India faces a huge challenge of newborn survival
with high neonatal mortality rates (NMR), more so in early neonatal
period [1]. There is an increased thrust accorded to Institutional
deliveries, especially after the launch of Janani Suraksha Yojna
(JSY). Ensuring survival of all births taking place at health facilities
and community will be vital to achieve gains envisaged as part of
National Rural Health Mission. Mortality statistics in the neonatal
period from health facilities usually captures events till discharge for
normal babies or those who get admitted within 28 days of birth.
Accurate data of neonates should reflect the status of all babies
discharged from the hospital. Many of them never return to public
hospitals, even during any episode of illness. This necessitates follow
up of babies till the end of their neonatal period i.e., 28 days.
In the current state of poor community registration and recording of
neonatal deaths, tracking survival status of discharged newborns by
routine health personnel in public health delivery system remain a
viable option to generate accurate levels of neonatal survival status.
Methods
We carried out survival tracking of institutional
births occurring in district hospitals (DH) for the month of March 2010
in two districts-Nagaur in Rajasthan and Chhatarpur in Madhya Pradesh,
with a NMR of 42 and 51 per thousand live births, respectively [2].
Special registers were designed to note all the details for
institutional births, taking place both in labour room and operation
theatre. Details regarding family and nearest health centre contact
along with name of concerned Auxiliary Nurse Midwife (ANM) were also
noted.
Key personnel from district health system were
identified for undertaking this activity - District epidemiologist at
Nagaur and the District immunization officer at Chhatarpur. Training was
provided for recording relevant details to all staff concerned.
The actual tracking was performed in two distinct
ways. In Nagaur, phone calls were made from the district level at the
end of neonatal period. If phone numbers were not available, then the
concerned ANM was contacted to make house visits. In Chhatarpur,
neonatal births were sorted block-wise. The Block Medical Officer
in-charge and the concerned ANMs were given the responsibility to track
the neonates within their geographic area of work by either making phone
calls or house visits. The filled report from each block was collated at
the district level.
A 20% sample was cross checked by the research team
to validate the findings. The Indian Council of Medical Research Causes
of Death by Verbal Autopsy, questionnaire for Neonatal Death [3] was
used in carrying out interviews by research team and causes of death
were ascertained by two study team physicians independently. Informed
consent was obtained from participants before interviews. The ethical
clearance for the study was obtained from Institutional ethical
committee of Public Health Foundation of India.
Results
Of the 321 recorded births at the DH Nagaur in the
month of March 2010, 8 were still births; the district personnel were
able to assess survival status at completion of neonatal period in 79%.
In Chhatarpur, out of total 415 recorded births in the study month, 17
were still births; 84% live births were tracked (Table I).
TABLE I Neonatal Survival Tracking Status in Study Districts (March 2010)
District |
Total live |
Survival status |
Missing data |
Alive out of |
Neonatal |
NMR (per 1000
|
|
births |
tracked (%) |
(%) |
total tracked (%) |
deaths |
live births) |
Nagaur |
313 |
247 (79) |
66 (21) |
241 (98) |
6 |
24.3 |
Chhatarpur |
398 |
360 (91) |
38 (9) |
349 (97) |
11 |
30.6 |
Total |
711 |
607 (85) |
104 (15) |
590 (97) |
17 |
24 |
There were 17 neonatal deaths (6 in Nagaur and 11 in
Chhatarpur) reported by the tracking, verbal autopsy was conducted for
13 deaths (Table II). In Nagaur, out of five neonatal
deaths tracked, four were females and in Chhatarpur, out of 8 neonatal
deaths tracked, five were females. Maximum deaths (12/13) took place
within first 7 days in both the districts. Prematurity and infections
were the commonest causes for deaths (Table II). Out of 13
deaths where verbal autopsy was done, care from any health facility was
sought only in six neonates.
TABLE II Causes of Neonatal Deaths by Verbal Autopsy
Cause of death |
Nagaur
|
Chhatarpur |
Prematurity/low birth weight |
2 |
4 |
Sepsis/diarrhoea/pneumonia |
1 |
3 |
Asphyxia |
1 |
– |
Unknown# |
1
|
1 |
Could not be traced/ interviewed*
|
1 |
3 |
Total |
6 |
11 |
# cause could not be ascertained; *at
time of visit. |
Discussion
Based on the experience of undertaking the neonatal
survival tracking exercise at the end of 28 days through involving local
district officials, the strategy seemed feasible in identifying extra
deaths taking place at community settings. In absence of special care
newborn units functioning at time of conduct of this study in these
districts, neonatal mortality estimates were generated only through
labor room records and pediatric admissions, outcomes. Only relying on
facility based records for reporting neonatal mortality through admitted
newborns will possibly have a limitation of under-reporting and thus
will not be in true sense a reflection of accurate NMR.
While only 38 neonates (9%) could not be traced in
Chhatarpur, 66 neonates (21%) were not traceable in Nagaur. These were
due to deficiencies in noting accurate contact details in the reporting
register. Inaccuracies in recording contact details are also due to
families citing false addresses for obtaining higher cash incentives
under JSY. Larger missing data resulted from Nagaur than Chhatarpur,
indicative of better yield of block-wise approach than centralized
district approach for tracking.
The present study was limited in its scope as it
included only district hospitals and was conducted only for one month.
The utility of this approach can be in all institutional settings where
deliveries are conducted and routine staff can be assigned
responsibility of tracking the outcomes at the end of neonatal period.
Sustained regular use of the methodology will build confidence in the
approach and integration within routine health system. Similar approach
has been tested for newborns admitted in two special care newborn units
of Madhya Pradesh where tracking for survival was performed at one year
of age [4]. The tracking efforts if integrated within routine health
systems will improve accuracy of neonatal and infant mortality data.
This will also provide an opportunity to understand the social factors
responsible for newborn deaths, which will be helpful in improving
quality of care for newborns.
Contributors: All authors contributed to study
design, data collection, analysis and drafting the manuscript.
Funding: Ministry of Health and Family Welfare,
Government of India;
Competing interests: None stated.
References
1. Ministry of Health and Family Welfare. Family
welfare statistics in India 2009. New Delhi: Government of India; 2009.
2. Government of India. Annual Health Surveys
Bulletin. 2010-11. Available online at http://www.censusindia. gov.in/vital_statistics/AHSBulletins/ahs.html
(Accessed 15 August, 2011).
3. Indian Council of Medical Research (ICMR), 2009.
Study on causes of death by verbal autopsy in India, ICMR, New Delhi:
2009.
4. UNICEF. Tracking babies treated in Special Care
Newborn Units at district level to see survival at one year of age.
Available online at http://kcci.org.in/SitePages/new%20
born%20care%20unit.aspx (Accessed 10 October, 2011).
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