Looking beyond the rhetoric of Gorakhpur
At first glance, the tragedies at hospitals in Gorakhpur and Farrukhabad indicate that neonatal mortality (NMR: death of a newborn within 28 days per 1,000 live births) is an issue unique to these hospitals. This is not true.
NMR is one of those metrics that just hasn’t improved adequately across India. According to World Bank statistics, we moved from 33 in 2010 to 28 in 2015. As a benchmark, the UN Sustainable Development Goal (SDG) for NMR is 12 by 2030. If India continues on this slow trajectory, we will achieve the SDG only by 2040.
An NMR of 28-30 implies that any hospital which has roughly 40-50 births per day will see 30-40 newborns die in a month. The larger, more overburdened public hospitals in the poorer states will see a much higher number. Hence, Gorakhpur and Farrukhabad are not anomalies; rather, they are quite close to the norm for large public hospitals.
Is this an unsolvable problem? Absolutely not. Sri Lanka, with an NMR of 5.4, tells us otherwise. Closer home, Kerala is already at 6 and Tamil Nadu at 14. Achieving the SDG by 2030, or even faster, will require five key interventions—all related to the basic management of public health.
Need for 2-3 emergency obstetric points (C-section points) in every district: We usually find only one-two operational C-section points in most districts. This implies longer travel times for women in labour, creating distress and overburdening facilities—which in turn cannot provide adequate care, thereby endangering the newborn. While research indicates that the C-section rate in India is now beyond the optimal range (greater than 10–15%), the situation in public institutions is quite the opposite. In Uttar Pradesh and Bihar, the C-section rates in public institutions remain at 4.7% and 2.6%, respectively.
To achieve two-three fully operational C-section points on priority, a functional trio of specialists (paediatrician, gynaecologist and anaesthetist) and specialized equipment are needed. To tackle the somewhat overhyped specialist shortage, some states have tried innovations like rationalization of staff across hospitals to complete the trio as well as leveraging private anaesthetists. However, 10–20% of facilities have a complete trio but still do not perform procedures due to behavioural and accountability issues. This also needs to be addressed.
Quality special newborn care units (SNCUs): Conditions like asphyxia, prematurity or sepsis require specialized care. Two-three SNCUs should be fully functional per district. This means that three-four beds per 1,000 deliveries need to have critical equipment, including radiant warmers and phototherapy machines. Additionally, the critical nature of the newborns warrants round-the-clock care—a minimum of four nurses. Additionally, SNCUs need to be integrated with newborn stabilization units at secondary facilities like community health centres through a strong referral system.
Addressing key clinical skill gaps: Global research like Johns Hopkins’ Lives Saved Tool indicates that seven basic clinical skills can prevent a majority of neonatal deaths. These include monitoring labour progress using partographs to detect complications. Unfortunately, many clinical staff lack these basic skills, or don’t practise them. For example, research indicates that the simple process of placing a pre-term child against the mother’s chest keeps the baby warm and facilitates weight gain through breastfeeding. However, this practice (kangaroo mother care) is still not widely practised. Similarly, clinical staff are diffident about practices like neonatal resuscitation that can tackle asphyxia.
Several tools, including a “safe birth” checklist, are available. Development agencies (for example, Jhpiego, Unicef) conduct specialized training programmes for clinical staff. However, states should mandate such training and the practice of these basic protocols.
Improving care of pregnant women: While many complications are detected during labour, many can be identified during pregnancy through tests, like those for blood pressure and haemoglobin. However, coverage of antenatal visits by front-line workers is alarmingly low: 51% according to the National Family Health Survey, 2015-16. Additionally, the quality of nurse and pregnant women interactions is often poor. Simple diagnostic procedures are not conducted, resulting in dismal rates of high-risk pregnancy identification. Availability of basic diagnostic equipment, an expansion of front-line worker capacity (using methods like supportive supervision) and their increased accountability towards coverage and quality of antenatal visits are key.
Data tracking and accountability: Data tracking would enable success. Currently, management information systems are only able to track around 20-40% of actual deaths. This is because staff are rarely held accountable for the data. Complex and multiple registers are also to blame. Field data collection processes need to be simplified. Wherever possible, technology like mobile apps should be used. Systemized data-driven reviews of key NMR-related measures, including still-birth rates, are necessary.
More often than not, it is not cutting-edge science that will save lives. Simple fixes, many of them administrative and managerial, don’t get addressed. Let us use this important perspective to fix the foundations of our health system.
Seema Bansal, Rohit Sahani and Subhadra Banda are respectively, director, social impact, BCG India, consultant and specialist consultant, BCG.