Feature

In the past few decades, India has made significant progress when it comes to reducing maternal, newborn, and infant mortality. The national maternal mortality rate (MMR) is 97 per 100000 live births (2018-20) and the neonatal mortality rate (NMR) is 22 per 1000 live births (2019). 

Although India is steadily advancing when it comes to women and children’s health; the progress is fraught with challenges. We spoke with Dr Raghuram Mallaiah, Director - Neonatology, and Director/Founder - Amara Human Milk Bank at Fortis La Femme, about India’s neonatal healthcare system, its challenges, the need for human milk banks; and why breastfeeding is critical in reducing NMR. Edited excerpts: 

I came back to India in 2004 after doing most of my medical training in the United Kingdom. I think the private healthcare sector has made a lot of progress since 2004. I still remember that there was a huge problem of infrastructure and getting equipment at that time. Getting simple things like specialized ventilators, blood gas machines etc was a challenge for us. Now things have changed in a positive sense when it comes to infrastructure and facilities. We now have almost all the equipment that is available in the developed countries.

We at Fortis La Femme, were probably the first specialized mother and child hospital in India. Now there are so many private hospitals in cities and a patient has a lot of choices. However, according to me, this expansion happened mainly in tier 1 and tier 2 cities. Another disadvantage of having so many hospitals, especially from the maternity and neonatology perspective, is that it dilutes the manpower and the outcome for babies.

Another area where we have lacked, even in the private sector, is in terms of manpower. A field like mine is hugely manpower-dependent. It is not just the doctor; we need to have many skilled and specialized nurses. In fact, we have various fields within neonatology like neonatal neurology, neonatal nutrition, and so on, in which we are still improving and specializing, and we need to invest in manpower accordingly.

There is no simple answer to that. India being a vast and diverse country, the neonatal care and outcomes are hugely based upon a number of factors including which part of the geography you are based in; are you in an urban setting or rural setting; and again, whether you are in the private or the government sector. For outcomes are hugely different in the government health care sectors. In urban care centers too, outcomes are different in a highly specialized units like ours as compared to other private centers. And hence, an overall picture it is very difficult to give.

Although, there is still a huge amount of mortality and morbidity that happens but if I talk about neonatal care in our unit, our neonatal outcomes and standard of care is almost equivalent to what happens in most of the developed countries. We are now saving babies from 24 weeks gestation which is the period of viability in most parts of the world. We have been doing neonatal surgeries for very complex procedures. For eg, we have done very complex cardiac interventions surgeries with good outcomes in babies that were 600-700 grams. But these are sporadic so it would be wrong for me to say that neonatal care across India is the same and is comparable to across the world.

The government has some very clever and intuitive policies when it comes maternal and neonatal outcomes. For eg., The India Newborn Action Plan 2014, in which the government wanted to decrease the neonatal mortality rate to a single digit figure, as compared to 40-45% in 2008. A lot of planning was done towards it. However, the initial drop is much easier to achieve but to bring it down to single digit number is going to be a challenge.

The problem is in terms of executing and accountability of these plans. I think the way forward is that the government and the private sector should work together in forming public private partnership and PPP programs.

The general impression that everybody has is that the private sector is very expensive and may not work in the rural areas. However, the private sector is much more accountable and better at executing projects. And we also have specialized manpower, which is another huge challenge in rural areas. From that perspective, we can also work on low cost and high-volume models when it comes to implementing government’s programs and policies.

 

India has always been a breast-feeding nation. We were among the first people in India, in the private sector, to start a human milk bank in 2016. In our units, we tend to deal with a lot of premature babies. If the mother doesn’t get milk in the first few days of baby’s life, the only other option is to give formula feed. Now there is very clear evidence that formula feeds increase the mortality rate as well as morbidity in these babies and the breastmilk is hugely protective, and that’s where the concept of milk bank came into place. We now have one in Bengaluru as well which we started in 2017.

Interestingly, we are the only public milk bank in Delhi and we supply to almost abut 50-60 hospitals across Delhi-NCR. The government is also in the process of establishing milk banks, but most of the government banks are mainly in government hospitals which only collect enough milk to distribute for their own unit and for their own hospitals. They are not actually distributing to different hospitals. 

A lot of money is involved in the whole process. There is a cost involved in collecting the milk; then the milk needs to pasteurized; we then need to check the milk for any infection and analyze the quality of the milk. Then the milk is bottled and stored and transported to other sites.  It is wise to establish, let’s say in a city like Delhi, 3-4 milk banks rather than trying to establish 25 different milk banks because the cost goes up very high at that point. 

We have established a very good system for collection and distribution of milk. But I think again there is a huge role of public-private partnership over here as well as we can help the Government as we have the expertise and the knowledge to run these milk banks. 

I think the most important factor, when it comes to the health of the new born babies in India, is nutrition which is extremely important for long term outcomes of babies. Malnutrition or lack of nutrition is not limited to the rural areas, but also in the urban areas as well. It is now being proven that the first 1000 days of life, which means from the time the baby was conceived in the mother’s womb, to the second year of life is extremely important in terms of giving correct amount of nutrition. Also, the mother should not be anaemic during her pregnancy; she needs to take good diet and supplements like calcium and iron. She needs to have good antenatal care so that the baby grows well inside the womb. Hence, the growth and the nutrition part start from the time the fetus was conceived till immediately after the birth.

Breastfeeding is by far the most important thing for the baby in terms of nutrition. It is very important that people concentrate on breastfeeding for the first six month at least. Then after weaning, giving the correct type of food to the baby becomes critical. If you get your nutrition correct in the first 1000 days of life it is prone to decrease a lot of problems like diabetes, hypertension, and other lifestyle disorders.

The second important thing is prevention of infections in these new born babies. Infections are an important cause of mortality in new born babies as well as the first one two years of life. The most important thing to prevent these infections is breastfeeding. Breastfeeding also helps in increasing immunity. Other than this, a very important part is to make sure that the child gets vaccinated on time. Vaccinations are extremely important and has been proven across the world to prevent and even eradicate the diseases.

The third important part is congenital anomalies or birth defects that occur prenatally. It is something easily preventable in today’s world, if the mother has good antenatal care including a lot of screening programs and ultrasounds. I think it is very important to go through these screening programs during your pregnancy and immediately after birth as well. For eg., a simple condition like hyperthyroidism, if not picked up, can develop into mental retardation later in life. So, these are simple things that can be corrected as long as you do the screening program.

Most countries, where neonatal care is at a high standard, follow the model of having one or two big or hub centers and the other are smaller or spoke units where babies are referred to the big center if need be. Highly specialized care can be given in these 3-4 bigger units. Even countries like UK, who decided to take neonatology to the community in 80s and 90s, are slowly reverting back to this hub and spoke model. However, any successful healthcare model is dependent on systems being in place and these systems need to work properly.