Reducing neonatal mortality in Jhagadia Block, Gujarat: we need to go beyond promoting hospital deliveries

Epidemiology of Infant Deaths in Predominant Tribal Areas of Two Districts of Gujarat: Results of Pregnancy and Mortality Surveillance Program

OBJECTIVE

To understand epidemiology of the neonatal and infant deaths in predominant areas of two tribal districts of Gujarat.

METHODS

A secondary analysis of pregnancy and mortality surveillance data was done to understand the causes and determinants of infant deaths in predominant tribal areas of two districts of Gujarat, India from 2015 to 2018. All pregnancies, their outcomes, and infant deaths were prospectively registered. A verbal autopsy tool was used to understand the cause of death.

RESULT

A total of 25,130 live births were recorded; 20,994 (83.5%) deliveries occurred at the hospital. Total 1,309 infant deaths (IMR - 52.08/1,000 live births) and 879 neonatal deaths (NMR - 34.97/1,000 live births) occurred during the program duration. The odds of infant deaths was high among male child aOR - 1.5 (CI:1.3-1.7, p < 0.001), born to illiterate/primary educated mother aOR - 1.2 (1.03-1.4, 0.013), born at home or on the way aOR - 1.4 (1.1-1.8, 0.003), born with low birth weight (< 2.5 kg), aOR - 3.7 (3.2-4.3, < 0.001), born preterm (< 37 wk) aOR - 1.9 (1.7-2.2, < 0.001), and born twins aOR - 1.5 (1-2.1, 0.037) in comparison to female child, born to secondary/or above educated mother, born in hospital, born normal weight (>= 2.5 kg), born full-term (>= 37 wk), and born single, respectively. The asphyxia/respiratory distress syndrome (RDS) 282 (56%), sepsis/pneumonia and asphyxia/RDS 188 (63%), and sepsis/pneumonia 281 (65%) were leading cause of death among 0-3 d, 4-28 d, and 29-365 d infant deaths.

CONCLUSION

There is a need to improve quality of intrapartum and postpartum care. Additionally, sepsis detection among infants and referral by community health workers also need to be improved to reduce infant mortality due to sepsis.

Effect of home-based childcare on childhood mortality in rural Maharashtra, India: a cluster randomised controlled trial

Background

Melghat, an impoverished rural area in Maharashtra state, India; has scarce hospital services and low health-seeking behaviour. At baseline (2004) the under-five mortality rate (U5MR) (number of deaths in children aged 0–5 years/1000 live births) was 147.21 and infant mortality rate (IMR) (number of deaths of infants aged under 1 year/1000 live births) was 106.6 per 1000 live births. We aimed at reducing mortality rates through home-based child care (HBCC) using village health workers (VHWs).

Methods

A cluster-randomised control trial was conducted in 34 randomly assigned clusters/villages of Melghat, Maharashtra state, between 2004 and 2009. Participants included all under-five children and their parents. Interventions delivered through VHWs were patient–public involvement, newborn care, disease management and behaviour change communications. Primary outcome indicators were U5MR and IMR. Secondary outcome indicators were neonatal mortality rate (NMR) (number of neonatal deaths aged 0–28 days/1000 live births) and perinatal mortality rate (PMR) (number of stillbirths and early neonatal deaths/1000 total births). Analysis was by intention-to-treat at the individual level. This trial was extended to a service phase (2010–2015) in both arms and a government replication phase (2016–2019) only for the intervention clusters/areas (IA).

Findings

There were 18 control areas/clusters (CA) allocated and analysed with 4426 individuals, and 16 of 18 allocated IA, analysed with 3230 individuals. The IMR and U5MR in IA were reduced from 106.60 and 147.21 to 32.75 and 50.38 (reduction by 69.28% and 65.78%, respectively) compared with increases in CA from 67.67 and 105.3 to 86.83 and 122.8, respectively, from baseline to end of intervention. NMR and PMR in IA showed reductions from 50.76 to 22.67 (by 55.34%) and from 75.06 to 24.94 (by 66.77%) respectively. These gains extended to villages in the service and replication phases.

Interpretation

This socio-culturally contextualised model for HBCC through VHWs backed up with institutional support is effective for significant reduction of U5MR, IMR and NMR in impoverished rural areas. This reduction was maintained in the study area during the service phase, indicating feasibility of implementation in large-scale public health programmes. Replicability of the model was demonstrated by a linear decline in all the mortality rates in 20 new villages during the government phase.

Trial registration number

NCT02473796.