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majority of neonatal deaths occurred at home: CRY Study

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21, September, Varanasi: Findings of the study were made public through a webinar which included a session where eminent experts shared their insights. The panel of experts included Dr Ved Prakash, General Manager Medical and Health (National Health Mission) Uttar Pradesh, Dr Neelam Singh – Secretary, Vatsalya (UP) and Managing Trustee of Jan Mitra Nyas (UP). The panel was moderated by Dr.Ritu Priya, Professor of the Centre of Social Medicine and Community Health (JNU) and honourable member of the board of trustees at CRY. 

The first 28 days of life (the neo-natal period) is the most vulnerable time for a child’s survival. Children face the highest risk of dying in their first month of life (UNICEF, 2018). The Right to Life as enshrined in Article 21 of the Indian Constitution, and the United Nations Conventions on the Rights of the Child (UNCRC) is a Fundamental Right, and Goal 3 of the Sustainable Development Goals (SDGs) states that by 2030, the aim is to end preventable deaths of new-borns and children under five years of age, and reduce neo-natal mortality rate (NMR) to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births. In the National Plan of Action (NPA) 2016, India has committed to reducing neo-natal mortality to 21 by 2021.India currently contributes to one-fifth of global live births and more than a quarter of neo-natal deaths. In India, the NMR stood at 23 deaths per thousand live births in 2018 (SRS 2018). Around 72 percent of total infant deaths and more than half of under-five deaths fall in the neo-natal period; deaths in the first week alone account for 55 percent of total infant deaths (SRS 2018). The latest round of the National Family Health Survey (NFHS-IV) 2015-16 indicates that only 24 percent of children received a health check-up from a qualified medical personnel within 2 days of birth, and that less than 3 percent of children born at home were taken to a health facility for check-up within 24 hours of birth.  The causes, drivers and determinants of these occurrences are myriad and multifaceted which includes infrastructure gaps, parental education and non-optimal health seeking behaviours along with other socio-economic drivers. There are medical causes also of neo-natal deaths like prematurity and low birth weight, birth asphyxia, etc. Over the years, consistent efforts to address the above issues have been made by both the State and Civil Society Organisations (CSOs). While the steps taken to reduce mortality have shown some positive trends over the last few decades, India still has a higher neo-natal mortality rate compared to the world average. The state of Uttar Pradesh has one of the highest neo-natal mortality rates in the country with 32 deaths for every 1000 live births (SRS 2018). The rural-urban differential in the state is also one of the highest in the country with rural areas witnessing 34 deaths for every 1000 live births and urban areas recording 21 deaths for every 1000 live births in the neo-natal period.

In Uttar Pradesh, CRY- Child Rights and You, recognising the pressing need for improving the maternal and child health, has a range of holistic interventions both at the system and the community levels in the grassroots, through a host of measures. The CRY experience shows that the issue of infant and neo-natal deaths is complex with a cluster of interlinked drivers and a need was felt for the study to further explore the socio- cultural determinants and different health aspects of the occurrence. The study findings will guide CRY and other civil society organisations’ (CSOs) endeavours to address issues related to neo-natal health and mortality in Uttar Pradesh and also strengthen the policy dialogue with different stakeholders including policy makers and influencers at different forums.

The study was conducted in rural areas of three districts of Uttar Pradesh namely – Kaushambi, Sonbhadra and Varanasi. CRY has intervention programmes in all these three districts. Presently, CRY has presence in 60 villages of Kaushambi, 50 villages of Varanasi (Rural) and 28 villages of Sonbhadra district through various program initiatives. 

As part of the research methodology in the above districts, the field staff of implementing NGO partners of CRY visited and studied all neo-natal deaths in detail and collected detailed information from the families including demographics, socio-economic status, health-seeking practices etc. (neo-natal deaths that were reported between April 2018and 31st March 2019). Out of the 55 identified cases, a random sub-sample of 29 mothers was additionally chosen (distributed proportionately with respect to number of deaths in the respective districts) for in-depth interviews. In-depth interviews were conducted in the month of February 2020and mothers who had lost their child in the last one year prior to the survey were interviewed for detailed exploration. Reflexive notes during the field visits were also documented to substantiate the findings.

A majority of the births occurred were institutional births (78%), out of which 60 percent were at a public health facility and 18.2 percent at a private health facility. The proportion of home births were highest in Sonbhadra (28.6%), followed by Varanasi Rural (23.1%) and Kaushambi (10.7%). 

Mothers during interview also gave similar information – 62 percent of the deliveries took place in government health facilities, 24 percent of the births took place in private clinics, and 10 percent deliveries took place at home and 3  percent during transit. Among the women who delivered in an institution, 69 percent were discharged on the same day as the delivery and only 28 percent mothers reported the child receiving post-natal check-ups in the first week after birth.

Among the women who had institutional delivery, only one in every ten deliveries (14%) were assisted by a doctor. A majority of them were conducted by an ANM (86%). District wise, in Varanasi rural 80 percent of the deliveries were assisted by an ANM, while 20 percent were done under the supervision of a Doctor. In Kaushambi ,88 percent were assisted by an ANM and only 12 percent by a Doctor. The data from Sonbhadra shows that 87.5 percent of institutional deliveries were assisted by ANMs and 12.5 percent by a doctor. The findings also highlight that 17 percent of the deliveries were not assisted by any skilled or trained birth attendant (attended to by Dais and relatives).

In one in every ten cases, old or unsterilized instrument/blade was used to cut umbilical cord. This was highest in Varanasi Rural (33.1%), followed by Sonbhadra (14.3%), and did not occur in Kaushambi.  Half of the new-borns (51%) were not breastfed immediately and/or within an hour of birth and one in every tenth child (12.7%) was fed with something other than breast milk (e.g. cow milk or honey due to varied cultural practices followed in the study areas). Only 28.6 percent of the new-borns were breastfed within an hour of birth in Sonbhadra, followed by 38.5 percent in Varanasi Rural and was the highest in Kaushambi (64.3%). Mothers’ interviews also revealed that only 35 percent children were given colostrum within an hour. Among women who did not give colostrum within an hour, 56 percent reported that the child was never given colostrum.

There were multiple causes leading to the deaths of neonates. Neo-natal Pneumonia and Respiratory Distress Syndrome emerged as the two highest probable causes accounting for 27 percent and 24 percent of the deaths overall. In Varanasi Rural, Neo-natal Pneumonia and Respiratory Distress Syndrome accounted for 23 percent and 21 percent of the deaths respectively. In Kaushambi similarly, Neo-natal Pneumonia and Respiratory Distress Syndrome accounted for 21 percent and 32 percent of the deaths respectively. In Sonbhadra, 43 percent of the deaths are likely to have occurred due to Neo-natal Pneumonia, and in none of the cases, Respiratory Distress was reported. Overall, 30 percent of the deaths were sudden deaths and in 18 percent of the cases, there was insufficient information. 

Overall, children died within 4 days of birth on an average, ranging from 5 days in Varanasi rural to 3.6 days in Sonbhadra. 82 percent of the deaths took place within 7 days of birth, and hence are conclusively early neo-natal deaths. This was highest in Kaushambi (86%), followed by Sonbhadra (79%) and Varanasi Rural (77%).  Range of days was lower in Sonbhadra (0 to 15 days) indicating that children survived for very less number of days in the district.  35 percent of the deaths were same-day deaths.

In the interviews with mothers it was revealed that deaths of girl children, among the sub-sample chosen for in-depth interviews, were also slightly higher accounting for 51.7 percent of the total neo-natal deaths. 62 percent of the neo-natal deaths (as revealed in case studies also) were early deaths i.e., within 7 days; 31 percent of the deaths were same-day deaths.1st order and 4+ order births accounted for 72.3 percent of the deaths, in line with the findings from the larger sample presented in the section above.

This study shows that there is a need to adopt state-specific strategies and multi-sectoral approaches to bring down neo-natal mortality, and move closer towards achieving the targets and goals of  INAP, NHM, NAPC and SDGs. Policy options for new-born and child survival  should include community awareness, adopting preventive strategies, enhancing local health infrastructure and increasing investment in child health and related maternal and adolescent health polices and schemes; the recommendations are as follows:

  1. Birth and death registration should be strictly mandated. Civil Registration and Vital Statistics (birth and death registration with cause of death assignment) should be progressively strengthened for counting every new-born.
  2. Micro level research, information and reliable data about mortality are required for improving programmes. The system of reporting NNM should be strengthened and each neo-natal death should be audited to improve new-born health.
  3. Periodic monitoring of Annual Implementation Plans should be encouraged by state authorities. Annual health plans should reflect local needs and effective budgeting processes should be put in place. Periodic health facility audits and needs assessment studies at the facility level should be promoted by health authorities to assess gaps in services and take corrective measures.
  4. Trained mobile health teams should be deployed for screening and early detection of risks so that immediate actions can be taken during emergencies to reduce the risk of death.
  5. Periodic training and assessment of training should be promoted for outreach workers on varied topics related to maternal and child health. Though incentives are inbuilt in national programmes for promoting institutional deliveries, healthy practices such as colostrum feeding, exclusive breastfeeding, nutritious food intake during pregnancy and lactation and maintaining personal hygiene could also be incentivised.
  6. Intensive awareness programmes should be promoted to disseminate information about maternal/ child care and available government schemes to enhance coverage. Efforts should also be made to address issues such as early marriage of girls and nutritional deficiencies among adolescent girls through school and community level programmes and activities.
  7. Focus should be on promoting postnatal visits, as across the world this strategy has been accepted as the best practice to reduce neo-natal and infant mortality. Hence the role of ASHA is significant. The government guidelines specifies 3 post-natal contacts within 7 days of birth. This is extremely vital and should be monitored and implemented strictly.
  8. Also need to focus on improving the quality of institutional care and formulating and implementing the delayed discharge protocols. The institutional care can significantly bring down NMR especially early NMR which in the study findings was also a significant percent (82%) all the NMRs.
  9. Steps to be taken by the Health department and government health workers to improve the quality of ANC especially focusing 4th ANC and more so the last ANC within last week of pregnancy and BP/ CR (birth preparedness and complication readiness) can be addressed.
  10. Urgent need to shift from generalised strategy to focused approach (narrowed down approach) needs to be applied to reduce NMR to attain the targets of SDG. One strategy is focussing on the tribal pockets as significant numbers of deaths are happening there. Further focus needs to be on the 1st born as it increases the NMR significantly. 
  11. Most of the recommendations related to addressing adequacy of human resources as per IPHS standards, their training, availability of quality infrastructure etc. are contingent on adequate budgetary allocations. Trends in budgetary allocations for child health as a proportion of overall child budget has been progressively declining from 3.9 per cent (2018-19 BE) to 3.57 percent (2019-20 BE) to 3.4 percent (2020-21 BE). Thus, there is an urgent need to universalise quality health services by increasing public provisioning for health.

 

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A former Assistant Secretary with the Ministry of Women and Child Development in West Bengal for three months, Lakshmi Bhavya has been championing the cause of menstrual hygiene in her district. By associating herself with the Lalana Campaign, a holistic menstrual hygiene awareness campaign which is conducted by the Anahat NGO, Lakshmi has been slowly breaking taboos when it comes to periods and menstrual hygiene.

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