Two little sisters Gudiya & Archana of Hardua Village of Unchahara block of Satna district lost their life with a week’s time. Pappu their father said that “it is hard to believe that I had two daughters & both of them passed away with seven days”. They are extremely weak (malnourished) doctors told the Pappu. But now when Puppu talks about the death of his malnourished children, the government officials prevent him saying that his daughters died due to some unknown illness & not due to malnutrition. But Pappu said that why to deny the fact, they were weak (malnourished).

The above incident portraits the sensitivity of the government officials & efforts done by the government in curbing the neonatal & infants deaths due childhood illness under the Integrated Management of neonatal & childhood illness in 12 district selected as IMNCI district under Eleventh Five year plan(2007-12).The findings of survey done by Madhya Pradesh Right to Food Campaign & Adivasi Adhikar Manch,Satna exposes the recent death of 93 children under 0-6years in a just nine months from May’08 to Jan’09 in two blocks of Satna district.

Even the data obtained from department of Public Health & Family Welfare discloses that the situation of IMNCI district is no better than other districts in the state. For example Satna registered highest number of 1469 infant deaths in last 10 months in 2008-09 (April-Jan) i.e. 6.21% of total infant deaths in the state. Similarly in Shivpuri, another IMNCI district 1048 & 912 infants lost their life in 2007-08 & 2008-09 respectively.

Introduction-The most common causes of infant and child mortality in developing countries including India are perinatal conditions, acute respiratory infections, diarrhoea, malaria, measles and malnutrition. These are also the commonest causes of morbidity in young children. Infant Mortality Rate continues to be high at 72/1000 [SRS 2007 released in Oct 2008] live births per year in Madhya Pradesh. Neonatal mortality contributes to over 64% of infant deaths and most of these deaths occur during the first week of life. Mortality rate in the second month of life is also higher then at later ages. Any health program that aims at reducing Infant Mortality Rate needs to address mortality in the first two months of life, particularly in the first week of life.

What is IMNCI?- Integrated Management of Neonatal & childhood illness (IMNCI) is a Child Health Intervention to be implemented as part of NRHM/RCH-II to bring down neonatal, infant & child mortality rate. During the mid-1990s, the World Health Organization (WHO), in collaboration with UNICEF and many other agencies, institutions and individuals, developed strategy known as the Integrated Management of Childhood Illness (IMCI). Although the major reason for developing the IMCI strategy stemmed from the needs of curative care, the strategy also addresses aspects of nutrition, immunization, and other important elements of disease prevention and health promotion. The objectives of the strategy are to reduce death and the frequency and severity of illness and disability, and to contribute to improved growth and development. But since newborn care is an important issue for bringing down the infant mortality rate in India, this aspect has been included in the IMNCI package adapted by India. This strategy has been expanded in India to include all neonates and renamed as ‘Integrated Management of Neonatal and Childhood Illness (IMNCI)’.

Implementation of IMNCI in the districts has to be seen as part of the Child Health Strategy under the National rural health mission/Reproductive and Child Health Programme- Phase II. It includes –

• Care of Newborns and Young Infants
• Promotion of Breastfeeding Practices/Counseling on feeding for all children below 2 years.
• Recognition of illness in newborn & childhood illness & management/referral
• Complete Immunization of all children under 5 years.
• Home visits in the postnatal period

Home visits are an integral part of this intervention. Home visits by health workers (ANMs, AWWs, ASHAs and link volunteers) help mothers and families to understand and provide essential newborn care at home and detect and manage newborns with special needs due to low birth weight or sickness. Three home visits are to be provided to every newborn starting with first visit on the day of birth (day 1) followed by visits on day 3 and day 7. For low birth weight babies, 3 more visits (total of six visits) are to be undertaken before the baby is one month of age. The details of these visits are given in the training package.

There will be 2 kinds of districts in each state i.e. those implementing IMNCI and those not implementing IMNCI but continuing with existing interventions. In districts not implementing IMNCI the existing interventions including immunization, diarrheal disease control, ARI control, vitamin A supplementation and essential newborn care including promotion of exclusive breastfeeding for 6 months, and starting optimal complementary feeding from 6 months of age onwards should be vigorously implemented to achieve universal coverage.

IMNCI districts in Madhya Pradesh – Under IMNCI package in Madhya Pradesh 12 district has been selected as IMNCI districts namely (1) Bhopal (2) Sehore (3) Vidisha (4) Morena (5) Datia (6) Bhind (7) Shivpuri (8) Guna (9) Ratlam (10) Jabalpur (11) Katni (12) Satna.

Situation of Neonatal & Child Health IMNCI districts- Neonatal & child survival & health in the state is directly linked with ante-natal & post natal care of the mother during pregnancy, care of newborn during the first neonatal period, breastfeeding practices & complete immunization of the child. And this in turn are directly associated with the facilities & services available in the health institutions like CHCs, PHCs & SHCs at the block & village level.

Inadequate care during delivery enhance the risk the both to the mother & to the child. All maternal care variable have some influence on child survival, the analysis indicates the need for further strengthening of maternal care services. The cause of high infant mortality, especially prenatal & neonatal mortality are ultimately linked to untimely pregnancy, low birth weight, unsafe delivery, neonatal tetanus.

Maternal health care directly affects the health of neonates & infants. Maternal & child health Program are critically more important in states like Madhya Pradesh which are experiencing high infant & maternal mortality. According to SRS 2007 the infant mortality rate in Madhya Pradesh is 72/1000 live birth & as per the NFHS-III, neonatal mortality rate is 44.9 per thousand live births in MP. The average maternal mortality rate for the state stands at 397/100000.

Maternal & Child Health Indicators in IMNCI Districts -The Health Bulletin of Public Health & Family Welfare Department for last three years highlighted the grave situation of high infant mortality & maternal deaths even in IMNCI district of Madhya Pradesh. The number of infant died in 12 IMNCI districts of Madhya Pradesh in 2006-07 is 9427 which constitutes 31.13% of total infant deaths in the state in a given year. Similarly in 2007-08 & 2008-09 (April-Nov’08) total 7946 out of total 29385 infant deaths & 5369 out of 23660 infant deaths in Madhya Pradesh died in IMNCI districts respectively.

Comparative analysis of IMNCI districts shows that the scenario is more horrible in four IMNCI district i.e. Satna, Shivpuri, Guna & Bhind respectively. In Satna alone 2060, 1668, 1192 infant died in 2006-07, 2007-08 & 2008-09 respectively, followed by infants death in Shivpuri, Guna & Bhind. The number of maternal death is also very in these four IMNCI districts. Out of total 1422 maternal deaths in 2007-08 Satna has a share 60 maternal deaths & Guna partakes with 52 maternal deaths. The Bhopal district which holds the status of state capital & IMNCI districts demonstrates large number of maternal deaths. Within the seven moths of 2008-09, 49 maternal deaths have occurred in Bhopal which constitutes 4.9% of all maternal deaths in the state in a given time frame.

Status of Institutional Deliveries in IMNCI district:

Promotion of maternal and child health has been one of the most important objectives of the Family Welfare Programme in Madhya Pradesh. But still in 2007-08, the average percentage of institutional deliveries in the state is only 47.1% & it is only 40.8% in the rural areas of the state, reveals the according to DLHS-3 report.

Ante natal care refers to pregnancy related health care provided to women during pregnancy by doctors or health workers. ANC results in significant reduction in maternal morbidity & mortality because besides providing medical care it includes advice on correct diet & provision of iron & folic acid tablets to pregnant women. And the percentage of Mothers who had at least 3 ANC visits during Pregnancy to ensure safe deliveries is less than 50% in 10 IMNCI districts in Madhya Pradesh. The situation is even more critical in rural areas with less than 25% pregnant women receiving 3 ante natal check-ups.

Promotion of clean and safe delivery practices particularly in rural areas has been high on State priority, in view of high Maternal Mortality and Infant Mortality in the State. However the proportion of safe institutional deliveries in rural areas in IMNCI districts of Madhya Pradesh has put a question mark on health services in the state. Four IMNCI district Satna (42.4), Katni (43.7), Shivpuri (44.3), Vidisha (48.5) has less then 50% of overall institutional deliveries including both the urban & rural areas of that district, which further means that remaining 50% childbirth are at risk during their birth itself. Neonatal tetanus is one of the common causes of neonatal mortality.

Neonatal tetanus is very common when delivery takes place in unhygienic environment & non sterilized instruments used for cutting umbilical cord. Neonatal tetanus is preventable by giving two doses of tetanus toxiode to pregnant women. Unfortunately the percentage of mothers given TT in shivpuri is 30.1 & in Guna it is 32.9.This indicates upon the awful situation of institutional deliveries in Madhya Pradesh.

Status of Neonatal Care in IMNCI district

The first & foremost need of newborn care includes breastfeeding practices & medical check-up of the newborn within a day of birth & follow-up check-ups in the neonatal period. Yet the norm has not been followed even in IMNCI districts that are identified especially for providing care for newborn & infants. For example the percentage of children breastfed within an hour of birth in almost all IMNCI district lies between 40-55% only. Further the percentage of children received check-up within 24 hours after delivery (based on last live birth) in the IMNCI district is not more than 50%. This means that the remaining 50% children are not provided with any medical facilities to identify sick newborn. Shivpuri, Datia & Guna had less than 25% children given check-up within 10 days after birth. Jabalpur district has highest percentage of children having the medical check-up in neonatal period which is also below 60%.

Health Indicators in Rural Areas of Twelve IMNCI districts in Madhya Pradesh

Source: District Level Household Survey, DLHS-3 report 2007-08

Status of Child Immunization in IMNCI district:
           
Child immunization under the age group 12-23 months by promoting vaccination of children against six serious but preventable has been a cornerstone of the child health care programme. But even now two IMNCI districts (namely Datia & Shivpuri) had less then 20% fully immunized. Out of the 12 districts undertaken as IMNCI districts only Bhopal & Sehore has above 60% full immunization.8 districts are having less than 40% children fully immunized. Even after the mass polio elimination program on an average 25% children in IMNCI districts in M.P. have still not received 3 Polio doses. Infants and young children need vitamin A for optimal health, growth, and development. Shivpuri & Guna are having only 15.7% & 18.5% children (9-35months) received one dose of vitamin A supplement.

Scenario of Health Institution in IMNCI district: As per DLHS-III report Maternal & Child health can be ensured by facilitating better health care in health care in institutions like CHCs/ PHCs and SHCs at block & village level. Thus to assess the situation of maternal & child health in IMNCI districts, it is very important to analyze the facilities available at these health institutions. The CHC & PHC guidelines specifies that minimum requirement in these health institutions includes provision of separate labour room, blood storage unit, availability of Obstetrician/ Gynecologist, ambulance services & availability of large deep freezer.

• CHC/PHC/SHC having Labour Room – Even all the CHCs which are designed to provide referral & specialist health care to the rural population are not equipped with separate labour room. Similarly only 40.9% PHC & just 5.49% SHCs in IMNCI districts are having separate labour room needed to ensure hygiene maintenance during deliveries.  Unhygienic circumstance during delivery may be fatal for newborn.
• CHC having Blood Storage Facility – The percentage of caesarean delivery in rural areas is 5.6% [National Family Health Survey (NFHS III), 2005 – 06, India], which may require emergency blood supply. But merely 3 CHCs are having blood storage unit necessary to provide blood supply in case of complicated deliveries. This further means that just 4.61% are equipped to handle complication emerging during deliveries.
•  CHC having Obstetrician/ Gynecologist – Obstetrician/ Gynecologist are in place just 17% CHCs in IMNCI & 9.2% PHCs are having Lady Medical Officers.  CHCs at Bhopal, Datia, Katni, Ratlam, Satna, Shivpuri & Vidisha are not having a single obstetrician & gynecologist.
• CHC/PHC having large deep freezer – Large deep freezers are needed for safe storage of necessary medicines & vaccines but only 46 CHCs & 45 PHCs in IMNCI district in the state are provided with large deep freezer.
• PHC having Normal Delivery Kit – In spite provision of availability of normal delivery kit, only 42.73% PHCs are having the same. This indicates the use of unsafe instruments during deliveries at large.
• PHC having Neonatal Warmer (Incubator) – Barely 27 PHCs among 227 PHCs in IMNCI districts are having neonatal incubators. In Ratlam district none of the PHC of 25 PHCs had neonatal warmer to warm-up newborn especially in winters to adjust to the room temperature.
• Sub Centers having auto disposable syringes – only 14.75% (298 out of 2019) SHCs are provided with auto disposable syringes used for immunization & treatment. Of all the 12 IMNCI district not a one district has sub centers with more than 30% auto disposable syringes. Only 8.91% sub centers are equipped with auto disposable syringes in Satna district.

Though the budget on Child Health under the eleventh plan has increased from Rs.1079.59 lakhs in 2007-08 to Rs.3170.47 lakhs. Implementation of IMNCI in 12 districts (including Training, Logistics Support to Training Centers & Follow-up) budgeted for Rs.571.78 lakhs & it further aims at establishment of ‘Sick Newborn Units’ in 10 IMNCI districts Hospitals & Level-1 units in 2 CEmONC each of these districts & Operational Cost of 2 already existing sick new born units with the estimated budget of Rs.578.00 lakhs. But indicators of child health have not shown any signs of relevant improvement & is unable to put a break on high percentage of infant deaths in these districts.

For providing better services, it is necessary on the part of the government department that first of all they much accept malnourishment as the major cause of deaths of children. All the pains to curtail malnutrition will be baseless till they accept the fact of malnutrition deaths. Along with that to produce effective results it is necessary to established to coordination between ICDS & Health department.

Why only 12 districts selected under IMNCI?

While looking at indicators of child health the one basic question that arises in the mind is what are criteria behind selecting these 12 districts under IMNCI. Why other district are put apart. If infant death is the criteria then why districts with high infant mortality in like Chhatarpur, Balaghat, Sagar, Betul, Sidhi, & Ujjain are not included in the list. In April-Jan 2008-09 Chhatarpur (1415), Balaghat (1261), Sagar (1728), Sidhi (975), Betul (962) & Ujjain (800) infants lost their life in lack of proper care & attention.  Comparing to these districts the percentage of infant deaths IMNCI district like Bhopal, Vidisha, Sehore & Ratlam is comparatively lesser.

Seema Jain