What impact Navjaat Shishu Suraksha Karykram will have on IMR

1. What impact Navjaat Shishu Suraksha Karykram will have on IMR ? respected chairpersons, my seniors in academy, invited guests and dear delegates. A very good morning to all of you! My topic today is what impact NRp will have on IMR? respected chairpersons, my seniors in academy, invited guests and dear delegates. A very good morning to all of you! My topic today is what impact NRp will have on IMR?

2. This is very famous slide of year 2003 which you might have seen thousand times. India continue to be epicenter of childhood mortality even in 2010. This is very famous slide of year 2003 which you might have seen thousand times. India continue to be epicenter of childhood mortality even in 2010.

3. Childhood MortalityState of World�s Children 2008 9.7 million < 5 yrs deaths annually world over India 2.1 million (21%) India contribute to 21% of underfive child mortality world over. While contribution of neonatal deaths to underfive deaths is about 37% in rest of the world, in India it is 50%. Out of 2.1 million underfive deaths every year in India . One million deaths are in neonatal period. India contribute to 21% of underfive child mortality world over. While contribution of neonatal deaths to underfive deaths is about 37% in rest of the world, in India it is 50%. Out of 2.1 million underfive deaths every year in India . One million deaths are in neonatal period.

4. Neonatal deaths and the Millennium Development Goal 4

5. WHERE? The 10 States in India where newborns have the highest risk of dying Where these newborn are dying ? These are the 10 states of India with highest neonatal mortality.Where these newborn are dying ? These are the 10 states of India with highest neonatal mortality.

6. WHEN do newborns die? The first days of life are the riskiest Up to 50% of all NB deaths are on the first day of life (500,000 babies in India dying on their birth day) 75% of NB deaths are in the first week Next question is when do newborn die? 50% of all newborn deaths occur on first day of life and 75% newborn deaths are within a week after birth. So it is early neonatal mortality which is important.Next question is when do newborn die? 50% of all newborn deaths occur on first day of life and 75% newborn deaths are within a week after birth. So it is early neonatal mortality which is important.

7. Leading causes of NB death Severe Infections (36%) Pre-Term Births (25%) Birth asphyxia (23%). Other Neonatal Causes (6%) Neonatal Tetanus (4%) Source: WHO World Health Statistics 2007 (India) Why do these newborn die? There are 3 important causes 36% due to severe infections,25% due to causes related to preterm births and 23% due to birth asphyxia Why do these newborn die? There are 3 important causes 36% due to severe infections,25% due to causes related to preterm births and 23% due to birth asphyxia

8. What can be done to save these newborn lives now? Are there any evidence based interventions known to us?What can be done to save these newborn lives now? Are there any evidence based interventions known to us?

9. Neonatal Resuscitation :6-42% Breastfeeding :55-87% Prevention and management of hypothermia :18-42% Kangaroo Mother Care (LBW):incidence of infection :51% (7-75%) The Bellagio Child Survival Series published in The Lancet in 2003 identified newborn survival as a priority, but lacking on information and action This data from Lancet neonatal survival series 2005 presents information regarding efficacy and costs of interventions for newborn care. Here we will focus on first four interventions: The Bellagio Child Survival Series published in The Lancet in 2003 identified newborn survival as a priority, but lacking on information and action This data from Lancet neonatal survival series 2005 presents information regarding efficacy and costs of interventions for newborn care. Here we will focus on first four interventions:

10. WhyNewborn resuscitation is important ? Now why Neonatal resuscitation is important ? Now why Neonatal resuscitation is important

11. Birth Asphyxia Major cause of �Mortality� and �Stillbirth� Major cause of short and long term morbidity Substantially treatable Read from the slideRead from the slide

12. Still Births Till now focus is on live born infants only; SB - have largely been overlooked. SB are deaths that matter too � to the mother, family, society and the health care system. Asphyxia also results in Still Births . Read from the slide:Asphyxia also results in Still Births . Read from the slide:

13. Estimated - 1 million SB/ Yr in India > 1/3rd of these are in intrapartum (during delivery) and are largely preventable by the same interventions In Dahanu, India, the SB rate ? (18.6% to 9%) with introduction of a TBA training program in neonatal resuscitation Similar findings from Fatehpur, Belgaum India, Read from the slideRead from the slide

14. I million children who survive birth asphyxia eacg year go on to suffer cerebral palsy and other disabilities I million children who survive birth asphyxia eacg year go on to suffer cerebral palsy and other disabilities

15. American Academy of pediatrics and american heart association launched a well structured program NRp- neonatal resuscitation program in 1987 . Nrp is now being taught in 130 countries of the world. American Academy of pediatrics and american heart association launched a well structured program NRp- neonatal resuscitation program in 1987 . Nrp is now being taught in 130 countries of the world.

16. Impact of NRP in China 10 Provinces 2007 Birth Asphyxia - Decreased 60% Mortality in delivery room - Decreased by 40% Since introduction of NRp impact have been assessed in many countries. After introduction on NRp in 10 provinces of China , birth ashpyxia rates decreased by 60% and mortality in delivery room decreased by 40%.Since introduction of NRp impact have been assessed in many countries. After introduction on NRp in 10 provinces of China , birth ashpyxia rates decreased by 60% and mortality in delivery room decreased by 40%.

17. Impact of NRP on asphyxia mortality In rural Gadchiroli India interventions by the trained VHW in basic newborn resuscitation reduced case fatality in severe asphyxia by nearly 50% and asphyxia specific mortality rate by 65% in comparison to management by TBA alone* *Bang AT. Management of birth asphyxia in home deliveries in rural Gadchiroli: the effect of two types of birth attendants and of resuscitation with mouth-to-mouth, tube-mask or bag-mask. J Perinat 2005; S82-91. In a study by Abhay Bang and colleagues in rural Gadchiroli in India case fatality in severe asphyxia reduced by nearly 50% and asphyxia specific mortality rate by 65% when an person trained in basic newborn resuscitation was present during delivery. In a study by Abhay Bang and colleagues in rural Gadchiroli in India case fatality in severe asphyxia reduced by nearly 50% and asphyxia specific mortality rate by 65% when an person trained in basic newborn resuscitation was present during delivery.

18. Aim to have one NRP trained person attending every delivery ( > 27 millions deliveries /year in India ) Joint venture of IAP-AAP-LDSC Johnson and Johnson, India has agreed to provide academic grant to train More than > 200,000 health professionals and workers in private sector in next 4 years Iap executive board realized that to have a real impact on neonatal mortality this nrp program needs to scaled up substantially as every year there are about 27 million deliveries take place in India and we need one person trained in basic newborn resuscitation attending every delivery. Iap with its vast network of 18000 members and 300 braches is the only professional body capable of doing this. In partnership with AAp and LDSC NRp First Golden minute project was launched in Jan 2009 with Dr.panna choudhury as chairman. More than 1500 people were trained in 2009. Johnson and Johnson India came forward and signed a MoU with Iap to provide academic grant to train more than 200,000 health care providers. Iap executive board realized that to have a real impact on neonatal mortality this nrp program needs to scaled up substantially as every year there are about 27 million deliveries take place in India and we need one person trained in basic newborn resuscitation attending every delivery. Iap with its vast network of 18000 members and 300 braches is the only professional body capable of doing this. In partnership with AAp and LDSC NRp First Golden minute project was launched in Jan 2009 with Dr.panna choudhury as chairman. More than 1500 people were trained in 2009. Johnson and Johnson India came forward and signed a MoU with Iap to provide academic grant to train more than 200,000 health care providers.

19. NRP First Golden Minute Project NRP FGM is not restricted to resuscitation only IAP has adopted NSSK manual of GOI �Basic New born Care and Resuscitation Program� which focuses on Resuscitation, Prevention of Infection, Thermal Protection, Feeding and Transport of Newborn As we have seen there are 3 imp causes of neonatal mortality : Infection, preterm and complications associated with it and birth asphyxia and there are evidence based interventions to address these issues. That is why Iap has not restricted First Golden Minute project to resuscitation only. Iap has helped GOI with other experts to prepare program on Basic newborn care and resuscitation under Navjat Shishu Suraksha Karyakram and with permission of govt has adopted same module for training under FGM project. In this module focus is on Resuscitation, prevention of infection, thermal protection, feeding and transport of newborn.As we have seen there are 3 imp causes of neonatal mortality : Infection, preterm and complications associated with it and birth asphyxia and there are evidence based interventions to address these issues. That is why Iap has not restricted First Golden Minute project to resuscitation only. Iap has helped GOI with other experts to prepare program on Basic newborn care and resuscitation under Navjat Shishu Suraksha Karyakram and with permission of govt has adopted same module for training under FGM project. In this module focus is on Resuscitation, prevention of infection, thermal protection, feeding and transport of newborn.

20. Participants like you are.... Learned Experienced Responsible Catering to NB care daily Science is ever evolving / keeping abreast is the need of the hour

21. We do regular pretest and posttest evaluation of the training. We evaluate knowledge by written evaluation. This is example from one of the training of pediatricians to become trainers , most of them from medical colleges. You can see there was very little change in level of knowledge . Only 11% increase from pretest level. We do regular pretest and posttest evaluation of the training. We evaluate knowledge by written evaluation. This is example from one of the training of pediatricians to become trainers , most of them from medical colleges. You can see there was very little change in level of knowledge . Only 11% increase from pretest level.

22. But when performance evaluation was done of the same group to see difference in pre and post test level- there was increase of 54% in skill development as NRp is highly skilled based training. We are in process of compiling data fro other traning. But when performance evaluation was done of the same group to see difference in pre and post test level- there was increase of 54% in skill development as NRp is highly skilled based training. We are in process of compiling data fro other traning.

23. New Child Health Initiative by GOI A new programme on Basic Newborn Care and Resuscitation, has been launched nationally by GoI to address important interventions of care at birth

24. Lives can be saved now Again referring to lancet newborn survival series 2005 if we can reach 90% coverage with all essential interventions 36-67% lives could be saved. Again referring to lancet newborn survival series 2005 if we can reach 90% coverage with all essential interventions 36-67% lives could be saved.

25. NFHS 3: Trends in Delivery Care If we see NFHS 3 data 2005-6 with implementation of Janani Suraksha Yojana institutional deliveries rates have increased to 41%. In some states it has increased to more than 80%. % of deliveries conducted by health personnel is 49% and we aim to target this sector at present. We also plan to launch a massive media campaign to create awareness about benefits of institutional delivery and presence of NRp trained persons at birth to create demand. If we see NFHS 3 data 2005-6 with implementation of Janani Suraksha Yojana institutional deliveries rates have increased to 41%. In some states it has increased to more than 80%. % of deliveries conducted by health personnel is 49% and we aim to target this sector at present. We also plan to launch a massive media campaign to create awareness about benefits of institutional delivery and presence of NRp trained persons at birth to create demand.

26. Expected outcomes If we train more than 90% health personnel attending institutional deliveries (41%) in essential interventions ,an estimated 15 � 30 % reduction in NMR can be expected There will be greater impact in states with higher neonatal mortality So we plan to reach 90% coverage in institutional deliveries and we hope this will bring down neonatal mortality by 15-30% and proportionate reduction in infant mortality. There will be much more impact in states which have higher neonatal mortality rates and number. This is most conservative estimate of reduction in infant mortality.I expect actual impact will be more than projected. I am not calculating here reduction in number of still births and babies saved . I am also not calculating DALY. How many babies will have better quality of life.So we plan to reach 90% coverage in institutional deliveries and we hope this will bring down neonatal mortality by 15-30% and proportionate reduction in infant mortality. There will be much more impact in states which have higher neonatal mortality rates and number. This is most conservative estimate of reduction in infant mortality.I expect actual impact will be more than projected. I am not calculating here reduction in number of still births and babies saved . I am also not calculating DALY. How many babies will have better quality of life.

31. IAP�s Initiative For improving Child Survival, Neonatal resuscitation Program (NRP) with emphasis on management of First minute after birth is crucial.

32. Approach followed Government Sector � Named as Navjat Shishu Surakhsha Karyakram (NSSK) in partnership with GOI Private Sector � Named as First Golden Minute (FGM). Supported by J & J.

33. NSSK Launched on 15 Sep, 09 at Jaipur by hon�ble minister of Health Mr Ghulam Nabi Azad Besides NRP, NSSK also includes Essential Newborn Care Breast Feeding Thermal Control � KMC Prevention of Sepsis IAP is playing Key Role

34. IAP will provide

37. Journey so far� Delhi Bihar Orissa Jharkhand Rajasthan Madhya Pradesh Uttar Pradesh J & K Haryana Now Uttarakhand

38. Written Evaluation Test This is a simple written test of 25 TRUE/FALSE questions to measure the changes in knowledge levels of basic neonatal resuscitation procedure and essential new born care

41. All District Instructors who are trained will receive : Resuscitation Training Kits, including One Basic manikin; One bag & mask Other practice supplies (stethoscope, blankets,) Master copies of training materials Power point and/or flip chart presentation Tests and answer keys Resuscitation booklet (30 pages, adapted from the NRP Text)

42. �First Golden Minute� These District NRP Instructors will conduct provider courses in their districts involving pediatricians, Obstretricians , Institutions conducting deliveries In order to retain their card they are suppose to conduct one course/ train 30 persons

43. Type of courses-need based Basic NRP- is recommended for resource limited settings where skilled manpower and /or instruments are not available. Manual and Format will differ for doctors and health workers Advanced NRP- is recommended for persons responsible for performing a complete resuscitation (or providing direct assistance) Self explanatory Self explanatory

44. Basic Steps in Neonatal Resuscitation The diagram illustrates the relationship between resuscitation procedures and the number of newly born babies who need them. At the top are the procedures needed by all newborns. At the bottom are procedures needed by very few. � The diagram illustrates the relationship between resuscitation procedures and the number of newly born babies who need them. At the top are the procedures needed by all newborns. At the bottom are procedures needed by very few. �

45. Everyone has a role to play�.. Ghulam Nabi Azad Union health minister INDIA As I said this is biggest ever child survival project taken anywhere in the world. Every one has a role to play. Iap president, past president. President elect have shown strongest commitment to this program. Everyone is most welcome to join this movement. Let us forget our differences, leave aside who gets the credit Let us all unite to make every newborn count.As I said this is biggest ever child survival project taken anywhere in the world. Every one has a role to play. Iap president, past president. President elect have shown strongest commitment to this program. Everyone is most welcome to join this movement. Let us forget our differences, leave aside who gets the credit Let us all unite to make every newborn count.

46. Not only a project.. But �� �.a mission Friends ,this is not a project, not a program but a mission which will be achieved with your support. Friends ,this is not a project, not a program but a mission which will be achieved with your support.

47. It�s a long road ahead... But Challenge is to ensure that every newborn counts Today I stand here not as past president of Iap but I am here today to make a case for newborns of this vast country because I strongly believe that a healthy newborn changes the future! Message of my presentation is very simple : If you want to decrease child mortalily, Count every newborn and make every newborn count. . Today I stand here not as past president of Iap but I am here today to make a case for newborns of this vast country because I strongly believe that a healthy newborn changes the future! Message of my presentation is very simple : If you want to decrease child mortalily, Count every newborn and make every newborn count. .