If I were ever to have cardiac arrest in a bus, I would appreciate a cardiac massage by the conductor or a fellow passenger to save my life rather than wait for the cardiologist or coronary care unit staff, because the wait for an expert may turn out to be fatal.
This holds true for a baby who cannot breathe on his/her own at birth. The condition is called Birth Asphyxia. A time lag of more than five minutes is detrimental. It can lead to death on the spot or, in the case of delayed breathing, many of the baby's brain cells get severely damaged. The after-effects of this damage due to a lack of oxygen may be permanent mental disability or problems in muscle movements. A physically or mentally handicapped child is a life-long burden to itself, the parents and the community.
All this could be avoided if someone helped while the newborn baby was struggling to breathe and start its life on earth. It is cruel for people around to be passive onlookers. With minimal training a birth assistant can help the baby breathe and have a normal life by clearing its nose, throat and air passages from secretions and by puffing in some air into its chest using a self-inflatable silicone bag. It is easily doable.
This is the basis of the Home-Based Newborn Care by a Community Health Volunteer. This is the hard choice we have to make till such time all births in India take place in health institutions or are supervised by health staff. Unfortunately, it is not. Thirty-two per cent of deliveries in rural areas in this vast country still take place in homes and not in health institutions (UNICEF 2009 CES). There is a potential risk for the newborn life in home delivery, including Birth Asphyxia, if the delivery encounters complications, which occur in around 15 per cent of the total home births.
The figure of 32 per cent home delivery is a great climb-down from 73.5 per cent during 1992-93 (NFHS-1) and 65.4 (NFHS-2), thanks to the Janani Suraksha Yojana and institutional strengthening under the NRHM; it is still a long way to go to reach the goal of institutional delivery for all in the high mortality and morbidity States.
The ‘State of India's Newborns,' published by Save the Children and the National Neonatology Forum (2004), says 1.2 million out of the 26 million newborn children a year die within four weeks of birth. This is the highest share of any single country, i.e., 30 per cent of 3.9 million neonatal deaths worldwide. Indian Council of Medical Research data (2003) indicates that almost 40% of neonatal deaths in Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh and Orissa occur on the first day itself.
Birth Asphyxia is found to be responsible for 28.7% deaths in hospital settings (NNF collected data under National Neonatal & Prenatal Death Database) and 20% deaths in rural/tribal areas of Gadchiroli, Maharashtra (SEARCH, an organisation that did pioneering work on Neonatal survival revealed).
Even if we go by a rough middle path of the above two estimates, say 25% approximately, 3,00,000 of newborn deaths due to Birth Asphyxia a year in the country could have been minimised, if not fully avoided, by timely interventions at birth settings whether at institution or home. And the scope for saving is more dramatic and impressive in the 83,20,000 home deliveries in rural/tribal areas in India. If only officials in the Ministry of Health/NRHM and paediatric/neonatal/ public health experts realised this opportunity and seized it in time!
But the tragedy is that the Ministry has reversed certain steps through its orders to the States on the role of ASHAs in Newborn Care.
What happened? Based on the success in reducing neonatal mortality under the SEARCH, Gadchiroli model, there was an effort at the national level to train ASHAs in providing immediate care at birth. This included skills in resuscitation of babies with breathing difficulty and visiting newborn children to recognise the early onset of neonatal infection and referring them to the doctor for antibiotic injections. ASHA training Module 7 had chapters on these skills to be taught. Chhattisgarh launched a pilot scheme in one block in every district.
Then the Centre communicated to all State Mission Directors of the NRHM that ASHAs would not provide any “clinical intervention,” attaching the minutes of the National RCH review meeting of August 31, 2010, held at AIIMS, New Delhi.
Now what is the definition of this “clinical intervention” and what is so objectionable about this so-called clinical intervention are the moot questions. Nobody seems to be clear about it. In fact, we have trained ASHAs to provide tablets for malaria, tuberculosis and leprosy, in the use of pregnancy testing kits, and in rehydrating a baby with ORS. Is it not clinical intervention?
On what ground is clearing the airways at birth and ensuring the first breath of life by a trained Community Health Volunteer objectionable? If a baby is blue and severely asphyxiated, the timely use of Ambu bag and mask to puff in some air to save its life and brain for future is highly ethical and mandatory.
People who are against it are dogmatic and do not know what the parents of that child would have to suffer for the rest of its lifetime. They have no technical answers or alternatives to mitigate the tragedies that occur in about 3,00,000 homes in far-flung rural, mountainous, forest and tribal areas. Who will give voice to and fight for the right to breathe of those newborn citizens of this country who are in trouble for no fault of theirs?
(The writer is a former Health & Nutrition Specialist for UNICEF and former Director, State Health Resource Centre, Chhattisgarh. email@example.com)