Suggested health services research action to achieve reduction of neonatal mortality in India

doi:10.4236/ojpm.2011.12009

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Vol.1, No.2, 62- 65 (2011)

doi:10.4236/ojpm.2011.12009

Open Journal of Preventive Medicine

Suggested health ser vices research action to achieve

reduction of neonatal mortality in India

Manoj Kumar1*, Haresh M. Kirpalani2

1Neonatal Division, Department of Pediatrics, University of Alberta, Edmonton, Canada;

*Corr es ponding a uthor : [email protected]

2Div ision of Neona tology, The Children’s Hospital of Philadelphia , Pennsylvania , U SA .

Received 28 May 2011; revised 19 July 2011; accepted 28 July 20 11.

AB S TRAC T

Despite several national programs to reduce

infant mortality, India had repeatedly failed to

achieve its set targets for infant mortality. There

are approximately one million neonatal deaths

in India each year which accounts for nearly

two-thirds of the infant deaths in India. India’s

current trajectories of neonatal and infant mor-

tality rates make it unlikely that it will achieve it s

targets for infant mortality rate for 2015 set un-

der the Millennium Development Goals. Since

two-thirds of infant deaths in India are neonatal

deaths, implementation of effective neonatal

care strategies would be essential to reduce

infant mortality considerably. The history of

child health services in India suggests an inat-

tention to qualitative parameters, hindering a

reversal of its failures. We discuss a format of

mixed-methods participatory research, inte-

grated with routine district level household sur-

veys (DLHS), as a model of health services re-

search which would better delineate the prob-

lems encountered in delivering effective new-

born care at the primary care level.

Keywords: Health Services Research; Infant

Mortality; Neonatal Mortality; Mixed-Methods

Research; Qualitative

1. INTRODUCTION

India is signatory to the United Nations’ declaration of

the Millennium Development Goals (MDGs); accord-

ingly, it is expected to decrease childhood mortality by

two-third by year 2015 from its level in 1990 (MDG4).

For India, the target for infant mortality rate (IMR) is 27

per thousand births [1]. In past, India has repeatedly

failed to achieve health targets that it had set for itself.

For example, in 2002, a revised national policy set the

target for reduction in IMR to less than 30 by 2010 [2],

whereas the most recent estimate of India’s IMR is

above 50 [3].

Approximately two-thirds of the infant deaths in India

are neonatal deaths (deaths between 0 - 28 days of life),

resulting in nearly one million deaths annually [4]. 70%

of India’s population still resides in rural and semi-urban

areas which is serviced by the primary healthcare net-

work [5]. Thus large strides in reduction of IMR would

be dependant upon improving neonatal survival in those

areas. As 75% of the neonatal deaths occur within first

week of life, a strategic focus on dealing with the factors

leading to the three main causes of early neonatal deaths,

i.e., prematurity, birth asphyxia and neonatal sepsis will

be paramount [6].

India has a well-developed basic health infrastructure

at the primary care level (Table 1). In rural and semi-

urban areas, this now consists of 146,036 sub-centers,

23,458 primary health centers and 4276 first-referral

units [7]. More so, in last two decades, it has launched

several large public programs targeted to the reduction

of neonatal and infant mortality, namely Child Survival

and Safe Motherhood (CSSM) Program in 1992 [8],

Reproductive and Child Health (RCH) program in 1997

[9], followed by its second phase in 2005. More recently,

it has launched a program of conditional cash transfers,

Janani Suraksha Yojana(JSY), to encourage in-facility

deliveries [10]. However, the decline in the neonatal

mortality rate (NMR) and IMR continue to be less than

satisfactory. Approximately 47% of all births occur in

any sort of health facilities [11]. If these trends continue,

India will not able to achieve its MDG target for infant

mortality [12].

2. REASONS FOR PROGRAMMATIC

FAILURES

India lacks behind several other developing countries

M. Ku mar et al. / Open Journal of Preventive Medicine 1 (2011) 62-65

Table 1. Primary Health Care structure in India and the MCH and newborn care services planned for each level.

Primary care level Population servedHealthcare Personnel

for newborn care MCH services provided

Village 500 - 1500 Trained Birth attendant (TBA) Assistance in home delivery under hygienic

conditions, prompt recognition of danger signs

and early refe rral

Sub-center (SC)

(one per 5 - 6 villages) 3000 - 5000 Multi-

urpose health worker(MPHW),

(female MPHW also known as Auxil-

iary nurse midwife)

Antenatal check up, tetanus toxoid immuniza-

tion, and iron and folic acid supplementation of

prospective mothers, referral of at risk mothers.

Primary Health Centre (PHC)

(one per 4 - 5 SCs ) 20,000 - 30,000 General physician, nurse midwife Essential newborn care including institutional

deliveries, referral services.

First Referral Unit (FRU)*

(one per 4 - 5 PHCs) 80,000 - 120,000 General physician, Availability of ob -

stetrician/anaesthetist

Essential newborn care, oxygen hood, Radiant

warmer, facilities for caesarean section, X-ray

and basic laboratory facilities.

*Also known as Community Health Center (CHC).

(e.g., Brazil, China, Bangladesh, Thailand and Indonesia)

in its ra te of reductio n of neona tal and infan t mortality

[5], despite launch of various targeted programs as out-

lined above [7]. Reasons for these failures are likely to

be multi-factorial. Whilst, health personnel and infra-

structure shortfalls, suboptimal quantity and quality of

services available at primary level, financing and gov-

ernance issues are well recognized [12]; lack of effective

community participation in planning and delivery of its

services has not received as much attention.

To date, the government’s approach to planning of

health services at the primary level is rooted in a ‘top-

down’ mentality and reflects a pattern of trial and error.

Changes to MCH programs were made repeatedly, often

based on ideas generated by small group of prominent

individuals, without strong empirical research to support

them. Alternatively, the ideas were imported from else-

where and implemented without appreciating the con-

textual differences between the settings. For example,

the JSY scheme to increase births in health facilities was

initiated without availability of good quality obstetrics

and neonatal services at the grass-root level, squandering

precious national resources that could have been used to

develop those urgently needed services.

Although, planning of services at the primary care

level based on a process of community n eeds assessmen t

(CNA) was included in the 2nd phase of the RCH pro-

gram, this process is focussed on generating routine re-

quirements of existing services for the year at each level

(e.g. reproductive care needs of eligible couples) rather

than making structural changes. Households surveys

conducted by primary care employees are limited in

scope and are rarely carried out in true spirit [13].

3. WH AT MORE CAN BE DONE TO

ACHIEVE DESIRED REDUCTION IN

NMR IN INDI A?

Wide differences in the IMR across the various states

of India (in 2008, the IMR ranged from 12 to 70) suggest

that large gains may be possible with relatively few ad-

ditional resources, by systematically identifying knowl-

edge gaps and barriers faced by general population in

accessing services at primary healthcare level and de-

vising local solutions to those unique barriers.

The International Institute of Population Sciences

(IIPS) at Mumbai has been regularly conducting on a

large scale district level household surveys (DLHS) in

each district of the country, to collect representative in-

formation, to generate estimates of maternal and child

health indicators and more recently on infrastructure and

services provided at each level of primary care (in its

most recent survey, 720,320 households were surveyed

across 601 districts of India) [11]. However, the data

generated to date via DLHS surveys are predominantly

quantitative, and does not provide answers to questions

such as why so little progress might be happening in

those districts, nor suggest what programmatic changes

would result in desired improvements.

We suggest a format of mixed-methods participatory

research with active involvement of the communities to

better understand the local healthcare needs and their

barriers to utilization of health services at primary level.

The mixed-methods research combines quantitative and

qualitative research methods in its design and is increas-

ingly utilized in the setting of primary health care [14,

15]. Information gathered via this combined approach

helps to portray a holistic picture of a healthcare pro-

gram, including its bottle necks, which is further used for

making critical programmatic changes.

There are several examples of success of such meth-

odology in reducing neonatal or infant mortality in re-

source-poor settings in recent years. A cluster random-

ised controlled trial(RCT) conducted in rural Nepal

showed that active involvement of the community in

identifying local perinatal problems and formulating

intervention strategies tailored to its needs, as compared

to standard package of perinatal services, reduced neo-

natal mortality by 30% [16]. Similarly, the two other

RCTs recently completed in the resource-poor setting in

M. Ku mar et al. / Open Journal of Preventive Medicine 1 (2011) 62-65

rural India [17,18], with variable levels of community

involvement in identification and planning of interven-

tions showed 32% to 54% reduction i n NMR. Ho wever,

such packages of interventions may not replicate desired

benefits in other settings when scaled up to the entire

country, due to contextual differences among the settings

[19].

4. HOW COULD THE PROPOS E D

MIXED-METHODS PARTICIPATORY

RESE ARCH BE DESIGNED AT THE

NATIONAL LEVEL?

The current data collection approach at the national

level could itself be adapted into the methodology for

the purposed mixed-method research. Alongside the

quantitative data that are routinely collected through the

district level surveys (DLHS), additional qualitative

questions could be posed as an add-on questionnaire,

seeking responses from households on their health seek-

ing behaviours, barriers for using health services and

their perceived solutions. Salient themes that should be

explored are shown in Table 2, along with proposed

collection methods. When questions would be framed as

open-ended queries, an enhanced response is likely.

We also suggest that an additional data set of qualita-

Ta bl e 2 . Proposed themes for add-on questionnaire to current

DLHS data reporting forms.

Questions should explore:

Care-seeking behaviours during the most recent episode of neona-

tal or infant illness? (Semi-structu red questio nnaire with Open -ende

questions where applicable)

 How was illness id entified?

 Durati on between suspicion of i llness and arri val at hea lth facilit y,

resons(s) for delay

 Satisfaction with the treatment received at the primary healthcare

facility

 Reason(s) for not seeking care at a health facility (if, applicable)

Were referral made to another health facility? If so, further explore the

ollowing:

 Cause(s) for referral

 Duration between referral advice made and arrival at suggested

health facility, Cost s involved in following referral advice

 Satisfaction with the t r eatment received at the referral fa cili ty

 Reason (s) for not acting upon referral advic e (if, applicable)

Barriers to utilization of health services (Semi-structured question-

naire as above, and also via focus group discussions)

 Reason(s) if regular antenatal care was not obtained during the

most recent pregnancy

 Reason(s) if a trained birth attendant was not used during the mos

recent birth

 Reason(s) if the most recent birth was not obtained in a health

facility

 Reason(s) that would prevent you from attending the nearest SC,

PHC and FRU if you baby gets sick?

 What are the likely solutions to the above barriers from your per-

spective?

tive information be obtained via holding focus group

discussions in local communities at regular intervals. To

enable frank discussion by those normally not vocal, we

strongly suggest focus groups be both socially and gender

homogenous. Information obtained through these sepa-

rate sources, would better delineate the existing barriers

to local populations in seeking healthcare and utilizing

existing healthcare facilities. In addition, such discus-

sions are likely to identify solutions that would be more

acceptable among the communities, rooted in their active

participation in arriving at those decisions.

5. DISCUSSION

Based on the current trends of decline in the neonatal

and infant mortality in India, it is unlikely to meet its

MDG target for IMR set for 2015. There are known cost-

effective interventions targeting acute obstetrical and

neonatal care in developing countries that could reduce

NMR by over 50% [20]. However, understanding of the

contextual differences are important for success of those

packages of interventions when applied to another re-

source poor setting [19].

We have proposed a format of mixed-methods re-

search, conducted concurrently with national level sur-

veys, which will generate additional qualitative data on

the community needs which would serve the useful

function of providing clients’ perspective on bottlenecks

in the delivery of health services. There are several po-

tential advantages of undertaking this research action at

the national level. First, the inferences drawn from the

data collected would have greater validity due to appro-

priate sampling techniques used in its collection, and its

collection by an independent agency (DLHS staff) rather

than local healthcare employees who may have vested

interest in maintaining status quo. Second, quantitative

data from each community (or district) could be easily

collated with its qualitative data on an ongoing basis to

understand its unique barriers and its felt needs. Lastly,

the availability of these results would help program

managers make timely and more effective programmatic

changes at local level, as the changes made in the deliv-

ery of health services will be based on direct inputs from

those communities.

In summary, the organization and delivery of MCH

services at primary care level in India have been grossly

inadequate in meeting its population’s needs, resulting in

India’s repeated failures in achieving its set targets for

infant and neonatal mortality. We have suggested a

framework of mixed-methods research at the national

level, strongly grounded in active participation from

local communities, as a model for ongoing health ser-

vices research which would better delineate the prob-

M. Ku mar et al. / Open Journal of Preventive Medicine 1 (2011) 62-65

[11] The International Institute for Population Sciences (IIPS),

Mumbai (2010) District level household and facility sur-

vey (DLHS-3), 2007-08, India.

http://www.rchiips.org/pdf/INDIA_REPORT_DLHS-3.pdf

lems encountered in delivering effective newborn care at

the primary level and generate unique solutions tailored

to the needs of the each communit y.

[12] Paul, V.K., Sachdev, H.S., Mavalankar, D., Rama-

chandran, P., Sankar, M.J., et al. (2011) Reproductive

health, and child health and nutrition in India: Meeting

the challenge. Lan cet, 377, 332-349.

doi:10.1016/S0140-6736(10)61492-4

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