Special Newborn Care Plus Project in India: Preliminary Findings from Community-Based Follow-up of Newborns Discharged from Facilities

research paper

Indian Pediatr 2021;58:250-252

Harish Kumar,¹ Ashfaq Ahmed Bhat,² Varun Alwadhi,³ Rajat Khanna,² Sutapa B Neogi,⁴
Pradeep Choudhry² and PK Prabhakar⁵

From ¹VRIDDHI, IPE Global Ltd., ²Norway India Partnership Initiative; ³Department of Pediatrics, Kalawati Saran Children Hospital; ⁴Indian Institute of Public Health Delhi; and ⁵Ministry of Health and Family Welfare, Government of India; New Delhi, India.

Correspondence to: Dr Ashfaq Ahmed Bhat, Norway India Partnership Initiative, New Delhi, India.
Email: [email protected]

Received: April 10, 2019;
Initial review: August 13, 2019;
Accepted: December 11, 2019.

Published online: January 02, 2021;
PII: S097475591600271

Objective: An innovation of structured community based followup of SNCU discharged babies by ANM and ASHA was piloted under Norway India Partnership initiative. The current study describes the survival status and other outcomes among newborns discharged from SNCUs and followed at community level in first 42 days of life.

Methods: It is a retrospective cohort study on newborns discharged from SNCUs from 13 districts across four states of India. Routine health systems data have been utilized to record key parameters like birth weight, sex, weights during follow-ups, any illnesses reported, status of feeding and survival status. These were compared between normal and low birth weight babies. Newborns discharged from special newborn care units (SNCUs) and followed up at community level at 24 hours, 7 days after first visit, and at 6 weeks of life.

Results: Follow up of 6319 newborns were conducted by the ANM (25.4%), ASHAs (4.7%) or both (69.8%); 97% of the babies were followed-up at all the visits. The median duration of follow- ups were 1 day post-discharge, 13th day and 45th days of life. Majority (97%) of them were breastfed, and were warm to touch at the time of the visit. More than 11% of the babies needed referral at every visit. Mortality rate in the cohort of babies discharged from SNCUs till 6 weeks of follow up was 1.5%. Among normal birth weight newborns, it was 0.4% while it was 2.02% among LBW babies. The proportion of girls among those who died increased from 20% in the first follow up to 38.1% at second follow up and 41% at 6 weeks. Conclusions: Babies with LBW were at higher risk of death as compared to babies with normal birth weight. Follow-up at critical timepoints can improve survival of small and sick newborns after discharge from SNCUs.

Keywords: Facility-based care, Mortality, Outcome, Survival.

India has witnessed a huge increase in facility-based newborn care in the past decade. Since its inception in 2003, there are more than 700 special care newborn units (SNCU) functional across the country [1]. The utilization of services in these units has shown an exponential rise [2]. However, follow-up data of SNCU discharged babies indicates that almost 65% of the mortality is within one month of discharge, majority being during first week after discharge [3]. Follow-up of newborns after discharge from the hospital is therefore crucial. In many low- and middle-income countries (LMICs), the follow-up rate is as low as 8% over the first week of life and 23-65% over the first six weeks [4,5].

The World Health Organization (WHO) recommends that mothers and newborns receive initial postnatal (PNC) care visit within the first 24 hour after delivery and a minimum of three additional PNC visits within 48-72 hours, 7-14 days, and 6 weeks after delivery. Achieving this recommended three clinical visit regimen of care at a 90% level of coverage could avert 18-37% of newborn deaths per year [6]. Evidence from a randomized trial in Kenya suggested that administration of the checklist during home visits increased early recognition of postnatal problems, and increased their likelihood of seeking care for the child [7].

In India, Accredited social health activist (ASHA) workers (grassroot level functionaries) are mandated to conduct home visits till 28 days of age. In order to improve contacts with the families and for an extended period, in 2013, the SNCU plus initiative was introduced to facilitate contacts with babies discharged from SNCUs. The Government of India approved an incentive for ASHAs to provide follow up newborn care for babies discharged from SNCU and for LBW newborns every quarter from 3rd month until 1 year of age [3]. The current study reports the survival status and other outcomes among newborns discharged from SNCUs under the SNCU plus initiative.

METHODS

The present study was a retrospective cohort design. The study was conducted in 13 districts located in four states of Rajasthan, Odisha, Madhya Pradesh and Bihar where the SNCU plus intervention by Norway India Partnership Initiative (NIPI) was carried out with the concurrence of the state governments. The SNCU plus intervention comprised follow-up of SNCU discharged newborns in the community at 24 hours after discharge (first visit), 7 days after first visit (second visit) and 6 weeks after birth (third visit) by ASHAs, and/or Auxiliary Nurse Midwives (ANMs). During each visit, the health care providers recorded weight of the baby, status of feeding (breast/non-human milk), provision of kangaroo mother care (KMC), any illness reported by the mother or detected by the ASHAs/ ANMs based on clinical signs and symptoms in the SNCU plus card. The filled cards were submitted by the health care providers to the block health office where they were entered into a database and stored.

For the purpose of the present study, a trained team of field investigators, extracted the data on a predesigned performa from the SNCU records and SNCU plus cards for all babies who were discharged alive between 2014-16 from the SNCUs in the 13 identified districts where this intervention was implemented. Information on birth weight, gender, reasons for SNCU admission was extracted from SNCU records. The follow-up data was extracted from the SNCU plus cards. In addition, survival and referral data was also extracted from the SNCU plus cards. During the implementation of intervention, KMC practices at home was also monitored in a sub-sample and this data was also utilized for the present study.

Permission from the states and districts were obtained before accessing their data. Since the data were collected and captured by the ASHAs and ANMs as part of the ongoing health programs, informed consent from individual families was not deemed necessary. During the process of data retrieval by our study team, all the identifiers like names of the mothers or fathers and their addresses were masked in order to maintain anonymity.

Statistical analyses: Data were entered in an Excel spreadsheet and analysis was done using SPSS version 21.0. All the key variables were compared between babies with low birthweight (<2500 g) and normal birthweight (³2500 g) using Chi-square test for proportions and student t test for continuous variables. A P<0.05 was considered significant.

RESULTS

For the period 2014 to 2016, follow-up data was available for 6319 newborns who were discharted from SNCUs. The distribution of the available data was 3791 (60%) from Rajasthan, 1101 (17.4%) from Odisha, 972 (15.4%) from Madhya Pradesh and 455 (7.2%) from Bihar.

Data on place of delivery was available for 5678 newborns. It was noted that 5301 (83.9%) had delivered at a government health facility, 282 (4.5%) at private facilities and 95 (1.5%) at home. Two thirds of the neonates whose follow-up data was available were males. Follow-up at home was done by the ANMs (25.4%), ASHAs (4.7%) or both (69.8%). It was noted that 97% of the babies had been visited at all three time points. The follow up rates in normal and LBW babies were similar. The median interval between the date of discharge and date of first visit was 1 day, and for second and third visit it was the 13th and 45th day after birth, respectively.

Table I  Neonatal Follow-up Indicators After Discharge From Special Newborn Care Units in Four States in India 
Follow-up, n/N (%)

	Follow-up, n/N (%)
Indicators	24 h after discharge	7 day after first visit	6 wk after birth
Frequency of breastfeeding
Birthweight ≥2500 g	2208/2274 (97.1)	2223/2288 (97.1)	2192/2258 (97.1)
Birthweight <2500 g	2940/3032 (96.9)	2951/3035 (97.2)	2853/2940 (97.0)
Receiving non-human milk
Birthweight ≥2500 g	590/2244 (26.3)	594/2247 (26.4)	597/2217 (26.9)
Birthweight <2500 g	703/3014 (23.3)	717/2998 (23.9)	710/2899 (24.5)
Baby warm to touch at the time of visit
Birthweight >2500 g	2226/2277 (97.7)	2231/2286 (97.6)	2199/2251 (97.7)
Birthweight <2500 g	2963/3030 (97.8)	2960/3032 (97.6)	2865/2938 (97.5)
Babies that needed referral
Birthweight ≥2500 g	321/2222 (14.5)	287/2225 (12.9)	258/2189 (11.8)
Birthweight <2500 g	509/2944 (17.3)a	481/2943 (16.3)b	394/2854 (13.8)c
No. who had died
Birthweight >2500 g	2/2263 (0.1)	2/2270 (0.1)	5/2244 (0.2%)
Birthweight <2500 g	8/3013 (0.3)	19/3031 (0.6)‡	34/2949 (1.1%)d
aP<0.05; bP=0.02; cP=0.001; dP<0.001.

Table I compares the key indicators of the newborn on follow-up. A quarter of neonates were receiving non-human milk (mixed feeding) at all follow-up points, which was similar in normal and LBW infants. Significantly more LBW babies needed referral or had died compared to normal weight babies during follow-up till 42 days of life. Among the babies who died, 44 (63.8%) were males. The proportion of girls among those who died increased from 20% in the first follow-up to 38.1% at second follow up and 41% at 6 weeks. Table II depicts the weight change in babies during follow-up. A stratified analyses in weight gain by gender did not reveal any significant difference in the two birth weight strata.

Table II  Follow-up Weights After Discharge From Special Care Newborn Unit in Four States in India

Timepoint	Birthweight ≥2500g		Birthweight <2500g
	n	Weight	n	Weight
At birth	2368	2865.1 (307.4)	3162	1948.4 (357.8)
At SNCU discharge	2070	2792.9 (353.2)	2857	1938.8 (431.5)
24 h after discharge	2123	2822.7 (394.6)	2855	2032.5 (623.6)
7 d after first visit	2115	2995.2 (427.6)	2828	2204.9 (513.9)
At 6 wk after birth	2059	3629.4 (702.2)	2715	2864.8 (711.9)
All values in mean (SD); SNCU: Special newborn care unit.

Advice on KMC was provided to all the mothers who had a LBW newborn admitted in the SNCU. A sample of 520 new borns discharged from SNCU were followed up during periodic assessments between 2015 to 2017. It was observed (data not shown) that 75% of eligible mothers practiced KMC at home till one month after discharge.

DISCUSSION

A descriptive analysis of a cohort of more than 5000 newborns discharged from SNCUs showed that a large majority of newborns (97%) were followed up at the recommended time points of 24 hours after discharge, at 7 days after first visit and 6 weeks after birth. The mortality among SNCU discharged newborns was 1.5% till 6 weeks of birth with the rates being higher among LBW babies. Also, more LBW babies were in need of referral during follow-up.

The follow-up rates within two weeks after birth in a community hospital from developed nations has been reported to be more than 80% [8,9]. While in USA it included both facility and home visits, in South Africa only facility visits within one week were considered. In LMICs, the follow-up rates were as low as 8-10% [4,5]. In China, only 8% received timely postnatal visit within one week of delivery which increased to 24% till 42 days of delivery [4]. In contrast, it was relatively high (>65%) until 1 year in Tanzania [5]. In India, a large scale nationally representative data in 2007-8 suggests that 45% of the newborns were checked within 24 hours of birth. Around 62% of the babies eventually received two or more check-ups within the first 10 days after birth [10]. Inequalities in receipt of two or more check-ups for the baby before 10 days of life were found to be more pronounced in case of home births.

Quality of home visits, rather than the coverage of visits within 24 hours of birth, play a predominant role in deciding the impact of home visits. It is reported from China that 30-40% of the newborns were weighed and counselled during postnatal visits. However, only 18% were counselled for danger signs [4]. In a study from India on a small sample, it was found that 36% of the mothers were not counselled on newborn care [11]. It is reported that children of mothers who were advised on ‘keeping baby warm (kangaroo care) after birth’ during their antenatal sessions were significantly less likely to die during the neonatal period compared to those who were not advised about the same [12]. Almost every mother was counselled on KMC, which could account for the lower mortality in the present study.

Mortality rates among sick newborns discharged from facilities varies from 2-4% in different studies. Previous reports from India have suggested that around 10% babies die within one year after discharge from SNCUs [2]. The present analysis gave us much lower rates till 6 weeks of birth. However, this is similar to the independent assessment by the Oxford policy management (OPM) group which noted in 2013 (two years prior to this study) in the same 13 districts of 4 states (N=418), 5.7% of new-borns died after discharge from SNCUs. The study also revealed that only 25.7% of newborns discharged from SNCU who were 6 weeks old or more, had received at least three follow up visits by 6 weeks of age [13].

The study suffers from several limitations. Secondary data available with the health system was utilized for analysis. Since it is a program level data, only key variables, enough to monitor the program, are recorded routinely. The data were retrieved from paper forms and hence there was no check on its completeness or validity. Of the total newborns discharged from SNCUs in 13 districts of 4 states, only 43% were provided home visits under SNCU plus intervention. It is not known if the babies whose records were unavailable were similar to or different from the babies whose records we have. This is a major lacunae that may explain why our rates are different from other studies. Nevertheless, this was a large cohort of more than 6000 babies discharged from SNCUs. Variables like weight at every visit and mortality rates were captured in majority of the cases. Since the data was collected from four different states, we believe the results are more generalizable.

To conclude, newborns discharged from SNCUs, need to be followed up regularly, more so if they are LBW babies, as they are at higher risk of death upto 6 weeks of life. This can improve the overall survival of small and sick neonates discharged from SNCUs.

Acknowledgements: Mr. Ashwani Verma for supporting the cleaning and analysis of SNCU Plus project data.

Contributions: HK has conceptualized the studyand provided overall guidance. AAB and VA guided the data collection process and supervised different steps involved in the study. RK developed the data reporting system, compiled and analyzed the data. SBN reviewed the literature and drafted the manuscript. HK, AAB,RK,PC and PKP provided technical inputs in finalizing the manuscript. All the authors have approved the final version of the manuscript.

Funding: This study was conducted as part of the Newborn care project supported by Norway India Partnership Initiative (NIPI). Competing interests: None stated.

WHAT THIS STUDY ADDS?

• SNCU+ programme is a community-based follow-up of babies discharged from neonatal intensive care units at 24 hours after discharge, 7 days after first visit, and at 6 weeks of life.

• Follow-up at critical timepoints can improve survival of small and sick newborns after discharge from SNCUs.

REFERENCES

1. Ministry of health and Family Welfare. Health Management Information System New Delhi: Ministry of Health and Family Welfare, Government of India; 2017.

2. Neogi SB, Khanna R, Chauhan M, et al. Inpatient care of small and sick newborns in healthcare facilities. J Peri-natol. 2016;36:S18-23.

3. National Health Mission. Revised Guidance note for follow up of LBW and SNCU discharged infants by ASHA New Delhi: Ministry of Health and Family Welfare; 2016.

4. Chen L, Qiong W, van Velthoven MH, et al. Coverage, quality of and barriers to postnatal care in rural Hebei, China: A mixed method study. BMC Pregnancy Childbirth. 2014;14:31.

5. Kanté AM, Chung CE, Larsen AM, Exavery A, Tani K, Phillips JF. Factors associated with compliance with the recommended frequency of postnatal care services in three rural districts of Tanzania. BMC Pregnancy Childbirth. 2015;15:341.

6. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005; 365:977-88.

7. McConnell M, Ettenger A, Rothschild CW, Muigai F, Cohen J. Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: Evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya. BMC Pregnancy Childbirth. 2016;16:136.

8. Madlon-Kay DJ, Asche SE. Factors that influence the receipt of well baby care in the first 2 weeks of life. J Am Board Fam Med. 2006;19:258-64.

9. Milambo JPM, Cho K, Okwundu C, et al. Newborn follow-up after discharge from a tertiary care hospital in the Western Cape region of South Africa: A prospective observational cohort study. Glob Health Res Policy. 2018; 3:2.

10. Singh A, Padmadas SS, Mishra US, Pallikadavath S, Johnson FA, Matthews Z. Socio-economic inequalities in the use of postnatal care in India. PLoS One. 2012;7:e37037.

11. Sinha LN, Kaur P, Gupta R, Dalpath S, Goyal V, Murhekar M. Newborn care practices and home-based postnatal newborn care programme - Mewat, Haryana, India, 2013. Western Pac Surveill Response J. 2014;5:22-9.

12. Singh A, Yadav A, Singh A. Utilization of postnatal care for newborns and its association with neonatal mortality in India: An analytical appraisal. BMC Pregnancy Childbirth. 2012;12:33.

13. Impact Evaluation of the Norway India Partnership Initiative Phase-II for Maternal and Child Health. In: Limited OPM, editor. Norwegian Agency for Development Cooperation; 2015.