival and growth of the newborn. However, studies also identify a number of hazardous practices that leads to many prevalent causes of neonatal death such as sepsis, pneumonia, birth asphyxia, injuries, tetanus and diarrhea. The lack of institutional care system and prevalence of such harmful neonatal care practices are correlated to the higher concentration of neonatal death in villages, slums and traditional communities. Some of these practices are described here briefly to understand their impact.

Harmful Local Neonatal Care Practices
Health Consequences
Home Delivery by Untrained Individual
More than one third of deliveries in the rural areas are conducted outside health institutions. One in every four deliveries is conducted by untrained individual/person in the villages.
The unsafe places of deliveries and untrained person conducting deliveries cannot handle complicated cases. This increases probability of health complications in mother and neonatal care.
Thermal Care
Common practices in slums and rural areas identified by number of studies reveals that most of the newborn were given a bath immediately after birth.
Bathing immediately after birth causes hypothermia and may lead to death
Delay in Breastfeeding
According to the latest SRS data, during 2012-13 as high as 3.72 million newborns in India were not breastfed within one hour of the birth
The delay in breastfeeding and feeding baby with any liquid and solid food other than mother’s milk before the age of six month is a harmful practice for health and survival of the newborn.
Asphysia Care
To clean the airway of secretion, the newborn needs to be held upside down and the back slapped immediately after birth. Many studies found that there is a lack of knowledge about asphyxia in communities across the country and also amongst traditional birth attendants.
Asphyxia is one of the major causes of the neonatal death in India. Common community practices such as holding the baby upside down and patting or massaging it, blowing in the ears, sprinkling and dipping it in water and making loud noises are harmful for the newborn
Postpartum Hygiene
Umbilical cord care is a big issue in villages, tribal areas and in the slums.
Cord cutting and tying practices in rural India is one among high risk factors for neonatal infections. The blade is commonly used to cut off the umbilical cord in rural and geographically difficult areas but following the steps of clean cord care remain a problem. Most people lack knowledge about sterilization of the blade and after care.

Policy Responses and Way Forward

The entire cycle of reproduction and local cultural practices are intertwining. There are number of good neonatal care practices but we have also witnessed a number of harmful practices that fuel mortality of newborns. It shows us that the issue is not just medical but also has social dimensions. Indian Maternal and Child health policies have always addressed social aspect in various ways. In the last decade, National Rural Health Mission promoted community level interventions through ASHAs. However, TBAs remain the main source for delivering both good and bad community practices. The Indian policies never took TBAs seriously to involve them in health system other than providing them some skill trainings. There were no serious efforts to exchange knowledge between TBAs and modern medical professionals. Health system needs to accommodate TBAs and consider their community influence, traditional knowledge and skills along with knowledge gap to promote better neonatal care in the country.

Jeet Singh and Shriyam Gupta

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