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Editorial Indian Pediatrics 2001; 38: 327-331 |
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Birth Attendants: One or Two? |
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Conditions leading to high child mortality are multifactorial. Like in other societies, in our country also the overall infant mortality rate (IMR) declines with increasing education of mothers. According to current statistics, the Infant Mortality Rate (IMR) is 87 deaths per 1000 live born of illiterate mothers, in contrast to 33/1000 infants born to mothers who have completed high school(1). As expected, IMR also declines substantially with increasing standard of living of the family(1). If households are classified as low or high for standard of living (based on economic factors), the IMR is 89/1000 among the former and 43/1000 in the latter(1). These determinants illustrate the contribution of social factors to the vulnerability of children to the biological outcome of death versus survival. Ensuring education and improving economy are very much part of good governance, but outside the immediate purview of pediatrics. There are other biological factors of social origin which affect child survival, such as pregnancy at stage below 20 years, shorter than 24 months birth interval, sub-optimal nutrition of the mother, poor access to or utilization of antenatal care, pre-term birth and intrauterine growth retardation(1). It is a national public health imperative for the government to address these and related determinants of unacceptably high child mortality, for both humanitarian and economic reasons. The purpose of this paper is to address child survival from a pediatric perspective and to present argument and advocacy for a feasible and practical design of reducing child mortality. The approach will be selective, attributing priority for survival during the period of high vulnerability for death.
Since routine reporting and registration of births and deaths are not enforced in our country, estimates of mortality rates of children are obtained from various sample surveys. According to the national Sample Registration Scheme (SRS), the IMR was 105/1000 in 1983 and 74/1000 in 1993(2). The SRS estimate of IMR during the five-year period 1994-1998 was 73/1000, showing virtually no decline since 1993(1). The International Institute for Polpulation Sciences, Mumbai conducted a National Family Health Survey in 1992-93 (NFHS-1) and repeated it in 1998-99 (NFHS)(1,3). According to these survey results, the under-five mortality has declined from 107/1000 during 1989-93, to 95/1000 in 1994-98(1,3). Similarly, during these periods the IMR declined from 78 to 68, and the neonatal mortality rate (NMR) declined from 52 to 43 per 1000 live births(1,3). These figures do show a slow decline, but still they are unacceptably high. It is clear that 71-73% of under-five mortality is in the first year of life, and 60-64% of that occurs in the first month of life(1,3). Therefore, our immediate priority ought to be to reduce Neonatal Mortality Rate (NMR), in order to reduce the high death rate of our children during their pre-school years. To get an idea of what is possible, it is worth noting that many rich nations have achieved under–five mortality rates below 10/1000(4). Even countries like China, Mexico and Sri Lanka, with annual per capita incomes not too different from ours, have under-five mortality rates of less than 50/1000, indicating that India’s failure cannot be simply blamed on low income alone(4). In Kerala, where the economic indices are no better than in most other States, the NMR is 14/1000, IMR is 16/1000 and under-five mortality is only 19/1000(1). This achievement has most probably resulted from two major factors, namely the high level of literacy and the availability, access and high utilization of health care facilities. When the other States also reach education and health care standards of Kerala, child mortality will decline, but we believe that there is urgency to reduce child mortality now, by specific and selective interventions. Even in Kerala, 84% of under-five mortality is in the first year, and 88% of that occurs in the first month. In short, the immediate priority is to reduce NMR, without which IMR and under-five mortality are unlikely to decline very much.
While most babies breathe spontaneously after birth, some 5% may not do so, or in other words, develop birth asphyxia. Without active resuscitation many would die and those who survive may develop neuromotor disability(5). Newborn babies are very prone to develop hypothermia, unless adequate care is taken to protect them(5). Hypothermia may lead to hypoglycemia, bleeding diathesis, pulmonary hemorrhage, acidosis, apnea, respiratory failure, shock and death(5). Newborn babies are at increased risk for systemic/invasive bacterial infections (usually called neonatal sepsis), manifesting as pneumonia, septicemia or meningitis(5). Unless detected and treated promptly, neonatal sepsis is associated with high risk of mortality. The early start and maintenance of exclusive breastfeeding is crucial for the survival of the infant. Introduction of bottle-feeding in the neonatal period is fraught with risks of inadequate nutrition and of enteric infections, both of which may contribute to increased mortality. All of the above risk factors and causes of death are more frequent among pre-term or low birth weight babies, but they are also the common causes of death even of babies with normal birth weight. All of them are also relatively easily corrected or managed, even in the home setting, provided trained attendant is available, in which case we can drastically reduce NMR. These are not the only causes of death. Respiratory distress syndrome, particularly due to meconium aspiration or hyaline membrane disease, and congenital malformations are less frequent causes of death, the prevention of which may require more specialized treatment in institutions, for which a functional referral system is essential. In this paper we focus attention on the prevention and/or early detection and treatment of asphyxia, hypothermia, feeding problems and sepsis, as a package.
The thesis of our viewpoint is that specific remedial measures by a trained worker can drastically reduce the currently excess NMR. We believe that such an approach is feasible and practical. The proof of principle of a drastic reduction of NMR, when a second trained person is present at delivery for receiving and caring for the newborn, and for follow-up, has been obtained by Bang and colleagues in a well-conducted, large, rural, field trial in Gadchiroli District in Maharashtra(6). We have visited the study site and observed the skills of the second birth attendant and are convinced of the suitability of this model for the rest of the country. The NFHS-2 had found that only one-third of births took place in public or private health care facilities, while the rest were in the homes of the women themselves or their parents(1). About one-third of all deliveries were assisted by trained birth attendants (Dais), and a nurse, midwife or auxiliary nurse midwife (ANM) attended another 12%. This attendant is mainly concerned with the mother. She cares for the mother in the process of birth, and the baby is received and kept aside. She then continues to attend on the mother until the placenta is expelled and the uterus contracts and stops bleeding. These may take several minutes. Only then the birth attendant can turn her attention to the infant. Often the grandmother or another woman relative may be at hand to be in charge of the infant. If the baby does not begin to breathe, marked usually by crying, within one minute, the risk of asphyxia and its consequences set in. Therefore, the infant should be carefully watched and if spontaneous breathing does not occur within a minute, then timely interventions, such as physical stimulation, and suction to remove secretions at the pharynx should be applied. If these fail, then bag and mask ventilation should be started immediately. Only a person specifically trained for them can take these steps. Untrained persons tend to bathe the infant soon after birth. The subsequent evaporation of moisture on the skin tends to cause hypothermia, especially in small babies. Hypothermia can set in any time during the first week of life, usually during night. The second worker has to be trained to anticipate hypothermia, prevent it, and to detect it if it develops and to take corrective steps. In the Gadchiroli model, the second worker encouraged, counseled and promoted breast-feeding by the mother(6). For low birth weight babies who failed to suck, expressed breast-milk was given by a ‘paladai’ or spoon, until the baby was able to suck(6). Nutritional adequacy was monitored by the weight gain. Thus the second birth attendant continued to follow up the babies during the first month, by making regular periodic home visits, for example, daily in the first week and twice each week for three more weeks. The worker watched the baby for a set of clinical criteria of sepsis and when it was diagnosed, she gave antimicrobials, as she was trained to do(6). The second birth attendant was an adult woman, selected from within the village, trained and tested. In a population of 1000, she would attend on some 20-25 deliveries per year(6). She was given a limited monetary payment proportional to her work and success in ensuring the survival of the newborn. Even though low birth weight, home delivery and rural residence are associated with increased mortality, we will not address them at this time since it is not immediately feasible or desirable to alter them. Even under these circumstances, much of mortality after the birth of the baby is preventable by the above interventions. Although, the Dai or ANM who attends on the mother during delivery can be easily trained to develop these skills, she may not be able to use them at the appropriate time since she would be preoccupied with the mother during and immediately after delivery. Hence, there is the need for a specific second birth attendant who will be caring exclusively for the baby.
The second worker, if available, could be trained to follow up the infant during the first year of life, and be a source of information and support for the mother. If the infant has to be cared for correctly, the mother needs advice, help and guidance, which the proposed infant’s health worker could be trained to give. She can periodically monitor weight gain and detect and correct any growth faltering. The immunization of the infant is another area where the mother may be informed, counseled and supported. She can also be trained to give oral rehydration therapy for preventing or correcting dehydration in diarrhea, and a also to detect lower respiratory illness by counting breaths per unit time, and to initiate treatment. As mentioned earlier, a child’s health care worker in a village may have to follow up some 20-25 infants from birth to the first birthday. This is very likely to have a positive effect on the overall survival, growth, development and immunization of infants. Thus, this approach may reduce both NMR and IMR. As stated above, the second birth attendant’s role in reducing NMR has been field tested and proven, but the additional role we have suggested could be established on assumption and evaluated for documentation of success.
NMR and IMR? There are three possibilities regarding the source of funds for establishing the infant’s health worker. They are the families them-selves, and the departments of health or family welfare. Since we do not wish to suggest that the government should enroll more staff on its payroll, an innovative system will have to be designed. If the family is made to pay a fee for service, they may opt not to employ the second birth attendant during delivery. To encourage all families to accept the second worker, the health or family welfare departments may compensate her, by paying a contractual fee for service. Obviously, community participation is essential for selecting the right candidates for training, but the training itself ought to be funded by the health department. Monitoring, supervision and continuing training and follow up also require the full support of the primary health care system. We believe that the traditional or trained birth attendants should continue to serve the mothers while the child’s attendant should have clearly demarcated functions focusing on the neonate and the infant. The Anganwadi worker may be one potential person to function as the infant’s worker, in certain situations, but we feel that she ought to concentrate on children over one year. These and several related issues deserve scrutiny, discussion and design. However, implementation of a modified Gadchiroli model should begin in as many States as possible, as soon as possible. T. Jacob John, Uday Bodhankar, Funding:
Nil.
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