Current status of neonatal intensive care in india, karthik nagesh n,archives dis. child,2016

1. Current status of neonatal intensive care in India
N Karthik Nagesh, Abdul Razak
Department of Neonatology,
Manipal Hospital, Bangalore,
India
Correspondence to
Professor N Karthik Nagesh,
Chairman of Neonatology and
Manipal Advanced Children’s
Centre, Manipal Hospital,
Bangalore Karnataka, India;
karthik.nagesh@
manipalhospitals.com,
drkarthiknagesh@gmail.com
Received 10 June 2015
Revised 9 February 2016
Accepted 10 February 2016
To cite: Karthik Nagesh N,
Razak A. Arch Dis Child
Fetal Neonatal Ed Published
Online First: [please include
Day Month Year]
doi:10.1136/archdischild-
2015-308169
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.
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 vari-
ation 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 neo-
natal 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 insti-
tutions) 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 techni-
ques, 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 gov-
ernment 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 sur-
vival 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
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
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
Karthik Nagesh N, Razak A. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F5. doi:10.1136/archdischild-2015-308169 F1
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2. care (subdivided into IIIA and IIIB (HFOV
, iNO therapy))
(http://www.nnfi.org).
1. 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 ven-
tilation 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.
2. 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 child-
birth) 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 ventila-
tion 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 hospi-
tals. 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.
COSTS AND FUNDING FOR NICU CARE
Private sector hospitals
Costs here are either self-funded by the family or through insur-
ance 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
Figure 1 Year-wise trend of neonatal mortality rate of India.
Table 1 Infant and child mortality rates
Current child and neonatal mortality rate
Under-five child mortality rate 52
Infant mortality rate 42
Neonatal mortality rate 29
Early neonatal mortality rate 23
Late neonatal mortality rate 6
From SRS Statistical Report.1
Rates expressed per 1000 live births.
F2 Karthik Nagesh N, Razak A. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F5. doi:10.1136/archdischild-2015-308169
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3. 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 insti-
tutions.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 treat-
ment 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 implemen-
tation has not become universal so far. The estimated cost of an
SNCU per million population is US$203 836 and annual main-
tenance 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 govern-
ment 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 expend-
iture, maintenance issues, costly repairs, delayed arrival of
newer technology, and so on were major setbacks in the devel-
opment of NICUs in the past. However, the situation has signifi-
cantly 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, ‘thera-
peutic cooling’ for neonatal hypoxic encephalopathy with a
low-cost model has been shown to work in resource-poor set-
tings.21
These trials indicate that indigenisation with proven evi-
dence 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
Table 2 Calculation of requirement of level 2 neonatal beds in
India
Population of India 1.25 billion
Newborns born annually 27 million
Number of beds required in the
special newborn care unit
12 beds for 3000 annual deliveries plus 4
beds additionally for each 1000 deliveries
Required number of level 2/
special newborn care unit beds
27 million×4/1000=1.08 million beds
Figure 2 Comparison between the
rural and urban neonatal mortality rate
(NMR) of the major states of India.
Karthik Nagesh N, Razak A. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F5. doi:10.1136/archdischild-2015-308169 F3
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4. 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 interven-
tions: 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 mater-
nal 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 develop-
ment index (0.92), strong public–private partnership and ease in
accessibility to healthcare services. The INAP needs ‘prioritisa-
tion’ 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 mor-
tality (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 refer-
ral 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 neonatol-
ogists, 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 neo-
natal 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 develop-
ment 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 alli-
ances 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 plan-
ning, learning from learned ones (Tamil Nadu’s model), improv-
ing literacy, propagandising the availability of healthcare
services, improvising healthcare accessibility, centralising/secur-
ing 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 partner-
ship with an integrated free flow referral-back-referral system
would be the immediate solution to improve neonatal care and
hence survival in India.
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.
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