Madhya Pradesh has recorded the highest percentage of newborn deaths of 11.5% against the total admissions to government-run sick newborn care units (SNCUs) in the past three years across the country, a rate ominously spiralling since 2017, according to the National Health Mission (NHM). The country’s average is 7%.
Although admissions of neonates (under 28 days) in the State have dropped from April 2017 to December 2019 — remaining lower than West Bengal, Rajasthan and Uttar Pradesh — the percentage of deaths at 12.2% surpassed Bihar’s last year. Meanwhile, West Bengal, where 34,344 neonatal deaths occurred in the period, the most in the country, the declining percentage of deaths from 9.2% in 2017 to 8.9% in 2019 coincided with a slump in admissions.
Staff crunch, low community referrals, absence of a special neonatal transport service to health centres, reliance on units in cities as last resort and the non-availability of enough units to cater to increasing institutional deliveries had contributed to the spike in the percentage of deaths, said Dr. Saloni Sidana, Additional Mission Director, NHM State unit.
“We have just half of the required staff nurse strength at the units across the State. For instance, in the Jabalpur unit, there are only 14 against a required 22 nurses,” she said. “Recently, 700 nurses were recruited.”
The crunch is magnified as only one against the required five (82% shortfall) of surgeons, gynaecologists, physicians and paediatricians is available at hospitals. While 4,074 doctors were in position in March 2019, 18,422 more are required, reveals the NHM data.
“Reasons for neonatal deaths are more clinical than other child deaths,” said Dr. Vandana Prasad, community paediatrician and of the Public Health Resource Network. “The younger the baby is, more specialised intervention is required.”
As the units are located at hospitals with the delivery load of more than 3,000 infants per year, mostly in District Headquarters, transporting neonates on time is crucial as they may succumb to fatal diseases within hours. “Although there is a dedicated service to transport pregnant women to hospitals from remote areas, there is none for neonates, who are mostly dependent on the 108 ambulance service,” said Dr. Sidana.
Moreover, she added, with increasing institutional deliveries in the State (80.8% as per the National Family Health Survey-4, 2015-2016), the number of neonatal care units, being optimally utilised, had not been increased proportionally.
There was no system of continuity of care, said Dr. Prasad. She added, “The health of children and mothers is not tracked in a systematic way by one platform, and services are often given randomly.”
The major challenge, however, remained community referrals, significantly aided by ASHA workers — only one in ten sick neonates born outside a hospital is taken to an SNCU. “This is due to the absence of transport, inability to identify a disease by parents, and lack of awareness,” said Dr. Sidana.
Abysmal sex ratio
Madhya Pradesh has also recorded an abysmal sex ratio in admissions — of 663 (number of girls admitted against 1,000 boys) in the three years against the country average of 733, though its sex ratio was 931 as per the 2011 census. “In almost three fourths of the cases relating to boys, more admissions can be attributed to the prevailing bias against the girl child in society,” said an NHM official, requesting anonymity, “While other cases can be attributed to better immunity among girl children to combat diseases.”
In Bhopal, the capital city of Madhya Pradesh, one in every five children admitted to a unit died in the three years — the highest death percentage of 19.9% in the State, ten times above the NHM’s mandated key performance indicator of below 2%. Meanwhile, in 31 of 51 districts, mostly tribal and having low nutrition and maternal health levels, have a death percentage of more than 10.
Urban areas higher
“Urban areas report a higher death percentage as they offer tertiary care, and admit several serious cases from peripheral districts,” said the official, who stated that several districts had under-reported deaths, too. “In order to improve neonatal mortality rate, many notorious units admit fit patients, only to discharge them within hours. If we go by actual figures, Madhya Pradesh has a death percentage of close to 15%,” the official said.
The case of underreporting is illustrated by the NHM’s Child Health Review 2019-2020, which spotlights 43 districts where government officials didn’t report more than 50% of deaths of children under five, to falsely jack up their score.
Sachin Jain, of Vikas Samvad, a non-profit in Bhopal, said, “More than 70% neonatal deaths occur within the first week, most within 48 hours. When the first week passes, the probability of survival increases. Therefore, when the number of institutional deliveries are increasing, the child is the unit’s responsibility. Blaming everything on the community and lack of awareness is a convenient way out for the NHM.”
According to the Sample Registration System, neonatal deaths in India mainly occur owing to premature births and low birth weight (35.9%), pneumonia (16.9%), birth asphyxia and birth trauma (9.9%), other non-communicable diseases (7.9%), diarrhoea (6.7%), congenital anomalies(4.6%) and infections (4.2%).
Under the United Nations’ Sustainable Development Goals, each country, including India, has aimed to bring down neonatal mortality to at least 12 per 1,000 live births. In 2018, it stood at 23 for India.