Integrating Results from Formative Phase Studies for Informing the Design of Intervention Studies on Neonatal Health in India

The millennium development goal (MDG) for India envisages reducing infant and child mortality by two-thirds between 1990 and 2015. Population-specific systematic and comprehensive clinic-based strategies are required to reduce neonatal mortality at the national level. The present formative research is a step towards evolving operational strategies to improve infant survival by reducing neonatal morbidity and mortality in the country. It aims at prompt recognition referral and treatment of sick neonates. It also seeks participation of the community and healthcare providers (a public-private mix) taking into consideration the existing resources and facilities addressing the diverse socio-cultural beliefs that influence the newborn care practices in various strata of the community. A multi-centric community-based study involving cross-sectional surveys and nested case-control designs was conducted in 10 districts from 9 different Indian states. Cross-sectional surveys were conducted to assess existing healthcare facilities and to assess health-seeking behaviour of various stakeholders. A case-control study nested in a cohort was conducted to identify the risk factors and to validate the verbal and social autopsy tools. A combination of standard qualitative and quantitative research methods was used for data collection purposes by trained research associates with stringent quality checks. From the cohort study of 10420 pregnant women the annual neonatal mortality rate was estimated to be 48.4 per 1000 live births. The case-control study identified maternal characteristics like age low parity and diseases during pregnancy; neonates characteristics like not crying immediately after birth low birth weight congenital anomalies pre-term birth non-vaccination infections and small for date of birth; and community factors like unhygienic practices and no breast-feeding to newborn immediately after birth among the significant risk factors. The cross-sectional survey of health facilities found lack of nurses and midwives (37% in rural vs. 79% in tribal) lack of essential equipment and devices (22% in urban vs. 28% in tribal) lack of supplementary training to health workers in essential newborn clinical care (40% in urban vs. 53% in rural) and inadequate drug supplies (37% in rural vs. 50% in tribal) as barriers in offering effective antenatal and neonatal care services in peripheral rural and difficult-to-reach tribal settings. The cross-sectional study of stakeholders regarding knowledge and perceptions on neonatal health issues suggested community stakeholders have a good perception about common neonatal health problems like respiratory infections fever and diarrhea but lacked sensitivity to specific neonatal morbidities like asphyxia sepsis low birth weight and hemorrhagic diseases. Population-specific interventions need to be instituted as perceptions and behaviour of stakeholders the health facilities and the risk factors for neonatal mortality were found to vary among rural tribal urban slumand urban communities. Interventions for health behaviour modification and reduction of sepsis asphyxia and low birth weight should be undertaken as the next phase of the study. (authors)