Neonatal Health


The Indian Newborn Action Plan and RMNCH+A

While efforts to reduce maternal and child mortality rates over the past 20 years have had a striking impact, stillbirths and newborn deaths have over the same period missed out on the attention they need.

Neonatal mortality rates have reduced much less than post-neonatal deaths, with 748,000 newborns  still dying each year from largely preventable causes. At the same time, the high numbers of stillbirths have largely remained invisible. About 572,000 babies are stillborn each year, the highest number in the world and often under-reported.  
Fortunately, newborn health has now come to the attention of policymakers and UNICEF is joining their efforts to address these preventable deaths. The Indian government has introduced two landmark programmes, the National Rural Health Mission (NRHM) and the Reproductive, Maternal, Newborn, Child and Adolescent Strategy (RMNCH+A Strategy). The NRHM has provided an unprecedented focus and resources for newborn health, while the RMNCH+A strategy marks a significant shift in approach, basing services on a continuum-of-care model and on strengthening health systems.
The government has also now developed the India Newborn Action Plan (INAP) in response to the global Every Newborn Action Plan (ENAP) launched at the World Health Assembly in June 2014. INAP, in which UNICEF is a key partner, aims to significantly reduce preventable newborn deaths and stillbirths and to bring down the Neonatal Mortality Rate and Still Born Rate to “single digits” by 2030.

The plan includes clear timelines to implement, monitor and evaluate, and scale up interventions and is built on six types of intervention package: Pre-conception and antenatal care; Care during labour and child birth; Immediate newborn care; Care of healthy newborn; Care of small and sick newborns; and Care beyond newborn survival. 

Challenges to better Newborn Survival and Child Health

Though India accounts for highest burden of under-5 deaths, it has shown faster decline in under-5 mortality reduction compared with the global fall. Worldwide, the under-5 mortality rate reduced by 49 per cent from 90 per 1000 live births in 1990 to 46 per 1000 live births in 2013, while India achieved a reduction of 59 per cent in under-5 mortality from 126 in 1990 to 52 in 2012. 
However the decline in neonatal mortality has been much slower compared with under-5 mortality. In order to accelerate progress it is important that preventing neonatal deaths has been prioritized. Undernutrition is an underlying factor in 45 per cent of under-5 deaths and breaking the intergenerational cycle of malnutrition needs to focus on nutrition of adolescent girls and pregnant women. It is also important to focus on improving breastfeeding rates, Water, Sanitation and Hygiene (WASH) practices at both facility and household level.
Other challenges to maternal, neonatal and child survival:
Mothers and children in the lowest economic bracket have about a two and a half times higher mortality rate. 
Social norms and socio-cultural factors often affect accessibility to healthcare and nutrition as well as water and sanitation services and facilities in many regions.
Groups such as rural communities, Scheduled Castes and Scheduled Tribes and minorities have a higher IMR and U5MR. The IMR in rural India is 44 while in urban areas it is 278.
Families have little access to accurate and comprehensive information about healthy maternal, neonatal and child health practices, social services entitlements and how to use them. These keys to child survival include: the age of a mother at childbirth and her education level, spacing between children, gender-discriminatory child rearing practices  (more girls die than boys, with the IMR for boys 39 and for girls 428), access to improved sanitation, drinking water quality and maternal and child nutrition.
There aren’t enough skilled personnel and specialists in child healthcare, leading to a lack of demand for health services and the promotion of healthy practices and care-seeking behaviours among families.


Big Picture

Each year in India there are 1.34 million deaths of children aged under five ; 1.05 million infant deaths ; and 0.748 million newborn deaths . The country accounts for more than a quarter (26 per cent) of the world’s neo-natal deaths.
The states of Uttar Pradesh, Madhya Pradesh, Rajasthan and Bihar contribute to more than half of newborn and under-five deaths in India.
More than half (56 per cent of under-five deaths happen in the first 28 days of life and nearly three-quarters of these newborn deaths occur in the first week of life.

The major causes of newborn deaths in India are pre-maturity/preterm (35 per cent); neonatal infections (33 per cent); intra-partum related complications/ birth asphyxia (20 per cent); and congenital malformations (9 per cent).  

Most newborn deaths are preventable by improving quality of care during delivery and care at birth. Simple interventions like skilled birth attendance and access to emergency obstetric care can reduce NMR by 41 per cent while early initiation of  breast feeding can reduce NMR by per cent.

India’s Neo-natal Mortality Rate (NNMR), Infant Mortality Rate (IMR) and Under-five Mortality Rate (U5MR) stand 29, 40 and 52 respectively. Pleasingly, they have consistently declined over the decades.

In the post-newborn period, most deaths occur due to preventable diseases and infections like pneumonia , diarrhoea, malaria and measles. About 39 per cent of children have not been fully immunized .

UNICEF In Action

As the lead technical partner in the country for Newborn and Child Health, UNICEF has been involved from the beginning of the Integrated Management of Newborn and Childhood Illness (IMNCI) programme in India.

It has also played a key role in strengthening Facility Based Newborn Care (FBNC) in the country in line with increasing institutional delivery, scaling up the model of Special Newborn Care Units (SNCUs) that were first piloted by UNICEF with the Government of West Bengal in Purulia district. The SNCU online monitoring developed by UNICEF in Madhya Pradesh has been adopted by the Government of India for national scale-up.
UNICEF has also been the main partner in developing INAP, providing a key role in bottleneck analysis, identification of strategic intervention packages and monitoring indicators for INAP. The roll-out of key interventions under INAP and its dissemination is being supported through UNICEF field offices.
Click here for more information about the Indian Newborn Action Plan

Acting on India's Call to Action 
In February 2013, policymakers joined leaders from the private sector and civil society in Mahabalipuram, Tamil Nadu for India’s Call  to Action – ‘Child Survival and Development for Every Child in India.’ Convened under the  banner of A Promise Renewed, the high-level forum launched the ‘Strategic Approach to
Reproductive Maternal Newborn Child and Adolescent Health,’ an ambitious roadmap for accelerating child survival and development. 
The government is making steady progress implementing this bold strategy, which identifies 184 high-priority districts across  some of the country’s poorest states. With the support of partners, including UNICEF, USAID, the Bill & Melinda Gates Foundation, UNFPA, the Norway India Partnership Initiative and the Government of the United Kingdom, the Government of India is developing strategies for bridging and financing health care gaps in the priority districts, and implementing a system for monitoring and reviewing local-level health care services.  
The results are beginning to show. In Maharashtra alone, the health care budgets for high-priority districts increased by 100 to 300 per cent. As in other states with high-priority districts, Maharashtra faces a limitation in trained health care providers. The government is tackling the problem through innovative partnerships that harness the comparative advantage s of the private sector and civil society.

For instance, in Aurangabad, teams  from private medical colleges are deployed to service primary health care facilities n urban  and peri-urban areas. Another priority is to strengthen the monitoring of Special Newborn Care Units and to develop systems for tracking the babies’ development once they are home. Piloted in 2012, a new digital monitoring  system developed in Madhya Pradesh is now used across six states to monitor 245 newborn care units. The real-time informationhelps policymakers monitor outcomes and prioritize resources.
The strategy is off to an impressive start, thanks to committed government leadership and robust coordination among partners.  These partnerships with civil society, the private sector and international agencies demonstrate the country’s strong potential to give every Indian child the best possible start in life.