From the Department of
Neonatology, LTMMC & LTMG Hospital, Sion, Mumbai*, and INS
Ashwini Hospital, Colaba, Mumbai+ and SNEHA.
Correspondence to: Dr.
A. Fernandez, 53, Sea Sprints, Bandstand, Bandra, Mumbai 400 050,
Maharashtra, India.
E-mail: mcfhi@vsnl.net
Abstract:
Urbanization is rapidly
spreading throughout the developing world. An urban slum poses special
health problems due to poverty, overcrowding, unhygienic surroundings
and lack of an organized health Infrastructure. The primary causes of
neonatal mortality are sepsis, perinatal asphyxia and prematurity.
Home deliveries, late recognition of neonatal illness, delay in
seeking medical help and inappropriate treatment contribute to
neonatal mortality. Measures to reduce neonatal mortality in urban
slums should focus on health education, improvement of antenatal
practices, institutional deliveries, and ensuring quality perinatal
care. Success of a comprehensive health strategy would require planned
health infrastructure, strengthening and unification of existing
health care program and facilities; forming a system of referral and
developing a program with active participation of the community.
Key words: New
born infant, Urban slum.
Improving newborn
survival is a national priority in child health today. A staggering 26
million babies are born in our country every year. Of these 1.2
million die in the first 28 days of life accounting for 20% of the
global burden of newborn deaths(1). If these deaths have to be
reduced, one must begin by improving health of mothers during
pregnancy and upgrade services for delivery.
The pregnant mother and
her neonate form the vulnerable sector of our society, more so in the
rural areas and in the urban slums. In the past few decades a greater
emphasis has been laid on rural health as 80% of our population lived
in villages. Urbanization is rapidly spreading throughout the
developing world resulting in changing proportion of urban to rural
population. In 1988 for the first time the percentage of urban poor
surpassed the rural poor(2). The urban poor are at the inter- face
between under development and industrialization. Urban health in the
slums presents serious public health concerns and challenges
predominant among them is neonatal health and mortality. Although
urban mortality statistics are comparatively better than the rural,
there is a wide disparity between the urban rich and the urban poor
and hence the existing urban statistics do not give a true
representation of urban slums. Another major problem in urban slums is
that unlike its rural counterpart there is no envisaged Primary Health
Center with its planned network. In urban slum, multiple health
authorities administer health services. Unfortunately, these services
are not effectively organized, resulting in duplication of services in
some areas and non- existence of health services in other areas.
Neonatal Mortality
Primary Causes
The neonatal mortality
is stagnant at 46/1000 live births for the last five years(1). The
principal causes of neonatal mortality are sepsis, perinatal asphyxia
and prematurity(3-4). Irrespective of the primary cause of death over
two third of deaths occur in low birth weight infants weighing less
than 2500 grams(1). These facts have important implications for
interventions planned to decrease mortality.
Similar patterns for
mortality are reflected in the urban slums. Kapoor, et al.(5)
in their study in the urban slums of Lucknow reported sepsis as a
cause of death in 12.3% of cases. Asphyxia and prematurity accounted
for 42% and 14%of the deaths respectively(5). In another study carried
out by Bhandari, et al.(6) sepsis contributed to 45% of
neonatal mortality, asphyxia to 25% and prematurity 20% of the
mortality. Despite national efforts of antenatal immunization of
mothers with tetanus toxoids, Awasthi, et al.(7) reported
tetanus as the cause of neonatal deaths in 36.4% cases.
Maternal Health and Related Issues
Maternal factors
contributing to poor neonatal outcome include early age at conception.
In a Delhi based study(8) the age at marriage was 13.8 years and the
consummation of marriage was at 16 years. The neonatal mortality in
this study was 58.1. Short inter-pregnancy intervals are also
associated with poor perinatal outcomes. The percentage of women
receiving two or more injections of tetanus toxoid is 54 % among the
low SLI (standard of living index) population (rural-urban average)
whereas the national average stands at 66.8%(9).
Fewer births in urban
slum (50%) were attended by a trained professional than were births in
rural areas (65%)(9). Gulati, et al.(10) reported that 96% of
deliveries were conducted at home in urban slums of Ludhiana.
Nutrition of the mother
before pregnancy can influence the weight of the neonate. Macro and
micro deficiencies, infections, addictions in urban slums predispose
mothers to adverse pregnancy outcomes and low-birth weight. In a
multi-centric study on urban slums, 68% of the expectant women had a
pre-gravid weight of 45 kg or less. Nearly 51.7 % of the women had
moderate anemia. Of these mothers 41.4% delivered low birth weight
babies(8).
Underlying
socio-economic causes of mortality in urban slums are the poor living
conditions, illiteracy, ignorance and poverty resulting in women not
paying attention to pregnancy and health. A large number of women in
slums work outside the home(8). This results in inadequate rest during
pre-gnancy and early return to work undermining exclusive
breastfeeding practices and increase neglect of the newborn.
Health Care Delivery
The health structure in
slums vary from city to city and often depends on the stability i.e.
the number of years the slum has been in existence. Well-established
slums may have ICDS services in place. A few large cities like Mumbai,
Calcutta, Chennai under the Indian Population Project have looked at
health infrastructure establishment in urban slums. News slums, may
have just private clinics and hospitals situated either in the slum or
in the vicinity. Availability and accessibility as a rule is not a
major problem in urban slums. Transport is comparatively easier in
urban areas. Affordability could be an issue, since medical services
are more expensive in a city. Despite the fact that free maternity
services are available provided by the government or the municipal
corporation the first preference for medical advice is the private
practitioners(6).
Studies on a few urban
slums have indicated that despite availability of public hospitals, up
to 90% of deliveries in certain slums take place at home and antenatal
care is minimal(11). Late recognition of neonatal illnesses and delay
in seeking medical help were responsible for increased neonatal
mortality. Private practitioners in the locality were the first
preference. Only 19% of neonates were taken directly to the hospital.
Care takers reported full compliance with prescribed oral therapy, 50%
did not comply with advice for hospitalization reasons include lack of
perception that the child was gravely ill, other siblings at home,
economic reasons and unpleasant past experience(6).
Other problems
Urban slums have a
heterogeneous population that migrate from different parts of the
state and country. The sense of collective responsibility is low and
voluntary efforts are less common. A multiplicity of agencies are
involved including government and voluntary agencies which makes
coordination difficult. Presence of a large number of unqualified but
affordable health practitioners on one hand and poor image of the
public sector result in delay and inappropriate care for the sick
newborn.
Measures Directed at
Improving Neonatal Survival in Urban Slums
Maternal Health Related Issues
Neonatal survival
depends on maternal well being during pregnancy. Early registration,
regular monitoring of pregnancy, identification and referral of high
risk pregnancies and safe delivery practices by trained personal are
essential keys to improving outcome. Today there is sufficient
evidence to show that improvement in birth weight is a function of the
pre pregnancy maternal weight rather than any short term measures to
improve nutrition during pregnancy(12,13). Chronic undernutrition also
influences birth weight through it’s effect on maternal stature
independent of body weight(14). Hence focus on child and adolescent
nutrition and health would be a stepping stone to long term far
reaching consequences of improved birth weights – a crucial need,
given that two thirds of neonatal deaths currently occur in low birth
weight infants.
Female literacy coupled
with woman empowerment on right to health, have been demonstrated to
show resounding success in lowering NMR to 10/1000 in states like
Kerala(1).
Issues of Utilization of Health Care
Services
1. Home
based care versus hospital care
Over two thirds of
deaths take place in the first week of life as a result of perinatal
asphyxia and sepsis. These problems can be best tackled by technically
skilled personnel in hospitals. This is an important issue in the
context of urban slums. In remote rural areas where medical care is
difficult and hospital care inaccessible, training of traditional
birth attendants and auxiliary nurse midwives is necessary to make
delivery safe and ensure home based care of the neonate. In urban
slums accessibility is not a major issue. Traditional practices, lack
of awareness of the need for antenatal care, fear of hospitals,
attitude and behaviour of the staff, and the cost of hospitalization
are deterrents to accessing hospital care. Some public hospitals
impose fines on mothers with more than two deliveries and there is
some coercion for family planning. These are issues that need to be
tackled if hospital deliveries have to be promoted. In the long run if
one has to reduce early neonatal deaths, promoting institutional
deliveries must be accorded priority. If promotion of safe delivery at
home in urban slums is given emphasis the quantum shift from home to
hospital deliveries will be further postponed.
Improving Health Care Systems
Data on existing
morbidity and mortality in neonates in the slums is lacking.
Indicators in maternal and neonatal health are needed to plan
necessary interventions. It is equally important to study factors that
influence health seeking behaviour for mothers and babies. In order to
plan programs and policies, there is need to collect data on maternal
and neonatal health. The SRS (Sample Registration Survey) data does
not include urban slums.
Improving the Quality of Perinatal Care
Quality of perinatal
care available in the public sector leaves much to be desired.
Improvements in knowledge and technical skills of the staff are
necessary. Emphasis must also be laid on improving behavior and
attitude of the health personnel at all levels. Hospitals must be made
"Mother and Child Friendly". This would require training
both in technical and communication skills. Services for mothers and
babies should be free.
Setting up a Referral System
In order to facilitate
maximum and effective utilization of health services in urban areas,
it is necessary to set up a definite system of referral. There is also
a need to create linkages between domiciliary, health centre and
hospital level. Protocols for admissions to primary, secondary and
tertiary levels must be laid down. This will ensure adequate
utilization of primary and secondary level hospitals and prevent
overcrowding in tertiary hospitals.
Motivating Health Workers
Urban slums have a
variety of health workers that could be voluntary or paid. Health
workers from existing government and municipal corporation from NGOs
and CBOs should be involved in neonatal health. Additional training
and responsibilities of the health worker could include early
detection and referral for illness and infection. Since the CHV in the
existing health sector is already burdened with a number of
responsibilities, an additional worker that only attends to the
newborn at birth and follows up the newborn with frequent visits has
been suggested. This has shown reduction in neonatal mortality in the
rural community(11).
Community Medical Practitioners
Studies have shown that
a majority of slum dwellers will visit a general practitioner for
advice(6). The practitioner could be of different systems of medicine
and include non-qualified practitioners. These care providers are
excluded from training under national programs. Training of all
practitioners with respect to diagnosis, early management and referral
of newborns should be considered.
Community Participation
Mother and family are
among the key players in reduction of neonatal mortality and
improvement in neonatal health status. There is need to understand and
document the processes underlying infant deaths-recognition of illness
by the parents, care seeking practices and quality of care received
when it is sought. If we understand how families behave and why they
do so then we could focus our interventions to improve them. Inability
to recognize serious illness has been cited as a main cause for late
medical advice.
The strength of any
program lies in community mobilization and participation. Since the
community in the slums is a heterogeneous group community
participation is more of a challenge. Formation of self-help groups
and use of the existing platform of Mahila Mandals should be used for
health education including neonatal care in health and sickness.
Adolescent groups and
men should be included in planning, training and motivation. Getting
the community to take responsibility for the health of mother and
newborn should be the goal.
Integration of Services
In order to effectively
manage and treat the large number of neonates it is necessary to
integrate all existing health services – public, private and NGOs.
Each one’s role must be identified and work divided to avoid
duplication. Emphasis must be on education, training and community
participation.
In conclusion the success of a
comprehensive urban health strategy would require fundamental changes
of attitude and approach in city health systems and government
agencies. Experiences, problems, ideas and approaches should be
exchanged between cities to promote innovation, collaboration and
technical cooperation. It would need inclusion of all key players,
provision of health infrastructure, forming an effective system of
referral and developing programs with active, democratic participation
of the community.