The document discusses factors that helped in the survival of weak newborns in Bihar, India. It identifies technical factors like clean delivery, complication identification and management, breastfeeding, warmth, cleanliness, and referral to district hospitals. It also discusses social factors such as the presence of the husband, family support, social support, birth order and sex of the child, previous child deaths, economic status, and the roles of organizations like CARE India and government officials. Interviews were conducted with parents, community health workers, and officials to understand what helped the survival of weak newborns in the community.

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RURAL INTERNSHIP REPORT
ASSIGNMENT 1
TO IDENTIFY THE FACTORS THAT HELPED IN THE SURVIVAL OF WEAK
NEWBORNS AND ROLE OF CARE INDIA, GOVERNMENT OFFICIALS, FAMILY
AND SOCIETY IN THEIR SURVIVAL
Submitted by: Ishan Narma (M2014HE008)
Internship Coordinators
Dr. Nilesh Gawde
Dr. Matthew George
Dr. Narendra Kakade
Internship Supervisor
Mr. Amlan Majumdar

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Contents
Page No.
Background 3
Objectives 3
Methodology 3
Findings 4
Technical Factors 4
Clean & Sterile Delivery 4
Complications Identification &
Management
4
Breast Feeding 5
Warmth 5
Cleanliness 5
Referral to District Hospital 5
Treatment Seeking Behavior 5
Social Factors 6
Presence of Husband 6
Family Support 6
Social Support 7
Birth Order & Sex of child 7
Pevious history of child death 7
Similar Incidences in locality 8
Economic Status 8
Role of CARE India 8
Role of Government officials 9
Conclusion 10
Recommendations 10
Annexures 11
References 11

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BACKGROUND
Low birth weight (LBW) is one of the indirect causes of neonatal death. A weight of less
than 2500 grams is LBW (as per WHO). Across the world, 60 to 80% of neonatal deaths occur
in LBW neonates.1
Intrauterine growth restriction (IUGR) and short gestation are the main
causes of LBW. A weak newborn is the newborn in need of extra care. A baby with a birth
weight of less than 2000 grams and a baby born more than a month before the expected date of
delivery is a weak newborn. Also, a baby who does not suck vigorously at the breast from the
time of birth is categorized under weak newborn.2
Almost 52% of the under-five deaths are neonatal deaths3
and these neonatal deaths
constitute nearly three-fourth of the infant death.4
In the neonatal period, 74.1% of the newborn
die in the first week of their birth. A closer look will show that 39.3% of the neonates die on the
first day of their birth3
. It shows that first month of the birth is very vital for the newborn. As
most of the neonatal deaths occur in low birth weight babies, CARE India focused on the weak
newborn care to decrease the infant mortality rate in Bihar.
In cases of weak newborn, facility based interventions are asphyxia and infection management,
and Post natal care counseling (PNC). Newborn Care Chamber (NBCC) is used for management
of weak newborn, and complicated cases are referred to the district hospital. In PNC counseling,
increased attention to breast feeding, increased warmth, increased level of cleanliness, home
based newborn care and danger signs of the newborn are taught to the mother and the family.
Community based interventions include daily home visits of Accredited Social Health Activist
(ASHA) for first 7 days. After that, home visit on 14th
, 21st
and 42nd
day is done by her. The PNC
counseling is again done during each visit for reinforcement. The mother is asked to contact
ASHA immediately in case of presence of any danger sign. The Block Managers are supposed to
monitor the baby through the phone call as well as field visits till the 30th
day. They also have to
ensure that NBCC in the Primary Health Center (PHC) remains functional. If a child remains
alive till the 30th
day then further monitoring is not done as the highest chances of death in weak
newborn is in first month of birth.
OBJECTIVE
The objective of the study is to identify the factors that helped in the survival of weak
newborns and role of CARE India, Government officials, Family and Society in their survival.
METHODOLOGY
Four cases each was selected from Krityanand Nagar, Jalalgarh and Amour PHC of
Purnia district by Simple Random Sampling. The responses were taken from the mother, father
and the attendant at the time of delivery. Responses were also taken from the concerned Block

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Manager, Auxiliary Nurse Midwife (ANM), and ASHA. A pre-defined semi-structured interview
schedule with open-ended questions was used. The responses were taken independently from the
mother and father of the baby without the presence of ASHA, ANM & Block Manager to avoid
bias. Only cases from June, July, and August, were taken to avoid recall bias. The babies who
were born minimum 30 days back were taken as they are the successful cases.
FINDINGS
The findings are based on the interviews conducted with parents of 9 successful cases
where the baby is alive and 3 unsuccessful cases of death of the baby, ANMs, ASHAs and Block
Managers. (Annexure 1) The survival of a weak newborn is determined by factors that can be
classified as Technical Factors and Social Factors.
Technical Factors
Clean & Sterile Delivery
As per the ANM, macintosh and rubber sheets are changed to ensure infection free
environment after each delivery. All the instruments are properly sterilized after every delivery.
Hands are properly washed, and sterile gloves are used during delivery. These interventions have
reduced the spread of infection to newborn and increased their chances of survival.
Complications Identification & Management
After training and weekly clinical discussion, ANMs can identify complications in most
of the cases and properly manage them. AMANAT programme has improved their knowledge
and skills to a great extent. The number of complications in the hospital has increased over the
past few months. This increase is due to the identification of the complications that used to
remain undetected in the past. The most common complication of asphyxia is managed through
the mucous extractor, Ambu bag, and oxygen concentrator. The baby is referred to the district
hospital in the complicated cases.
"The no. of asphyxia cases and other complications have raised in the past few months. This rise
is because, we can identify more complications now. The AMANAT training program and weekly
clinical discussions have increased our skill in complication identification and management."
- ANM PHC, Krityanand Nagar

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Breast Feeding
Early initiation of breastfeeding is done within 30 minutes in all cases. Those who were
not able to suck properly were referred to the district hospital and given spoon and gavage
feeding. All the babies were exclusively breastfed except for mothers who were not able to
produce enough milk. Those babies were given milk supplements prescribed by the doctor. All
the babies were properly fed as they were passing urine for more than 8 times a day.
Warmth
All the weak babies were kept under the radiant warmer. All the families were told to
keep the babies warm. The families were suggested not to give a bath to the baby at least for the
first week. The families keep the babies properly covered to keep them warm. One of the family
didn’t even take the baby out of the room for 15 days. Kangaroo Mother Care (KMC) was given
by few mothers as KMC was not taught to all of them.
"We have a custom of giving a bath to newborn and mother before entering the house after
delivery. We were told not to give bath at least in the first week, but the family was not ready to
follow that. ASHA tried to convince us for not bathing them, and finally my family agreed to give
only warm water sponge bath."
-Kunita Devi, Mother of twin LBW babies (Prasadpur, Krityanand Nagar)
Cleanliness
Families were counseled to maintain cleanliness at home. They were told to wash the
hand properly before feeding the baby. Hand washing was practiced before handling the baby by
most of the families. This practice lead to a reduction in the transmission of infection to the baby.
Referral to District Hospital
The babies who had a problem with sucking milk, any illness or weighing less than 1500
grams were referred to the District Hospital. A large proportion of families took babies to the
home due to financial constraints. Some families went to a Private practitioner who either gave
medicines or admitted the baby. Those who went to the district hospital, the babies were kept in
Special Newborn Care Unit (SNCU) till their condition become stable.
Treatment-Seeking Behavior
ASHA visited the families regularly during the first week. She referred the babies to the
health center in case of any illness. Families also went to Private practitioners in case of illness.

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Some families also visited quacks due to financial problems and poor accessibility to the
hospital.
"My baby became pale after 3 days of delivery. My mother called the ASHA, and She asked us to
seek treatment from Purnia. We immediately went to a private doctor in Purnia where the baby
remained admitted for 6 days. He was diagnosed with Jaundice."
- Ruby (Sahalo, Amour)
Social Factors
Presence of Husband
The presence of husband during delivery and afterward is a great support for the mother.
His presence helps in seeking treatment during an illness of the baby. The families, where the
father of the baby was present, went to district hospital on referral while his absence leads to
negative treatment seeking behavior.
"My husband works out of the state. I live here with my Mother-in-law, 3 years old daughter,
and 2 years old son. I was accompanied by my Mother-in-Law and Aunt-in-Law during delivery.
When my baby was referred to District Hospital from PHC, nobody was ready to come with me.
My baby fell sick after 4 days, and I went to a local doctor. He remained ill for few days, and I
thought of going to Purnia but nobody was there to accompany me. My baby finally died on the
23rd day. My husband was not able to come home during this period. If he had been here, my
baby would have survived."
- Arbina Khatoon (Dhangama, Jalalgarh)
Family Support
Family support is provided by managing the baby by family members when the mother is
not around. Family members also accompanied the mother to the health center. They also took
care of mother’s diet so that the baby gets adequate nutrition from the mother's milk. Many
women used to come to their parent’s place during delivery to avoid workload at home.
"We have a culture of coming to Parent's place before delivery. I have delivered all my children
in Amour. I came here to make sure that I can take proper rest before delivery and devote all my
time to care for the newborn after delivery. I have no household work to do here, so I can take
proper care of my baby.”
- Ruby (Sahalo, Amour)
“My Mother-in-Law was very worried after looking at my baby’s weak health. She always
remains near to the baby. She prepares special pulses and green vegetables for me so that baby
gets adequate nutrition from breast milk."
- Nauseen Fatima (Magrabi Tola, K.Nagar)

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Social Support
Social support is given by the relatives and the neighbors. They also accompanied the
mother and baby to the health center during delivery and afterward. Experienced people in the
community helped in identification of signs of illness and recommending to see a doctor.
"When I gave birth to LBW twins, I was worried about their care as I have other household
works also. When I returned home, my babies were constantly looked after my Aunt-in-Law and
Cousin-in-Law. My Cousin-in-Law spends most of the time at our house and takes good care of
my babies. My Aunt-in-Law has good experience in the care of newborn. She always suggests the
best way to take care of babies. Sometimes I feel that how blessed I am to have such relatives."
- Kunita Devi (Prasadpur, Krityanand Nagar)
Birth Order and Sex of Child
It was seen that the first child and the male child got better care than the female child.
The first and the male child were taken more often to District Hospital or Private doctor on
referral. Also, the health seeking behavior was much better in the families where either the first
child is born, or a male baby is born.
"This was my first baby. He was very weak & was not able to suck milk after birth. The baby was
referred to District hospital. We took the baby to Sahay Nursing Home for better services. He
was given milk through a pipe. He also contracted Jaundice and was kept under the light. He
remained admitted for 14 days, and we spent almost Rs. 35000 to 40000 in that period. Although
we are poor, money is not a concern when it comes to life of my baby "
- Mohd. Jafrul (Father of Baby) (Magrabi Tola, Krityanand Nagar)
Previous history of child death
The families where there is a history of child death took better care of the baby. They
went to the doctor for any illness and regular follow up.
"I was told at PHC that my baby has a weight of 1500 grams and needs special care for survival.
I became anxious and restless after looking at my baby's body. He was very thin. I had delivered
one still birth girl earlier and lost my 1.5-year-old son last year due to a hole in his heart. I don't
want to lose another baby and ready to give the highest level of care to my baby. My baby
remained admitted to a private hospital for 6 days as he was not able to suck milk. I am
regularly visiting the doctor for follow up and even during minor illness."
- Ruby (Sahalo, Amour)

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Similar Incidence in locality
The families who have seen the similar cases of weak newborn with bad consequences
took better care of their baby. On the other hand, the family that has seen same case with good
consequence had a casual approach to the care of the baby.
"My nephew was also a LBW baby. He was not able to suck milk and was given Cow's milk. He
didn't have mother's milk till now. Now he often gets convulsions, and there is continuous
drooling of saliva from his mouth. I don't want my baby to suffer from same, so when she was not
able to suck milk initially, I immediately took her to the doctor."
- Phulo Devi (Bhawanipur, Amour)
"When we were told that the baby is weak, I was not at all worried. My son was also weak when
he was born, but I took his good care, and now he is very healthy. Baby was referred to Purnia,
but I took my daughter-in-law to home as we can also take care of the baby at home. It is a waste
of money to go Purnia. I never expected that the baby will die after 30 days."
- Grandfather of dead weak newborn (Katheli, Jalalgarh)
Economic Status
The most common reason for not taking the baby to district hospital on referral was the
lack of money. It also leads to either home based treatment or seeking treatment from quacks in
the village during illness.
ROLE OF CARE INDIA
Health system development initiative is one of the 7 interventions of CARE India in
Bihar. Survival of weak newborn is ensured by tracking him/her for first 30 days of life as it is
the most vulnerable period for the death of the baby. The tracking is done by block managers
posted in the PHCs by phone calls to family as well as concerned ASHA. Block Manager also
ensures functional NBCC with properly working radiant warmer, digital weighing scale, Ambu
bag, mucous sucker and oxygen concentrator. He also initiates the practice of Post Natal
Counseling by ANM. He regularly reviews the NBCC register and discusses LBW Babies during
weekly clinical discussion and review meeting. He also disseminates information on LBW
babies to concerned ANMs in the weekly meeting of ANM and ASHAs in monthly meeting. He
regularly reviews ASHA and ASHA Facilitator on Home Based Newborn Care (HBNC) and
LBW babies. The block managers report to the district manager and a review meeting is
conducted at Purnia office every month. This review meeting is conducted to discuss the

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problems faced by block managers and the solutions. Apart from district manager, regional
technical specialist also gives the technical support to the programme.
Recently a workshop on strategies for strengthening weak new born care was organized
by Regional Programme Management Unit, Purnia which was supported by CARE India. The
workshop was attended by block managers of care, block health managers and block community
mobilizers of all the blocks.
CARE India is also conducting the nurse mentoring programme called AMANAT to
improve the skills of ANMs and Labor room nurses. This intervention has also improved the
survival of weak newborns by early identification and management of complications by ANMs.
CARE India has also developed a Facility Assessment Tool (FAT) for PHCs which can
identify gaps in the infrastructure, human resource, equipments, instruments, consumables, etc.
These gaps are discussed during Quality Improvement meetings and funds are allotted through
Programme Implementaion Plan budget which gets approved in Rogi Kalyan Samiti meeting.
ROLE OF GOVERNMENT OFFICIALS
ASHA plays an important role in the tracking of weak newborns. She accompanies the
mothers to PHC. She also counsels the mother about exclusive breast feeding, warmth, delayed
bathing, and cleanliness after delivery. ASHAs also teach KMC to mothers. ASHA visits the
weak newborn’s home during the initial 1 week and at regular intervals afterward to monitor the
baby. ASHA also refers the baby in case of any sign of sickness.
ANMs conducts delivery in an infection-free environment by using sterilized instruments
and sterile gloves. She also initiates breastfeeding within 30 minutes of delivery. She ensures the
survival of LBW babies using NBCC with Radiant warmer, Digital Weighing Scale, Ambu Bag,
Mucous Sucker and Oxygen Concentrator. She takes the weight of babies to find LBW babies.
She also informs Block Manager about LBW babies. She gives post natal counseling to mother
and family on maintaining warmth, feeding, and cleanliness. She refers the sick newborn to
District Hospital. Outreach ANM supports the ASHA during Village Health, Sanitation and
Nutrition Day (VHSND) and counsels the mothers.
The Regional Programme Management Units conduct trainings and workshops for block
managers, block health managers (BHM) and block community mobilizers (BCM) at regular
intervals. Also the involvement of BHM and BCM with CARE India staff has increased over the
time. They also accompany the block manager during the home visit to weak newborn. ASHA
and ANMs are also supervised by BHM and BCM to ensure proper weighning of newborn and
home visits to weak newborn.

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CONCLUSION
Better identification & management of complications, proper counseling, referral to
District Hospital and treatment seeking in the case of any illness has improved the survival rate
of weak newborn. The nurse mentoring programme, AMANAT has also improved the skills of
ANMs in identification of complications and their management. Family & social support, birth
order, gender of the baby, previous history of child death & similar incidences of weak newborn
in locality also influenced the survival of weak newborn. The direct support of ANM & ASHA
and indirect support of Block Managers played a vital role in LBW baby’s survival. This shows
the good relationship and understanding between the CARE India staff and GoB staff. One
factor that hindered the survival of weak newborn is the economic condition of the family.
RECOMMENDATIONS
Ante natal care (ANC) can reduce the chances of low birth weight. Counseling regarding healthy
diet should be given during ANC visits. Also the required ANC visits should be ensured to
decrease the cases of weak newborn. Various cultural practices like bathing on first day, use of
kohl in eyes of baby, excessive use of mustard oil on baby’s body, etc are followed by families,
which are harmful to babies. These practices should be stopped through counseling by ASHA
and ANM. It is also seen that ANMs use to ask for Rs.500 to 1000 before delivery otherwise
they threaten the family to refer them to district hospital for delivery. This unethical practice
should be tackled as soon as possible. The referral to district hospital is often neglected by the
families and is an area to be worked upon. KMC is not taught to all the mothers. ANM, ASHA
and MAMTA should teach the KMC to all the mothers and a KMC sling should be provided to
the the mother for free. The behavior of staff at PHC is often very rude towards the patient’s
family. This leads to negative treatment seeking behavior and results into home deliveries and
visits to quacks. This rude behavior should be discouraged to make the hospital patient friendly
leading to a healthy society.

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ANNEXURES
Annexure 1
Block Village Age of
mother
Date of
Birth
Date of
Interview
Weight of
the Baby
Gender Status of
Baby
K.Nagar Prasadpur 25 23 Jun 1 Sep 1505, 1880 F,F Alive
K.Nagar Bishanpur 18 6 Jul 2 Sep 1435 M Died @ 4th
day
K.Nagar Sabutar 21 17 Jul 3 Sep 1700 M Alive
K.Nagar Magrabi Tola 20 3 Jul 4 Sep 1950 M Alive
Jalalgarh Katheli 23 7 July 7 Sep 1900 F Died @ 30th
day
Jalalgarh Bhatgava 25 9 July 7 Sep 1700 F Alive
Jalalgarh Dhangama 26 6 July 7 Sept 1750 F Died @ 21st
Day
Jalalgarh Harishchand-
erpur
23 18 July 7 Sep 1700, 2400 F, M Alive
Amour Sahalo 20 21 July 11 Sep 1500 M Alive
Amour Rasailli 30 21 July 11 Sep 1750 F Alive
Amour Rani 23 18 Aug 18 Sep 1900 F Alive
Amour Bhawanipur 24 17 Aug 18 Sep 1600 F Alive
REFERENCES
1
Who.int,. (2015). WHO | Care of the preterm and/or low-birth-weight newborn. Retrieved 29 September 2015,
from http://www.who.int/maternal_child_adolescent/topics/newborn/care_of_preterm/en/
2
CARE India,. Newborn Care at the Community Level. Retrieved from
https://drive.google.com/file/d/0B_opU2kYABvXN0tiSXBmRmYtaDQ/view?usp=sharing
3
MoHFW,. (2014). HOME BASED NEWBORN CARE Operational Guidelines (Revised 2014). Retrieved from
http://tripuranrhm.gov.in/Guidlines/2205201401.pdf
4
Who.int,. (2015). WHO | Infant mortality. Retrieved 29 September 2015, from
http://www.who.int/gho/child_health/mortality/neonatal_infant/en/