A strong economic case is required to advocate for the earmarking of funds specifically for developing and sustaining high-quality inpatient newborn care.
Every year an estimated 4 million babies die in the first 4 weeks of life and 75 percent of neonatal deaths occur in the first week. More than a quarter of global neonatal deaths occur in India owing to prematurity, sepsis, and perinatal asphyxia. As a result, there is small or no decline in the neonatal mortality rate (NMR) in the country in past years. This stagnation of neonatal mortality in India highlights the importance of improving the quality of perinatal as well as neonatal care.
The Millennium Development Goal 4 (MDG), which stipulates a two-third reduction in under-five mortality by 2015, has shown uneven success due to failure of ensuring a substantial reduction in the NMR. Moreover, there is no proper accreditation system to categorize the neonatal intensive-care units (NICUs) into Level-I, Level-II, and Level-III depending on the facilities available. The National Neonatology Forum (NNF), the major academic body involved in carrying out the agenda of neonatal survival in India, has only recently begun the proper accreditation process for NICUs. To improve survival and health of newborn babies, the government has made effective interventions in the country.
Government Initiatives - Baby Steps
The health-financing issues faced by many low-income countries are due to the lack of financial resources for health and development overall, and are not unique to the newborn; newborns requiring inpatient care are at greater risk due to their need for specialized facility-based care. Newborns are relatively neglected in official development assistance and specialized, intensive care is often perceived as prohibitively expensive. A strong economic case, including the relative burden of newborn mortality globally, and the argument for prevention of long-term morbidities, is required to advocate for the earmarking of funds specifically for developing and sustaining high-quality inpatient newborn care.
To improve neonatal care the government has strengthened 2706 referral hospitals to act as first referral units (FRUs), 13,667 PHCs/CHCs to provide 24├ù7 services, 14,441 newborn care corners (NBCCs), 575 special newborn care units (SNCUs), and 2020 newborn stabilization units (NBSUs) under National Health Mission (NHM) in 2015. The focus of this aspect could be more on equipping beds at NICUs wards with properly functioning equipment before increasing the number of beds.
In another move, to bridge the gap between underserved urban poor and those in rural areas, the government has launched India Newborn Action Plan. Though it is a right step in the right direction with the aim of ending preventable newborn and stillbirths by 2030, but a strong public-private partnership and prioritization is needed to achieve better neonatal care.
NICUs across the country are still deficient in data management. Many units are using databases obtained from foreign collaborators and sharing data externally. Nationally, no such database existed till very recently. The UNICEF Madhya Pradesh has developed a user-friendly SNCU online software which is being used across the entire state. This software is now being used by other states supported by National Rural Health Mission (NRHM). It is planned that National Neonatology Forum (NNF) with its existing pool of over 115 SNCUs accredited by the new accreditation guidelines can partner with UNICEF to adopt this database in the NICUs in private. This will provide a heterogeneous mix of data from both private as well as government/UNICEF-supported SNCUs at the national level.
Recently, the government has been positive on increasing neonatal care in the country but more concrete steps need to be taken to even out the success. Along with increase in the resources and healthcare delivery system, radical transformation of traditional technologies should be focused upon, if the nation is to achieve the government's vision of assuring Health for All.
The last decade has seen a tremendous growth of neonatal intensive care in India. The proliferation of NICUs, as also the infusion of newer technologies with availability of well-trained medical and nursing manpower, has led to good survival and intact outcomes. Traditional equipment including baby warmers, incubators, phototherapy units, ventilators, and pulse oximeters continue to be the backbone of basic neonatal intensive care. Various advances which make these systems baby- and doctor-friendly have been incorporated in the last few years.
Combined devices. There is a substantial market for combined devices, especially for infant incubators with radiant warmers, phototherapy systems with radiant warmers, and transport incubators with the capabilities of a mobile NICU. Hospitals are demanding technologically improved and sophisticated devices, which include hybrid warming devices that can be configured as open or closed incubators, and double-walled incubators.
Fetal imaging. Fetal imaging is one of the fastest-developing radiology fields. Improved ultrasound technologies including high-resolution linear transducers, advanced Doppler, and 3D capabilities, have enabled earlier and more accurate fetal evaluations. Faster MRI sequences can obtain high-resolution images in multiple planes, revolutionizing the ability to examine and care for the developing fetus. The increased popularity of fetal MRI and help in completing the diagnosis of complex or large anomalies in the fetus is one of the major emerging trends in the fetal and neonatal equipment market.
Infant resuscitators. The high cost of bag-and-mask newborn resuscitator devices resulted in a lack of availability and accessibility of resuscitators in the public sector in developing countries including India. Advanced resuscitators are now suitable for effective ventilation for infrequent users in low-resource settings, which have fewer parts and cost less than the current standard resuscitators.
Innovative methods including the intubation-surfactant-extubation (INSURE) technique, newer modes of ventilation, stringent aseptic measures, and improved control of nosocomial sepsis are contributing to significantly improved survival among preterm babies. New equipment including infant resuscitators; techotherm and miracradle used in the management of hypoxemic birth injury; and nitric oxide systems for babies who cannot be managed on traditional and high-frequency ventilators are expected to grow manifold, especially in tertiary care centers.
Challenges and Opportunities
The continuous R&D activities being carried out by market players, increasing incidences of preterm births, increasing prevalence of hospital-acquired infections in newborn babies, and high level of awareness along with demand are offering opportunities to the development of neonatal care. Facility-based neonatal care frequently remains under-prioritized and under-funded.
Few standardized indicators exist to measure quality of newborn care in facilities and challenges remain to improve the metrics and core competencies. Inadequacies in supplies and safe use of medicines and equipment including effective phototherapy and case management for sick neonates are common hitches despite the fact that evidence-based interventions exist that can be delivered in resource-constrained environments. The major challenge is the limited availability of NICUs to tertiary referral hospitals and inaccessibility to rural communities. Even where NICUs are available, the case load of neonates requiring care may exceed the available bed capacity.
Technological developments in prenatal and neonatal care equipment, and initiatives taken by government and non-profit bodies aimed at improving fetal and neonatal care are expected to give rise to significant growth opportunities for the market in coming years. Various non-profit organizations along with the governments are attempting to offset the effect of consolidation by funding the hospitals to increase the number of beds and staff in the NICUs.
To improve neonatal survival, community-based interventions comprising delivery of packages through home visits and community mobilization should expand. A nationwide creation of NBCC at every point of child birth, NBSUs at community health centers, and special SNCUs at district hospitals should be given a thrust to neonatal care in India. Guidelines and toolkits for standardized infrastructure, human resources, and services at each level developed and a system of reporting data on the facility-based newborn care should be followed to achieve better neonatal care in the country.