THE INDIA NEWBORN ACTION PLAN

THE INDIA NEWBORN ACTION PLAN

▪ Current Situation

▪ Vision & Goals

▪ Guiding principles

▪ Strategic Intervention Packages

▪ Milestones

▪ Way Forward

CAUSES OF NEONATAL DEATHS : INDIA

Data Source : Liu et all. Lancet 2012 Statistical report

• Prematurity is the major cause (35%)

• Neonatal infections cause 1/3rd

of neonatal deaths (Pneumonia and Diarrhoea - 18%, and Sepsis-15%)

• Intra-partum causes / Birth asphyxia – responsible for 1/5th

of neonatal deaths

TIMING OF NEONATAL DEATHS

5

Contribution of Neonatal to Under Five Mortality (%)

64 63 63 6259 58 58 57 56 56

54 54 54 5349

39

0

10

20

30

40

50

60

70

Data Source – SRS 2012

WHERE ARE THESE DEATHS HAPPENING…..

4 states: UP, Bihar, MP and Rajasthan contribute to 56% of neonatal deaths

in India

14% of global newborn deaths

TRENDS IN MORTALITY RATES IN INDIA (2000-2012)

Source: SRS

6866

6360

58 58 5755

5350

4744

4244

40 4037 37 37 37 36 35 34 33

3129

32

2725 25 26

28 28 2927 27

25 24 23

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Infant Mortality Rate

Neonatal Mortality Rate

Early Neonatal Mortality Rate

MAJOR MILESTONES FOR INDIA'S NEW BORN

1992 – Child Survival & Safe Motherhood Program (CSSM) – RI, ARI, Diarrhoea, Safe delivery kits, FRUs

1997 – RCH I – RTI and STI component added

2005 - RCH II/ NRHM –

Cash transfers for institutional delivery;

Introduction of ASHAs

2011 – JSSK – Free health care made an entitlement for Pregnant women and New Born

2013 – Call to Action Geographical prioritization – 184 HPDs and RMNCH+A

Rapid scale up of Facility based new born care – 548 SNCUs

Largest Community based program for New born in place –Home visits by 900,000 + ASHA workers

Major Policy gaps around high impact interventions addressed

Seven States have achieved MDG 4

THE INDIA NEWBORN ACTION PLAN

India envisions a health system that eliminates preventable deaths of newborns and stillbirths and where:

- every pregnancy is wanted

- where every birth is celebrated, and

- where women, babies, and children survive, thrive, and reach their full potential.

Targets to achieve single digit NMR and SBR by 2030

GOAL 1: ATTAIN SINGLE DIGIT NEONATAL MORTALITY RATE BY 2030

29.0

26.2

22.1

18.6

15.7

25.9

20.5

15.2

9.9

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

2012 2015 2020 2025 2030 2035

NMR (Based on Current AAR) NMR (Accelerated levels to achieve global targets)

GOAL 2: ATTAIN SINGLE DIGIT STILL BIRTH RATE BY 2030

22.0 21.420.5

19.718.8

20.0

16.6

13.2

9.8

0.0

5.0

10.0

15.0

20.0

25.0

2012 2015 2020 2025 2030 2035

SBR (Projected Levels Based on Current AAR) SBR (Accelerated levels to achieve global targets)

JOURNEY OF INAP IN INDIA

2013, April - Johannesburg, Global Newborn Health Conference

Constitution of a National Committee

Constitution of Sub-committees: HBNC, FBNC, Urban Newborn Health, Pvt Sector and RMNCH+A

Bottleneck Analysis: Rajasthan, Odisha and Andhra Pradesh

RECENT POLICY INITIATIVES TO STRENGTHEN NEWBORN INTERVENTIONS

Antenatal Corticosteroids in Pre-term Labour

Gentamicin use by ANMs for sepsis management in young infants

Vitamin K at birth

Scaling up FBNC

Revised guidelines for HBNC

SNCU online monitoring and follow up tracking

system

RECENT POLICY DECISIONS TO STRENGTHEN MATERNAL HEALTH

▪ Distribution of Misoprostol by ASHAs in home delivery cases

▪ Calcium supplementation during pregnancy

▪ Screening for ▪ Gestational Diabetes

▪ Hypothyroidism

▪ Congenital Syphilis, and

▪ Hepatitis B

▪ De-worming during pregnancy

▪ Ultrasonography during pregnancy

▪ Breast and Cervical cancer screening

▪ Training of Surgeons for Caesarean section

▪ 3-day hands-on training programme for intrapartum and newborn care

Integration

Partnerships

Equity

Gender

Accountability

Quality of care

ConvergenceI

N

A

P

SIX GUIDING PRINCIPLES

SIX INTERVENTION PACKAGES

Pre-conception & Antenatal

Care

Care during

labour & childbirth

Immediate newborn

care

Care of healthy

newborn

Care of small &

sick newborn

Care beyond survival

I

N

A

P THUMB RULES:

1. All interventions delivered at family &community level are also available at outreach/ Sub Centre level.

2. All interventions delivered at outreach/Sub Centre level are also delivered at health facility level.

WHERE SHOULD WE FOCUS….

High Impact Interventions For Reducing Neonatal Deaths

Interventions around Birth – 41% impact

(Skilled birth attendance, emergency obstetric care, neonatal

resuscitation and immediate care at birth)

Care of Small and Sick newborn – 30% impact

( Kangaroo mother care, SNCU, Full supportive care)

Community Care – 25 to 30% impact (Exclusive Breast

feeding, hand washing, home based care, behaviors & practices)

WHERE SHOULD WE FOCUS….

Day of Birth is Most Dangerous for Mother & Newborn

46% of Maternal Deaths

40% of Neonatal Deaths

40% of Still Births

Interventions Targeting Day of Birth – Triple Returns on Investment

19

43,500 45,500

4,56,000

52,000 54,500

1,87000

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

PreconceptionNutrition

Antenatal Care Care during labourand birth including

complications

ImmediateNewborn Care

Care of the healthynewborn

Care Of The Small& Sick Newborn

Dea

ths

aver

ted

Stillbirths averted

Maternal lives saved

Newborn lives saved

India specific analyses based on EN Lancet Paper 3, 2014 by AIIMS, V.K Paul

Number of Deaths Averted by Stage of Intervention

PRECONCEPTION AND ANTENATAL CARE INTERVENTIONS PACKAGE

Family and Community

• Reproductive Health & Family Planning

• Nutrition related interventions

• Counselling & Birth Preparedness

• Prevention against Malaria

Outreach/Sub Centre

• Screening for Anemia and Hypertension

• Malaria screening

• Prevention and management of mild to moderate anemia

• Maternal tetanus immunization

• Adolescent friendly health services

• Interval IUCD insertion

Health Facility

• Antenatal screening & management of Severe anemia, Hypertension in pregnancy, Gestational Diabetes, Syphilis

• Screening & management of Hep B, Hypothyroidism, HIV, Malaria

• Adolescent friendly health clinics

• Post-partum family planning services including PPIUCD insertion

• Prevention of Rh incompatibility

CARE DURING LABOUR AND CHILDBIRTH

Family and Community

• SBA

• Clean birth practices

Outreach / Sub Centre

• Identification of complications and timely referral

• Pre-referral dose by ANM (Antenatal corticosteroids in preterm labour; antibiotics for PROM)

Health Facility

• EmOC

• Management of pre-term labour

IMMEDIATE NEWBORN CARE

Family and Community

• Delayed Cord clamping

• Interventions to prevent hypothermia

• Early initiation and exclusive breastfeeding

• Hygiene to prevent infection

Outreach/ Sub Centre

• Vit. K at birth

• Neonatal resuscitation

Health Facility

• Advanced neonatal resuscitation

CARE OF THE HEALTHY NEWBORN

Family and Community

• Home visits till six weeks by trained ASHA

• Exclusive breastfeeding

• Clean postnatal practices

Outreach / Sub Centre

• Immunisation

Health Facility

• All interventions (except home visits)

CARE OF SMALL & SICK NEWBORNS

Family and Community

• Thermal care and feeding support (for home deliveries)

Outreach/ Sub Centre

• Integrated management using IMNCI and use of oral antibiotics

• Injectable Gentamicin by ANMs for sepsis

Health Facility

• KMC

• Full supportive care at block and district level (NBSU, SNCU)

• NICU at regional level

CARE BEYOND NEWBORN SURVIVAL

Family and Community

• Screening for birth defects, failure to thrive and developmental delays

• Follow up visits of SNCU discharged infants (till 1 year of age), small and low birth weight babies (till 2 years of age).

Outreach/Sub Centre

• As before

Health Facility

• Newborn screening

• Management of birth defects for conditions enlisted under RBSK

• Follow-up of high-risk infants (discharged from SNCUs, and small newborns)

24

43,500 45,500

4,56,000

52,000 54,500

1,87000

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

PreconceptionNutrition

Antenatal Care Care during labourand birth including

complications

ImmediateNewborn Care

Care of the healthynewborn

Care Of The Small& Sick Newborn

Dea

ths

aver

ted

Stillbirths averted

Maternal lives saved

Newborn lives saved

India specific analyses based on EN Lancet Paper 3, 2014 by AIIMS, V.K Paul

Number of Deaths Averted by Stage of Intervention

MONITORING & EVALUATION FRAMEWORK FOR INAP

M&E Framework

MCTS

HMISOn-line SNCU

Monitoring

Milestones

Year National Milestones2014 National launch – India Newborn Action Plan

2015 - 2016 State Newborn Action Plans developed

Reporting by states on Dashboard Indicators

Quality assurance mechanisms strengthened at national and state level

Institutional mechanism established for research and knowledge

management

Gender disaggregated data available and monitored for various

interventions

2017 Mid-course review

2018 - 2019 Stillbirth tracking mechanism strengthened

Accountability framework developed and operationalized at all levels of

health care

Equity disaggregated data available and monitored for all interventions

2020 Review and update action plan

WAY FORWARD

▪ State level action plans to be developed

▪ Forging partnerships as envisaged with various professional bodies

▪ Scale up newer initiatives along with quality trainings

▪ Up gradation of SNCUs and establishment of Kangaroo Mother Care Units

▪ Affirmative actions to address stillbirths

▪ Research priorities to gather evidence to be addressed

A healthy start is central to the human life course….

Every newborn must be able to survive and thrive!