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Indian Pediatr 2012;49: 136-138
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Impact of National Rural Health Mission on
Perinatal Mortality in Rural India
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Sharad Kumar Singh, Ravinder Kaur, Madhu Gupta and Rajesh Kumar
From PGIMER School of Public Health, Chandigarh,
India.
Correspondence to: Dr Madhu Gupta, Assistant
Professor of Community Medicine, School of Public Health, Post Graduate
Institute of Medical Education and Research (PGIMER), Chandigarh, 160
012, India.
Received: February 27, 2011;
Initial review: March 10, 2011;
Accepted: May 31, 2011.
Published online: 2011 August, 15.
PII: S097475591100161-2
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Abstract
Innovations under National Rural Health Mission have
paved the way for increased utilization of hospitals for childbirth. The
association of increase in hospital deliveries with decline in the
perinatal mortality rate in rural India after the launch of NRHM in 2005
was assessed using the Sample Registration System reports. Relative
increase in hospital deliveries was 57% from year 2005 to 2008 but
relative decline in the PNMR was only 2.5% in the rural areas of Indian
states (r=0.2; 95% confidence interval -0.2-0.6; P=0.3).
Hence, quality of care at the time of childbirth needs to be assessed.
Key words: Evaluation, Mortality, Perinatal, Rural, Quality of
care.
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Safe motherhood and child survival have always
been a concern for the policymakers but perinatal mortality, especially
stillbirths, have not received due attention [1].
There are 5.9 million perinatal deaths worldwide,
almost all of which occur in developing countries. Stillbirths account
for over half of all perinatal deaths [2,3]. United Nations’ Millennium
Development Goal 4 - reduction in Under-5-Mortality by two thirds by
2015 - would be unattainable without a considerable decline in the
perinatal mortality. According to WHO global perinatal estimates for
year 2000, one third of stillbirths occur during delivery.
These deaths are largely avoidable with skilled
care [4]. Institutional
deliveries can avert a number of avoidable complications which emerge
during child birth by early detection and appropriate management.
Although services like emergency obstetric care are the most challenging
and costly to provide, they also have the highest potential to save
lives [5].
The National Rural Health Mission (NRHM) - initiated
in 2005 in India - envisaged providing affordable and quality health
care to the poorest households in the remotest regions of the country.
This mission has encouraged changes in the pattern of place of delivery.
Innovations under NRHM like Janani Surakhsha Yojana (Maternity
Security Scheme), Accredited Social Health Activists (ASHA), Delivery
Huts, 24×7 Primary Health Centers and Community Health Centers, and
Medical Obstetric Care in First Referral Units have paved the way for
increased utilization of health institutions for child birth. According
to Sample Registration System (SRS), deliveries in govern-ment and
private hospitals in India have increased.
However, perinatal mortality rate (PNMR) continues to be
high, though wide inter-state and intra-state variations exist [6].
The aim of present study was to find whether
increase in hospital deliveries is associated with decline in perinatal
mortality in rural areas of India after the launch of NRHM.
Methods
Institutional deliveries (in government and private
hospitals) and perinatal mortality rate reported by the sample
registration system (SRS) operated by the Registrar General of India on
a representative sample from 2005-2008 was used for this study [6]. The
relative change in PNMR and hospital deliveries was calculated for rural
areas in each of the major states of India from year 2005 to 2008, and
correlation between relative change in PNMR and hospital deliveries was
examined using SPSS version 17. The study had 80% power at 5%
significance level for finding a correction co-efficient of 0.54 or
higher.
Results
In most of the Indian states, hospital deliveries in
rural areas have increased during 2005 to 2008. However, PNMR has
declined only marginally during this period; it has even increased in
few states (Table I) (r=0.2, 95% confidence interval –0.2,
0.6; P=0.3). At the national level, relative increase in hospital
deliveries was 57% and relative decline in PNMR was only 2.5% in the
rural areas of Indian states.
TABLE I Relative Change in Institutional Delivery and Perinatal Mortality in Rural India from 2005 to 2008
State |
Hospital delivery % |
|
|
2005 |
2008 |
% Change*
|
2005 |
2008
|
% Change* |
Andhra Pradesh |
43.5 |
62.6 |
43.9 |
44 |
43 |
–2.3 |
Assam |
21.0 |
36.7 |
74.8 |
35 |
34 |
–2.9 |
Bihar |
20.0 |
23.5 |
17.5 |
31 |
28 |
–9.7 |
Chhattisgarh |
18.2 |
30.7 |
68.7 |
55 |
52 |
–5.5 |
Delhi |
51.3 |
63.6 |
24.0 |
27 |
17 |
–37.0 |
Gujarat |
36.1 |
60.8 |
68.4 |
39 |
37 |
–5.1 |
Haryana |
24.9 |
40.4 |
62.2 |
33 |
33 |
0 |
Himachal Pradesh |
29.8 |
43.9 |
47.3 |
39 |
39 |
0 |
Jammu & Kashmir |
39.5 |
56.4 |
42.8 |
39 |
43 |
10.3 |
Jharkhand |
4.9 |
7.2 |
46.9 |
24 |
29 |
20.8 |
Karnataka |
45.0 |
63.3 |
40.7 |
43 |
44 |
2.3 |
Kerala |
98.7 |
98.9 |
0.2 |
18 |
15 |
–16.7 |
Madhya Pradesh |
13.2 |
37.4 |
183.3 |
46 |
46 |
0 |
Maharashtra |
35.7 |
57.5 |
61.1 |
35 |
34 |
–2.9 |
Orissa |
21.3 |
42.0 |
97.2 |
57 |
48 |
–15.8 |
Punjab |
29.4 |
48.9 |
66.3 |
39 |
36 |
–7.7 |
Rajasthan |
16.2 |
43.4 |
167.9 |
49 |
47 |
–4.1 |
Tamil Nadu |
58.6 |
78.7 |
34.3 |
38 |
30 |
–21.1 |
Uttar Pradesh |
9.4 |
18.2 |
93.6 |
45 |
46 |
2.2 |
West Bengal |
36.7 |
49.4 |
34.6 |
34 |
31 |
–8.8 |
India
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24.4 |
38.3 |
57.0 |
40 |
39 |
–2.5 |
*Relative change =
(2008-2005)/2005×100. |
Discussion
NRHM is a novel initiative by the Government of India
to provide health care to people living in the rural areas of relatively
poorer states of India. It is evident from the present study that post
NRHM there have been a significant rise in hospital deliveries in rural
areas (Table I). It was expected that the rise in the
institutional delivery will lead to decline in PNMR. A study by WHO in
six developing countries had concluded that advancement in institutional
care could lead to a decrease in the perinatal mortality [7]. Another
study in Mexico also reported that sufficient prenatal care and
standards of care for labor, delivery and for the care of the newborn
are strong predictors of perinatal mortality [8].
We did not find significant association between
the relative rise in hospital deliveries and relative decline in PNMR.
Though deliveries in hospitals have increased but quality of delivery
care may not be appropriate. Under NRHM focus is on ‘universal
institutionalised deliveries’ rather than ‘improved maternal/neonatal
health’.
A UN report has highlighted that India is not
training a sufficient number of skilled birth attendants and technical
senior managers [9].
District Level Household and Facility Survey 2007-08 has revealed
substantial gaps in availability of qualified service providers,
equipment and supplies in primary and secondary level health facilities
in India [10]. Shortage of human resources could be one of the reasons
for less than optimum quality of services. Other reason could be
non-availability of infrastructure for providing essential newborn care
in the hospitals and health centers, e.g., newborn corners where
newborns can be given essential care in various levels of health care
facilities. All health professionals who attend the mother during child
birth should be skilled at resuscitation and know how to recognize
babies at risk.
Anticipating insufficient impact of institutional
deliveries alone, other strategies like Navjaat Shishu Shuraksha
Karyakaram (Newborn Survival Program) has been started in India
recently to train health personnel for newborn care Facility-based
integrated management of childhood illness (F-IMNCI) is also being
integrated with the community-based IMNCI package. Maternal and
perinatal death inquiries can also identify the bottlenecks and
stimulate corrective actions at local level.
To conclude, although hospital deliveries have
increased considerably since the launch of NRHM but PNMR has not shown
significant decline. NRHM strategy of increasing institutional delivery
rate should look into quality of care issues at the time of greatest
risk, i.e., birth and the first few days of life which could be
the way forward for reducing the high perinatal death rate in India.
However, progress in reducing deaths in perinatal period also depends on
other factors like cultural, social and demographic characteristics.
These factors also need to be addressed so as to have better impact on
perinatal health. Political
support and public ownership needs to be developed for accessing the
right to health as an entitlement guaranteed by the state not only for
those who are alive at birth but also those who die before birth.
Contributors: SKS: Design, analysis,
interpretation of data and drafted manuscript; RK: Analysis,
interpretation of data and drafted manuscript; MG: Interpretation of
data and revised manuscript for important intellectual content and RK:
Concept, design and revised manuscript for important intellectual
content.
Funding: None; Competing interests:
None stated.
What This Study Adds?
• National Rural Health Mission is successful in
increasing hospital deliveries considerably but perinatal mortality
has registered only a small reduction in the rural areas of Indian
states.
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