We continue to grapple with strategies for reduction in neonatal mortality rates across the country. These remain stagnant or are declining at a frustratingly slow rate (<xref ref-type="bibr" rid="bib001">1</xref>,<xref ref-type="bibr" rid="bib002">2</xref>). There have been consistent efforts to deal with the problem and issues, which are believed to contribute to neonatal mortality. Unfortunately, despite a clear understanding of what maximally contributes to it, intervention strategies have been only partially successful. In broad terms this problem could be ascribed to causes relating to pre-gravid health of women, pregnancy, pregnancy care & complications, delivery & newborn care at birth and subsequently and, perhaps more importantly to community practices, its perception, participation, expectations and availability of appropriate neonatal care facilities and their utilization by the community.There is a large volume of data related to neonatal survival affected by maternal health, pregnancy & related causes, intra-natal & newborn care at birth & subsequently but not enough relating to community perceptions, participation and expectations (<xref ref-type="bibr" rid="bib003">3</xref>-<xref ref-type="bibr" rid="bib005">5</xref>). The country adopted primary care module for health care as per Bhore committee recommendations (<xref ref-type="bibr" rid="bib006">6</xref>). It also opted for a top down health care policies planned centrally through planning commission. It also followed five year planning as a module for the country as a whole irrespective of the demographic profile of the states, region or specific community. It appears that in this process it did not sufficiently dwell on the existing situation regarding the vital statistics and status of delivery of newborn health. It also ignored the need to involve the community in determining its policies, priorities, needs, necessities and logistics on delivery of newborn care; it’s impact and monitoring. The following quote (<xref ref-type="bibr" rid="bib007">7</xref>) aptly sums what we need to do if the aforesaid assumptions are some of the reasons for the current situation of newborn care in the country. <list list-type="simple"><list-item><bold>Go to the people,<break /> Live with them,<break /> Learn from them,<break /> Start with what they know,<break /> Build with what they have</bold></list-item><list-item>Lao Tsu–700 B.C.</list-item></list></sec><sec id="sec002"><title>Social Profile

JNNFI

Journal of Neonatology

0973-21870973-2179

National Neonatology Forum

jn-19-1-002

RESEARCH METHOD

Community and the Newborn Survival in India: A Perspective

Bhargava

Santosh K.

Singh

Bhaskar

Center for Newborn care, Department of Pediatrics, S.L.Jain Hospital, Ashok Vihar–III, Delhi 110 052. E-mail:drskbhargava@yahoo.com

12005

191820

We continue to grapple with strategies for reduction in neonatal mortality rates across the country. These remain stagnant or are declining at a frustratingly slow rate (<xref ref-type="bibr" rid="bib001">1</xref>,<xref ref-type="bibr" rid="bib002">2</xref>). There have been consistent efforts to deal with the problem and issues, which are believed to contribute to neonatal mortality. Unfortunately, despite a clear understanding of what maximally contributes to it, intervention strategies have been only partially successful. In broad terms this problem could be ascribed to causes relating to pre-gravid health of women, pregnancy, pregnancy care & complications, delivery & newborn care at birth and subsequently and, perhaps more importantly to community practices, its perception, participation, expectations and availability of appropriate neonatal care facilities and their utilization by the community.There is a large volume of data related to neonatal survival affected by maternal health, pregnancy & related causes, intra-natal & newborn care at birth & subsequently but not enough relating to community perceptions, participation and expectations (<xref ref-type="bibr" rid="bib003">3</xref>-<xref ref-type="bibr" rid="bib005">5</xref>). The country adopted primary care module for health care as per Bhore committee recommendations (<xref ref-type="bibr" rid="bib006">6</xref>). It also opted for a top down health care policies planned centrally through planning commission. It also followed five year planning as a module for the country as a whole irrespective of the demographic profile of the states, region or specific community. It appears that in this process it did not sufficiently dwell on the existing situation regarding the vital statistics and status of delivery of newborn health. It also ignored the need to involve the community in determining its policies, priorities, needs, necessities and logistics on delivery of newborn care; it’s impact and monitoring. The following quote (<xref ref-type="bibr" rid="bib007">7</xref>) aptly sums what we need to do if the aforesaid assumptions are some of the reasons for the current situation of newborn care in the country. <list list-type="simple"><list-item><bold>Go to the people,<break /> Live with them,<break /> Learn from them,<break /> Start with what they know,<break /> Build with what they have</bold></list-item><list-item>Lao Tsu–700 B.C.</list-item></list></sec><sec id="sec002"><title>Social Profile

India is an ancient country with ancient civilization, its own culture, community practices and beliefs extending over several thousand years. It is multilingual, multi-religious and multi-ethnic. It believes in caste system, has caste within castes and sub castes and practices it (8). It is predominantly rural, has a large urban population with tribal and nontribal population who reside in plains, hills, forests, mountains, deserts and islands (9). The language and dialects vary from region to region, state-tostate and community-to-community. The country irrespective of the religion or caste believes in tradition and religious practices for conception of pregnancy, pregnancy, delivery, newborn care at birth, immediate neonatal period & subsequently and then at different age periods. These customs and traditions vary in different regions, religions and castes (10-24). Thus, to understand the community and its perception which may have a lasting bearing on the outcome of pregnancy, newborn care and child survival, it is necessary to know about them, take cognizance of them in the context of current situation and knowledge and if required, plan appropriate responses.

Demographic Profile

India currently has a population of over 1,027 million. Amongst these 741million (72.22%) live in rural and 285.4 million (27.78%) live in urban area. It has a predominant Hindu (80.5%) population with Muslims (13.4%), Christians (2.33%), Sikhs (1.84%) and Buddhists (0.8%) constituting the other religious significant population. The proportion of scheduled caste is 166,635,700 (16.2%) and that of tribal 84,326,240 (8.2%) (9,10). It continues to have high crude birth rate, high female illiteracy rate and widely prevalent teen age and child marriages. Its maternal mortality rate is 407, and neonatal mortality rate of 44.4. Over 2/3 births continue to occur at home. 60-80% births of scheduled caste, tribes and backward classes occur at home. Traditional births attendants and family members, neighbors and others conduct these births usually. Skilled birth attendants, not necessarily of uniform quality, are available to 42.3%. Institutional facilities where these births occur hardly have any newborn care facilities at births or subsequently (Table I, II). Thus, a significantly large proportion of births, which contribute maximally to maternal and neonatal deaths, continue to occur in community at home and are attended by community/family recognized and accepted trained or untrained health professional and/or relatives and neighbors. (1,2,5) Table I

Maternal and Neonatal Social and Demographic Profile (1,2,9)

Population	1,02,70,15,247
-Rural	72.22%
-Urban	27.78%
-Scheduled Tribal	16.2%
-Scheduled Caste	18.4%
Crude birth rate	27.4
Literacy rate	65.38 (Combine)
-Female	54.1
-Male	75.85
Sex Ratio M:F	933
Mean age at marriage Female	19.5
Maternal Mortality Rate (1998)	407
Under five child mortality rate	95 per 1000 live births
Neonatal mortality rate	44.4 per 1000 live births
Estimated number of neonatal deaths	1.16 million

Table II

Place of delivery (1,2)

Place of delivery	Health facilities	Home

Rural	24.6	74%
Urban	65.1	33%
Scheduled caste	26.8	72.1
Scheduled tribe	17.1	81.8
Other backward	36.1	62.8
Other	40.1	59.0
Assistance during delivery
Skilled	49.3% (Doctors 37.3, ANM 11.1)
Unskilled	50.7% (TBA–31.4 ; Others)

Newborn Care

Maternal and Newborn Care in Ancient India

India is believed to be a mythical country. It has an ancient system of medicine known as Ayurveda. It is further believed that this system emanated directly from learning, preaching and practices propounded by Dhanvantari–the mythical God physician who came to earth from churning of the sea (25).The principles and practices of Ayurveda are enshrined in the sacred Vedas-Rigveda, Samaveda, Yajur Veda, Atharva Veda and scriptures. Ayurveda later branched off, like today’s allopathic system of medicine, into Atreya School, Sushtra School and Kashyap School. The Atreya School deals with general medicine, Sushrta with surgery, and the Kashyap School dealt with maternal and child care (Current obstetrics and Pediatrics (25,26).

The principles and practices of maternal care from pre pregnant state to pregnancy and prenatal care, childbirth & postnatal care & childcare from birth to adolescence are described in detail in Koumaara Bhritya (27).

It is amazing that this document describes in great detail the prerequisites to successful outcome of a pregnancy and child birth from physical state of men and women, to mental attitude, time of conception, sex preference rituals, pregnancy care, complications, delivery, child birth, nutrition, birthing room, care at birth, resuscitation, breast feeding, newborn care, and post natal care of the mother. A following quote describes childbirth as a fruit of conception distained to be endowed with vigorous health, beauty, intelligence and long life

Traditional Practices in Newborn Care

Traditional beliefs are an integral part across the country in different communities, tribes, castes & sects and have been in practice from ancient times. These vary in emphasis, priority, rituals and time. But a critical appraisal reveals that by and large these were beneficial and developed by observations over a long period. These include from maternal and paternal rituals for seeking conception and healthy progeny to sex preference of the fetus, and the recommendations extend from pregnancy care, intra-natal care, childbirth, newborn care at birth and newborn period to childhood and postnatal care. Example of sound practices abound. For instance taking pregnancy in stride and continuing to be physically active, prohibiting alcohol and addictive food and beverages, special body massage, breathing and perineal exercises, first delivery at mother’s house and so forth. For delivery identifying the place, planning, hygiene, cleanliness and warmth. The practice of giving childbirth in squatting position or while leaning on the back, and early ambulation after delivery. Avoiding induction of placental delivery by medication or by pressure or pull, delayed clamping of cord if the infant does not cry, religious ceremonies to fumigate and remove pollution. In the post natal period these covered from giving warm bath to mother, oil massage, providing warmth in the room, special nutritious food, sitting over fumigation, exercises and restricted visiting for several weeks (Table III) (11-24). Table III

Some examples of Pregnancy, Birth and Neonatal Rearing Related Ancient Practices in Communities

	Ancient Practices
Pregnancy
• Concept of Pregnancy	- Natural Phenomenon
	- Abnormal Period
• Change in physical and social activities	- No change
	- Restricted social activities
• Prohibition in feeding	- (Alcohol), Salfi
	- Meat, fist liquor, chillies, papaya
	- Mahua liquor given to mother
	- Eating slaughtered meat or offered meat
	- Twin Fruit, hot chillis
• Special diet to mother during pregnancy	- Some give special food
	- Some not due to low economic condition
• Antenatal care	- No special care
	- Cleanliness of birthing room etc
Delivery
• Preparation for delivery	- No special care
• Delivery is conducted by	- Traditional Dai
	- Elder Woman
	- Supported by husband and mother
• Delivery position	- Squatting position
	- Standing
	- Back inclined posture
	- Suphine
• Placenta disposal	- Bury
	- Roasting/Heating
• Umbilical Cord cutting	- By arrow head or blade
	- In case of male child arrow is used whereas incase of girls knife is used
	- Sickle
	- Razor
	- Bamboo strip
Post Natal Care
• Care of mother	- Bathed with warm water
	- Neem water, turmeric
• Food given after delivery	- Normal–Hot
	- Special–fish, coconut etc
	- Medicinal herbs
• Food not given	- Sour food, cold gold foods, vegetable
• Final purification	- Varies (6th,7th,2months)
• Religious ceremony to remove the pollution	- Fumigation
	- Breaking of coconut
	- Worshipping of local deity
• To protect babies from evil eye	- Black string ties on the arm, ankle, waist
	- Wearing of amulet and copper coins etc

Similarly for the newly born to keep placenta and umbilical vessel intact till babies cries, oropharayngeal cleaning with clean cloth, mouth to mouth breathing, massage and early feeding, using old soft clothes for clothing, body massage, restricting visiting of newborn and mother for 40 days and so forth.

However, over the years some of these practices became rituals and community ceremonies for material gains and became distorted and harmful. These practices include beliefs such as pregnancy and child birth to be dirty, isolating the pregnant women, birthing in isolated dark unhygienic corners or room, use of discarded dirty rags/clothes for delivery, abdominal pressure to hasten delivery or an obstructed labour, keeping placenta and cord attachment intact and warming or roasting it for reviving asphyxiated births, applications on umbilical cords or tying with rags, bathing the newborn immediately after birth, removing vernix, delaying breast feeds, pre-lacteal feeds, keeping the baby naked and so forth (Table II-IV). Table IV

Traditional Practices of Neonatal Care and recommendations of Indian System of Medicine(ISM) Neonatal Care (TPNC) (22)

Traditional Practices Neonatal Care (TPNC)	Indian System of Medicine (ISM)

1. Resuscitation
Routine	(Pranpratyagamanam)
Cleaning of the face and oral cavity with ghee and rock salt Swab soaked in Balatail applied on head Face cleaned with water Anal and urethral orifices cleaning Tongue, lips, throat and palate cleaning with right index finger Ghee and rock salt given for vomit out the swallowed amniotic fluid	ISM does not support the following which are practices as TPNC Excessive physical stimulation Flicking of the sides Crushing of the placenta Striking of the stones near the base of ears and cleaning of the mouth, upper respiratory and alimentary canal with rock salt and ghee can be used in the absence of suction of mucous catheter etc.
Unconscious Child:
Two stones stricken near the base of ear to asphyxiated baby Hot and cold water sprinkle over the face Fanning with blackened broken earthen pot
2. Cord Care Practices
Cord cutting: with knife or sickle cut shaped sharp edged instrument Cord tying: with silken-soft and pure thread Cord dressing: Materials are different for wet and dry cords Lodharadi Churna on wet cord Kushtatial or IO dhraditial on dry cord	Binders are not mentioned in the ISM for cord The cut end of the stump is gently dressed with soft cotton Preservations of shed cord is not mentioned Bamboo spikes etc. are not advised for cutting the cord Sickle shaped instrument advised Turmeric as antibiotic and antiinflammatory an be used for cord dressing
3. Prelacteal feeds and bathing
Practice of giving pre-lacteal feeds before giving breast feeding (Jatkarma Samskar) Massaged with ‘Balatail"and bathed with hot or luke warm decoction	Appreciate all practices
4. Colostrum and breast feeding
Throwing away colostrums as advised by the elders	After giving the pre-lacteal feed ISM suggests giving mother’s milk, few drops should be discarded before giving every feed, for purifying the tubules
5. Galactogogues
Believed that the galactogogues are only breast milk promoters	Medicines purifying breast milk is to be given before giving galactogogues
6. Baby massage and exercise
Massage with medicated oil or ‘tiltail’ given to neonate Gentle exercises enhance flexibility and coordination, practiced in TPNC	Also describe this practice beneficial Special exercise should not be given to neonate
7. Nose and ear piercing
Practice followed in immediate neonatal period	Nose piercing is not mentioned in ISM. Ear piercing recommended at the age 6^th and 7^th month of life
8. Kajal application
Prevalent as more of a tradition	No specific recommendations are found in ISM for its use in neonates
9. Janamghutti
Used at every house as home remedy for better development	Lehya (medication) used in ISM for common neonatal problems (constipation)

Community Perceptions, Myths andBeliefs in Newborn Care

The birth of a newborn is almost always a joyful event and its outcome whether favourable or other wise is considered God’s wish. The delivery and childbirth is often considered a dirty untouchable/unhealthy process and is conducted in a dark, dingy corner or room of the house. The community often follows family practices or beliefs for pregnancy care, determines the place of child birth as per elder or the family wish, the birth is conducted as per community birth attendant or family tradition by an elder/or experienced family member, a relative or a neighbour. It follows its own tradition for placenta disposal, cord cutting, resuscitation, and feeding practices including prelacteal feeds, time to initiate the feeding, type and frequency of feeding. It further follows newborn practices of giving a bath, clothing, massage, eye care, cord care visiting mother and newborn and religious ceremonies such chatti (sixth day) naming or annaprashan as per family traditions (28-44).

These beliefs are deeply rooted and practiced by almost all social classes, castes & religious community irrespective of the status and education of mother or family (10-24).

Newborn Care in Contemporary India

Post independence the country adopted a population based primary care health delivery system for rural areas. It has a tiered system of sub center, primary and community health center, and first referral unit and district hospital. There is no such health delivery system for urban population. State Government & non-government agencies and Municipal Corporation provide the health care to urban population.

In recent times private sector is emerging as a significant provider of health care in both urban and rural areas. The cities and metropolitan towns are beginning to attract corporate sectors, groups and individuals to provide state of the art hospital services and satellite clinics.

But, despite all the recent changes and developments, the national surveys and data relating to maternal and newborn care unquestionably establish the fact that it is still determined and/or influenced by community and family perceptions, traditions and beliefs. More than 50% in rural and almost 33% in urban area deliveries still occur at home. These continue to be conducted largely by unskilled, untrained or poorly trained traditional birth attendants or family members and neighbors. (1,3,5) (Table I, II).

The institutional deliveries and births comprise only 1/3 of the total births and the delivery and newborn care facilities are grossly inadequate and unsatisfactory. The antenatal clinics are over crowded and the quality of antenatal care questionable. The delivery rooms are shabby. The lighting and ventilation, cleanliness, hygiene, temperature and general environment is often poor (29,30). The basic facilities as recommended in the Essential Newborn Care Programme of RCH are negligible. Further more, even where facilities are available the community for its own reasons prefers to go elsewhere than to the Government provided institutional facilities. Thus a realistic and pragmatic analysis of the current scenario for the state neonatal health and mortality rate points to following:

There is limited quality facilities for maternal, delivery and neonatal care in rural infrastructure and there is an absence of linkages between the tiered systems, inter referral and transport system.

Organized infrastructure facilities for maternal and neonatal care in urban population and difficult terrain such as deserts, mountains and islands are nonexistent.

Poor utilization of existing facilities by the community.

Community and families are seeped in traditional and religious beliefs, perceptions, and practices for pregnancy care, delivery and childbirth and newborn care.

Almost 60-80% of births specially in scheduled caste, scheduled tribes and backward classes occur at home by community/family accepted traditional birth attendants/family members or neighbors.

Lack of participation or involvement of the communilty in determining its needs prioritization and monitoring of maternal and newborn care services.

The policy makers, administrators and professionals involved with maternal, perinatal and neonatal care too have begun to appreciate these concerns and are in the process of evolving strategies to address these problems. The country is in the process of launching RCH II with Integrated Management of Neonatal and Childhood Illness (IMNCI) as the pivotal programme for newborn and childcare (31). The neonatal component in this programme is unique to this global programme. It has been included at the insistence of India as per the country needs. It has following aims:

Improve neonatal, infant and child survival in order to achieve the goals laid down in the National Population policy, the National Health policy and the 10^th Five Year plan goals by 2007.

Reduction in under-five mortality to two thirds as envisaged in Millennium development Goals.

Reduction in IMR to under 30/1000 live birth by 2010

Reduction of Neonatal mortality to 26/1000 by 2007.

Improvement in Intermediate Child Health Care indicators.

The programme further aims to encourage institutional deliveries, focus on home based care effected through ANM, Anganwadi worker, Traditional Birth Attendant (TBA) and by creation of a new cadre of Skilled Birth Attendant in the community. It also includes strengthening of health care facilities and community involvement.

It is planned to implement this programme in phases and is expected to cover 250 districts by 2010. Health planners without adequate consultation or participation from the community again essentially design the programme centrally. It involves massive effort in extensive training of health professionals of different categories from top down to grass root workers including medical officer, Auxiliary Nurse Midwife (ANM), anganwadi workers, nurses, TBA, and so forth. Anganwadi worker is expected to anchor the programme and play a key role. A new category of skilled birth attendant is to be trained for the community.

But this programme has several limitations. It excludes newborn care at birth, the most crucial period for newborn survival. It aims to train the same category of health professional who have received such training in the past in several other initiatives of similar nature. It also does not clearly define delivery of newborn and childcare in the urban community as it has no formal health delivery system and lacks an infrastructure like the rural health delivery system. It also does not clearly specify the strengthening of health care facilities at institutional level.

The other programmes for newborn care include TBA training programme, District newborn care and Janani Suraksha Programme and several small satellite programme in different states and parts of the country (3-5,31,32).

But irrespective of these initiatives and focus on newborn health, it is unlikely that these programme including IMNCI, which has still to take off, one will enable the country to meet it’s national goals of reduction of NMR, IMR and under five mortality by 2007 and 2010 (33,34).

Thus, to bring about an immediate perceptible, sustained and effective change in the current situation and accelerating the decline in neonatal mortality and as a consequence infant and under five mortality rates and to meet the national goals for the same for 2007, 2010 and 2020 there is need to rethink and re-strategize. It is necessary now to separate the grain from the chaff, adopt practical pragmatic approaches based on local, state and regional situation rather than to adopt strategies which disregard facts and make recommendations, which though may be ideal, are neither practical nor feasible, nor acceptable or implementable within a time frame in the community and the country. It is imperative that the programme recognize the ground realities, accept community practices and perceptions and utilize the existing resources for immediate and long-term gains rather than disregard these and hope to achieve national goals through creation of new cadres or add additional responsibilities to existing cadre of health professionals.

Community and the Newborn Health and Survival

For long, health issues have been discussed, planned and implemented through policies and programmes designed centrally and uniformally. It has not critically considered the ground situation, which varies enormously in different parts of the country from region to region, state to state or district to district. The neonatal mortality varies from 10-22 in the state of Kerala, Manipur, Karnataka, Goa, Tamil Nadu to 46.5-54.9 in Bihar, Rajasthan, Uttar Pradesh, MP and so forth. (1,2) While several factors including socio-economic conditions, educational status, basic amenities contribute to these, it is also known that availability of facilities, level of training and skills of health professionals and community perceptions and beliefs also contribute, if not more, but equally to neonatal survival. It is therefore necessary to consider the neonatal mortality rate, prevalent practices of delivery, child birth and newborn care, availability of facilities and their utilization by community while planning and determining strategies for improving neonatal health and intact survival. In this entire process the community should be involved from the beginning for determining its priorities and needs and ultimately monitoring its impact. Some of the strategies, which could be adopted, are as follows:

Neonatal mortality rate and tiered primary, secondary and tertiary newborn care

Neonatal mortality rate should be strongly considered as an indicator of neonatal health and the neonatal care facilities and strategies planned accordingly. Thus, a neonatal mortality rate of 30 or more should focus on provision of primary or level I care with emphasis on ensuring provision of appropriate components of Essential Newborn Care at home based domiciliary care or institutional based care. The neonatal mortality rate of 20-29 should have strong emphasis on facilities of Level II neonatal care in both urban and rural areas and the high-risk newborn treated or managed at institutional facilities. A neonatal mortality of 19 or less will need level III or tertiary facilities (3,4).

We have, for long shied away from a concept of concurrent provision of primary, secondary and tertiary care. We have accepted the logic and advise that India only needs primary care because of high NMR and secondary and tertiary care are expensive and will utilize a major share of limited resources. This is a myth and needs to be exploded. The country has progressed in so many ways, the technical and higher level of education is an example. Irrespective of the continuing high illiteracy rate the country continues to provide and expand on higher education. The result is visibly seen with the country being acknowledged globally as rich in knowledge and a leader in information technology. We need without any doubts or question all the three levels of care, linkages, transport and referral between them, with judicious utilization and disbursement of its resource.

Neonatal care through Panchayat System of Governance

Panchayat system of governance is a political and administrative reality. Its importance is being increasingly recognized. Community, which elects its panchayat body with women as a president/or a vice president, should be involved from inception and planning to implementation and monitoring of the programme. It is a tiered system at village, block, and district and a similar programme for newborn care of primary, secondary and tertiary could be linked and created with the existing system. The Panchayat is empowered in many ways and thus can monitor utilization of resources, creation of facilities and evaluate through its own parameters the impact of the programme. So far involvement of Panchayat has been very limited, but wherever it has been done it has been successful. It is possible to develop such a programme with state governments and professional bodies such as National Neonatology Forum (NNF), Indian Academy of Pediatrics (IAP), Federation of Obstetrics and Gynecological Society of India (FOGSI) coming together to pool expertise and resources. The NNF had indeed developed such a programme with Government of Madhya Pradesh and an extensive programme for the entire state but unfortunately due to change in the political situation the programme could not be piloted. An earnest attempt at the national level is urgently needed to evaluate this strategy, which is by the community and for the community (3, 4).

Newborn care through Municipal Corporation and City Governance in Urban Communities

A similar strategy could be attempted in city and metropolitan area. As a matter of fact the challenge of delivery of newborn care in urban areas is more difficult and needs to be much more dynamic and flexible. The population is constantly in flux and most of the civic amenities are over burdened. There is a growing population of urban slum in jhuggi-jhopdi (JJ) colonies. All the vital statistics and parameters relating to maternal and child health are worse in slums than any other community in the country. (4)

But the encouraging feature in urban areas is the growing private sector, which is expanding at a rapid rate in the form of clinics, nursing homes and private hospitals. A significant proportion of population is utilizing these services. Thus, it is imperative and necessary to involve private sector in delivery of neonatal and child care.

Traditional Birth Attendant (TBA) and Newborn Survival

The role of Traditional Birth attendant in maternal and newborn has been under considerable debate (35). As a matter of fact several donor agencies do not recommend support for their activities or training as part of perinatal services. Their inclusion or otherwise is therefore a subject of much concern for the country as they continue to be a major provider of delivery and newborn care in both urban and rural community. Irrespective of what is being said, the fact remains that they are presently an integral part of maternal, delivery and neonatal services in the country. The government of India has been recognizing their role and has actively involved them in the care with a national Dai training programme from 1995, which has only recently been revamped (2-5).

There are several success stories of TBA’s successfully conducting deliveries and newborn care (36-44). They have not only been trained in tasks of delivery but actually in conduction of safe births, resuscitation of newborns, identification of low birth and providing essential newborn care such as warmth, identification of at risk infant and referral, weighing and recognition of low birth weights and early breast-feeding (37-39).

If the national goals for 2007 and 2010 are to be attained then the country has no alternative but to make them a part of maternal and neonatal health delivery care. Some of the reasons why they have not be so successful has been inadequately defined, expectations or too much of expectations from them by burdening them with unnecessary knowledge and cumbersome Dai kits. We need to precisely identify and define their role and accordingly draw their training programme and the Dai kit. In our experience they could be trained in identification of at risk pregnancy, difficult labour, clean and safe delivery features such as use of clean linen, cord, place of delivery, hand washing, use of clean blades, cutting of cord, placenta disposal, providing warmth to infant, early breast feeding, identification of low birth weight clinically, or by spring balance weighing or bangle use, timely referral of at risk or sick newborn (39). There is considerable scope in modifying their programme to focussed, task related and skill acquisition acquired through short courses. The delivery kit can be modified to be more users friendly, appropriate, effective, and practical.

Anganwadi worker and Newborn care

The IMNCI programme in RCH II National programme proposes to involve anganwadi worker in newborn care. The experience with field studies has been extremely limited at micro level and the logistics of coordinating and implementing at a national level are still being worked out. They have never been a traditional community delivery and newborn care provider and have been providing childcare with totally a different mindset, expectations and training. The community also perceives them in a different way as the provider of nutrition, childcare and immunization. To train several thousand of these professionals and monitoring them is a huge effort. But the greater concern is their acceptability by the community and the traditional birth attendants regarding them as colleagues rather than a competitor in their profession (5-34).

District Newborn Care Programme

This is an ongoing national programme being conducted by National Neonatology Forum with support from Government of India, Ministry of Health and Family Welfare. In over 80 districts health professionals including medical officers have been trained in Essential Newborn Care. In addition to training the district hospital, First referral Unit (FRU), Primary Health Centre (PHC), and Community Health Centre (CHC) are being provided with equipment as per Essential Newborn Care programme. There is need to coordinate this programme with the National Dai Training Programme and link these with Janani Suraksha Programme. A concerted and coordinated effort of such a nature in the same population is likely to be successful and rewarding in meeting national goals.

Community Awareness

There is a tremendous need to inform, educate and communicate with both urban and rural communities regarding the necessity of providing basic care to every newborn irrespective of its weight, gestation, place of birth and person conducting the birth. The often-repeated sentiment that the survival of the newborns is God’s wish has to be exploded. The community is to be made aware that the occurrence of low birth weight/or small babies and neonatal deaths are preventable with simple care such as regular antenatal care, safe delivery by trained professionals, spacing of 2 years or more between consecutive births, delaying pregnancy beyond teenage, good home cooked simple meals of vegetable and cereals, rest and so forth. The community has to be informed of harmful neonatal care practices and beneficial newborn care practices. Community awareness has to be undertaken and implemented perhaps at the same level and with as much commitment from the government and nongovernment national and international agencies as the Pulse Polio Immunization. There is a tremendous opportunity to link Newborn Care with national Immunization, Breast-feeding, AIDS, and Hepatitis B preventive programmes.

Telemedicine and Telecommunication

This has a place in delivery of routine maternal and newborn care especially in areas with difficult terrain such as mountain deserts and islands. This can be further effectively used not only to provide medical assistance but also in training programme as it will considerably reduce time for travel and finances. The country has the logistics needed for the same. Possession of Television and Mobile phones are no more the exclusive prerogative of the elites or economically well to do.

These are becoming routine needs and necessities of daily life of a common man. There are examples in the country where these are being successfully used in the health care (45). Thus, there is a strong case to make use of these technological advances in care and survival of the newborn in the community.

References1

Indian Institute of Population Studies

National Family Health Survey (NFHS-2) 1998-99Mumbai2000.2Family Welfare Programmes in India, Year Book 2001,Department of Family Welfare, Government of India http://health.nic.in/ybol.pdf.3

Bhargava

The Challenge of neonatal mortality in India

Indian Pediatr200441657662.4

Bhargava

Newborn care in India. At the Cross Roads

J Neonatology200317513.5

Dadhich

Paul

State of India’s Newborn’s National Neonatology Forum and save the children/US

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