Neonatal Mortality In India Research Articles

Integrating social networks and human social motives to achieve social influence at scale.

The innovations of science often point to ideas and behaviors that must spread and take root in communities to have impact. Ideas, practices, and behaviors need to go from accepted truths on the part of a few scientists to commonplace beliefs and norms in the minds of the many. Moving from scientific discoveries to public good requires social influence. We introduce a structured influence process (SIP) framework to explain how social networks (i.e., the structure of social influence) and human social motives (i.e., the process of social influence wherein one person's attitudes and behaviors affect another's) are used collectively to enact social influence within a community. The SIP framework advances the science of scientific communication by positing social influence events that consider both the "who" and the "how" of social influence. This framework synthesizes core ideas from two bodies of research on social influence. The first is network research on social influence structures, which identifies who are the opinion leaders and who among their network of peers shapes their attitudes and behaviors. The second is research on social influence processes in psychology, which explores how human social motives such as the need for accuracy or the need for affiliation stimulate behavior change. We illustrate the practical implications of the SIP framework by applying it to the case of reducing neonatal mortality in India.

Estimation of Gestational Age, Using Neonatal Anthropometry: A Cross-sectional Study in India

Prematurity is a significant contributor to neonatal mortality in India. Conventionally, assessment of gestational age of newborns is based on New Ballard Technique, for which a paediatric specialist is needed. Anthropometry of the newborn, especially birthweight, has been used in the past to predict the gestational age of the neonate in peripheral health facilities where a trained paediatrician is often not available. We aimed to determine if neonatal anthropometric parameters, viz. birthweight, crown heel-length, head-circumference, mid-upper arm-circumference, lower segment-length, foot-length, umbilical nipple distance, calf-circumference, intermammary distance, and hand-length, can reliably predict the gestational age. The study also aimed to derive an equation for the same. We also assessed if these neonatal anthropometric parameters had a better prediction of gestational age when used in combination compared to individual parameters. We evaluated 1,000 newborns in a cross-sectional study conducted in Guru Teg Bahadur Hospital in Delhi. Detailed anthropometric estimation of the neonates was done within 48 hours after birth, using standard techniques. Gestational age was estimated using New Ballard Scoring. Out of 1,250 consecutive neonates, 1,000 were included in the study. Of them, 800 randomly-selected newborns were used in devising the model, and the remaining 200 newborns were used in validating the final model. Quadratic regression analysis using stepwise selection was used in building the predictive model. Birthweight (R=0.72), head-circumference (R = 0.60), and mid-upper arm-circumference (R = 0.67) were found highly correlated with gestation. The final equation to assess gestational age was as follows: Gestational age (weeks) = 5.437 x W-0.781 x W(2) + 2.815 x HC-0.041 x HC(2) + 0.285 x MUAC-22.745 where W=Weight, HC=Head-circumference and MUAC=Mid-upper arm-circumference; Adjusted R = 0.76. On validation, the predictability of this equation is 46% (+/-1 week), 75.5% (+/- 2 weeks), and 91.5% (+/- 3 weeks). This mathematical model may be used in identifying preterm neonates.

Outcome of LBW Babies Admitted in the N.I.C.U. - A Hospital based Study

<strong>Background and Objective:</strong> More than 20 million infants worldwide, representing 15.5 per cent of all births are born with low birth weight. More than 95 percent of them are born in developing countries. The incidence of low birth weight in developing countries (16.5 per cent) is more than double the incidence in developed regions (7 per cent). In India, nearly 8 million babies are born with a Low Birth Weight every year. In India, we are still struggling to get minimum care facilities for our neonates. The neonatal mortality rate in India is still 5 to 6 times higher compared to that in developed countries. Because of their susceptibility to complications, low birth weight neonates require specialized and expert care during the neonatal period. This study was undertaken to study the role of various morbidities in the mortality of LBW neonates admitted in the N.I.C.U. <br /><br /><strong>Material and Methods:</strong> The study was conducted in the N.I.C.U. of a Tertiary Health Care Centre, in Department of Pediatrics. 106 neonates with birth weight less than 2500 grams from among the neonates admitted in the NICU were included in the study. Results: There were 48 deaths out of 106 cases studied thus making the mortality rate of 45.28% and the survival rate of 54.72% (58/106 cases). Respiratory distress contributed maximum to mortality, followed by Septicemia/Sepsis. Neonatal Hyperbilirubinemia followed septicemia in prevalence. Among the spectrum of Respiratory distress, Hyaline Membrane Disease (HMD) contributed maximum to mortality.

Outcome of LBW Babies Admitted in the N.I.C.U. – A Hospital based Study

Background&Objective: More than 20 million infants worldwide, representing 15.5 per cent of all births are born with low birth weight. More than 95 percent of them are born in developing countries. The incidence of low birth weight in developing countries (16.5 per cent) is more than double the incidence in developed regions (7 per cent). In India, nearly 8 million babies are born with a Low Birth Weight every year. In India, we are still struggling to get minimum care facilities for our neonates. The neonatal mortality rate in India is still 5 to 6 times higher compared to that in developed countries. Because of their susceptibility to complications, low birth weight neonates require specialized and expert care during the neonatal period. This study was undertaken to study the role of various morbidities in the mortality of LBW neonates admitted in the N.I.C.U. Material and Methods: The study was conducted in the N.I.C.U. of a Tertiary Health Care Centre, in Department of Pediatrics. 106 neonates with birth weight less than 2500 grams from among the neonates admitted in the NICU were included in the study. Results: There were 48 deaths out of 106 cases studied thus making the mortality rate of 45.28% and the survival rate of 54.72% (58/106 cases). Respiratory distress contributed maximum to mortality, followed by Septicemia/Sepsis. Neonatal Hyperbilirubinemia followed septicemia in prevalence. Among the spectrum of Respiratory distress, Hyaline Membrane Disease (HMD) contributed maximum to mortality.

Assessment of essential newborn care services in secondary-level facilities from two districts of India.

India faces a formidable burden of neonatal deaths, and quality newborn care is essential for reducing the high neonatal mortality rate. We examined newborn care services, with a focus on essential newborn care (ENC) in two districts, one each from two states in India. Nagaur district in Rajasthan and Chhatarpur district in Madhya Pradesh were included. Six secondary-level facilities from the districts-two district hospitals (DHs) and four community health centres (CHCs) were evaluated, where maximum institutional births within districts were taking place. The assessment included record review, facility observation, and competency assessment of service providers, using structured checklists and sets of questionnaire. The domains assessed for competency were: resuscitation, provision of warmth, breastfeeding, kangaroo mother care, and infection prevention. Our assessments showed that no inpatient care was being rendered at the CHCs while, at DHs, neonates with sepsis, asphyxia, and prematurity/low birthweight were managed. Newborn care corners existed within or adjacent to the labour room in all the facilities and were largely unutilized spaces in most of the facilities. Resuscitation bags and masks were available in four out of six facilities, with a predominant lack of masks of both sizes. Two CHCs in Chhatarpur did not have suction device. The average knowledge score amongst service providers in resuscitation was 76% and, in the remaining ENC domains, was 78%. The corresponding average skill scores were 24% and 34%, highlighting a huge contrast in knowledge and skill scores. This disparity was observed for all levels of providers assessed. While knowledge domain scores were largely satisfactory (> 75%) for the majority of providers in domains of kangaroo mother care and breastfeeding, the scores were only moderately satisfactory (50-75%) for all other knowledge domains. The skill scores for all domains were predominantly non-satisfactory (< 50%). The findings underpin the need for improving the existing ENC services by making newborn care comers functional and enhancing skills of service providers to reduce neonatal mortality rate in India.

Neonatal sepsis: A risk approach

Background: Neonatal sepsis continues to be a major cause of neonatal mortality in India. Incidence of neonatal sepsis in India was 30/1000 live births and is not changed much over the past decade. Aims and Objectives: The present study was intended to know the incidence and mortality rates of neonatal sepsis among hospital admission, whether there is any change in the risk factors over a decade and to evolve a risk approach in the management of neonatal sepsis. Patients and Methods: This was a cross-sectional study in a tertiary care teaching hospital. One hundred and twenty neonates with confirmed sepsis were enrolled. Cases were divided into early onset sepsis (EOS) (presenting in the first 72 h) and late onset sepsis (LOS) (presenting after 72 h). Information regarding risk factors was collected by questionnaire. All cases were started on ampicillin and gentamycin later upgraded based on culture and sensitivity. Cases were followed-up to discharge/death and the risk factors associated with fatal sepsis were analyzed using Chi-square test. Results: During 2003-2004, the incidence of sepsis was 6.04% of total pediatric admissions with EOS and LOS 3.08% and 2.96%. The same in 2013-2014 were 6.03%, 2.57% and 3.44%, respectively. Highly significant risk factors were inadequate antenatal care, assisted vaginal delivery, and premature rupture of membranes, low birth weight and associated complications. Klebsiella, Staphylococcus aureus and Escherichia coli were the most common organisms in both EOS and LOS. Conclusion: Overall incidence of sepsis and EOS is not changed much but the incidence of LOS has increased from 2.94% to 3.44%.

Do antenatal care interventions improve neonatal survival in India?

Although antenatal care (ANC) interventions have been in place for a long time, there is hardly any systematic evidence on the association between ANC interventions and neonatal mortality in India. The present study attempts to investigate the association between ANC interventions and neonatal mortality in India using data from the District Level Household Survey conducted in India during 2007-8. The ANC interventions included in the analysis are at least four antenatal visits, consumption of 90 or more iron-folic acid (IFA) tablets, and uptake of two or more tetanus toxoid (TT) injections. We have used discrete-time logistic regression models to investigate the association between ANC interventions and neonatal mortality. Risk of neonatal mortality was significantly lower for infants of mothers who availed four or more antenatal visits [odds ratio (OR): 0.69; 95% confidence interval (CI): 0.60-0.81], consumed 90 or more IFA tablets (OR: 0.85; 95% CI: 0.73-0.99), received two or more TT injections (OR: 0.73; 95% CI: 0.63-0.83). When we analysed different combinations of antenatal visits, IFA supplementation and TT injections, TT injections provided the main protective effect-the risk of neonatal mortality was significantly lower in newborns of women who received two or more TT injections but did not consume 90 or more IFA tablets (OR: 0.69; 95% CI: 0.60-0.78), or who received two or more TT injections but did not avail four or more antenatal visits (OR: 0.75; 95% CI: 0.66-0.86). In the statistical model, 6% (95% CI: 4-8%) of the neonatal deaths in India could be attributed to a lack of at least two TT injections during pregnancy. Indian public health programmes must ensure that every pregnant woman receives two or more TT injections during antenatal visits.

Authors' Response: The equity impact of participatory women's groups to reduce neonatal mortality in India: secondary analysis of a cluster-randomized trial

Authors' Response: The equity impact of participatory women's groups to reduce neonatal mortality in India: secondary analysis of a cluster-randomized trial

The Equity Impact of Participatory Women’s Groups to Reduce Neonatal Mortality in India

The Equity Impact of Participatory Women’s Groups to Reduce Neonatal Mortality in India

Reducing neonatal mortality in India: critical role of access to emergency obstetric care.

BackgroundNeonatal mortality currently accounts for 41% of all global deaths among children below five years. Despite recording a 33% decline in neonatal deaths between 2000 and 2009, about 900,000 neonates died in India in 2009. The decline in neonatal mortality is slower than in the post-neonatal period, and neonatal mortality rates have increased as a proportion of under-five mortality rates. Neonatal mortality rates are higher among rural dwellers of India, who make up at least two-thirds of India's population. Identifying the factors influencing neonatal mortality will significantly improve child survival outcomes in India.MethodsOur analysis is based on household data from the nationally representative 2008 Indian District Level Household Survey (DLHS-3). We use probit regression techniques to analyse the links between neonatal mortality at the household level and households' access to health facilities. The probability of the child dying in the first month of birth is our dependent variable.ResultsWe found that 80% of neonatal deaths occurred within the first week of birth, and that the probability of neonatal mortality is significantly lower when the child's village is closer to the district hospital (DH), suggesting the critical importance of specialist hospital care in the prevention of newborn deaths. Neonatal deaths were lower in regions where emergency obstetric care was available at the District Hospitals. We also found that parental schooling and household wealth status improved neonatal survival outcomes.ConclusionsAddressing the main causes of neonatal deaths in India – preterm deliveries, asphyxia, and sepsis – requires adequacy of specialised workforce and facilities for delivery and neonatal intensive care and easy access by mothers and neonates. The slow decline in neonatal death rates reflects a limited attention to factors which contribute to neonatal deaths. The suboptimal quality and coverage of Emergency Obstetric Care facilities in India require urgent attention.

The equity impact of participatory women's groups to reduce neonatal mortality in India: secondary analysis of a cluster-randomised trial.

Progress towards the Millennium Development Goals (MDGs) has been uneven. Inequalities in child health are large and effective interventions rarely reach the most in need. Little is known about how to reduce these inequalities. We describe and explain the equity impact of a women’s group intervention in India that strongly reduced the neonatal mortality rate (NMR) in a cluster-randomised trial. We conducted secondary analyses of the trial data, obtained through prospective surveillance of a population of 228 186. The intervention effects were estimated separately, through random effects logistic regression, for the most and less socio-economically marginalised groups. Among the most marginalised, the NMR was 59% lower in intervention than in control clusters in years 2 and 3 (70%, year 3); among the less marginalised, the NMR was 36% lower (35%, year 3). The intervention effect was stronger among the most than among the less marginalised (P-value for difference = 0.028, years 2-3; P-value for difference = 0.009, year 3). The stronger effect was concentrated in winter, particularly for early NMR. There was no effect on the use of health-care services in either group, and improvements in home care were comparable. Participatory community interventions can substantially reduce socio-economic inequalities in neonatal mortality and contribute to an equitable achievement of the unfinished MDG agenda.

Discrimination Begins in the Womb: Evidence of Sex-Selective Prenatal Investments

This paper investigates whether boys receive preferential prenatal treatment in a setting where son preference is present. Using micro health data from India, we highlight sex-selective prenatal investments as a new channel via which parents practice discriminatory behavior. We find that mothers visit antenatal clinics and receive tetanus shots more frequently when pregnant with a boy. Preferential prenatal treatment of males is greater in regions known to have strong son preference and among women whose previous children are female. We address other mechanisms such as selective recall, medical complications that might cause male fetuses to receive greater prenatal care in general, son preference-based fertility stopping rules and biases due to sex-selective abortions. Our calculations suggest that sex-selective prenatal care in maternal tetanus vaccination explains between 2.6–7.2 percent of excess female neonatal mortality in India.

Erratum to: Early Neonatal Mortality in India, 1990–2006

1. ‘‘postnatal’’ should be replaced by ‘‘post neonatal’’ in the 3rd line of the first column under the ‘‘Abstract’’ section, on p. 1. 2. ‘‘and for major states in India’’ should be deleted in the 15–16th line of the first column under the ‘‘Abstract’’ section on p. 1. 3. ‘‘postnatal’’ should be replaced by ‘‘post neonatal’’ in the 5th line of the first column under the subheading ‘‘Data’’, on p. 2. 4. ‘‘postnatal’’ should be replaced by ‘‘post neonatal’’ in the 8th line of the first column under the subheading ‘‘Trends in ENMR in India: 1970–2008’’, on p. 4. 5. In Figs. 1, 2 and their caption, ‘‘postnatal’’ should be replaced by ‘‘post neonatal’’.

High Neonatal Mortality Rates in Rural India: What Options to Explore?

The neonatal mortality rate in India is amongst the highest in the world and skewed towards rural areas. Nonavailability of trained manpower along with poor healthcare infrastructure is one of the major hurdles in ensuring quality neonatal care. We reviewed case studies and relevant literature from low and middle income countries and documented alternative strategies that have proved to be favourable in improving neonatal health. The authors reiterate the fact that recruiting and retaining trained manpower in rural areas by all means is essential to improve the quality of neonatal care services. Besides this, other strategies such as training of local rural healthcare providers and traditional midwives, promoting home-based newborn care, and creating community awareness and mobilization also hold enough potential to influence the neonatal health positively and efforts should be made to implement them on a larger scale. More research is demanded for innovations such as “m-health” and public-private partnerships as they have been shown to offer potential in terms of improving the standards of care. The above proposed strategy is likely to reduce morbidity among neonatal survivors as well.

Early Neonatal Mortality in India, 1990–2006

The increased reach of health programs in India during the past few decades has contributed to a decline in postnatal mortality including infant and child mortality; however, reduction in neonatal mortality remained negligible. About seven out of ten neonatal deaths take place within a week after birth. The progress in reduction as well as dimension along which early neonatal mortality is patterned in India remains unclear. We examine the trend in early neonatal mortality and its possible demographic and socioeconomic predictors using nationally representative data. Data from the three cross-sectional rounds of the National Family Health Survey of India from 1992 to 1993, 1998 to 1999 and 2005 to 2006 were analyzed. Early neonatal mortality rate was estimated for selected demographic and socioeconomic population groups and for major states in India using information on births and deaths during the 3 years preceding the respective surveys. Using the multivariate logistic regression model, we assessed proximate determinants of early neonatal deaths during 1990-2006. Sex of the child, child's birth size, birth order and interval, type of child's birth, mother's age at child's birth, mother's educational status, religion, household economic status and region of residence emerged as significant predictors of early neonatal deaths. The adjusted multivariate analysis indicates that majority of the socio-demographic predictors reveal a negligible decline in the probability of early neonatal deaths during 1990-2006. Moreover, based on comprehensive reviews of scientific literature on newborn's survival we document some of the recommended ways to prevent early neonatal mortality in India.

Utilization of postnatal care for newborns and its association with neonatal mortality in India: An analytical appraisal

Background39% of neonatal deaths in India occur on the first day of life, and 57% during the first three days of births. However, the association between postnatal care (PNC) for newborns and neonatal mortality has not hitherto been examined. The paper aims to examine the association of PNC for newborns with neonatal mortality in India.MethodsData from District Level Household Survey, waive three (DLHS-3) conducted in 2007–08 is utilized in the study. We used conditional logit regression models to examine the association of PNC with neonatal mortality. The matching variables included birth order and the age of the mother at the birth of the newborn.ResultsThe findings suggest no association between check-up of newborns within 24 hours of birth and neonatal mortality. However, the place where the newborns were examined was significantly associated with neonatal mortality. Moreover, findings do reveal that children of mothers who were advised on ‘keeping baby warm (kangaroo care) after birth’ during their antenatal sessions were significantly less likely to die during the neonatal period compared to those children whose mothers were not advised about the same.ConclusionsThe findings are relevant because ‘keeping baby warm’ is one of the most cost-effective and easiest interventions to save babies from dying during the neonatal period. Though randomized controlled trials have already demonstrated the effectiveness of ‘keeping baby warm’, for the first time this has been found effective in a large-scale population-based study. The findings are of immense value for a country like India where the neonatal mortality rates are unacceptably high.

Challenges in scaling up of special care newborn units-lessons from India

Neonatal mortality rate in India is high and stagnant. Special Care Newborn Units (SCNUs) are being set up to provide quality level II newborn care services in district hospitals of several districts to meet this challenge. The units are located in some of the remotest districts where the burden of neonatal deaths and accessibility to special care is a concern. A recently concluded evaluation of these units indicates that it is possible to provide quality level II newborn care in district hospitals. However, there are critical constraints such as availability and skills of human resources, maintenance of equipment and bed occupancy. It is not the SCNU alone but an active network of SCNU (level II care), neonatal stabilization units (level I care) and newborn care corners can impact neonatal mortality rate reduction higher. Number of beds is also not sufficient to cater to the increasing demand of such services. Available number of nurses is a problem in many such units. An effective and sustainable system to maintain and repair the equipment is essential. Scaling up these units would require squarely addressing these issues.

The challenge of improving neonatal mortality in India: Key to global achievement of MDG 4

In Millennium Development Goal four (MDG4), national leaders committed to reduce 1990 levels of child mortality in their countries by two-thirds by 2015. Between 1990 and 2009, child mortality has reduced globally from 89 to 60 per 1000 live births [1]; however, this trajectory is not sufficient to achieve MDG4. India has the highest number of births in the world and also accounts for over 20% of all child deaths. Achieving MDG4 globally depends on the progress and success in India, more than in any other single nation [2].

Assessment of Special Care Newborn Units in India

The neonatal mortality rate in India is high and stagnant. Special Care Newborn Units (SCNUs) have been set up to provide quality level II newborn-care services in several district hospitals to meet this challenge. The units are located in some remotest districts where the burden of neonatal deaths is high, and access to special newborn care is poor. The study was conducted to assess the functioning of SCNUs in eight rural districts of India. The evaluation was based on an analysis of secondary data from the eight units that had been functioning for at least one year. A cross-sectional survey was also conducted to assess the availability of human resources, equipment, and quality care. Descriptive statistics were used for analyzing the inputs (resources) and outcomes (morbidity and mortality). The rate of mortality among admitted neonates was taken as the key outcome variable to assess the performance of the units. Chi-square test was used for analyzing the trend of case-fatality rate over a period of 3-5 years considering the first year of operationalization as the base. Correlation coefficients were estimated to understand the possible association of case-fatality rate with factors, such as bed:doctor ratio, bed:nurse ratio, average duration of stay, and bed occupancy rate, and the asepsis score was determined. The rates of admission increased from a median of 16.7 per 100 deliveries in 2008 to 19.5 per 100 deliveries in 2009. The case-fatality rate reduced from 4% to 40% within one year of their functioning. Proportional mortality due to sepsis and low birthweight (LBW) declined significantly over two years (LBW <2.5 kg). The major reasons for admission and the major causes of deaths were birth asphyxia, sepsis, and LBW/prematurity. The units had a varying nurse:bed ratio (1:0.5-1:1.3). The bed occupancy rate ranged from 28% to 155% (median 103%), and the average duration of stay ranged from two days to 15 days (median 4.75 days). Repair and maintenance of equipment were a major concern. It is possible to set up and manage quality SCNUs and improve the survival of newborns with LBW and sepsis in developing countries, although several challenges relating to human resources, maintenance of equipment, and maintenance of asepsis remain.

Use of Biomass Fuel for Household Cooking is Associated with Neonatal Mortality in India

Background and aims: Exposure to indoor air pollution due to burning of biomass cooking fuel and its association with respiratory infections is common in low income countries, but little is known of its impact on neonatal mortality. We evaluated whether exposure to biomass fuels is associated with neonatal mortality using data from the three nationally representative National Family Health Surveys (NFHS-1, NFHS 2 and NFHS 3) in India. The surveys were conducted by the International Institute for Population Sciences and Macro International between 1992 and 2006. Methods: The type of cooking fuel was classified as low pollution fuel (LPF, liquid petroleum gas, electricity) or high/medium pollution fuels (HPF/MPF, wood, agricultural waste, etc). We included households that had births in the preceding 3 years. Neonatal mortality was compared in households exposed to LPF vs. HPF/MFP using cross-tabulations and multivariate analyses, with adjusted odds ratios (OR). Results: In NFHS-1 (1992) 92% of the 36,253 households, in NFHS-2 (2002) 88% of 32,716 households and in NFHS-3 (2005-6) 82% of the 29,611 households used HPF/MPF. Neonatal mortality rates per 1,000 live births were 23, 26 and 22 in LPF households and 49, 41 and 42 in households using HPF/MPF in NFHS-1, NFHS-2 and NFHS-3 respectively. The adjusted odds ratio for neonatal mortality was 1.53; CI: 1.01-2.31, p-0.04 in NFHS-3 (2005-6). Conclusions: Neonatal mortality was higher in households using HPF/MPF in all 3 surveys so there is an urgent need to adopt LPF for household cooking in India.