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Neonatal Mortality

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Definition

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Neonatal Mortality Rate (NMR)

NMR = (Number of deaths of children under 28 days of age in a year / Total live births in the same year) × 1000

• India (2018): NMR = 9 per 1000 live births (both rural and urban areas)

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Sub-classification

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Causes of Neonatal Mortality (Global, 2018)

• Intrapartum-related complications, low birth weight, and preterm birth are causal factors in 60% of neonatal deaths
• Prematurity and congenital anomalies account for ~60% of newborn deaths, mostly in the first week of life
• ~25% of neonatal deaths are attributable to asphyxia - also mainly in the first week
• In the late neonatal period (after day 7), infections (diarrhoea, tetanus) predominate
• The role of tetanus as a cause of neonatal death has diminished sharply due to intensified immunization

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Determinants / Risk Factors

• Neonatal mortality is a measure of "endogenous factors" (e.g., low birth weight, birth injuries)
• Directly related to birth weight and gestational age
• Neonatal mortality rates of babies born to mothers with no education are nearly twice as high as those born to mothers with secondary education or higher
• Family wealth and rural/urban residence remain powerful determinants
• Ending child marriage, reducing adolescent pregnancy, and extending birth intervals are key to reducing newborn mortality risk

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Priority Areas to Improve Newborn Health (Park's Table)

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International Comparisons (IMR, 2018)

• World IMR (2018): ~29 per 1000 live births
• Developed countries: 4 per 1000 | Least developed: 46 per 1000

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RMNCH+A Strategy (2013)

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Background / Launch

• In June 2012, the Governments of India, Ethiopia, USA and UNICEF convened the "Global Child Survival Call to Action: A Promise to Keep" summit in Washington, DC.
• More than 80 countries pledged to reduce child mortality to ≤ 20 per 1000 live births in every country by 2035.
• In February 2013, the Government of India launched "A Strategic Approach to RMNCH+A in India" at its own historic Summit on Call to Action for Child Survival.
• RMNCH+A became the heart of the National Health Mission (NHM).

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The "+" (Plus) Significance

1. Including adolescence for the first time as a distinct life stage
2. Linking maternal and child health to reproductive health, family planning, adolescent health, HIV, gender, preconception care, and PCPNDT
3. Linking home and community-based services to facility-based care
4. Ensuring linkages, referrals, and counter-referrals between PHC, CHC, and District Hospital (primary, secondary, tertiary levels)

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Five Pillars (Thematic Areas)

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5 × 5 Matrix

• 5 high-impact interventions across each of the 5 thematic areas
• 5 cross-cutting and health systems strengthening interventions
• Minimum essential commodities

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Goals and Targets (12th Five Year Plan, 2012-2017)

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Implementation Strategies - Area-wise

1. Reproductive Health

• Focus on spacing methods - PPIUCD at high caseload facilities
• Home Delivery of Contraceptives (HDC) and Ensuring Spacing at Birth (ESB) through ASHAs
• Pregnancy Testing Kits ("Nischay Kits"), comprehensive abortion care
• Quality sterilization services

2. Maternal Health

• Use MCTS (Mother and Child Tracking System) for early registration and full ANC
• Detect high-risk pregnancies (including severely anaemic mothers)
• Equip delivery points with trained HR; access to EmOC at FRUs
• Distribution of Misoprostol to selected women in 8th month of pregnancy
• Strengthen referral system for high-risk pregnancies

3. Newborn Health

• Early initiation and exclusive breastfeeding
• Home-based newborn care through ASHA
• Essential Newborn Care and resuscitation at all delivery points
• Special Newborn Care Units (SNCUs) with trained HR
• Community-level use of Gentamycin by ANM

4. Child Health

• Complementary feeding, IFA supplementation, nutrition focus
• Diarrhoea management with ORS and Zinc
• Management of pneumonia
• Full immunization coverage
• Rashtriya Bal Swasthya Karyakram (RBSK) - screening for 4Ds: Birth Defects, Development Delays, Deficiencies, and Diseases

5. Adolescent Health

• Address teenage pregnancy; increase contraceptive prevalence in adolescents
• Community-based services through peer educators
• Strengthen ARSH (Adolescent Reproductive and Sexual Health) clinics
• Roll out National Iron Plus Initiative with weekly IFA supplementation
• Promote menstrual hygiene

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Cross-Cutting Interventions

• Bring down out-of-pocket expenses - JSSK, RBSK, and other free entitlements
• ANMs and nurses to provide specialized, quality care
• Address social determinants through convergence
• Focus on un-served, underserved villages, urban slums
• Performance-based and difficult-area incentives

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Health Systems Strengthening

• Caseload-based deployment of HR at all levels
• Ambulances, drugs, diagnostics, reproductive health commodities
• Health education, demand promotion and BCC (Behaviour Change Communication)
• Supportive supervision and HMIS-based scorecard monitoring
• Public grievance redressal and quality assurance

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Clinical Services at Facility Level

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Key Coverage Targets (Table 14)

• Increase institutional births (Government + accredited private) at 5.6%/year from 61% baseline
• ANC coverage increase at 6%/year from 53% baseline
• Postnatal care increase at 7.5%/year from 45% baseline
• Exclusive breastfeeding increase at 9.6%/year from 35% baseline
• Reduce under-five underweight at 5.5%/year from 45% baseline (NFHS-3)
• Reduce unmet need for family planning at 8.8%/year from 21% baseline
• Reduce anaemia in adolescent girls (15-19 years) at 6%/year from 56% baseline

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🏫 School Health Services

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🧠 Quick Memory Hook

"School = Future Community" School health is NOT just about checking sick kids - it's about building the health of future generations.

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What is School Health Service?

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📅 Historical Timeline (India) - Easy to Remember

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🎯 Objectives - Remember "PEEA"

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🏥 Health Problems of School Children in India

1. Malnutrition
2. Infectious diseases
3. Intestinal parasites
4. Skin, Eye & Ear diseases
5. Dental caries

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📋 12 Aspects of School Health Service

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🔍 Health Appraisal - Deeper Look

• History + physical examination
• Tests for vision, hearing, speech
• Routine blood & urine tests
• Nutritional deficiency screening
• Stool examination for parasites
• Tuberculin testing / mass screening

Flushed face, rash, cold symptoms, cough/sneeze, sore throat, rigid neck, nausea/vomiting, red eyes, headache, chills/fever, listlessness, won't play, diarrhoea, body pains, scabies/ringworm, pediculosis (lice)

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🍎 Health Education - The MOST Important Element

1. Personal hygiene - skin, hair, teeth, clothing, posture; address cigarette smoking
2. Environmental health - keeping surroundings clean, participating in community health campaigns
3. Family life - healthy attitudes towards human reproduction

💡 Key quote from Park: "Every school child is a health worker" - children carry health messages home to their families!

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🏛️ School Health Administration

(a) School Health Committee

• Coordinates between Education and Health departments
• Sets policy, reviews progress

(b) School Health Committees (at school level)

• Principal + teachers + health staff
• Day-to-day implementation

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📝 School Health Records - Contents

1. Identifying data - name, DOB, parent's name & address
2. Past health history
3. Physical examination findings and screening test results
4. Record of services provided

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🧩 Quick Revision Summary

School Health = 12 Aspects
├── EXAMINE: Health appraisal (entry + every 4 yrs)
├── TREAT: Remedial measures + follow-up
├── PREVENT: Communicable disease prevention
├── ENVIRONMENT: Safe school building
├── FEED: Nutritional services (mid-day meals)
├── EMERGENCY: First aid
├── MIND: Mental health
├── TEETH: Dental health
├── EYES: Eye health (Vit A, refractive errors)
├── EDUCATE: Health education (MOST IMPORTANT)
├── SPECIAL NEEDS: Handicapped children
└── RECORD: School health records

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⭐ High-Yield Exam Points

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Infant Mortality in India - Causes & Healthcare Organization

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Definition & Formula

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IMR - India at a Glance

• Highest IMR state: Madhya Pradesh - 48
• Lowest IMR state: Kerala - 7
• Critical infant mortality belt: Odisha, Madhya Pradesh, Assam, Bihar, Chhattisgarh, Uttar Pradesh, Rajasthan (all above national average)
• Rural IMR always higher than urban in all states

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PART 1 - Important Causes of Infant Mortality in India

A. Medical Causes (Table 26)

Key percentages in India:

• Low birth weight - 57% (single largest cause)
• Respiratory infections - 17%
• Congenital malformations - 5%
• Diarrhoeal diseases - 4%
• Birth injury - 3%
• Cord infection - 2%
• Unclassified - 18%

In developing countries: mainly LBW + infections + malnutrition In developed countries: mainly congenital anomalies + anoxia/hypoxia

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B. Factors Affecting Infant Mortality

1. BIOLOGICAL FACTORS

• LBW (<2.5 kg) AND high birth weight (>4 kg) are at risk
• Main cause of LBW = poor maternal nutrition

• Risk highest if mother is <19 years or >30 years
• Teen mothers are poorer, less educated

• Highest mortality: 1st born; lowest: 2nd born
• Risk escalates from 3rd child onwards
• Nutritional deficiency deaths 3-4× higher for 5th+ birth order

• Khanna Study (India): IMR highest when births <1 year apart
• WHO study: Same finding in rural India
• Births within 1 year of each other = 2-4× higher risk of death
• Optimal spacing: >2-4 years between births

2. ECONOMIC FACTORS

• Socioeconomic status is most important variable - both directly and indirectly
• IMR highest in slums, lowest in richer localities
• Health care quality and child's environment are closely related to socioeconomic status

3. CULTURAL AND SOCIAL FACTORS

• Neonatal death rate: higher for males
• Post-neonatal death rate: higher for females (due to neglect)

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PART 2 - Organization of Healthcare Delivery to Reduce Infant Mortality

1. Prenatal Nutrition

• Improve maternal nutrition - risk of infant death begins before birth
• Food supplementation during pregnancy: extra 500 kcal + 10g protein in last 4 weeks → birth weight increases by ~300g (Indian controlled study)
• ICDS (Integrated Child Development Services) is key programme in India

2. Prevention of Infection

• Universal Immunization Programme (1985) - protection against 9 vaccine-preventable diseases for mothers and children
• Immunization prevents neonatal tetanus, diphtheria, pertussis, measles etc.
• Specially targets EPI diseases

3. Promotion of Breast-feeding

• Most effective single measure for lowering IMR
• Protects against gastrointestinal and respiratory infections
• Protects against protein-energy malnutrition (PEM)

4. Growth Monitoring

• Weigh all infants at least once a month
• Maintain growth charts (Road-to-Health chart)
• Early identification of children at risk of malnutrition
• Low-cost, high-impact technology

5. Family Planning

• Birth limitation + birth spacing substantially lowers IMR
• Risk is greatly enhanced if:
  • Last child born <2 years ago
  • Mother already has ≥4 children
• Wider birth spacing = improved infant and child survival in all societies

6. Environmental Sanitation

• Safe water supply, proper housing, drainage, control of flies
• Infant risk of dying closely related to environment
• IMR = indicator of social environment quality

7. Provision of Primary Health Care (Organization)

• All personnel from obstetrician to local dai must work as a team
• Prenatal care to detect mothers with high-risk factors (toxaemia, APH, diabetes)
• High-risk mothers to be hospitalized and treated
• Special Care Baby Units (SCBUs) for all babies <2000g
• Proper referral services at all levels

8. Socio-economic Development

• Ultimate solution lies in overall socioeconomic development:
  • Spread of female literacy (most powerful single determinant)
  • Safe water + basic sanitation
  • Improved housing
  • Growth of agriculture and industry
  • Commerce and communication

9. Education (especially Female Education)

• Educated women:
  • Avoid early pregnancies
  • Space pregnancies better
  • Have better personal hygiene knowledge
  • Make better use of health services
• Tamil Nadu example: Mid-day meal programme + improved MCH care → IMR fell from 90 (1984) to 57 (1991) → fertility reduced to 2.5 per woman → eventually zero population growth

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Quick Summary Mnemonic - Preventive Measures: "PPI-FG SSE"

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Preventive Geriatrics

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🧠 Opening Quote to Remember

"You do not heal old age. You protect it; you promote it; you extend it." - Sir James Sterling Ross

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Key Definitions

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Size of the Problem

• World elderly population (2019): 694 million (540 million in developing countries)
• India (2019): 9.3% of total population above 65 years
• By 2025: elderly expected to exceed 1.2 billion globally
• Countries with highest proportion of elderly: Italy and Japan (~24% and 16% respectively)
• Brings social, economic, and healthcare policy challenges

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Health Problems of the Aged

(1) Problems Due to the Ageing Process

• Senile cataract
• Glaucoma
• Nerve deafness
• Osteoporosis (affecting mobility)
• Emphysema
• Failure of special senses
• Changes in mental outlook

Note: Biological age ≠ Chronological age. "Years wrinkle the skin, but worry, doubt, fear and self-distrust wrinkle the soul."

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(2) Problems Associated with Long-Term Illness

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(3) Social and Psychological Problems

🔺 Poverty + Loneliness + Ill-health

• Social isolation, depression, dementia
• Retirement → loss of income, purpose, social role
• Dependence on family, institutional care needs

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Potential for Disease Prevention in the Elderly

1. PRIMARY PREVENTION

• Diet and nutrition: Adequate calories, proteins, vitamins (especially Vit D, Vit B12), calcium; avoid obesity
• Physical activity: Regular moderate exercise preserves muscle strength, bone density, cardiovascular fitness, mental health
• Avoidance of risk factors: Stop smoking, reduce alcohol, control hypertension and diabetes
• Immunization: Influenza vaccine annually; Pneumococcal vaccine; Tetanus booster
• Accident prevention: Remove home hazards (loose rugs, poor lighting), use of walking aids, hip protectors
• Social integration: Maintain social contacts, productive activities; combat loneliness

2. SECONDARY PREVENTION

• Periodic health examination / screening for:
  • Hypertension
  • Diabetes mellitus
  • Cancer (colorectal, prostate, breast, cervical)
  • Glaucoma and cataract
  • Hearing loss
  • Osteoporosis (bone density scans)
  • Depression and cognitive decline (dementia screening)
  • Dental disease
• Geriatric assessment (comprehensive)

3. TERTIARY PREVENTION

• Rehabilitation after stroke, fractures, joint replacement
• Physiotherapy, occupational therapy, speech therapy
• Prevent complications of chronic diseases
• Day-care centres and old-age homes for those unable to live independently
• Home-based care programmes

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Implications for Preventive & Social Medicine

• Ageing population = greater demand on health services
• Healthy ageing is a prerequisite for economic growth
• Predicted explosion of NCDs (CVD, cancer, depression) will cause enormous human and social costs unless preventive action is taken
• Developing countries face a double burden of infectious + non-communicable diseases with limited resources
• Modern philosophy: The old must continue as active members of the community

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Government Programmes for the Aged in India

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Quick Revision Summary Table

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