Single Digit NMR and SBR: Ways to Achieve

India has reached even the most hard-to-reach area and vulnerable children with affordable life-saving interventions despite numerous challenges with significant rural-urban, poor- rich, gender, socio-economic, and regional differences, which is evident by its triumph over polio. The country has acted to reduce maternal and child mortality rates and witnessed dramatic reduction in it over the past two decades. But success was not found up to the desired level in neonatal & still birth rate. Neonatal mortality has reduced much less than post-neonatal deaths, thereby increasing the contribution of neonatal deaths from 41% of under-5 deaths in 1990 to 56% in 2012. The estimated Stillbirth rate (SBR) in the country is 22 per 1000 live births. Unavailable history about pregnancy for women and misclassification of deaths have posed a real challenge to valid estimation of SBR in our country. The neonatal mortality rate is not uniform across India. While the state of Kerala has already attained Single Digit NMR (7/1000 live births); Odisha, Madhya Pradesh, Uttar Pradesh, Rajasthan, and Chhattisgarh have experienced a higher neonatal mortality rate at 30 or more per 1000 live births. As a result, newborn health has drawn the attention of policymakers at the highest level in India. This has resulted in strong political commitment to end preventable newborn deaths and stillbirths, and recognize newborn health as a national priority.¹

By this time India has passed through the child survival programmes adopted from time to time like Child Survival and Safe Motherhood Programme (CSSM) in 1992; Reproductive and Child Health Programme Phase I (RCH I) in 1997; RCH II & the National Rural Health Mission (NRHM) in 2005 ; the National Health Mission and Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) strategic framework in 2013.^1,2,3

The RMNCH+A strategy is based on a continuum-of-care approach and defines integrated packages of services for different stages of life cycle, to be delivered at family/ community level, Outreach/sub-centre level & facility level.⁴

Since NRHM, a lot of achievement we could notice. Institutional delivery increased resulting in reduced MMR & NMR as a consequence of JSY scheme. A nationwide network of facility- based newborn care has been established at various levels: Newborn Care Corners at the point of child birth; Newborn Stabilization Units at CHC level & Special Newborn Care Units (SNCUs) for sick and small newborns at district levels and Intensive care unit (NICU) at Medical Colleges & Regional Centres.^1,2,3

Mothers as well as children are getting benefits of free transport, food, & treatment facilities through Janani Shishu Suraksha Karyakram (JSSK).² Skilled management of sick young infants & children in community, sub-centre as well as facility level was facilitated through implementation of IMNCI/FIMNCI.^5,6 Incentivized Home-Based Newborn Care programme has been launched in 2011 through ASHAs who were trained to improve newborn practices at the community level including early detection and referral of sick newborn babies by making home visits.⁷

Recently, the government has made some robust policy decisions to combat the major causes of newborn death with particular focus on sick newborns, babies born too soon, and babies born too small for their gestational age. The India Newborn Action Plan (INAP) is India’s committed response to the Global Every Newborn Action Plan (ENAP), launched in June 2014 at the 67th World Health Assembly. INAP lays out a vision and a plan for India to end preventable newborn deaths, accelerate progress, and scale up high-impact yet cost-effective interventions. INAP has a clear vision supported by goals, strategic intervention packages, priority actions, and a monitoring framework. It is guided by the principles of Integration, Equity, Gender, Quality of Care, Convergence, Accountability, and Partnerships with the Goals to end Preventable Newborn Deaths and still births to achieve “Single Digit NMR” & “Single Digit SBR” by 2030, with all the states to individually achieve this target by 2035.¹ INAP includes six pillars of intervention packages across various stages with specific actions to impact stillbirths and new born health which are-

1. Preconception and antenatal care;

2. Care during labour and child birth;

3. Immediate newborn care;

4. Care of healthy newborn;

5. Care of small and sick newborn; and

6. Care beyond newborn survival.

Various proven action have been suggested under the six intervention packages which will be implemented at different levels of health care starting from community to facility. Few important components of them are as follows-

• Suggested action under Preconception and antenatal care are delaying age of marriage and first pregnancy, - birth spacing; multiple micronutrient supplementation (Iron, Folic Acid & Iodine); nutrition counselling of mothers & adolescent girls; counselling & birth preparedness of pregnant women; adolescent friendly health services (nutrition and reproductive health counselling) and interval IUCD insertion & Post-partum family planning services including PPIUCD insertion.

• Care during labour and child birth include actions like skilled birth attendance & clean birth practices; identification of complications and timely referral with pre-referral dose by ANM of antenatal corticosteroids in preterm labour & antibiotics for premature rupture of membranes; emergency obstetric care, basic and comprehensive.

• Immediate newborn care includes action like delayed cord clamping, interventions to prevent hypothermia (Immediate drying, head covering, skin-to-skin care, delayed bathing); early initiation and exclusive breastfeeding; hygiene to prevent infection; Vitamin K at birth, neonatal Resuscitation after delivery at NBC

• Counselling, prevention of hypothermia, cord care, early identification of danger signs, and prompt & appropriate referral, exclusive breastfeeding, clean postnatal practices and Immunization (BCG, OPV, Hepatitis B) are the important suggested action under Care of healthy new born.

Trained ASHAs in the villages are supposed to provide home based new born care by making visits to the families after childbirth.

• Suggested action for small & sick newborn are Integrated management using IMNCI and use of oral antibiotics, Injectable Gentamicin by ANMs for sepsis; full supportive care at block and district level & state & regional level by establishing Newborn stabilization unit (NBSU) at block level, special newborn care unit (SNCU) at district level, and Intensive neonatal care unit (NICU) at medical colleges & regional level

• Care beyond newborn survival suggested few important actions in the plan like screening for birth defects, failure to thrive and developmental delays followed by Management of birth defects ( Diagnosis, Treatment, including surgery) at health facility; follow up visits of SNCU discharged babies till 1 year of age, - small and low birth weight babies till 2 years of age; and follow-up of high-risk infants (discharged from SNCUs, and small newborns) for Developmental delay & Appropriate management.¹

Thus, integration of all the proven interventions, at all levels of health care, and different stages of life cycle, with logical mobilization of resources (HR, Money, logistics), multi-sectorial involvement & commitment of all the stakeholders could help to reach the goal of 1 digit NMR & SBR by 2030.