In December 2018, the Every Newborn Action Plan (ENAP) was released in India, with efforts and contributions from many stakeholders involved in maternal and child care. The plan brought alarming statistics on newborn care to the forefront.
Over 30 million babies are born too soon, too small or become sick every year and need specialized care to survive, WHO reports. It adds that the world will not achieve the global target of health for all unless it transforms care for every newborn. Without rapid progress, some countries will not meet this target for another 11 decades.
The first month in an infant’s life is when he/she is most vulnerable. It is this first month when most of the infant deaths can also be prevented. Deaths in the first month of birth make up 46 percent of total deaths among children under five. As mortality among children under five declines globally, deaths among children are more and more concentrated in the first days of life. This makes the focus on newborn care more critical than ever before.
India has witnessed a significant improvement in neonatal health after the National Rural Health Mission was introduced. Apart from the Janani Suraksha Yojana, the country has launched several new initiatives to improve neonatal care.
Notwithstanding this newfound focus on neonatal health, the annual rate of reduction in NMR and Early NMR still lags behind Infant Mortality Rate and under-5 Mortality Rate. Data from initiatives like the National Health Mission (NHM) has been commendable progress with a decline of 2.7 percent in the Maternal Mortality Ratio (MMR) to 130 during 2014-16, from 178 in 2010-12. Despite these efforts, the highest global share of deaths among the under-fives today still lies in our country.
The reason for this is simple: we still lack the funds and infrastructure needed to tackle problems like postpartum bleeding (15 percent of deaths), complications from unsafe abortion (15 percent), and hypertensive disorders of pregnancy (10 percent), postpartum infections (8 percent), and obstructed labour (6 percent). There is a lack of synergy and coordinated efforts between the public and private hospitals to achieve complete success rates.
Another related challenge is making healthcare affordable and accessible. The challenge of access to affordable healthcare is affected further by a lack of infrastructure and manpower. It is both the quality and quantity of manpower in the healthcare domain at this level that is keeping us from achieving our targets.
Every newborn that survives or does not survive teaches us something. From my experience in hospitals, inequality in neonatal deaths (by inequality I mean class inequality) is still rampant. Unless private hospitals do not collaborate with the governmental, professional and civil bodies towards this singular goal, our efforts will continue to fall short like they are now. This coordinated, focussed effort by all stakeholders in neonatal health will give the country a fighting chance at giving every Indian child the best possible start in life.
It is very important that every newborn death should be attended to and accounted for, and a stronger health system is what will get us there. We must not forget every newborn birth determines the progress of a country and this is related to maternal health too. Over 80 percent of all newborn deaths result from three preventable and treatable conditions – complications due to prematurity, intrapartum-related deaths (including birth asphyxia) and neonatal infections. Cost-effective, proven interventions exist to prevent and treat each of these main causes, and the alarming number of newborn deaths in the country is despite this.
Improving quality of care around the time of birth will save the most lives, but this requires educated and equipped health workers, skills, and availability of essential commodities.
Maternal malnutrition accounts for many babies with low birth weight and intra-uterine Growth Restriction (IUGR) – two conditions that account for the most newborn death and disease in India. Till we reduce these figures, we will not progress as a country because every mother lost in childbirth is a loss of a family. It puts enormous pressure on society. The journey to lower neonatal and infant deaths is to first address Maternal Mortality Rates (MMR).
In 2017, some 2.5 million newborns died, mostly from preventable causes. Almost two-thirds of these deaths were babies born prematurely. Even if they survive, these babies face chronic diseases or developmental delays. An estimated 1 million small and sick newborns survive with long-term disability. With nurturing care, these babies can live without major complications, but their quality of life takes a life-long beating.
Despite several efforts, it is important that we implement measures for ensuring new-born screening and periodic vaccinations are given that eliminates deaths due to preventable diseases. While significant efforts have been made in the private sector leading to single digit NMR & IMR still a lot needs to be achieved in the public sector as the burden of patients is more. Already we are seeing people avoiding public hospitals for many ailments unless they are left without a choice. We need continued investments and ongoing training to enhance the skill set of our healthcare workers.
In fact, investment in maternal, newborn and child health along the continuum of care from pre-pregnancy to childhood and beyond will strengthen a nation’s health system, whether public or private.
India can prevent new-born deaths through proper treatment, education, immunization campaigns, and better sexual and reproductive healthcare practices. Between 2016 and 2030, as part of the Sustainable Development Goals, the target is to reduce the global maternal mortality ratio to less than 70 per 100 000 live births. Small efforts like exclusive breastfeeding, skin-to-skin contact between the mother and the baby, medicines and essential equipment, and access to clean and well-equipped health facilities staffed by skilled health workers need to be prioritized.
The Sustainable Development Goals makes a bold commitment to also end the AIDS, tuberculosis, malaria and other communicable epidemics by 2030. Achieving the SDG target of a global MMR of fewer than 70 maternal deaths per 100,000 live births by 2030 will require continued investment in maternal health research, programs and policy at the global level and focused action in countries.
The author is a practising neonatologist at Cloudnine Group of Hospital, visiting Professor at Indira Gandhi Institute of Child Health, Bangalore and an Adjunct Professor of Neonatology at Notre Dame University, Perth, Australia. He is also the National coordinator, Accreditation Committee, National Neonatology Forum, and the views expressed in the article are personal.
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