India has made impressive gains in its child
survival indices during the past half a century. Infant mortality rate
has declined from 159.3 in 1960 to 44 in 2011 (average annualized
decline of 2.2 points). Neonatal mortality rate in the last 20 years has
declined from 47 (1990) to 32 (2010) (average annualized reduction of
0.8 points) contributing to almost half the rate of the reduction in
infant mortality [1]. However, despite these reductions, there are large
variations in neonatal survival between rural and urban India, across
health facilities and across states in the country.
National Health Policy and Neonatal Health
Focus on child health prior to the eighties was
mainly on infectious diseases, particularly the vaccine preventable
diseases, diarrhea and malnutrition. It was the publication of the
Report of the Task Force on Minimum Perinatal Care in 1982 by the
Ministry of Health and Family Welfare [2] that catalyzed neonatal health
onto the national agenda. A major concurrent milestone was the birth of
the National Neonatology Forum (an academic body of health care
providers committed to advancing neonatal health in the country) in
1980. The NNF has since then played a pivotal role in all major neonatal
health care milestones in the country. It took a decade before the
recommendations of the Task Force on Minimum Perinatal Care were
translated into program mode with introduction of "Essential Newborn
Care" under the Child Survival and Safe motherhood program (CSSM) in
1992. In 1997-98 CSSM got integrated into the country’s Reproductive and
Child health program. Since 2005 neonatal health at both community and
institutional level, has become an integral part of India’s National
Rural Health Mission (NRHM).
Facility Based Care
Identified neonatal care facilities providing
essentially primary and some secondary care began to dot the Indian
skyline during the sixties. However neonatal intensive care in India
began to make its appearance only in the eighties in a few select
teaching institutions across the country when a select group of
neonatologists decided to walk the "untrodden" path and import into the
country the western mores of neonatal intensive care facilities. Even in
the early nineties there was woefully small number of intensive care
facilities [3]. However, during the last decade there has been a
phenomenal growth of neonatal intensive care units in the country,
especially in the corporatized health care sector and to a lesser extent
in public sector health care facilities. Principal catalysts that have
contributed to this growth have been availability of trained
neonatologists (trained in India under its DM (Neonatology) doctoral
program, and fellowship programs in India and abroad) and equipment for
newborn care. The latter in particular was triggered by the publication
on biomedical equipment (1991) and operationalization of facility based
district newborn care under the CSSM program [4]. Accreditation norms
initiated in 1991 set the tone for quality institutional care in India.
However, the transformation of the district newborn
experiment in 30 districts under the CSSM program into district level
special newborn care units took another decade. The feasibility of
establishing and operating a special neonatal care unit at the district
level was first demonstrated in the Purulia district of West Bengal in
early part of this century [5]. This model was then adapted for scale up
by the Ministry of Health, Government of India under the NRHM. The State
Governments were assisted in the scale-up jointly by the NNF, UNICEF and
in some states by the Norway India Partnership Initiative (NIPI). The
operational guidelines provide details of designing the special care
newborn units (SCNU) at district level, newborn stabilization units
(NBSU) at first referral units and newborn care corners (NCC) at all
active delivery points in a district. It also provides details of
equipment and their procurement, manpower details, data collection and
newborn care protocols [6,7]. Currently about 300 SCNUs are reported to
be operational in the country [8]. The progress in making specialized
newborn care units more accessible and affordable to the community at
large has not been without its problems. The greatest challenges have
been in recruiting and retaining trained medical and nursing manpower,
equipment maintenance and mentoring these units.
The need for facility based newborn care has also
increased since the introduction of "Janani Suraksha Yojna"
(JSY), a cash transfer incentive scheme for promoting institutional
deliveries in 2005 and the " Janani Shishu Suraksha Karyakram"
(JSSK), a free and cashless maternity and newborn services in all
government health care institutions in the country in 2011 under NRHM.
The JSSK was approved with an outlay of Rs.1437 crores for 2011-12 and
Rs.2103 crores during 2012-13 [9]. Transport and access to health
facilities has been a major hurdle in newborn survival. The JSSK has
attempted to plug this void by assuring free transport for sick newborns
from home to health facility and back. Up to the first quarter of 2012,
10-30% of the target population has been able to avail of this benefit
[9]. But these are early days of the program and it holds promise to
improve access for mothers and newborns to health care facilities and
also decrease out of pocket expenses for health care amongst the poorer
sections of our community
Community Newborn Care
Despite the schemes outlined above, home deliveries
still constitute 30-40% of all deliveries in the country. Even after
institutional deliveries the mother-newborn diad is back home by 48 hrs
and there is little follow-up thereafter. Thus, a large proportion of
newborns in the country continue to be at risk of developing problems
that may not be recognized or receiving appropriate treatment in time.
There is thus a need for community based newborn care to complement
efforts in developing newborn care facilities at institutions. It was
the work in Gadhchiroli (in rural Maharashtra) in the nineties that
paved the way for community newborn care by trained community health
workers in the country [10]. This field experiment demonstrated that
basic health workers could be trained in providing essential newborn
care through regular home visits and that they also could be trained to
treat neonatal infection with drugs, under supervision. The Indian
Council of Medical Research initiated a large cluster randomized trial
in 2005 to assess the feasibility of scaling up the Gadchiroli
experiment [11]. A recent systematic review has supported the role of
community health workers in reducing neonatal mortality in regions with
high NMR [12]. At present delivery of Home Based Newborn Care (HBNC) by
Accredited Social Health Activist (ASHA) has become an integral part of
NRHM [13]. The SCNU and NBSU are being integrated to support HBNC. The
linkages between the two have initiated the process of tracking newborns
and their mothers during the first 4 weeks of life for survival.
Neonatal Research
Status of research in neonatology has paralleled the
evolution of neonatal care in the country. It has evolved from
descriptive studies and retrospective analysis of past experience to
epidemiological and experimental studies. In an evaluation by Narang,
et al. [14] of four major indexed Indian journals from 1996-2001, it
was observed that only 11.8% studies pertained to neonates, out of which
a third were analytical studies and about 9% were experimental. The
major areas of research still reflect the burden of neonatal disorders
that are documented in the country – birth asphyxia, low birth weight,
infections, jaundice, neonatal nutrition and long term outcomes. Most
studies have been unicentric and small to medium in scale with little
possibility of impacting policy or practice change. However, there have
also been high quality researches that have had not only national, but
global impact. One of the earliest publications that provided a
reference for intrauterine growth and recognition of fetal growth
retardation was by Ghosh, et al. in 1971 [15]. Since this seminal
publication there have been a large collection of works on low birth
weight and its many associations and outcomes. However, two outstanding
cohort studies, one from Delhi [16] and the other from Pune [17] have
provided valuable information on outcome of low birth weights not only
into childhood but also adulthood. Another multicentric clinical trial
that influenced global neonatal resuscitation guidelines on use of room
air was published in 2003 [18]. However, in the past five years one has
witnessed a changing scenario with several high impact clinical trials
having been published from the country [19-23]. Clearly neonatal
research is coming of age in India.
Education and Training
NNF in 1981 published its recommendations on
Education and Training in Neonatology. It laid standards for neonatal
teaching and training for medical graduate and postgraduate students as
also for nurses. The current curricula in neonatology have much to owe
to this document. Neonatology today comprises a quarter of graduate
medical training in pediatrics. Neonatal components of postgraduate
program in pediatrics are well structured. From humble beginnings, the
country now has at least 9 institutions that provide training in DM
(Neonatology) and a similar number offer neonatal training under the
aegis of the National Board of Examinations. Nursing curricula too have
been duly modified to incorporate neonatal training in their courses.
Neonatal health in India is making rapid strides.
However, the challenge of meeting the goals of MDG15 are still immense.
If newborn health has to become universal and meaningful in India, it
has to bring together not only clinicians and nurses, but social
scientists, public health experts, economists, biomedical engineers,
pharmaceutical industry and research scientists. The next 50 years has
to be one of collaboration.
1. United Nations inter-agency group for Child
Mortality Estimation. Levels and trends in Child Mortality. Report 2010.
UNICEF Headquarters, New York, USA.
2. Report of the Task Force on Minimum Perinatal
Care. Ministry of Health and Family Welfare, Government of India, 1982.
3. Fenandez A, Mondkar J. Status of neonatal
intensive care units in India. JPMG. 1993;39:57-9.
4. Paul VK. Newborn Care in India: A perspective.
Regional Health Forum - WHO South East Asia Region, 1996:1:25-31.
5. Sen A, Mahalanabis D, Singh AK, Som TK,
Bandyopadhya S. Development and effects of a Neonatal Care Unit in rural
India. Lancet. 2005;366:27–8.
6. Facility based Newborn care: Operational
Guideline. Ministry of Health and Family Welfare, Government of India,
2011.
7. Tool kit for setting up Special Care Newborn
units, Stabilization Units and Newborn Care Corners.
http://www.unicef.org/india/SCNU_book1_April_6.pdf. Accessed 31st
October 2012.
8. Operational Status of Special Newborn care Units
in India. Child Health Division, Ministry of Health and Family Welfare
and National Child Health Resource Centre, New Delhi, January-March
2011.
9. JSSK. Secretaries Review Meeting, September 2012.
http://www.mohfw.nic.in/NRHM/Review%20
Meeting%20on%20NRHM%20presentation/11th% 20Sep/PDF/JSSK%20(DC-MH).pdf.
Accessed 1st November 2012.
10. Bang AT, Reddy HM, Deshmukh MD, Baitule SB, Bang
RA.Neonatal and infant mortality in the ten years (1993 to 2003) of the
Gadchiroli field trial: effect of home-based neonatal care. J Perinatol.
2005;25:S92–S107.
11. Home based management of Young Infants (0-60
days). http://www.ctri.nic.in/Clinicaltrials. Accessed on 31st October
2012.
12. Gogia S, Ramji S, Gupta S, Gera T, Shah D, Mathew
JL, et al. Community based newborn care: A systematic review and
meta-analysis of evidence: UNICEF-PHFI Series on Newborn and Child
Health, India. Indian Pediatr. 2011;48:537-46.
13. Home Based Newborn Care: Operational guidelines.
Ministry of Health and Family Welfare, Government of India; 2011
14. Narang A, Murki S. Research in neonatology: need
for introspection. Indian Pediatr. 2004;41:170-4.
15. Ghosh S, Bhargava SK, Madhavan S, Taskar AD,
Bhargava V, Nigam SK. Intrauterine growth of North Indian babies.
Pediatrics. 1971;47:826-30.
16. Bhargava SK, Sachdev HS, Fall CH, Osmond C,
Lakshmy R, Barker DJ, et al. Relation of serial changes in
childhood body-mass index to impaired glucose tolerance in young
adulthood. N Engl J Med. 2004;350:865-75
17. Chaudhari S, Otiv M, Khairnar B, Pandit A, Hoge
M, Sayyad M. Pune Low Birth Weight Study – Growth from Birth to
adulthood.. Indian Pediatr. 2012;49:727-32.
18. Ramji S, Rasaily R, Mishra PK, Narang A, Jayam S,
Kapoor AN et al. Resuscitation of asphyxiated newborns with room
air or 100% oxygen at birth: a multicentric clinical trial. Indian
Pediatr. 2003;40:510-7.
19. Darmstadt GL, Kumar V, Yadav R, Singh V, Singh P,
Mohanty S, et al. Introduction of community-based skin-to-skin
care in rural Uttar Pradesh, India. Perinatology. 2006;26:597-604.
20. Suman RP, Udani R, Nanavati R.Kangaroo mother
care for low birth weight infants: a randomized controlled trial. Indian
Pediatr. 2008;45:17-23.
21. Taneja S, Bhandari N, Rongsen-Chandola T,
Mahalanabis D, Fontaine O, Bhan MK.Effect of zinc supplementation on
morbidity and growth in hospital-born,low-birth-weight infants. Am J
Clin Nutr. 2009;90:385-91.
22. Kumar GT, Sachdev HS, Chellani H, Rehman AM,
Singh V, Arora H, et al. Effect of weekly vitamin D supplements
on mortality, morbidity, and growth of low birthweight term infants in
India up to age 6 months: randomised controlled trial. BMJ.
2011;342:d2975.
23. Bhatnagar S, Wadhwa N, Aneja S, Lodha R, Kabra
SK, Natchu UC, et al. Zinc as adjunct treatment in infants aged
between 7 and 120 days with probable serious bacterial infection: a
randomised, double-blind, placebo-controlled trial. Lancet.
2012;379:2072-8.