Neonatal Mortality - Park's Textbook of Preventive and Social Medicine

1. Definition

• Park's SPM, p. 657

2. Classification

3. Causes of Neonatal Mortality

Global Distribution (Fig. 13, 2018 data):

• Park's SPM, p. 657-658

Key Points on Causes:

• Intrapartum complications + low birth weight + preterm birth together account for 60% of neonatal deaths
• Prematurity + congenital anomalies account for about 60% of newborn deaths - mostly in the first week of life
• Asphyxia accounts for a further quarter of neonatal deaths - also mainly in the first week
• In the late neonatal period (after first week), infections (including diarrhoea and tetanus) predominate
• The contribution of tetanus to neonatal death has diminished sharply due to intensified immunization efforts

4. Determinants / Risk Factors

Biological / Endogenous:

• Low birth weight (LBW)
• Preterm birth / prematurity
• Birth injuries / asphyxia
• Congenital anomalies

Sociodemographic:

• Maternal education - NMR of babies born to mothers with no education is nearly twice as high as those born to mothers with secondary or higher education
• Family wealth - remains a powerful determinant of inequities in NMR
• Rural vs. urban residence - significant inequity
• Child marriage and adolescent pregnancy - increase the risk of newborn mortality
• Short birth intervals - increase risk

Healthcare Access:

• Lack of antenatal care (in the least developed countries, ~50% of pregnant women have no ANC)
• Delivery without a trained birth attendant (~7 out of 10 in least developed countries)
• Malnutrition and high parity of the mother

5. India-Specific Data

• India's NMR for 2018 was approximately 9 per 1000 live births (total), with both rural and urban rates also at 9 per 1000 live births
• India remains among the high infant mortality rate countries (IMR = 32 per 1000 live births in 2018)

International Comparison of IMR (1990 vs 2018):

• Park's SPM, Table 23, p. 659

6. Priority Areas to Improve Newborn Health

Before and During Pregnancy:

• Delayed child-bearing
• Well-timed, well-spaced, and wanted pregnancies
• Well-nourished and healthy mother
• Pregnancy free of drug abuse, tobacco, and alcohol
• Tetanus and rubella immunization
• Prevention of mother-to-child transmission of HIV
• Female education

During Pregnancy:

• Early contact with health systems
• Birth and emergency preparedness
• Early detection and treatment of maternal complications
• Monitoring of foetal well-being
• Prevention and treatment of anaemia
• Prevention and treatment of infections (malaria, hookworm, syphilis, STIs)
• Good diet; prevention of violence against women

During and Soon After Delivery:

• Safe and clean delivery by skilled attendant
• Early detection and prompt management of delivery complications
• Newborn resuscitation
• Newborn care ensuring warmth and cleanliness
• Newborn cord, eye and skin care
• Early initiation of exclusive breast-feeding
• Special care for preterm/LBW infants
• Prevention and control of infections

During the First Month of Life:

• Early post-natal contact
• Protection, promotion and support of exclusive breast feeding
• Prompt detection and management of diseases
• Immunization
• Protection of girl child
• Park's SPM, p. 658

7. Home Based Newborn Care (HBNC)

Objectives of HBNC:

1. Provision of essential newborn care and prevention of complications
2. Early detection and special care of preterm and LBW newborns
3. Early identification of illness and appropriate referral
4. Support family for adoption of healthy practices and build confidence of the mother

ASHA's Responsibilities in HBNC:

• Mobilize all pregnant mothers for full antenatal care
• Undertake birth planning and birth preparedness
• Provide newborn care through home visits including: weighing the newborn, measuring temperature, ensuring warmth, supporting exclusive breast-feeding, promoting handwashing, providing skin/cord/eye care
• Assess high-risk babies (preterm/LBW) and increase visits for them
• Detect signs of sepsis, provide first-level care, and refer
• Recognize postpartum complications in the mother
• Counsel couples for family planning
• Provide immediate newborn care for home deliveries

ASHA Visit Schedule:

8. SDG Target

• Park's SPM, Table 4

9. Factors Explaining Decline in Infant Mortality

• Improved obstetric and perinatal care (oxygen availability, foetal monitoring, better labour management)
• Improvement in quality of life (economic and social progress)
• Better control of communicable diseases (immunization, ORS)
• Advances in chemotherapy, antibiotics, and insecticides
• Better nutrition (emphasis on breast feeding)
• Family planning (birth spacing)

Infant Mortality Rate (IMR) - Park's SPM - Complete Notes

1. Definition

IMR = (Deaths of children < 1 year in a year ÷ Live births in same year) × 1000

2. Importance of IMR

• The most important indicator of health status of a community
• A measure of the level of living of people in general
• A measure of the effectiveness of MCH (Mother & Child Health) services in particular

1. Infant mortality is the largest single age-category of mortality
2. Deaths at this age are due to a peculiar set of diseases and conditions to which adults are less exposed or vulnerable
3. Infant mortality is affected quickly and directly by specific health programmes and can change more rapidly than the general death rate

3. Components of IMR

• In developing countries: high IMR is mainly due to low birth weight + infections (diarrhoea, respiratory infections) + malnutrition
• In developed countries: mainly due to congenital anomalies, anoxia and hypoxia

4. Causes Flowchart

5. Factors Affecting Infant Mortality (Detailed)

A. BIOLOGICAL FACTORS

• Major determinant of infant and perinatal mortality
• Babies of LBW (<2.5 kg) and high birth weight (>4 kg) are at special risk
• Virtually all infants <1000g at birth succumb
• Key cause: poor maternal nutrition - not just during pregnancy but even before
• A mother well-nourished during her own growing-up years has an excellent chance of delivering a normal-sized baby

• IMR is greatest when mother is:
  • Very young (below 19 years) - teen mothers
  • Relatively older (over 30 years)
• Very young mothers tend to be poorer and less educated

• Highest mortality: first born
• Lowest mortality: second born
• Risk escalates after the third birth
• The 5th and later children always have worse outcomes than the 3rd child
• IMR from nutritional deficiencies is 3-4 times higher for 5th+ birth order vs. first three

• Repeated pregnancies cause malnutrition and anaemia in the mother → LBW → higher infant death
• The premature weaning of a displaced youngest baby leads to:
  • (a) Protein Energy Malnutrition (PEM)
  • (b) Diarrhoea and dehydration
• Khanna Study (India): IMR was highest for interval of 1 year, lower for 2-3 years, lowest for 4 years
• World Fertility Survey: Babies born within 1 year of each other have 2-4 times higher risk than those born >2 years apart
• Wider birth spacing is considered as important as immunization

• Higher risk due to greater frequency of LBW among twins/multiples

• IMR increases with family size
• Larger families = more infectious diarrhoea, malnutrition, respiratory infections
• Duration of illness is longer in families with 3 or more children
• Deprivation of maternal care is also found in large families

• High fertility and high infant mortality go together - one of the most important factors

B. ECONOMIC FACTORS

• Socio-economic status is the single most important variable affecting IMR (both directly and indirectly)
• Quality of healthcare and child environment are closely related to socio-economic status
• IMR is highest in slums and lowest in richer residential localities
• Major improvements in health status and fall in IMR require continuing socio-economic development including provision of health services

C. CULTURAL AND SOCIAL FACTORS

• Breast milk contains nutritional content and natural immunizing agents
• Early weaning and bottle-fed infants under poor hygienic conditions are more prone to die than breast-fed infants under similar conditions

• Differences attributed to socio-cultural patterns - habits, customs, traditions affecting cleanliness, eating, clothing, and child care

• Baby of a teenage mother has the highest risk for both neonatal and post-neonatal mortality

• In most parts of India, female infants receive far less attention than males
• Female infant mortality is higher than male infant mortality overall
• But when split: neonatal death rate is higher for males; post-neonatal death rate is higher for females
• Birth of a female child is unwelcome in many families → lack of nutrition and medical care

• Even in extreme poverty, children survive if they have an efficient mother
• "Quality of mothering" helps reduce IMR

• Illiteracy is the greatest barrier to health improvement
• Mother's education is a key determinant of children's health (Kerala experience)
• Educated women: marry later, delay childbearing, practice family planning, have fewer children with wider spacing

• Inadequate prenatal care and infrequent attendance at delivery
• High percentage of deliveries attended by untrained persons in rural India
• Only 47% of deliveries are attended by trained birth attendants in India

• Infant mortality tends to be high where the mother or father has died or separated

• A child born out of wedlock is generally unwanted → does not receive adequate nutrition or medical care

• Depriving the baby of colostrum (first milk)
• Frequent purgation
• Branding the skin
• Application of cowdung to the umbilical cord stump
• Faulty feeding practices and early weaning

• Greatly responsible for high IMR in India
• Usually illiterate, devoid of knowledge of hygiene
• Unhygienic delivery practice is an important cause of high IMR

• Lack of safe water supply, poor housing, bad drainage, overcrowding, insect breeding
• All increase the risk of infant mortality

6. International Comparison Graph

• World average IMR (2018) = 29 per 1000 live births
• Developed countries: 4 per 1000
• Least developed countries: 46 per 1000
• South Asian average: 35 per 1000

7. Factors Responsible for Decline in IMR

8. Preventive and Social Measures to Reduce IMR

IMR Causes — Detailed Flowchart

How to Read the Flowchart

IMR (Definition & Formula)
        ↓
Multifactorial Aetiology
   ↙         ↓         ↘
[A]         [B]         [C]
Biological  Economic   Cultural & Social
Factors     Factors    Factors
        ↓ (all converge)
Proximate Causes
(Infections · Malnutrition · LBW · Poor Health Care)
        ↓
INFANT DEATH
        ↓
Preventive Measures (9 key interventions)

Summary of All Causes (from Park's SPM)

A. Biological Factors (7 sub-factors)

B. Economic Factors (5 sub-factors)

C. Cultural & Social Factors (10 sub-factors)