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By Aarti Dhar

India contributes to one-fifth of global live births and more than a quarter of neonatal deaths. Nearly, 0.75 million neonates died in India in 2013, the highest for any country in the world.

The current Neonatal Mortality Rate is 28 per 1000 live births. Given the infant and under-five child mortality rates of 40 and 49 per 1000 live births respectively, 70% of total infant deaths, and more than half of under-five deaths fall in the neonatal period. Indeed, with the early NMR of 22 per 1000 live births, deaths in the first week alone account for 45% of total under-five deaths.

The ‘Committing to Child Survival: A Promise Renewed‘ goal of reducing under-five mortality to 20 or less per 1000 live births by 2035 would not be attained without specific efforts to reduce newborn mortality, a study on “State of newborn health in India’’ done by M.J.Sankar and others had warned. The study was published in the online edition of the Journal of Perinatology.  

The unacceptable number of crib deaths being witnessed in India over the past months is, perhaps, just an example of what the study had warned of and much more.  “There is an interplay of different demographic, educational, socioeconomic, biological and care-seeking factors, which are responsible for the disparities and the high burden of neonatal mortality. The country has to increase the coverage of key interventions and also improve the quality of care in health facilities on an urgent basis,’’ the study had emphatically said.

India has witnessed a significant improvement in neonatal health after the introduction of National Rural Health Mission. Apart from the Janani Suraksha Yojana, the country has launched several new initiatives to improve neonatal care. Notwithstanding this newfound focus on neonatal health, the annual rate of reduction in NMR and Early NMR still lags behind Infant Mortality Rate and Under-5 Mortality Rate. 

Only a quarter of pregnant women had full antenatal check-up, that is, three or more antenatal checkups, at least one tetanus toxoid injection and at least 100+ iron and folic acid tablets during pregnancy. About 73% of women had institutional deliveries. Only one-third of neonates were breastfed within 1?hour after birth. Less than half of the neonates received three postnatal visits by health-care providers in the first 10 days of life. 

The NMR is not uniform across the country. Although Kerala and Tamil Nadu have low NMRs (less than 20 per 1000 live births), Odisha, Madhya Pradesh and Uttar Pradesh have very high NMRs (35 or more per 1000 live births). Four states—Uttar Pradesh, Madhya Pradesh, Bihar and Rajasthan—alone contribute to 55% of total neonatal deaths in India and to 15% of global neonatal deaths that occur every year.

Although several initiatives, such as Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram, have attempted to address these gaps, their impact remains limited due to poor governance, shortage of health workers in primary health-care facilities and lack of preparedness of health-care facilities, the study had said. 

Ensuring equitable access to health services requires a clear understanding of the multiple levels of inequity across many sectors. The inter-sectoral approaches need to be promoted within and between departments. Improving access to safe water and sanitation, providing adequate food security, and poverty alleviation measures complemented by an equitable health system can ensure better health outcomes for every neonate in India, the study recommended. 

This study, done jointly by experts from AIIMS, Public Health Foundation of India and the Ministry of Health and Family Welfare, was supported by Save the Children’s Saving Newborn Lives program.

In contrast to children born in families with better financial resources, poorer children are more at risk for diseases due to inadequate water and sanitation, indoor air pollution, crowding and poor housing conditions. Access to clean water supply, and sanitation and good hygienic practices, especially at delivery points, is crucial for a safe delivery, and prevention of maternal and newborn mortality and morbidity. Creating conditions for better hygiene and reduced exposure to contamination makes children less susceptible to diseases and infections that may lead to death.

Maternal factors including age at birth, educational and nutritional status, and parity influence the neonatal survival to a great extent. It is estimated that the risks of neonatal mortality and low birth weight (LBW) are increased by almost 50% if maternal age at childbirth is less than 20 years. It is also estimated that shifting age at childbirth to above 20 years would reduce overall NMR by 9.4%.

An inverse relationship exists between the per capita net state domestic product and NMR—states with a high NMR usually have a low per capita GDP. But there are a few exceptions—Haryana and Gujarat have a similar or higher per capita GDP than Tamil Nadu, but almost double the NMR, the study pointed out. 

A pooled analysis of the data from three studies on the timing of neonatal deaths indicates that about three-fourths of total neonatal deaths occur in the first week of life. The first 24?hours account for more than one-third (36.9%) of the deaths that occur in the entire neonatal period.

Almost all deaths (97.8%) due to asphyxia occur in the first week of life, with 70% of them occurring within the first 24?hours (day 0). About three-fourth of deaths due to prematurity (74.8%) occur in the first week of life, with 30% in the first 24?hours and less than 50% of neonatal deaths secondary to sepsis occur in the first week of life. About 30% of sepsis-related deaths occur in the second week, whereas around one-fifth in weeks 3–4. Three-fourth of the deaths due to malformations occur in the first week of life, with day 0 alone contributing to nearly half of these deaths.