National Health Mission (NHM) and India Newborn Action Plan (INAP) Services in Newborn Health -An Overview

 

Mohanasundari SK¹, Dr. Padmaja A^2*

¹PhD Scholar in INC, Faculty, College of Nursing, AIIMS Jodhpur, Rajasthan.

²Vice-Principal/Professor, College of Nursing, SVIMS, Tirupati, AP.

 

ABSTRACT:

India contributes to 17.5% of the world’s population and nearly one-fifth of the total live births. Its contribution to the global burden of newborn deaths (27%) is higher when compared to that of maternal and under-5 deaths. Around 16% of global maternal death; and 21% of under-5 deaths is contributed by India. To overcome this problem UNICEF global campaign on “Every Child Alive” was launched to Protect the child from preventable causes by adopting 4 measures.  Recently, the government of India has also made some robust policy decisions to combat the major causes of newborn death with particular focus on sick newborns, preterm babies and low birth weight babies. India launched more health programs which focus on newborn care to control NMR; also those programs are given significant expected outcome.  The mile stones in maternal and child health are launch of- CSSM, RCH-II & RCH-II, NRHM, RMNCH+A, and INAP.

 

 

 

 

INTRODUCTION:

A data from three studies on the timing of neonatal deaths indicates that about 3/4^th of total neonatal deaths occur in the 1^st week of life. The 1^st 24 h account for > 1/3^rd (36.9%) of the deaths that occur in the entire neonatal period.  India contributes to 1/5^th of global live births and 27% of neonatal deaths. India contributes more than any other country to global under-5 and newborn deaths.

 

Despite considerable decisive steps, progress within India has not been uniform—i.e., reduction in neonatal mortality lags behind reduction in post neonatal deaths. Given its demographic and cultural diversity, India faces many challenges with significant rural-urban, poor-rich, socio-economic gender, and regional differences.

 

More girls are dying than boys, and newborns delivered in rural setting are twice as likely to die as those born in urban areas. Furthermore, neonatal mortality varies considerably between states and regions. The four large states of Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan together account for more than half of the country’s neonatal mortality, which accounts for about 14% of global newborn deaths. As per UNICEF report 2018 on NMR the India was ranked 12th amongst 52 lower middle-income nations. To overcome this problem UNICEF global campaign on “Every Child Alive” was launched to Protect the child from preventable causes by adopting 4 measures.

 

Action by Indian Health Policy Makers:

Newborn health has captured the attention among the policymakers at the highest level in India. Recently, the government of India has also made some robust policy decisions to combat the major causes of newborn death with particular focus on sick newborns, pre term babies and low birth weight babies. India’s efforts until now have contributed to valuable studies on newborn healthcare in settings and areas that are difficult to access. Specifically, it has:

1.     Demonstrated that community-level home-based postnatal care, including simple interventions such as thermal care and exclusive breastfeeding, can significantly improve newborn survival.

2.     Linked community- and facility-based care (FBNC), as well as referrals between various levels of the healthcare system, to create a continuous-care pathway under the NRHM.

3.     Demonstrated the country’s ability to scale up key interventions within the existing health system by establishing more than 500 Special Newborn Care Units (SNCUs) for sick babies across the country.

 

Milestones in Child Survival Programmes in India Are:

The Government of India is building on a series of efforts, policy decisions, and programmes introduced over the past two decades to address maternal and newborn health. The mile stones are launch of-

1.     Child Survival and Safe Motherhood Programme (CSSM) in 1992;

2.     Reproductive and Child Health Programme Phase I (RCH I) in 1997, followed by RCH II in 2005;

3.     The National Rural Health Mission (NRHM) in 2005 which, along with the National Urban Health Mission, became part of the National Health Mission in 2013; the Call to Action for Child Survival and Development,

4.     The subsequent Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) strategic framework in 2013. The RMNCH+A strategy is based on a continuum-of-care approach and defines integrated packages of services for different stages of life. These packages provide a framework for delivering services at the state and district level.

5.     India Newborn action plan (INAP) 2014.

 

The National Health Mission (NRHM and NUHM):

The National Rural Health Mission (NRHM) was launched on 2005 to run up to 2012 by the Govt of India to strengthen the healthcare infrastructure and to boost the failing public health indicators in the rural areas of 18 states in India. By 2013, the considerable success of the mission prompted the Union Cabinet to set up the National Urban Health Mission (NUHM) on 2013. Both the NRHM and the NUHM currently exist as sub-missions of the National Health Mission (NHM). The NHM, the NRHM and the NUHM are managed by the Ministry for Health and Family Welfare, in close association with the states.

 

Progress since the Launch of the National Rural Health Mission (NRHM) - 2005

·       Increased the number of women delivering in public health facilities to 107 lakhs each year.

·       Because of Janani Suraksha Yojana (JSY)

·       470 new MCH wings (30/50/100 bedded) have been sanctioned in the public health system, adding > 28,000 beds.

·       A nationwide network of FBNC has been established at various levels: 14,135 Newborn Care Corners at the point of child birth; 1,810 Newborn Stabilization Units; 548 Special Newborn Care Units (SNCUs) for sick and small newborns, with care to > 6 lakhs newborns being provided in SNCUs each year.

·       Janani Shishu Suraksha Karyakram (JSSK) has entitled all pregnant women and infants to free delivery, treatment, food, drugs, diagnostics, and transportation to & from facilities.

·       38,300 public health facilities constructed/ upgraded and >20,000 ambulances have been sanctioned.

·       The total number of technical HR supported under NRHM increased to 3.45 lakhs which includes 30,429 doctors/specialists including AYUSH doctors, 38,421 staff nurses, 21,965 paramedics and 2.39 lakhs ANMs.

·       Incentivized Home-Based Newborn Care programme has been launched in 2011: 8.95 lakhs ASHAs selected and more than 6 lakhs ASHAs trained to improve newborn practices at the community level; early detection and referral of sick newborn babies by making home visits as per schedule during the first 42 days after birth.

 

 

Table 1: Interventions under National Health Mission focusing on newborn care

Programmes	Objectives	Status
1.  Janani Suraksha Yojana (JSY) (2005)	·      Safe motherhood intervention to increase institutional delivery through demand-side financing and conditional cash transfer	·      Implemented in all States and Union Territories (UTs) ·      Special focus on Low-Performing States
2.  Integrated Management of Neonatal and Childhood Illnesses (IMNCI) at the community level and F-IMNCI at health facilities (2007)	·      Standard case management of major causes of neonatal and childhood morbidity and mortality	·      Operationalized in more than 500 districts 5.9 lakhs health and other functionaries, including physicians, nurses, AWWs, and ASHAs trained under IMNCI ·      26,800 medical officers and specialists placed at the CHCs/FRUs trained under F-IMNCI
3.  Navjat Shishu Suraksh Karyakram (NSSK) (2009)	·      Basic newborn care and resuscitation training programme	·      1.3 lakh health providers trained to date
4.  Janani Shishu Suraksha Karyakram (JSSK) (2011)	·      Zero out-of-pocket expenditure for maternal and infant health services through free healthcare and referral transport entitlements ·      The scheme provides free and cashless services to pregnant women accessing public health institutions including the delivery and the caesarean section charges and also treatment of the sick newborns till 30 days of life.	·      Implemented in all States and UTs ·      Assured service package benefits extended to sick children up to age one
5.  Facility Based Newborn Care (FBNC) (2011)	·      Newborn care facilities at various levels of public health services that includes ·      Newborn Care Corners (NBCCs) at all points of childbirth to provide immediate care; Newborn Stabilization ·      Units (NBSUs) at CHC/FRUs for management of selected conditions and to stabilize sick newborns before referral to higher centres; and Special ·      Newborn Care Units (SNCUs) at district/sub-district hospitals to care for sick newborns (all types of care except assisted ventilation and major surgeries)	·      14,135 NBCCs established at delivery points to provide essential newborn care ·      1,810 NBSUs established at CHCs/FRUs 548 SNCUs established at district/sub-district hospitals or medical colleges ·      More than 6,300 personnel provided FBNC training Online reporting system adapted and scaled up in seven states with 245 SNCUs made online and more than 2.5 lakhs newborns registered in the data base.
6.  Home Based Newborn Care (HBNC) (2011)	·      Provision of essential newborn care to all newborns, special care of preterm and low-birth-weight newborns; early detection of illness followed by referral; and support to family for adoption of healthy practices by ASHA worker	·      Implemented in all States and UTs ·      Most of the ASHAs trained in newborn care ·      ASHAs visited more than 12 lakhs newborn in 2013
7.  Rashtriya Bal Swasthya Karyakram (RBSK) (2013)	·      Screening of children with birth defects, diseases, deficiencies, and developmental delays (including disabilities)	·      All children, ages 0 to 18 years targeted ·      More than 8 crore children screened and more than ·      10 lakhs children identified for tertiary care in 2013
8.  Infant and young child feeding	·      Infant and Young Child Feeding is the single most preventive intervention for child survival. It advocates the following: Early initiation (within one hour of birth) and exclusive breast feeding till 6 months. ·      Timely complementary feeding after 6 months with continued breast feeding till the age of 2 yrs.	·      Children under three years breastfed within an hour of birth 33.5% increase in 2009 ·      Children 0-5 months exclusively breastfed 56.8% increase in 2009.

 

 

INDIA NEWBORN ACTION PLAN (INAP):

·       INAP was launched in September 2014, for accelerating the reduction of preventable newborn deaths and stillbirths in the country - with the goal of attaining ‘Single Digit Neo-natal Mortality Rate (NMR) by 2030’ and ‘Single Digit Still Birth Rate (SBR) by 2030’.

·       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, to advance the Global Strategy for Women’s and Children’s Health. The ENAP sets forth a vision of a world that has eliminated preventable newborn deaths and stillbirths.

·       INAP is guided by the principles of Integration (see fig-1). It includes six pillars of intervention packages across various stages with specific actions to impact stillbirths and newborn health (see fig-2). It will serve as a framework for the States to develop their area-specific action plans.

 

Snapshot of India Newborn Action Plan (INAP):

·       Builds on existing commitments under the National Health Mission and 'Call to Action' for Child Survival and Development

·       Aligns with the Global Every Newborn Action Plan (ENAP); defines commitments based on specific contextual needs of the country

·       Aims at attaining Single Digit Neonatal Mortality Rate by 2030, five years ahead of the global plan

·       Emphasizes strengthened surveillance mechanism for tracking stillbirths

·       Focuses on ending preventable newborn deaths, improving quality of care and care beyond survival

·       Prioritizes those babies that are born too soon, too small, or sick—as they account for majority of all newborn deaths

 

·       Aspires towards ensuring equitable progress for girls and boys, rural and urban, rich and poor, and between districts and states

·       Identifies major guiding principles under the overarching principle of Integration: Equity, Gender, Quality of Care, Convergence, Accountability, and Partnerships

·       Defines six pillars of interventions: Pre-conception and antenatal care; Care during labour and child birth; Immediate newborn care; Care of healthy newborn; Care of small and sick newborn; and Care beyond newborn survival

·       Serves as a framework for states/districts to develop their own action plan with measurable indicators.

 

 

Fig-1: Guiding Principles of INAP

 

 

Fig-2: Six pillars of intervention packages of INAP

 

Table-2:

Family and Community	Outreach/Sub Centre	Health Facility
.1 Preconception & antenatal care
1. Reproductive Health & Family Planning - Adolescent reproductive health - Delaying age of marriage & first pregnancy - Birth spacing 2. Nutrition related interventions - Balanced energy protein supplementation - Peri-conceptional folic acid - Maternal calcium supplementation - Multiple micronutrient supplementation (Iron, Folic Acid & Iodine) - Nutrition Counselling 3. Counselling & birth preparedness 4. Prevention against Malaria	5. Antenatal screening for Anemia and Hypertensive disorders of pregnancy (PIH, Preeclampsia, Eclampsia) 6. Antenatal screening for Malaria 7. Prevention and management of mild to moderate anemia 8. Maternal tetanus immunization 9. Adolescent friendly health services (nutrition and reproductive health counselling) 10. Interval IUCD insertion	11. Antenatal screening & management of Severe anemia, Hypertensive disorders of pregnancy (PIH, Preeclampsia, Eclampsia), Gestational Diabetes, Syphilis 12. Antenatal screening & management of Hypothyroidism, Hepatitis B, HIV, Malaria 13. Adolescent friendly health clinics (as per RKSK guidelines) 14. Post-partum family planning services including PPIUCD insertion 15. Prevention of Rh disease using anti D immunoglobulin
2. Care during labour & child birth
1. Skilled birth attendance 2. Clean birth practices	3. Identification of complications and timely referral 4. Pre-referral dose by ANM - Antenatal corticosteroids in preterm labour - antibiotics for premature	5. Emergency obstetric care - Basic and Comprehensive 6. Management of preterm labour - Antenatal corticosteroids in preterm labour - Antibiotics for premature rupture of membrane
3. Immediate newborn care
1. Delayed cord clamping 2. Interventions to prevent hypothermia • Immediate drying • Head covering • Skin-to-skin care • Delayed bathing 3. Early initiation and exclusive breastfeeding 4. Hygiene to prevent infection	5. Vitamin K at birth 6. Neonatal Resuscitation	7. Advanced neonatal resuscitation
4. Care of healthy newborn
1. Home visits till six weeks by trained ASHA • Counseling • Prevention of hypothermia, cord care • Early identification of danger signs • Prompt and appropriate referral 2. Exclusive breastfeeding 3. Clean postnatal practices	4. Immunization • BCG • OPV • Hepatitis B	5.All the interventions (except home visits)
5. Care of small & sick newborn
1. Thermal care and feeding support (for home deliveries)	2. Integrated management using IMNCI and use of oral antibiotics 3. Injectable Gentamicin by ANMs for sepsis • Pre referral • Completion of antibiotic course in case referral is refused / not possible “OR” as advised by treating physician	4. Kangaroo mother care at facility 5. Full supportive care at block and district level • NBSU at block level • SNCU at district level 6. Intensive care services (NICU) at regional level for • Assisted ventilation • Surfactant use
6. Care beyond newborn survival
1. Screening for birth defects, failure to thrive and developmental delays 2. Follow up visits of - SNCU discharged babies till 1 year of age - small and low birth weight babies till 2 years of age	3 Integrated management using IMNCI and use of oral antibiotics 4 Injectable Gentamicin by ANMs for sepsis • Pre referral • Completion of antibiotic course in case referral is refused / not possible “OR” as advised by treating physician	5. Newborn screening 6. Management of birth defects - Diagnosis - Treatment, including surgery 7. Follow-up of high-risk infants (discharged from SNCUs, and small newborns) for - Developmental delay - Appropriate management

 

CONCLUSION:

Last 10 years the newborn mortality has shown significant reduction globally, but India is still on the way to achieve SDG’s. India launched more health programs which focus on newborn care to control NMR; also those programs are given significant expected outcome.

 

REFERENCES:

1.      Bhutta ZA, Das JK, Bahl R, et al, for The Lancet Newborn Interventions Review Group and The Lancet Every Newborn Study Group. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384: 347-370.

2.      Blencowe H, Lee AC, Cousens S, et al. Preterm birth-associated neurodevelopmental impairment estimates at regional and global level for 2010. Pediatric Research 2013; 74 (Suppl 1): 17-34.

3.      Cousens S, Blencowe H, Stanton C, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet 2011; 377: 1319-1330.

4.      Every Newborn: An action plan to end preventable deaths; World Health Organization 2014.

5.      Sunita Kishor and Kamla Gupta. 2009. Gender Equality and Women’s Empowerment in India. National Family Health Survey (NFHS-3), India, 2005-06. Mumbai: International Institute for Population Sciences; Calverton, Maryland, USA: ICF Macro.

6.      Lawn JE, Blencowe H, Oza S, et al, for Th e Lancet Every Newborn Study Group. Every Newborn: progress, priorities, and potential beyond survival. Lancet 2014; 384: 189-205.

7.      Lee AC, Katz J, Blencowe H, et al, for the CHERG SGA-Preterm Birth Working Group. National and regional estimates of term and preterm babies born small for gestational agein 138 low-income and middle-income countries in 2010. Lancet Global Health 2013; 1:e26—36.

8.      Liu L, Johnson HL, Cousens S, et al; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012; 379: 2151-2161.

9.      National Family Health Survey (NFHS-3), 2005–06: India: Volume I. International Institute for Population Sciences (IIPS) and Macro International.

10.   National Neonatal Perinatal Database. Report for the year 2002–03.

 

 

 

Received on 08.07.2019         Modified on 25.07.2019

Accepted on 08.08.2019       ©A&V Publications All right reserved