Every newborn requires basic care which has to be provided by the mother at home. This includes warmth, feeding, basic hygiene and identification of danger signs, and seeking help from health personnel whenever required. Therefore, all newborns get home based newborn care as per the perception and sociocultural behavior of the society. However, it has been observed by various studies on the newborn care in the communities that the knowledge and the practices of simple care e.g. prevention of hypothermia, feeding of colostrum and exclusive breastfeeding, are lacking(7-10). The knowledge regarding identification of danger signs and care seeking behavior of the families has been found to be variable, and in general, poor(11).

The World Health Organization (WHO) guidelines for essential newborn care include clean delivery, keeping the newborn warm, early initiation of breastfeeding, exclusive breastfeeding, care of the eyes, care during illness, immunization and care of low birth-weight newborns(12). Therefore it is necessary for the mother and family to understand these aspects of childbirth and newborn care, and be prepared to react for the potential dangers. Baqui, et al.(13) in a recent study from Uttar Pradesh, India, reported very poor knowledge regarding newborn care practices among pregnant mothers, especially in rural areas. Only 7% pregnant women received any information regarding clean cord care from health professionals. Similarly, 5% women received information on thermal care and breastfeeding. The study also revealed that only 17% pregnant women received at least one antenatal check up during their entire period of pregnancy. Most of the deliveries were conducted at home and by family members or relatives. Initiation of breastfeeding within six hours of birth was practiced in only 6% cases but later on exclusive breastfeeding in the first month was given to 82% cases. Another study from rural areas of Makawanpur district, Nepal, reported that a very large proportion (>90%) of deliveries took place at home. The study also reported that only six percent of home deliveries were attended by skilled government health workers and newborn care practices were unhygienic and high-risk(14).

In India, 65.4% of all births and 75.3% of births in rural areas occur at home(7). According to National Family Health Survey-III (NFHS-III), the highest neonatal mortality rates are from the states of Chattisgarh, Jharkhand and Uttar Pradesh (Table I). As most of these deaths occur at home, unattended by skilled health worker, designing and prioritizing the interventions about the newborn care practices at home is essential to reduce mortality and morbidity. Implementation of an effective program for pro-motion of childbirth and newborn care practices requires understanding of the community and household traditional newborn care practices. Such information will enable the development of programs to promote culturally sensitive and acceptable change in practices. Information about reasons for delivering at home, home delivery and newborn care practices in many parts of the country is lacking. Identification of simple clinical signs by the health worker and timely intervention for these sick babies would be a key factor in reduction of neonatal mortality(15).

Table I



Child Mortality Rates (Per Thousand Live Births) in India (NFHS - III)

There is no uniformity on the exact definition of home based care. Damstadt, et al.(16) defined it as family oriented and community oriented services that support self care, including the adoption of improved care practices and appropriate care seeking for illness. It also involves community mobilization and the empowerment of individuals and communities to demand quality services that respond to their needs. The main emphasis of home based newborn care lies in preventive, promotive and curative services to the newborn as well as their mothers at home. Example of family oriented care include behavior change communications, community mobilization, antenatal, intrapartum and postnatal care practices, care seeking for illness, and in some settings, community based case management of illness e.g. management of sepsis or pneumonia by community health workers.

Bhutta, et al.(17) in a review of the evidence based, cost effective interventions for reduction of neonatal mortality, identified 16 possible interventions which have proven efficacy. The intrapartum and postnatal packages with 90% coverage have similar effects which are two to three fold greater than that of only antenatal care. Their analysis also reveals that a combination of universal i.e. for all settings-outreach and home based newborn care at 90% coverage can avert 18-37% neonatal deaths. It is interesting to note that the most beneficial effect is observed with family and community care in settings with high neonatal mortality.

Some of the postnatal interventions which have been studied with primary purpose of reduction of neonatal morbidity and mortality are summarized in the Box 1.

Box 1



Postnatal Interventions for Improving Neonatal Health

Table II summarizes the results of some more robust studies on home-based care for newborns. Bang, et al.(20), from Gadchiroli in Maharashtra, India, showed 62% reduction of NMR in their study areas at the end of three years of intervention of home-based newborn care. In their study, community based neonatal interventions were implemented through village health workers who were chosen among the residents of the same village. They served a population of 1000 people and were trained by a team of doctors in practices of essential newborn care including resuscitation and identification of danger signs. They were also trained in giving antibiotic (gentamicin) injections and oral cotrimoxazole to newborn babies. Workers made 8-12 postnatal visits to examine the newborn babies regarding weight, temperature, and identified any problem or sickness. The investigators also trained TBAs regarding safe delivery methods and basic newborn resuscitation, and provided them with disposable delivery kits. There was a close coordination between village health workers and the TBAs. The study team had an excellent rapport with the community as well as district and sub-district Government health functionaries, making it an ideal set up for the experimental intervention.

Table II



Summary of the Studies on Community-Based Interventions for Improving Newborn Health

In another community based interventional study from Sylhet district of Bangladesh, Baqui, et al.(22) reported a reduction of neonatal mortality by 34% in the home care group. In this study, female health workers were trained in home based newborn care according to an adapted version of WHO integrated management of childhood illness (IMCI). A newborn with very severe disease was either referred to a health facility or if not willing, then treated with single daily dose of injections procaine penicillin and gentamicin once a day for ten days. However, in their study of 478 sick newborn babies with very severe disease, the health worker could motivate only 162 families to seek advice from qualified care, 112 families refused treatment or any advice from the health workers, and 207 families wanted care at home by the village health workers. This shows resistance from the community regarding the advice from the community health workers who were exclusively meant for this study.

Community based newborn care strategies in resource poor countries with high neonatal mortality show significant reduction in neonatal mortality as evidenced by the above studies. However, all these studies were done by excellent researchers with good resources and dedicated workers supervised by trained researchers. However, there are innumerable problems in actual implementation of these strategies. It will be a challenging task to upscale the home care newborn package to the most vulnerable districts in certain states in India such as UP, Chattisgarh, Jharkhand and Bihar where NMR is alarmingly high. A pilot project was undertaken by Government of India with the help of Indian Council of Medical Research to implement home-based newborn care package developed by Bang, et al. but the study results (unpublished) are not reported to be very encouraging. Government of India is trying to upscale the maternal and newborn care services by a group of female community health volunteers who are known as ‘accredited social health activist’ (ASHA). They would identify all pregnant women in the village and also identify high risk pregnancy with timely referral to first referral units. After delivery, each newborn will be visited by them within 24 hours of birth, on 3-4th day and on 7th-10th day of life. Each low birth weight baby will receive three additional visits on 14th, 21st and 28th day. All babies with danger signs would be referred by them to the nearest first referral center. The referral and survival of the babies will be incentive linked. A large number of ASHA workers are already recruited in India and the training component is complete. However, the impact of the program is yet to be known.

In order to achieve the millennium development goal of reduction in neonatal mortality in resource poor countries with weak primary care health system, it is important to establish a good outreach and home based newborn care by improving home care practices and demand for skilled care at birth. There is an urgent need for improvement of care seeking behavior of the community by behavior change communication so that people accept the services provided by the Government. Mother and baby pair should be considered as a single unit to formulate strategies for improvement of neonatal care. Simultaneous expansion of clinical care for mother and newborn at all levels needs immediate attention. Although all systematic reviews as well as individual studies on home based newborn care have shown promising results, there are limitations when implementing at the country level as it should fit into the logistics of the available health care system in terms of manpower, infrastructure and policy. There has to be parallel development of adequate numbers of functional first referral units all over the country and especially in districts where the neonatal mortality is very high, so that the newborns requiring secondary or level II care get attention and proper treatment. The millennium development goal can only be achieved by improving all available services and not only by home based newborn care. The long term solutions can only be achieved by improving the literacy rate and empowerment of mothers, which has been clearly shown to be effective by reduction of neonatal mortality in Indian states of Goa, Kerala and Mizoram where female literacy and empowerment is at a high level. Building the capacity of mothers through basic education is a key long term strategy to improve perinatal and neonatal care.

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