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Abstract
Globally, newborn health is now considered as high-level national priority. The current neonatal and infant mortality rate in India is 29 per 1000 live births and 42 per 1000 live births, respectively. The last decade has seen a tremendous growth of neonatal intensive care in India. The proliferation of neonatal intensive care units, as also the infusion of newer technologies with availability of well-trained medical and nursing manpower, has led to good survival and intact outcomes. There is good care available for neonates whose parents can afford the high-end healthcare, but unfortunately, there is a deep divide and the poor rural population is still underserved with lack of even basic newborn care in few areas! There is increasing disparity where the ‘well to do’ and the ‘increasingly affordable middle class’ is able to get the most advanced care for their sick neonates. The underserved urban poor and those in rural areas still contribute to the overall high neonatal morbidity and mortality in India. The recent government initiative, the India Newborn Action Plan, is the step in the right direction to bridge this gap. A strong public–private partnership and prioritisation is needed to achieve this goal. This review highlights the current situation of neonatal intensive care in India with a suggested plan for the way forward to achieve better neonatal care.
- Neonatology
- Intensive Care
- India
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Introduction
Globally, India contributes to 27% of neonatal deaths; 40% of low birthweight (LBW) babies and a quarter of preterm births.1 ,2 More than one-third of these deaths are due to premature births. A recent survey of Indian neonatal intensive care units (NICUs) found that there is an extreme variation in the survival rates, more so in the extremely preterm group with a median survival of 44% (IQR 18–60) in those <28 weeks gestational age (GA).3 The government is trying to improve the situation, and has now come up with the India Newborn Action Plan (INAP) to reduce the neonatal mortality rate (NMR) to a single digit per 1000 live births by the year 2030.2
There were very few centres of excellence in the public sector hospitals (government teaching institutions) and some large private sector hospitals providing tertiary level of care in the mid-1980s. However, in recent years, the number of centres providing NICU care for neonates in India has grown exponentially. Advanced ventilation techniques, such as exogenous surfactant replacement therapy, high-frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO) therapy and organised neonatal transports, have been made available in many places in the last decade.4–6 Consumer demand, educated parents, the ability to pay for high-end care, availability of insurance and the liberalisation of economy have enabled these services to be provided by many hospitals in the private sector. Also, better funding from the government in recent times has allowed some public sector hospitals to offer these advanced facilities. The Government of India has been addressing the issue through its National Health Mission (NHM) programme by conceptualising and providing many rural and urban districts now with special newborn care units (SNCUs) with provision for at least secondary-level care along with providing trained manpower with the aim to reduce NMR from the current 29 per 1000 live births to <10 per 1000 live births across the country.2
Current mortality rates in India
The current child and infant mortality rates in India are shown in table 1. Emerging evidence and improved quality of care have led to better survival of extremely low birthweight (ELBW) infants in the country. The reported survival rate among ELBW infants during 2000–2003 varied from 22% survival at one centre to 48.7% at another centre.7 In 2013, however, reports have shown better survival rates (52–56%).8 ,9 A recent survey found the median survival rates of 58% and 88% among ELBW and very low birthweight (VLBW) infants, respectively.3 Similarly, the country figure for NMR has decreased from 68 to 29 per 1000 live births in the last decade (figure 1).1 ,2 But the contribution of neonatal mortality to the under-five deaths is still as high as 56% compared with the global figures of 44%.1 ,2
Infant and child mortality rates
Year-wise trend of neonatal mortality rate of India.
The NMR also varies significantly from single-digit (7 per 1000 live births in Kerala) to two-digit figures (30 per 1000 live births in few states) across the 29 states of India. The NMR also varies between urban and rural population, wherein the rural NMR is double and reaching even higher rates (2.5 times or more) in some states (figure 2).1 ,2 These demographics suggest failure to achieve the millennium development goals (MDGs) for 2015 in India. India has not yet achieved the goals set for reduction in infant mortality (goal 4) and improving maternal health (goal 5). The best description on performance of India in achieving the MDG is hence mixed: ‘moderately on track’ for MDG 4 but unequivocally ‘slow or off track’ for MDG 5.10
Comparison between the rural and urban neonatal mortality rate (NMR) of the major states of India.
Levels of NICU care in India
The National Neonatology Forum (NNF) of India stratifies levels of neonatal care as level I—basic resuscitation and healthy newborn care, level II—preterm care >32 weeks GA (subdivided into IIA and IIB based on brief ventilation of <24 h and CPAP support), and level III—extreme preterm care (subdivided into IIIA and IIIB (HFOV, iNO therapy)) (http://www.nnfi.org).
Private sector hospitals
Many private-run units are maternity and child centres that are accredited at level II A or B; some are even level IIIA. These units provide care for preterm infants, CPAP support and brief ventilation with care of moderately sick infants. The neonates who require extensive support, prolonged ventilation and surgical/cardiac procedures are referred to tertiary-level centres (level IIIA or B) in larger hospitals; transport facilities are provided by the referral centre. There are only four units in India that have been accredited at the highest level, that is, level IIIB.
Public sector hospital care and SNCUs
Under the NRHM, a network of facility-based newborn care has been established at different levels. Primary care provides essential newborn care such as neonatal resuscitation, thermal support, breast feeding and asepsis; is provided through newborn care corners (available at point of childbirth) and newborn stabilisation units (NBSU). NBSU is a four-bed unit providing basic level of sick newborn care. Secondary care is provided in SNCUs. SNCUs are special newborn units in a large hospital, generally at district level meant to reduce the case fatality among sick newborns, either born within the hospital or outside, including home delivery. These are 12–20 bedded units, with 4 trained doctors and 10–12 nurses and support staff with provision of 24×7 services to sick newborns, except assisted ventilation and major surgeries.2 ,11 Neonates who require higher intensive care are referred to public sector specialty hospitals (teaching hospitals) or to private sector multispecialty hospitals. The first public SCNU was established in 2003, the resounding success of which has led to increased coverage to >150 districts; however, the actual number of beds is far less than what is required.2 ,12 ,13 A total of 507 SNCUs with 6408 beds were available across the country in late 2013.11 ,14 Analysis of a district SNCU functioning showed a promising role in the reduction of neonatal mortality by 14% in the first year and by 21% in the second year.15 The effect on the country's NMR after the evolution of SNCU/NRHM is accelerated; NMR declined from 37 to 28 per 1000 live births (2005–2013).11
The recommended NICU bed strength per million populations is 30.16 India would need at least 100 000 level 2 neonatal beds (table 2). There is lack of data, however, to correctly estimate the current total NICU beds in India as many are in private sector hospitals.
Calculation of requirement of level 2 neonatal beds in India
Costs and funding for NICU care
Private sector hospitals
Costs here are either self-funded by the family or through insurance and are exorbitant, but the emergence of insurance has given a great boost to families. In 2003, a study on costing of NICU care in India found the average total NICU cost to be US$3800, US$2000 and US$950 for ELBW, VLBW and LBW infants, respectively.17 The current cost is probably 3–4 times more; the estimated cost of a sick neonate on cardiopulmonary support is US$385–600 per day.
Public sector hospitals
Under the umbrella of the National Rural Health Mission, the Government of India launched the Janani Shishu Suraksha Karyakram (JSSK) in 2011, which unquestionably signals a huge leap forward in the quest to make ‘Health for All’ a reality and assures ‘nil out of pocket expenses’ in all government institutions.11 ,18 The scheme provides free and cashless services to pregnant women accessing public health institutions including the delivery and the caesarean section charges and also treatment of the sick newborns till 30 days of life.11 The initiative promotes institutional delivery, facilitates prompt referral through free transport and eliminates out-of-pocket expenses that usually are a barrier for the public in seeking institutional care for mothers and sick newborns. This initiative led to increased use of the public health infrastructure by >16.6 million pregnant women last year. Unfortunately, the implementation has not become universal so far. The estimated cost of an SNCU per million population is US$203 836 and annual maintenance cost is US$388 189. It is estimated that if 100% of free coverage to sick newborns is provided through the JSSK scheme, then it would result in allocation of 8% of the current national budget to neonatal care alone. It is noteworthy that more than US$17 billion was invested by the central government since the inception of the NRHM.11
Manpower, infrastructure and equipment issues in neonatal care in India
Adequate and trained manpower is the backbone of NICU care and the key to better outcome. The ideal nurse–patient ratio is 1:1 for ventilated babies and 1:3–4 for all other babies.16 There is a serious concern of understaffing in both government and private sectors; an analysis has shown that only 50% of units were adequately staffed.13 Many trained doctors/nurses do not wish to take further training in neonatal care, and many trained ones go abroad for better remuneration and career growth. A specialised training programme for doctors under the Doctorate of Medicine /Diplomat of the National Board in Neonatology is being conducted by many centres, producing >40 specialists annually.3 Similarly, shorter fellowship programmes of 12 months produce >80 neonatal specialists annually.3 Apart from training, retaining doctors and nurses is a big challenge. These issues could be overcome by securing or centralising the permanent jobs, compulsory medical service following training, improving the future prospects and enrolling into fellowship programmes. Equipment shortage, high cost of capital expenditure, maintenance issues, costly repairs, delayed arrival of newer technology, and so on were major setbacks in the development of NICUs in the past. However, the situation has significantly changed in the last decade with liberalisation, easy imports and indigenisation. Indigenous equipment have led to cost reduction in NICUs in the country.19 Alternate low-cost devices like thermal care devices are being used in resource-constrained areas. Recently, a thermal device to keep VLBW neonates warm was found to be non-inferior to standard of care in a multicentre trial carried out in Bangalore.20 Also, ‘therapeutic cooling’ for neonatal hypoxic encephalopathy with a low-cost model has been shown to work in resource-poor settings.21 These trials indicate that indigenisation with proven evidence of efficacy is the way to go ahead for optimal care in resource-poor areas in India.
Neonatal research
Neonatal research has accelerated in India in the last decade. Its contribution in major indexed Indian journals is approximately 9–12%.22 The majority of studies are unicentric and hence the main drawback of acceptance internationally. Few multicentric trials, such as the use of ‘room air’ during neonatal resuscitation, have influenced practices globally. Similarly, follow-up studies on ELBW infants, skin-to-skin care, Kangaroo care, vitamin D and zinc supplementation in LBW infants have provided valuable information.23–25 There is a need for robust neonatal network for collaboration and to initiate multicentric trials.
The way forward
Globally, newborn health is now considered as a high-level national priority. Newborn survival and health were not specifically addressed in the framework of MDG's and hence an action plan (every newborn action plan) was set out by the WHO, which has a vision to have no preventable newborn deaths, every birth being celebrated, and women, babies and children to live, thrive and reach full potential.26 This vision/plan was launched in June 2014 at the 67th World Health Assembly to advance the Global Strategy for Women's and Children's Health. A committed and aligned response to this vision was the INAP, which builds on existing commitments under the NHM. This plan defines the six pillars of interventions: preconception and antenatal care, care during labour and childbirth, immediate newborn care, care of the healthy newborn, care of small and sick newborns, and care beyond newborn survival.2 Success of the plan would largely depend on many factors that need to be addressed parallelly. Newborn health cannot evolve on its own unless other factors are well looked into. Accomplishing the unachieved MDGs—reducing poverty and hunger, improving female literacy rate and universal primary education, and so on—will result in reducing the maternal and infant mortality. The main reasons for Kerala's lowest NMR (7/1000 live births) are ‘better demographics”, lower population density (34.8 million), high literacy rate (93.91%), higher per capita income (US$1326), higher human development index (0.92), strong public–private partnership and ease in accessibility to healthcare services. The INAP needs ‘prioritisation’ based on local data and geographical scenario on which levels of NICU care could be stratified.27 Level 1 care may be cost effective if NMR is >30, whereas level 2 care for NMR is 15–30 and level 3 care for NMR is <15. Furthermore, the plan should be ‘robust and watershed’, like the NRHM. The NRHM made a great impact accelerating neonatal mortality. Conditional cash transfer programme for facility deliveries and universal healthcare entitlement through the JSSK scheme were the crucial developments under the NRHM. The biggest challenge for its success is vast country (1.2 billion population) with low health expenditure (gross domestic product 1.2%).11 It is imperative that the local government support the INAP in achieving the target. An example set by Tamil Nadu in achieving MDGs in reducing the maternal (90/100 000) and infant mortality (21/1000), even though the country has not achieved it, is because of ‘strong and authoritative local governance’.28 The local government has a great deal of public–private partnership, provides robust healthcare and has focused on cohesive health policies and programmes providing uniform round-the-clock primary healthcare services. Apart from this, the state has a ‘structured neonatal transport system’ that helped transporting >7500 sick babies over 2 years saving >80% of the transported neonates.28 Similarly, there should be an ‘organised free flow referral system’ where deliverance of continuum healthcare is provided through an integrated district-based model run by empowered district coordinated bodies with a free flow of referral and back-referrals between different levels of healthcare.27
The primary and secondary healthcare services should be strengthened to ascertain them fully functional and accountable. There is a need for a leadership role, preferably senior neonatologists, at different tiers to support the system with an emphasis on proper use and directing the funding source for a proper cause. Non-governmental organisations and reputed foundations like the Bill and Melinda Gates Foundation or the Ford Foundation should also be roped in the right way and their funds made available to the most underprivileged. There is a need of local district perinatal committees on neonatal care for planning, implementing policies, auditing and accountability purposes. National bodies like the NNF and the Indian Academy of Pediatrics should be empowered to take decisions with respect to the country's neonatal health and an advisory committee should be constituted to channelise the central and local governments into the right direction. An excellent initiative recently taken up by the NNF, a professional body of 7000 neonatal paediatricians, has been the task of accreditation that has streamlined the growth of neonatal intensive care to a large extent in the country. This stringent accreditation process hoped to prevent the haphazard, unregulated and unlicensed development of NICUs in the country and will indirectly pave the way for the regionalisation of neonatal care that is currently non-existent (http://www.nnfi.org). Lastly, forming international alliances with other developed nations as well as streamlined funding from international organisations like Unicef and WHO can help the country tremendously in improving neonatal care and survival.
The biggest challenges still faced would be the enormous population, tremendous interstate variation, poor accessibility and use of healthcare, disapproving attitudes towards healthcare, diversities in economic/social/cultural aspects, manpower issues (training/retaining), funding issues (inaccessible, insufficient and improper use), local governance and politics. Population planning, learning from learned ones (Tamil Nadu's model), improving literacy, propagandising the availability of healthcare services, improvising healthcare accessibility, centralising/securing jobs with better prospects and a great deal of partnership with politicians and government should overcome the above-mentioned challenges. To conclude, it must be emphasised that the public SNCU network and a strong public–private partnership with an integrated free flow referral-back-referral system would be the immediate solution to improve neonatal care and hence survival in India.
References
Footnotes
Collaborators NKN made substantial contributions to the conception and design of the study, analysed and interpreted the data, and critically revised the manuscript for important intellectual content. AR made substantial contributions to the design of the study, acquired the data and made a substantial contribution to the analysis and interpretation of the data, and wrote the first draft of the manuscript. Both the authors approve this version of the manuscript.
Contributors NKN planned, conceptualised and finally reviewed and rewrote the manuscript. AR reviewed the literature and prepared the draft manuscript.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.