INTRODUCTION:

Newborns are very fragile and vulnerable beings. Health of children is an asset to any nation. India accounts for about twenty percent of births in the world. In India the health sector is a domain of individual states. The central government lays down policy guidelines, supplements resources, provides technical assistance, and funds and implements several national programmers through the states.¹

India is home to 20% of global births and highest number of neonatal deaths in the world. Nearly 27 million babies are born in India each year which accounts for 20% of global births. Among these, 1.0 million die before completing the first four weeks of life. This accounts for nearly 25% of the total 3.9 million neonatal deaths worldwide. About 40% of neonatal deaths occur on the first day of life, almost half within three days and nearly three-fourth in the first week.^2,3 India also harbors the highest number of low birth weight (LBW) infants born each year worldwide: eight million (40 %) of the total of 20 million LBW babies. ⁴

Health System in India:

Health system in India is diverse with public and private sectors.⁵

· Public Health System in India:

In India the health sector is in the domain of individual states. The central government lays down policy guidelines, supplementary resources, provides technical assistance, and funds and implements several national programs through the states. The rural health system in India is well structured. In addition to the modern health system, India also has almost 3000 hospitals of traditional systems of medicine.¹

· Private Sector Health Services:

India has vast, varied, vibrant and growing private sector health systems. A comparison of the national sample survey (1986–87) and 1995–96 has shown increased utilization of the private sector by sick patients, both in urban as well as rural areas. The utilization of private facilities is much more for inpatients services compared to outpatient services. Private facilities range from small clinics run by individuals to multispecialty corporate hospitals of international standards. Unfortunately the formal private sector remains in the urban areas and has not percolated into the rural areas.In villages low quality informal private health care is provided by untrained, unqualified registered medical practitioners referred to as quacks located in outpatient settings.^1,6

· NGO’s and Voluntary Sector:

It is estimated that about 7,000 voluntary agencies are involved in health related activities. NGO's often provide a limited range of services localized to a small geographical area. A number of NGO's like WRAI (The White Ribbon Alliance for Safe Motherhood in India), CARE-India, India CLEN, PATH, Population council, CEPDA etc. have contributed significantly in improving women and child health in India. Since any pregnant women and infant born anywhere, might require emergency and intensive care, all health facilities should have medical services that respond to neonatal and maternal emergencies. Hospitals lacking such facilities should transfer the high risk mother and or the infant to a facility capable of managing such patients. Limitations of trained personnel, expertise, and facilities preclude the availability of tertiary care services at all facilities. Such resources and services must be available to all women and infants in the community. A system must be developed on regional basis to assure equal access to all and at low cost.⁷

Levels of Neonatal Care:⁸^-10

Neonatal mortality and morbidity is directly related to birth weight and gestational maturity of the newborn. Based on the above a three tier system of neonatal care is recommended for developing countries which are described below.

· Level I Care:

o Neonates weighing above 2000 grams or having gestational maturity of 37 weeks or more belong to this category.

o Over 80% of the neonates require minimal care or primary level care which can be provided by their mothers under the supervision of basic health professionals.

o The care can be provided at home, sub centre and primary health centre level or by corresponding private sector health facilities.

o Basic care at birth, provision of warmth, maintenance of asepsis and promotion of breast feeding form the main stay of level I care.

Level I care does not require high level of expertise. However training in care of newborn is essential.

· Level II Care:

o Infants weighing between 1500-2000 grams or having gestational maturity of 32-36 weeks need specialized neonatal care delivered by trained nurses and doctors.

o Intermediate or secondary level neonatal care is needed for about 10-15 % of newborn population and should be available at all hospitals catering to 1000-1500 deliveries per year.

o District hospitals, teaching institutions, nursing homes, community health centres, and first referral units should be equipped to provide intermediate level care.

o Equipment for resuscitation, maintenance of thermo neutral environment, intra venous infusion and gavage feeding, phototherapy and exchange blood transfusion should be provided.

o There should be no compromise on the basic needs of adequate space , nursing staff and maintenance staff, asepsis including provision for disposable suction catheters, feeding tubes, end tracheal tubes, small vein infusion sets etc.

o Facilities for management of common neonatal problems like perinatal hypoxia, low birth weight babies, respiratory distress syndrome, septicemia, jaundice and life threatening congenital malformations should be available.

Level II units are further differentiated into 2 categories, on the basis of their ability to provide assisted ventilation into level IIA (provision for only resuscitative ventilation) and IIB (provision for short duration ventilation) It is considered mandatory for these units to have equipment (e.g. portable chest radiograph, blood gas laboratory) and personnel (e.g. physician, specialized nurses, respiratory therapists, radiology technicians, and laboratory technicians) continuously available to provide ongoing care as well as to address emergencies.

· Level III Care:

o Intensive neonatal care is required for babies weighing less than 1500 grams or those born before 32 weeks of gestation.

o Apex institutions, medical colleges or regional perinatal centers equipped with centralized oxygen and suction facilities, servo controlled incubators, vital sign and transcutaneous monitors, ventilators and infusion pumps etc are best suited to provide intensive neonatal care.

o About 3-5% of newborn population qualifies for intensive care. Skilled nurses and neonatologists specially trained in the art of neonatal intensive care are required to organize this service.

o Establishment of intensive care neonatal centre demands a sound infrastructure and should be envisaged only when optimal intermediate neonatal care facilities have already been in existence for sometime. Level III neonatal intensive care is a very labor intensive care of sick newborns which includes vital parameter stabilization, continuous noninvasive and invasive monitoring, ventilation and long term follow-up. The acquisition of ventilators and other patient care monitors is only a bit of the total intensive care and requires lots of dedication and commitment from the staff and the administrators. The capital and recurring expenditure for level III care is exorbitant and it is not cost effective unless service is regionalized. Ultimately, the aim of neonatal intensive care is to produce disability free survival and merely saving micro preemies.

The national neonatology forum has established guidelines for level II and level III neonatal units based on which accreditation is conducted from time to time. One-fifth of the babies require specialized care, level II or level III. Our country is expected to meet the demands of the situation. Neonatal mortality rate should be strongly considered as an indicator of neonatal health and the neonatal care facilities and strategies planned accordingly. Thus, a neonatal mortality rate of thirty or more should focus on provision of primary or level I care with emphasis on ensuring provision of appropriate components of Essential Newborn Care at home based domiciliary care or institutional based care. The neonatal mortality rate of 20-29 should have strong emphasis on facilities of Level II neonatal care in both urban and rural areas and the high-risk newborn treated or managed at institutional facilities. A neonatal mortality of 19 or less will need level III or tertiary facilities.^11,12

Current Scenario:

The quality of neonatal care in India varies from no care to highly advanced care comparable to any centers in the world. Similarly, the care providers vary from parents alone to highly trained and DM qualified neonatologists. The focused organized neonatal care came into existence in the country with the formation of National Neonatology Forum in 1980. Till then, most of the neonatal care units even in the medical colleges were ill equipped and the care was considered synonymous with putting the baby in a glass chamber (Incubator) with some heating devices or wrapping the baby with cotton, without any monitoring or preventive therapeutic interventions. Over the years because of reducing infant mortality rates with resultant relative increase in neonatal mortality rates, the neonatal care has attained a greater focus. The Accreditation process for Level II special care units started in 1990's by NNF was one pioneer step in standardizing the neonatal care. Currently, the care provided in many units is of highest standards comparable to any centers in the west and hence can easily be termed as centers of excellence.⁹

Around 1/3^rd of the accredited units are in the private sector. There are over 160 medical colleges in the country without even level II accredited units.¹Only 65 units in the country are awarded level II accreditation.¹³Singh M et a l ¹⁴ conducted a study to assess neonatal care facilities in 37 major hospitals in the country using a questionnaire survey. The results showed that 22 belonged to the government sector, the rest 15 to the private sector. Nursery bed: nurse ratio of less than 1.0 was reported by only 4 centers. Majority of the centers cited inadequate nursing strength and frequent transferring out of nurses as a major problem. Twenty nine (78%) centers had ventilation facilities. Most of them had one or two ventilators. Blood gas facility was available with 29 centers and parenteral nutrition was undertaken at 20 (54%) centers. The situation needs a lot of improvement.

The status of the health system reported in the Facility Survey shows that there are major deficiencies for this crucial level of health system especially with regard to the availability of specialists. Even Medical officers trained in newborn care and emergency obstetric care was grossly inadequate at all levels. The number of Medical Officers staying at the PHC is grossly inadequate.¹⁵Deorari AK et al conduced a survey in 40 neonatal units who reported that majority of neonatal units had inadequate equipments according to NNF level II criteria. About 20% of equipments were non functional.¹⁶In the last 10-15 years, newborn care services in large tertiary hospitals have improved further. Even small hospitals in cities and towns have small neonatal units with 4-6 beds and some equipment. But we are still to look at the quality of services provided by these units.

Existing Problems:

The three tier system of delivery of neonatal care is recommended in developing countries for improving the status of newborns. The National Neonatology forum is making immense efforts through the last decade to improve health care delivery to the newborn through accreditation. There are problems existing in the current scenario which comes in way of the delivery of quality services to the newborn as described below.

· Lack of Uniformity in the System:

The health care system in India and delivery of services are diverse in different regions of the country. The rural setting is having an organized system of health care delivery; the three tier system and majority of Indian population dwell in the rural areas. But the health system constitutes private sector and NGO’s as well. There is no organized system of health delivery in the urban setting which amounts to neglect of the ever growing urban poor. Home deliveries are still a norm in urban slum communities with 1.1 million births taking place in the debilitating environment of slums. As a result of lack of skilled or trained attendant at birth post-partum and neonatal care is a miss - only 36,000 of the 2 million babies are breastfed within one hour of birth.¹⁷Also we have inadequate number of accredited level II and level III units in the country which will not be able to meet the increasing demands of the neonatal community. There is no integration or uniformity between the public, private sectors and NGO’s in health care delivery for newborns.

· Delay in Recognition of Need for Care:

There may be a delay in recognition of early symptoms and in some cases even danger signs, by the mother/family members due to lack of knowledge of the same. Young mothers, who have no prior exposure to observing or nursing a sick newborn, may be particularly inapt in absence of experienced elderly members. Once recognized there may be delay in providing appropriate home based care as well.¹⁷Although complications are recognized, most of them are not regarded as danger signs by the mothers and their social milieu, as a result there is delay in seeking referral. Economic constraints, apathy on part of the family members were others reasons for delay in care seeking.¹⁸

· Inadequate Care Seeking:

Neonatal danger signs may be identified but the care seeking may be delayed or inadequate amounting to morbidity and mortality in newborns. Kaushal M. et al in the study to assess the care seeking behaviors for neonatal sickness in an Indian rural community reported that families have some knowledge about neonatal sickness but the health seeking from qualified providers were considerably delayed as village practitioners were preferred to government hospitals.¹⁹

Jain M et al ²⁰ conducted a qualitative study to assess the health seeking behaviour and perception of rural community regarding the quality of available health care services in Agra. The results showed that for health related problems community members first discuss with family members and other influential persons of their caste community and accordingly take decision regarding where to seek care and treatment. Majority of people first tried some home treatment and only when they are not relieved they opt for approaching any provider. Choice of health provider is in fact dependent on decision makers which could be elder male family members or some other person from the community. Literacy status, socioeconomic status, past experience and perceived quality of health care services also play pivotal role in selection of provider. Quality of available health care services was poor in the opinion of respondents as a result of which rural community prefers to approach private providers ranging from indigenous medical practitioners, Registered Medical Practitioners (RMPs) and qualified doctors. Bang AT et al ²¹reported that 54.4% of neonates observed in a study at Maharashtra had indications to seek health care. Only 2.6% of neonates were seen and treated by doctor, (often a private practitioner). Hospitalization for illness was provided only to 0.4% of the neonates. The above study reveals inadequate care seeking.

· Poor Community Newborn Care:

The rural health system is being strengthened by government from time to time but the quality of services provided remains low. Gouws E et al ²² reported that despite of availability of effective and affordable guidelines for management of sick children in first level health facilities in developing countries the quality and coverage of services remain low. Care provided for neonates at the primary levels is minimal. ²³

· Underutilization of Services:

Health facilities are available to some extend but the utilization of these services are very poor in certain regions of the country. De Zoysa et al ²⁴conducted an ethnographic study regarding the care seeking behaviors of families for sick infants which revealed that many mothers were able to identify sickness in their babies but were not able to decide regarding the care to be sought and generally preferred unqualified practitioners.

· Poor and Unorganized Referral and Transport System:¹⁷

There are limited quality facilities for maternal, delivery and neonatal care in rural infrastructure and there is an absence of linkages between the tiered systems, inter referral and transport system.⁵The various challenges confronting prompt and quality care and transport of sick newborn have been categorized at four levels based on sequence of events around a newborn's illness.

o Slum Home/Community:

There may be a delay in recognition of early symptoms, once recognized there may be delay in providing appropriate home based care. Newborns condition may worsen consequent to inappropriate practices like restrained breastfeeding, feeding ghutti etc. The family may not be able to decide when to seek treatment from a health service provider and continue traditional treatment. As a family decides to seek treatment it faces the challenge of whom to go to due to weak/no linkage with qualified health providers, lack of community support and guidance.

o During Transit:

The distance from health facility, expenses involved in arranging transport and cost of services are contentious issues for families. Lack of extra warmth during transit, worsens the condition of the neonate and sometimes contributes to mortality

o First Provider:

The first choice of the family may be a health provider (qualified or non-qualified) available at walking distance from the home. They sometimes lack formal training in neonatal care

o Health Facility:

Non-availability/absence of staff round the clock, lack of training and equipment to attend to neonatal emergency or sub optimal quality of care and service provision results in delayed care and neonatal mortality. There are no clear cut guidelines followed for referral, which may be added on by poor transport. Biswas AB et al reported from a study in 12 First Referral Units (FRUs), West Bengal that referral system was found to be almost nonexistent.²⁵

· Poor Quality of Health Services at Various Levels:

Biswas AB et al ²⁵ reported that Infrastructure facilities, record keeping, referral system and MCH indicators related to newborn care were documented. Inadequate infrastructure facilities (e.g. no sanctioned posts of specialists, no blood bank at rural hospitals declared as First Referral Units etc.), poor utilization of equipment like neonatal resuscitation sets, radiant warmer etc, lack of training of the service providers were evident. Records/registers were available but incomplete. Most of the deliveries (86.1%) were normal delivery. Deliveries (87.71%) and immediate neonatal resuscitation (94.9%) were done mostly by nursing personnel. Institution based maternal, perinatal and early neonatal mortality rates were found to be 5.6, 62.4 and 25.2 per 1000 live births respectively. The status of the health system reported in the Facility Survey shows that there are major deficiencies for this crucial level of health system especially with regard to the availability of specialists. Even Medical officers trained in newborn care and emergency obstetric care was grossly inadequate at all levels. At primary health center (PHC), the number of Medical Officers staying at the PHC is grossly inadequate.³

· Inadequate Personnel Training:

The number of professionals working at all level of health care is inadequate. The available professionals are less skilled as well. There were lacunas in the training provided for the workers. Mohan P et al ¹ primary providers are not very confident to manage sick neonates, and hence gets referred to higher facilities which may be far and entail high costs. A study from Andhra Pradesh ²⁶reported that there were only a few staff nurses to meet the needs of the community at all levels. The quality of education and facilities provided at ANM and GNM schools were inadequate. Hence quality of care rendered by those individuals was unsatisfactory. No in-service education programmes were provided.

· Absent Regionalization:

Regionalization of perinatal services refers to perinatal care of a geographically defined population is provided by a network of facilities stratified broadly into three levels of increasing sophistication and expertise in obstetric and neonatal care. At the most peripheral level is a set of primary care (level I) hospitals. These are linked to secondary care (level II) perinatal centres that, in turn, are linked to a tertiary care (level III) regional perinatal centre. An integral component of the regional perinatal services is the existence of an efficient referral transport system to ensure prompt and safe movement of the mothers and babies between the community and the facilities. Together, the regional and network centres are accountable for the overall perinatal health of the entire region. The requisite level of care to her and her baby is assured depending upon clinical needs. Such a system is nonexistent in India.²⁷

Strategies for Improvement:²⁸^{, 29}

Though India is making immense efforts to improve upon the neonatal care provided at all levels, neonatal mortality continues to be a burning issue. Following strategies may be adopted to improve upon the situation and to strengthen the health services provided.

· Setting up a System of Primary Health care and Referral:

In order to facilitate maximum and effective utilization of health services in urban areas, it is also necessary to set up a definite system of referral in the existing health services and to create linkages between domiciliary, health center and hospital level. Protocols for admissions to primary, secondary and tertiary levels must be laid down. This will ensure adequate utilization of primary and secondary level hospitals and prevent overcrowding in tertiary hospitals. To improve the quality of service all health care personal must be trained in maternal and neonatal care and appropriate facilities for each level of care must be available. Newer modules which include partnership with private sector and NGOs need to be evaluated. The health facilities are accredited based on NRHM recommendations presently. Comprehensive Newborn Care (CNC) for neonates should include an optimum mix of preventive curative and promotional services which are adequate, accessible and affordable. The primary, secondary and tertiary neonatal health care should be linked and not function in disjointed manner.

o Home based newborn care (HBNC) including Identification of sick neonates and resuscitation at birth. This could be provided through ANM, AWW and ASHA.

o Pre-transport stabilization and safe transport of sick neonates to health facility. ASHA could be trained to escort these neonates.

o Strengthening of health facilities (physical facilities and manpower) including PHC, CHC, First Referral Units, District Hospitals and Medical Colleges for provision of neonatal care. This should include provision of essential newborn care equipments.

· Meticulous Monitoring and Accreditation at all Levels of Health Care:

The standards (structure, process and outcome) of neonatal care laid down, needs to be communicated to all health set ups. The health facilities need to be monitored at intervals to appraise their functioning status so that the quality of care rendered will be high. The responsibility should be completely taken up by the National Neonatology Forum. Public and private sectors need to be integrated so that a uniform system of health delivery can be established. It would enable in improving the health status of the newborn.

· Improving Access to Health Services:

Primary health services must include basic maternal and neonatal services on an outpatient basis. Greater emphasis must be laid on education of the pregnant mother and detection and referral of the high risk mother and neonate to the appropriate facility. Home based care of the neonate has been successfully tried in rural settings. When necessary, linkages must be established between the public and private sector as significant population uses the services of doctors and maternity home in the private sector.²⁰

· Prioritize Health Interventions Provided at Various Levels:

In the neonate, exclusive breastfeeding, prevention, early diagnosis and management of infection and care of the low birth weight could help decrease neonatal mortality at primary level. Neonatal resuscitation is to be integrated with intranatal care. Priorities of neonatal care need to be established at all three levels.

· Increase Utilization of Health Services:

When quality services are offered there are greater chances of utilization of services. There is also need for behaviour change both at the facility and community level. Health care personal should have good communication skills and communities must be made aware of the existing health facilities. People need to be aware and be able to identify the need to seek care and utilize the available health services appropriately.

· Community Participation and Ownership:

Mother and Family are among the key players in reduction of neonatal mortality and improvement in neonatal health status. There is need to understand and document the processes underlying infant deaths recognition of illness by the parents, care seeking practices and quality of care received when it is sought. If we understand how families behave and why they do so then we could focus our interventions to improve them. The strength of any programme lies in community mobilization and participation. Formation of self-help groups and use of the existing platform of Mahila Mandals should be used for health education including neonatal care in health and sickness. Adolescent groups and men should be included in planning, training and motivation. Getting the community to take responsibility for the health of mother and newborn should the goal.

· Establishing an Efficient Neonatal Transport System:

A well developed neonatal transport system is the backbone for full fledged working of regionalized neonatal services based on the different levels of health care. It includes

o Chain of Command:

Transport decisions have to be facilitated by community members or a doctor at a small hospital. In the former circumstance, it would be useful if there is an identified nodal person in the village/community who has access to the vehicle, and the community funds to pay for the vehicle and also has information of where to transport the sick infant. In the case of the small hospital, the medical staff at the health facility must be able to provide vehicle for transportation, be able to communicate with the referral health facility to ensure the infant is admitted and provided appropriate care on arrival.

o Transport Vehicle:

The fastest and most reliable vehicle available with community/ health facility must be used for transporting the sick neonate.

o Transport team:

There can not be a transport team since most families have to manage on their own. At best, the community health care provider could be accompany the family more in way of moral support than being able to provide any medical assistance.

o Pre–Transport and Transport stabilization: Warmth provided by skin to skin contact, prevention of hypoglycemia by providing the infant with breast milk by assisted feeding with a cup and spoon. It would not be possible to stabilize infants with poor perfusion and hypoxia in the community, unless the infant being referred from a small health facility. If a trained health care provider is available, then it may be possible to provide the first dose of an antibiotic to the neonate.

o Communication Network:

The most important element for transportation to happen, is the availability of a road network In addition, a telephone network, could help in establishing contact with a the referral hospital.

o Training and Education:

There is a need to provide training for health care providers at all levels on how to facilitate transport of sick newborns. Educating communities and helping them develop their own emergency medical transport system would be of immense help in furthering the cause of neonatal survival. There is a paramount shift from the concept of concurrent provision of primary, secondary and tertiary care. The logic and advice that India only needs primary care because of high NMR and secondary and tertiary care are expensive and will utilize a major share of limited resources has been accepted. This is a myth and needs to be exploded. The country has progressed in so many ways, the technical and higher level of education is an example. Irrespective of the continuing high illiteracy rate the country continues to provide and expand on higher education.⁵

Nursing Implications^{1, 30}

Nurses play a very crucial role in neonatal care at all levels: level I, II, and III. Improving nurses skills in neonatal care is a challenge. Presently the nurses employed at all levels are general nurses who have a general training in nursing and midwifery. A few graduate nurses are working in some tertiary hospitals. ¹All the nurses have basic knowledge and skills in working with normal mothers and newborns but lack proficiency in dealing with high risk mothers and newborns. The nurses working in the neonatal units need to be skilled in the care of neonates. The specific skills required of neonatal nurses at various levels include

· Identification and assessment of risk factors

· Handling routine care of the baby at birth

· Resuscitation of a neonate

· New born examination and detection of life threatening abnormalities

· Thermoregulation

· Feeding - breast feeding, artificial, tube feeding, Total Parenteral Nutrition etc.

· Procedures for prevention of infections

· Monitoring of vital signs-clinically and with monitors

· Use and maintenance of basic equipment for care and investigations.

· Monitoring fluid therapy and calculation of dosages and administration of drugs

· Assisting with therapeutic and diagnostic procedures

· Immediate management of emergency situations

· Airway management and Care of a baby on ventilator

· Communication with family and members of the health team

· Management of the neonatal units

· Teaching nurses, para professionals and families using suitable media

· Planning and executing research in neonatal nursing

Training and education in improving the effectiveness of nursing care in various medical specialties has not been given the importance it deserves. In order to provide care to the sick neonates in highly specialized neonatal units and to manage the neonatal care units, there is a need to have a core of nurses trained in neonatal nursing at the post basic/ post graduate level. Few nurses who have the opportunity to undergo specialized training in neonatal nursing does not necessarily work in neonatal units. Specially trained post graduates in pediatric and obstetrical and gynecological nursing are absorbed into educational institutions. The nurses working in specialized units not only lack expertise but are employed in less numbers. Staff shortage is a key issue in most of the settings which would directly affect the quality of services delivered to the neonates.

As nurses are key providers of neonatal care at all levels, it is important that they are well informed about latest developments so that they are able to give their best in the care of newborns. Workshops and continuing education programmes need to be conducted on a regular basis for all nurses working with neonates and efforts need to be taken to utilize their expertise for the betterment of neonates. Indian nursing council has made an attempt to strengthen the curriculum of GNM course as well as BSc Nursing course with theory and skill components. Nurse educators should take up the responsibility for appropriate training that the future nurses would be efficient to take care of neonate at all levels of care.

CONCLUSION:

The status of newborn health in India needs urgent action. Uniform national standards such as requirements for equipment,personnel, facilities, ancillary services, and training, andthe organization of services (including transport) should bedeveloped for the capabilities of each level of care.Population-baseddata on patient outcomes, including mortality,specific morbidities,and long-term outcomes, should be obtainedto provide level-specificstandards for volume of patients requiringvarious categoriesof specialized care. Neonatal care if strengthened at all levels, with integration of public and private sectors and regionalization will help our country to improve upon the status of newborns. In order to improve the neonatal survival we must also ensure provision of quality nursing care to neonates at all levels of care.

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Received on 21.05.2015 Modified on 22.06.2015

Asian J. Nur. Edu. and Research 5(4): Oct.- Dec.2015; Page 545-552

DOI: 10.5958/2349-2996.2015.00112.3