Neonatal Care and Transport Among the Urban Poor: Challenges and Options

The challenge at hand: Data averages mask inequalities and disparities: urban poor have significantly worse rates of neonatal mortality indicators than suggested by urban average data. The Neonatal Mortality Rate (NMR) is 31/1000 for urban India while it is nearly 40/1000 for the urban poor. Neonatal mortality constitutes 40 percent of U5 mortality among urban poor in India. Maternal factors resulting in higher incidence of LBW and neonatal mortality revolve around the age of marriage and child bearing as well as maternal under nutrition. 43.2 percent of urban poor women were below 18 years at the time of first delivery. Closely spaced births deplete mother’s stores, making her anemic prior to conception and throughout pregnancy. Factors contributing to sub-optimal neonatal care among urban vulnerable: Low reach and utilization of maternal and neonatal care services among urban poor is evident from the following facts a) less than half (47.7 percent) of mothers received at least 3 antenatal check-ups. The 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 a) slum home/ community b) during transit c) intermediate provider or first provider d) health facility. At the slum home young mothers, who have no prior exposure to observing or nursing a sick newborn, are particularly unprepared to identify a danger sign and determine urgent action in absence of experienced elderly family members. Despite geographical access in terms of crow-fly distance, the expenses involved in arranging transport and cost of services are contentious issues for an urban poor family who have no prior financial reserves and may need to borrow money at interest rates as high as 20 percent from local money lenders. Lack of extra warmth during transit, worsens the condition of the neonate and sometimes contributes to mortality. Owing to proximity, availability, behavior and perceived competence builds community’s faith in private practitioners are frequented by the poor. Most of them, however, lack formal training in neonatal care. 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. What can we do: It is important to expeditiously a) build capacity of Accredited Health Volunteer (later named ASHA under NRHM) and slum based birth attendants where present in home-based newborn care; b) provide regular MNH counseling to mothers/key decision makers in the slum family through trained slum-level volunteers or members of slum Community Based Organisations (CBOs) with pictorial material, c) thereby facilitating adoption of appropriate neonatal care practices in slum home such as frequent breast feeding, thermal protection, early identification of danger signs; d) developing a community support system involving slum CBOs, Accredited Social Health Volunteers, ‘Dais’, AWW to form a ‘Basti Child Health team’ can provide support to mothers, even in absence of family and neighbor's support. It is also vital to link community through Accredited Health Volunteer to suitable, proximal health facilities (government and private) that are geographically proximate, affordable, provide unhindered access, quality and specialized services; e) there is a long standing need to engage and equip the first contact health providers who are usually the not-so-qualified health providers through training on screening cases for referral to specialized facilities and linking these less-qualified providers with these health facilities centers would go a long way in reducing delays in the chain of events for seeking care. Filling vacant positions at urban health facilities with contractual staff, upgrading skills for newborn care, enhancing the management capabilities of doctors, nurses and building sensitivity among health facility staff towards the poor is essential for timely and appropriate treatment of the sick newborn. It is critical to provide neonatal care equipment and optimally trained personnel at 2nd Tier facilities. Evidence shows that Special ‘Sick Newborn Care Units’ staffed with 2 pediatricians and 6 nurses, established in a rural district has shown to avert 330 newborn deaths per year and reduce the NMR of the district by 5 annually. Emphasis on quality of care at the health facility has the potential of preventing a substantial proportion of neonatal deaths at the hospital level with practical and affordable interventions to improve quality of care as demonstrated by SNEHA's "The city initiative for newborn health’ in collaboration with the Mumbai Municipal Corporation. There is also a need to establish a mechanism for subsidized treatment options in for-profit facilities to target the needy.