If more Indian mothers can be persuaded to care for their babies like kangaroo mothers do, many of the 750,000 babies younger than four weeks who die every year --the world’s highest death toll -- can be saved.
Kangaroo mothers keep babies in regular skin contact, an easy, low-cost intervention that can save lives in India, Somashekhar Nimbalkar, 45, a coordinator of the Advanced Neonatal Resuscitation Program of the Indian Academy of Pediatrics, told IndiaSpend in an email interview.
Although the rate of neonatal mortality has declined from 52 per 1,000 live births in 1990 to 28 in 2013, the rate of decline has been slower than that of infant and under-five mortality. But lasting change, said Nimbalkar -currently head of the pediatrics department at the Pramukhswami Medical College in Karamsad, Gujarat -can only come from transforming public-health institutions.
Q: The neonatal mortality rate (NMR) in India has declined, yet 750,000 babies under four months die every year in India, the highest in any country. What are the main causes of the high NMR rate?
A: The main causes are the same across the world. They are prematurity, infection and birth asphyxia.
Q: Rajasthan, Madhya Pradesh, Uttar Pradesh, Odisha and Chhattisgarh are the states with the highest neonatal mortality rate in India. Why don’t these states struggle to prevent neonatal deaths?
A: We do not have published literature which tracks reasons for mortality state-wise. We can however speculate that poor public-health infrastructure, including poor availability of human resources, would be the reason for this. Nurses are an important component of the system and resource allocation by states for nurses and doctors is poor. The salaries in the government sector across India are not competitive, and, thus, the best do not join government jobs.
Q: Pre-term birth complications (43.7%) and infections (20.8%) are the leading causes of neonatal deaths in India. What are the factors responsible?
A: The cause of prematurity cannot be pinpointed, but there are risk factors which occur in those who deliver preterm babies. For spontaneously delivered preterm babies, adolescent pregnancy, advanced maternal age, or short inter-pregnancy interval, diabetes, hypertension and other diseases are well known as risk factors.
Considering that most Indian adolescents are undernourished and anaemic, this can be one of the factors that can be pointed out. Also excess physical activity in poor women as well as domestic violence and bacterial vaginosis can be considered prevalent. There are no current studies which look at risk factors for prematurity in India and their relative prevalence.
Q: Despite the rise in institutional deliveries, 78.9% according to National Family Health Survey 2015-16, why do most deaths (36.9%) happen in the first 24 hours of birth?
Typically, 50% of neonatal deaths occur in the first day of life. Thus a figure of 36.9% constitutes a reduction from earlier figures and is encouraging. Unless the antenatal care and prematurity rates improve, reduction of neonatal mortality rates will be difficult though ongoing efforts show a reduction.
Overall there has been an increase in institutional deliveries across India and it is expected that mortality rates will improve. However, most studies have shown deficiency in quality of care at the public health institutions and unless steps are taken to improve quality, mortality rates will not improve.
Quality is again dependent on provision of resources - material as well as manpower - and using data locally for improvement.
Kangaroo Mother care (KMC) -- where babies are kept in skin-to-skin contact with their parent -- faces significant challenges in its implementation across India. It is a low-cost intervention which if scaled across India can have a major effect on neonatal mortality.
India has available expertise in KMC, but it is not utilised by state governments. However, no one knows how much is being given in public or private health institutions. Social support during childbirth has major advantages. While it may be used in primary health centres, it does not find support in larger centres, including medical colleges.
Anaemia is a major problem in Indian women. It is a known problem and there are cheap medicines that can treat it. However, this is one area that finds no solutions in the rural landscape. Many women do not consume the tablets given.
Most state governments and central governments do not use evidence-based policy making for launch of any health programmes. The programmes are also not evaluated by academic institutions for their impact.
Implementation science and launching of complex interventions are newer arenas in which there is poor interest from policy makers. Putting money after bad policies will never give the desired results.
Since 2005, India has made extensive budgetary allocations for rural healthcare. Whether the desired gains have occurred is not known. There is also a disconnect and differential funding between the health department and the national health mission department. The main issue is that the states do not have an idea as to how to solve the challenges. The solutions are based on good faith rather than demonstrated efficacy and hence the problems do not get solved.
Non availability of quality data, as there is pressure to dress up the data. Once one has poor data, one cannot plan an intervention. Poor availability of funds for research and absence of quality researchers is also an issue.
