Dr.

Ravikumar Chodavarapu
D.C.H; D.N.B; F.I.A.P(Nephrology)
Professor of Pediatrics
Kakatiya Medical College & M.G.M.Hospital
Warangal
WORLD - N.M.R - MAGNITUDE
NEONATAL CARE UPGRADATION
WHAT FOR (GOAL or OBJECTIVE)
To reduce NMR or CFR.

WHAT IS TO BE UPGRADED?
KNOWLEDGE, SKILLS, ATTITUDE.


WHAT IS THE EVIDENCE FOR IT?
How many depressed babies require
increasing levels of interventions?
PCNA, JUN 2009, VOL56, No 3, P 516.
Most compromised neonates who require assistance in
the transition from intrauterine to extrauterine life
respond to effective PPV.

Only 1% of all neonates require further intervention
in the form of chest compressions or administration of
intravenous fluids or medications.
(Kattwinkel J, editor. Textbook of neonatal resuscitation. 5
th
edition. Elk Grove Village (IL):
American Academy of Pediatrics and American Heart Association;2006.)
What does it mean?
At the most 1% of compromised babies require high-
technological assistance of cardio-pulmonary
management. All that may reduce NMR by 10.

Presently N.M.R is 44 in our country?

Other reasons if identified and corrective strategies
implemented, N.M.R can be reduced further.

What are those causes & strategies?
CAUSES N.M.R
MOST ORIGINATE FROM LACK OF BASIC NEONATAL CARE
MAIN REASONS FOR N.M.R
Immediate, Basic neonatal care, from the time of
delivery is not available to majority of babies.

Lack of prompt basic care leads to much mortality &
morbidity.

Skilled clinical care is not reachable & affordable.
Community Care or Clinical Care Strategies
Outreach and family-community services :
access of the poor to basic services
while professional clinical care is being strengthened
and made more equitable.

Even with a weak health system, measurable mortality
reduction can be achievedby starting with outreach
and at the family-community level.

Greatest success comes when both are linked.
(www.thelancet.com Vol 365 March 19, 2005 )
WHAT IS THE ROLE OF STRATEGIES TO REDUCE N.M.R?
WHAT ARE THE COSTS OF THOSE STRATEGIES?
MYTH - FACT
Countries or programmes should wait until post-
neonatal deaths are reduced before addressing neonatal
mortality

Fact: Neonatal mortality accounts for 38% of deaths in
children aged younger than 5 years.

Neonatal interventions, such as exclusive breastfeeding
and improved care of LBW infants will reduce post-
neonatal mortality in addition to neonatal mortality
MYTH - FACT
Only developed countries with high GDP have
succeeded in reducing neonatal mortality

Fact: Countries such as Honduras, Indonesia,
Moldova, Nicaragua, Sri Lanka, and Vietnam have
reduced neonatal mortality despite having fairly low
GDPs
MYTH - FACT
High-tech interventions, such as neonatal intensive
care units, are needed to reduce neonatal mortality



Fact: Most countries with a low NMR achieved
substantial reductions in neonatal mortality (to an
NMR of about 15 per 1000) before neonatal intensive
care became widely available.
MYTH - FACT
There are few effective, low-cost interventions




Fact: Several low-cost interventions are effective in
reducing mortality, including tetanus toxoid
vaccination, exclusive breastfeeding, K.M.C for LBW
infants, and antibiotics for neonatal infections.
Hand Hygiene
Evidence Based, Cost-effective interventions
Lancet 2005; 365: 97788
MYTH - FACT
Only facility-based, professional care can save
newborn babies

Fact: There is convincing evidence that neonatal
mortality can be greatly reduced by community-based
interventions delivered through non-midwife
community health workers.
MYTH - FACT
Neonatal-specific interventions are not needed, since
current safe motherhood and child survival strategies
are sufficient to reduce deaths of newborn babies

Fact: Although maternal care is essential for neonatal
survival, there are several specific neonatal care
interventions that can reduce neonatal deaths and
should be systematically included within the relevant
programmes.

There has been insufficient attention paid to neonatal
health in both maternal and child health programmes.
Reductions in N.M.R in developed countries
preceded the introduction of expensive neonatal
intensive care.
In England, for example, the NMR fell from more than
30 in 1940 to 10 in 1975, a reduction linked to the
introduction of free antenatal care, improved care
during labour, and availability of antibiotics.

MacFarlane AJ, Johnson A, Mugford M. Epidemiology. In Rennie JM, Roberton,
NRC, eds. Textbook of neonatology (3rd edn). Edinburgh: Churchill
Livingstone, 1999: 333.
Reductions in N.M.R in developed countries
preceded the introduction of expensive neonatal
intensive care.
In Sweden, perinatal mortality declined at the end of the
19th century by 1532% in those who used midwives for
home deliveries.

The training of midwives at that time, working largely in
community settings, emphasised keeping the baby warm,
neonatal resuscitation with tactile stimulation, daily cord
care, early breastfeeding, and the use of aseptic techniques.



Hogberg U. The decline in maternal mortality in Sweden: then and now. Am J Public Health 2004; 94: 131220.

Andersson T, Hogberg U, Bergstrom S. Community-based prevention of perinatal deaths: lessons from
nineteenth-century Sweden. Int J Epidemiol 2000; 29: 54248.

N.M.R REDUCTION DEVELOPING COUNTRIES
Born without the Basic care
Community neonatal care was more cost effective than institutional
care.
(Committee on Improving Birth Outcomes, Board on Global Health. Improving birth outcomes. Meeting the
challenge in the developing world. Washington, DC: National Academies Press, 2003.)


Bang and colleagues showed a 62% reduction in neonatal mortality
in rural India through a community based approach that included
training of TBAs and local women to treat sick newborn infants at
home.
(Bang A, Bang R, Baitule S, Reddy M, Deshmukh M. Effect of home-based neonatal care and
management of sepsis on neonatal mortality: field trial in rural India. Lancet
1999;354:1955-61.)


A trial in Nepal of a less intensive community intervention showed
a 30% reduction in neonatal mortality and, surprisingly, a
significant reduction in maternal mortality.

(Manandhar D, Osrin D, Shrestha B, Mesko N, Morrison J, Tumbahangphe K, et al. The effect of a participatory
intervention with womens groups on birth outcomes in Nepal: cluster randomized controlled trial. Lancet
2004;364:970-9.
N.M.R REDUCTION DEVELOPING COUNTRIES
Where the IMR is more than 30. HBNC has a proven
record of reducing it to below 30.
(Abhay T. Bang, Rani A. Bang, Hanimi M. Reddy. Home-Based Neonatal Care: Summary and
Applications of the Field Trial in Rural Gadchiroli, India (1993 to 2003). Journal of Perinatology
2005; 25:S108S122)

It is worth noting that Sri Lanka reduced its IMR down
to the level of 15, despite having only 50 NICU beds in
the entire country.
(Harenda de Silva DG. Perinatal Care in Sri Lanka: secrets of success in a low-income
country. Sem Neonatology 1999;3(4):201 8.)

This was done mostly by a decentralized health care
system reaching almost every mother and newborn.
LIMITATIONS OF NICU CARE
The substantial improvement in newborn survival in
the United States over the past several decades is
mostly due to better access to improved neonatal care
for low-birth-weight infants.

Although survival has improved, the proportion of
births born before term continues to increase and the
rate of disability among the preterm survivors has not
decreased.
P.C.N.A.JUN 2009.VOL 56. NUMBER 3

LIMITATIONS OF NICU CARE
Low birth weight in general is thought to place the
infant at greater risk of later adult chronic medical
conditions, such as diabetes, hypertension, and heart
disease.

Can NICU care prevent them Evidence so far tells
that NICU care is not related to the problem.

In that case prevention of LBW is needed for that
purpose.

NEONATAL MORTALITY
PROBLEM & CURRENT PRACTICE SOLUTIONS ARE DIFFERENT

Not practicing what is already known.

Not delivering the service to where it is needed.

Misconception that expensive, high-tech approaches are
necessary to save newborn lives.


Many countries - UK, Sweden, Sri Lanka - achieved
neonatal mortality rates of 15 per 1000 or less before such
care was available.
Bulletin of Tropical Medicine and International Health. Volume 13:No.1, 2007
PRIORITIES IN NEONATAL CARE IN DISTRICTS PUBLIC SECTOR
Train TBAs, Community in Antenatal and early neonatal care
& early referral.

Promote institutional delivery & delivery room care.

Warmth, Breast feeding,, Infection prevention measures
Core neonatology of any level

Simple & effective neonatal care of LBW & Preterm
Basic NICUs - Care and Monitoring Vs Gadgets

Parental & Family education in Neonatal Care
Hand Hygiene, Warmth, Feeding properly

Technology & intensive care for select cases.
INDIVIDUAL PEDIATRICIAN LEVEL NEONATAL CARE PACKAGES
PRIVATE SECTOR
Pediatrician + Obstetrician practice at one place
Develop Antenatal, Perinatal Care, Emergency care

Training their staff Nurses etc in neonatal care.

Educating parents to improve home care of babies,
recognition of illness, early care seeking.

Type and Level of NICU as per the practicing areas
Clinical/Curative needs.

ENOUGH EVIDENCE TO SAY
Feasible, highly cost effective interventions are
available that could avert up to 72% of neonatal
deaths.

NMRs of about 15 per 1000 are achievable with the
basic intervention packages.
REDUCTION OF N.M.R IS TO BE A PASSION
NICU IS NOT TO BE A FASHION,
BUT A PERCEPTION..