Burden of births and neonatal deaths

JNNFI

Journal of Neonatology

0973-21870973-2179

National Neonatology Forum

jn-19-1-001

Status of Newborns in India

From NNF President’s Desk

Mathur

Professor of Pediatrics, Incharge Referral Neonatal Unit, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi. E-mail: drmathur@nda.vsnl.net.in

12005

19147

Burden of births and neonatal deaths

India is home to 20% of global births and highest number of neonatal deaths in the world (1,2). Each year, 26 million infants are born in India. Of these, 1.2 million die during the neonatal period, before completing the first four weeks of life. The neonatal mortality rate (NMR) of 44 per 1000 live births in India (2000) translates into at least two newborn deaths every minute in this vast country (2). India, thus, contributes nearly 30 percent to the 3.9 million global neonatal deaths (3). India also harbors the highest number of low birth weights (LBW) infants born each year worldwide: eight million (40 %) of the total of 20 million LBW babies (4).

Estimates at the start of the new millennium puts India’s Infant Mortality Rate (IMR) at 68 per 1000 live births (2000) and under-5 child mortality rate at 95 per 1000 live births (1998-99) (5). Hence nearly two third of infant deaths and about half of under- 5 childhood deaths occur in the neonatal period. Moreover, the early neonatal mortality rate (ENMR) in India is 32 per 1000 live births (2). This implies that nearly three fourths of neonatal deaths, half of infant deaths, and one-third of under-5 child deaths occur within the first seven days of life (5). A recent study in 13 communities in Maharashtra, encompassing a population of 227000 in 231 villages and 6 urban slums, documented a NMR of 51 per 1000 live births (6). This figure was much higher than the 32 and 29 per 1000 live births reported by the NFHS II and SRS, respectively, for the state. This additional burden of hidden newborn deaths in the country needs to be accounted for when data from large surveys are interpreted. Many parents are reluctant to reveal the death of their babies. Many communities do not assign a name to the infant until she or he has survived a few weeks to avoid embarrassment and guilt in the event of death.

Neonatal mortality in different states

India is an immense country with a wide range of neonatal mortality rates in different states, from as low as 10 per 1000 live births in Kerela to around 60 in Orrisa and Madhya Pradesh (1). The highest burden of neonatal deaths occur in Utter Pradesh, Madhya Pradesh and Bihar which together accounts for 50 % of all newborn deaths in the country or 15 % of the global burden of neonatal mortality (1).

Trends in neonatal mortality

India has seen a substantial reduction in IMR and NMR in recent decades. Since the early 1970s, the IMR declined from 140 per 1000 live births to 64 (2000). The NMR has declined from 72 per 1000 live births in 1972 to 44 in 2000-a reduction of almost 40 %. The reduction in NMR is probably due three possible reasons: (a) a major decline in neonatal tetanus (NNT) due to a successful maternal tetanus toxoid (TT) immunization program, (b) a gradual increase in institutional deliveries and skilled attendance, and (c) birth spacing leading to indirect benefits for neonatal survival. However, the NMR decline in the 1990s was only 15 %. Between 1995 and 2000, there was only a negligible decrease of four points in NMR-from 48 to 44 per 1000 live births. This tapering off in the rate of decline is a cause of concern requiring serious planning and newer strategies.

Rural-urban, poor-rich differences in neonatal mortality

Rural-urban and socio-economic differences are important determinants of NMR. The NMR in rural areas is one and a half times that in urban areas, or 51.7 (per 1000 live births) compared to 33.5 in the urban population (5). An analysis of the NFHS II data shows that in India, the NMR among the poorest 20 % of the population is more than double the NMR of the richest 20 %-60 verses 26 per 1000 live births (7).

Skilled attendance and institutional deliveries

In India, Skilled Birth Attendants (SBAs) conducted only 42.3% of deliveries in 1998-99(5). Compared to the preceding five years, this rate had increased by 8 %, largely due to a 50% increase in the coverage by doctors in private sector. As expected, skilled attendance rates are low in rural areas among the poor and among illiterate women.

In 1989-99 only 33.6% of births occurred in health facilities/institutions according to the NFHSII (5). The increase from the 25.5% rate estimated in NFHS I (1992-93) (8) was essentially due to an increase in deliveries in government institutions. Amongst 75% of deliveries in rural areas continue to occur in the home, and over 80% of births among illiterate women or those with a low standard of living index took place at home in 1998-99 (5). The distribution of skilled attendance and institutional deliveries by states reveals an inverse relationship with NMR (5).

Cause of neonatal deaths

Three-fourths of all deaths occurred within the first week (6). Low birth weight infants have a higher mortality rate (23%) compared to normal birth weight infants (9%) (9). In a study to evaluate the causes of neonatal deaths in the community, specially trained village health workers examined neonates by visiting them at homes on eight or more occasions during the first four weeks. The workers meticulously recorded history and examination findings at birth and on subsequent visits. A neonatologist evaluated the details noted on the 40 infants who died in the neonatal period and assigned the primary cause of death. Neonatal sepsis including septicemia and pneumonia emerged as the most common cause, figuring in 52% of the deaths, followed by birth asphyxia (20%) and prematurity (15%). This profile presents the primary cause of neonatal deaths in an area of high neonatal mortality (51 per 1000 live births) a poor rural population, where tetanus deaths were no longer a problem (10).

Neonatal tetanus (NNT) was responsible for 350000 deaths or 25-33% of total deaths in the earlier 1980s (11). The world health organization (WHO) estimated that India led the world in NNT deaths in 1999, with 23% (n=48600) of the 215000 deaths worldwide (12).

Antenatal and postpartum care

According to NFHS II, only 65.4% of pregnant women received at least one antenatal checkup (5). Only 43.8 % of women received the recommended three or more checkups, and only one third of pregnant mothers were examined in the first trimester.

There are large variations in ANC coverage in different states. Over 90% of women received one or more checkups in Kerala, Tamil Nadu, and Andhra Pradesh but the figures for checkups dropped to only 36.3% in Bihar and 34.6% in Uttar Pradesh (5). Almost a quarter (24.1%) of pregnant women did not receive any tetanus toxoid (TT) immunization (5). Two or more of TT, recommended as an essential component of antenatal care (ANC), were delivered to 66.8% of women (5). This implies that potentially eight to nine million pregnancies in India are at risk of complications from maternal-NNT each year.

The frequency of a postpartum checkup was very poor; only 17% of the non-institutionally delivered women received a postpartum checkup (5).

Status of women

The sex ratio at birth in India is 933 females for 1000 males, a serious gender distortion with profound demographic, health, and social implications (2). India ranked 102nd in the world by the gender-related development index (GDI) (13). The female economic activity rate (age 15 and above) is 42.2%, which is half of the male rate. Of women in the 15-49 age group, only 50.8% are literate (5). The median age at marriage among 20- 49 year–old women surveyed in NFHS II was just 16.7 years. The median age at first birth among 25-29 year–old women surveyed was 19.6 years (3). NMR in mother under 20 years of age at delivery (63 per 1000 live births) was one and a half times that of mothers who were 20-29 years old (41 per 1000 live births). NFHS II data shows that NMR was 50% less if the birth interval was 2-4 years compared to that if the interval was less than two years (36 and 71 per 1000 live births, respectively) (5).

Newborn health among the urban poor

Of the one billion people in India, 28% live in cities. The annul growth rate of the urban population is 3.1% (vs. 1.9% of the overall population). As a result, by the year 2015 the numbers of urban dwellers will grow to 35%. It is estimated that 30% of urban dwellers are poor, with urban poverty amounting to 25% of the total poverty in India. Recent data suggests that poverty in urban India (26.6%) has now exceeded that in the rural area of India (11.1%) (1). Of the 285.4 million urban inhabitants, 61.8 million live in slums, about 28 million of whom (17.5%) are concentrated in six mega-cities.

The overall low rates of infant and neonatal mortality in the urban population mask the gross poor-rich disparities. These inequities are more acute than those seen in villages; the urban poor have almost double the NMR of the urban rich.

Impact of child survival and safe motherhood (CSSM) program

There has not been any national systematic study to assess the impact of CSSM program. Only a few quick reviews have been carried out, which provide patchy information on the program implementation and outcome. The second round of the National Family Health Survey (NFHS-II), done in 1998-99, shows almost no improvement in ANC, reasonable improvement in TT vaccination coverage and some improvement in institutional deliveries. The latter is mainly due to increase in deliveries in private institutions and not in the public institutions, which was the objective of CSSM program. Even the child immunization, which received the main priority in CSSM shows only moderate improvement.

Recently under the RCH project, rapid household survey has been done in most districts in 1998-99 (14). This survey gives some indicators such as ANC, place of delivery etc. this survey showed that even though 75% of women got TT, but only 32% the minimum ANC package (i.e. 3 ANC visits, TT and Iron Folic Acid tablets).

Health system

The status of the health system reported in the Facility Survey (15) is shown in table I and II. It is obvious that there are major deficiencies for this crucial level of health system especially with regard to the availability of specialists. Even Medical officers trained in newborn care and emergency obstetric care were grossly inadequate at all levels. At primary health center (PHC), the number of Medical Officers staying at the PHC is grossly inadequate. Table I

Staff (%) at District Hospital (DH), First Referral Unit (FRU) and Community Health Centre (CHC): Facility Survey 1999

Staff (%)	DH	FRU	CHC

Pediatrician	78	37	19
Obstetrician	78	48	28
Anesthetist	70	22	10
Medical Officer(MO)	94	89	81
MO trained in Newborn Care	21	22	17
MO trained in Emergency Obstetrics	19	17	11
Utilized for Referral	33	34	25

Table II

Facility Survey Primary Health Centres(PHC) 1999

Staff (%)	PHC

Medical Officer	88
Medical Officer (Lady)	20
Medical Officer (Staying)	34
Female Health Worker	91
Female Health Asstt	53

To conclude, the status of newborn health in India needs urgent action. Concerted efforts, strengthening of infrastructure and a National Program focused at the Newborn would be the minimum required to improve the lot of the Newborn

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