Vol.1, No.2, 62- 65 (2011)
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
Open Journal of Preventive Medicine
Suggested health ser vices research action to achieve
reduction of neonatal mortality in India
Manoj Kumar1*, Haresh M. Kirpalani2
1Neonatal Division, Department of Pediatrics, University of Alberta, Edmonton, Canada;
*Corr es ponding a uthor : manojk@ualberta.ca
2Div ision of Neona tology, The Children’s Hospital of Philadelphia , Pennsylvania , U SA .
Received 28 May 2011; revised 19 July 2011; accepted 28 July 20 11.
Despite several national programs to reduce
infant mortality, India had repeatedly failed to
achieve its set targets for infant mortality. There
are approximately one million neonatal deaths
in India each year which accounts for nearly
two-thirds of the infant deaths in India. India’s
current trajectories of neonatal and infant mor-
tality rates make it unlikely that it will achieve it s
targets for infant mortality rate for 2015 set un-
der the Millennium Development Goals. Since
two-thirds of infant deaths in India are neonatal
deaths, implementation of effective neonatal
care strategies would be essential to reduce
infant mortality considerably. The history of
child health services in India suggests an inat-
tention to qualitative parameters, hindering a
reversal of its failures. We discuss a format of
mixed-methods participatory research, inte-
grated with routine district level household sur-
veys (DLHS), as a model of health services re-
search which would better delineate the prob-
lems encountered in delivering effective new-
born care at the primary care level.
Keywords: Health Services Research; Infant
Mortality; Neonatal Mortality; Mixed-Methods
Research; Qualitative
India is signatory to the United Nations’ declaration of
the Millennium Development Goals (MDGs); accord-
ingly, it is expected to decrease childhood mortality by
two-third by year 2015 from its level in 1990 (MDG4).
For India, the target for infant mortality rate (IMR) is 27
per thousand births [1]. In past, India has repeatedly
failed to achieve health targets that it had set for itself.
For example, in 2002, a revised national policy set the
target for reduction in IMR to less than 30 by 2010 [2],
whereas the most recent estimate of India’s IMR is
above 50 [3].
Approximately two-thirds of the infant deaths in India
are neonatal deaths (deaths between 0 - 28 days of life),
resulting in nearly one million deaths annually [4]. 70%
of India’s population still resides in rural and semi-urban
areas which is serviced by the primary healthcare net-
work [5]. Thus large strides in reduction of IMR would
be dependant upon improving neonatal survival in those
areas. As 75% of the neonatal deaths occur within first
week of life, a strategic focus on dealing with the factors
leading to the three main causes of early neonatal deaths,
i.e., prematurity, birth asphyxia and neonatal sepsis will
be paramount [6].
India has a well-developed basic health infrastructure
at the primary care level (Table 1). In rural and semi-
urban areas, this now consists of 146,036 sub-centers,
23,458 primary health centers and 4276 first-referral
units [7]. More so, in last two decades, it has launched
several large public programs targeted to the reduction
of neonatal and infant mortality, namely Child Survival
and Safe Motherhood (CSSM) Program in 1992 [8],
Reproductive and Child Health (RCH) program in 1997
[9], followed by its second phase in 2005. More recently,
it has launched a program of conditional cash transfers,
Janani Suraksha Yojana(JSY), to encourage in-facility
deliveries [10]. However, the decline in the neonatal
mortality rate (NMR) and IMR continue to be less than
satisfactory. Approximately 47% of all births occur in
any sort of health facilities [11]. If these trends continue,
India will not able to achieve its MDG target for infant
mortality [12].
India lacks behind several other developing countries
M. Ku mar et al. / Open Journal of Preventive Medicine 1 (2011) 62-65
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
Table 1. Primary Health Care structure in India and the MCH and newborn care services planned for each level.
Primary care level Population servedHealthcare Personnel
for newborn care MCH services provided
Village 500 - 1500 Trained Birth attendant (TBA) Assistance in home delivery under hygienic
conditions, prompt recognition of danger signs
and early refe rral
Sub-center (SC)
(one per 5 - 6 villages) 3000 - 5000 Multi-
urpose health worker(MPHW),
(female MPHW also known as Auxil-
iary nurse midwife)
Antenatal check up, tetanus toxoid immuniza-
tion, and iron and folic acid supplementation of
prospective mothers, referral of at risk mothers.
Primary Health Centre (PHC)
(one per 4 - 5 SCs ) 20,000 - 30,000 General physician, nurse midwife Essential newborn care including institutional
deliveries, referral services.
First Referral Unit (FRU)*
(one per 4 - 5 PHCs) 80,000 - 120,000 General physician, Availability of ob -
Essential newborn care, oxygen hood, Radiant
warmer, facilities for caesarean section, X-ray
and basic laboratory facilities.
*Also known as Community Health Center (CHC).
(e.g., Brazil, China, Bangladesh, Thailand and Indonesia)
in its ra te of reductio n of neona tal and infan t mortality
[5], despite launch of various targeted programs as out-
lined above [7]. Reasons for these failures are likely to
be multi-factorial. Whilst, health personnel and infra-
structure shortfalls, suboptimal quantity and quality of
services available at primary level, financing and gov-
ernance issues are well recognized [12]; lack of effective
community participation in planning and delivery of its
services has not received as much attention.
To date, the government’s approach to planning of
health services at the primary level is rooted in a ‘top-
down’ mentality and reflects a pattern of trial and error.
Changes to MCH programs were made repeatedly, often
based on ideas generated by small group of prominent
individuals, without strong empirical research to support
them. Alternatively, the ideas were imported from else-
where and implemented without appreciating the con-
textual differences between the settings. For example,
the JSY scheme to increase births in health facilities was
initiated without availability of good quality obstetrics
and neonatal services at the grass-root level, squandering
precious national resources that could have been used to
develop those urgently needed services.
Although, planning of services at the primary care
level based on a process of community n eeds assessmen t
(CNA) was included in the 2nd phase of the RCH pro-
gram, this process is focussed on generating routine re-
quirements of existing services for the year at each level
(e.g. reproductive care needs of eligible couples) rather
than making structural changes. Households surveys
conducted by primary care employees are limited in
scope and are rarely carried out in true spirit [13].
Wide differences in the IMR across the various states
of India (in 2008, the IMR ranged from 12 to 70) suggest
that large gains may be possible with relatively few ad-
ditional resources, by systematically identifying knowl-
edge gaps and barriers faced by general population in
accessing services at primary healthcare level and de-
vising local solutions to those unique barriers.
The International Institute of Population Sciences
(IIPS) at Mumbai has been regularly conducting on a
large scale district level household surveys (DLHS) in
each district of the country, to collect representative in-
formation, to generate estimates of maternal and child
health indicators and more recently on infrastructure and
services provided at each level of primary care (in its
most recent survey, 720,320 households were surveyed
across 601 districts of India) [11]. However, the data
generated to date via DLHS surveys are predominantly
quantitative, and does not provide answers to questions
such as why so little progress might be happening in
those districts, nor suggest what programmatic changes
would result in desired improvements.
We suggest a format of mixed-methods participatory
research with active involvement of the communities to
better understand the local healthcare needs and their
barriers to utilization of health services at primary level.
The mixed-methods research combines quantitative and
qualitative research methods in its design and is increas-
ingly utilized in the setting of primary health care [14,
15]. Information gathered via this combined approach
helps to portray a holistic picture of a healthcare pro-
gram, including its bottle necks, which is further used for
making critical programmatic changes.
There are several examples of success of such meth-
odology in reducing neonatal or infant mortality in re-
source-poor settings in recent years. A cluster random-
ised controlled trial(RCT) conducted in rural Nepal
showed that active involvement of the community in
identifying local perinatal problems and formulating
intervention strategies tailored to its needs, as compared
to standard package of perinatal services, reduced neo-
natal mortality by 30% [16]. Similarly, the two other
RCTs recently completed in the resource-poor setting in
M. Ku mar et al. / Open Journal of Preventive Medicine 1 (2011) 62-65
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
rural India [17,18], with variable levels of community
involvement in identification and planning of interven-
tions showed 32% to 54% reduction i n NMR. Ho wever,
such packages of interventions may not replicate desired
benefits in other settings when scaled up to the entire
country, due to contextual differences among the settings
The current data collection approach at the national
level could itself be adapted into the methodology for
the purposed mixed-method research. Alongside the
quantitative data that are routinely collected through the
district level surveys (DLHS), additional qualitative
questions could be posed as an add-on questionnaire,
seeking responses from households on their health seek-
ing behaviours, barriers for using health services and
their perceived solutions. Salient themes that should be
explored are shown in Table 2, along with proposed
collection methods. When questions would be framed as
open-ended queries, an enhanced response is likely.
We also suggest that an additional data set of qualita-
Ta bl e 2 . Proposed themes for add-on questionnaire to current
DLHS data reporting forms.
Questions should explore:
Care-seeking behaviours during the most recent episode of neona-
tal or infant illness? (Semi-structu red questio nnaire with Open -ende
questions where applicable)
How was illness id entified?
Durati on between suspicion of i llness and arri val at hea lth facilit y,
resons(s) for delay
Satisfaction with the treatment received at the primary healthcare
Reason(s) for not seeking care at a health facility (if, applicable)
Were referral made to another health facility? If so, further explore the
Cause(s) for referral
Duration between referral advice made and arrival at suggested
health facility, Cost s involved in following referral advice
Satisfaction with the t r eatment received at the referral fa cili ty
Reason (s) for not acting upon referral advic e (if, applicable)
Barriers to utilization of health services (Semi-structured question-
naire as above, and also via focus group discussions)
Reason(s) if regular antenatal care was not obtained during the
most recent pregnancy
Reason(s) if a trained birth attendant was not used during the mos
recent birth
Reason(s) if the most recent birth was not obtained in a health
Reason(s) that would prevent you from attending the nearest SC,
PHC and FRU if you baby gets sick?
What are the likely solutions to the above barriers from your per-
tive information be obtained via holding focus group
discussions in local communities at regular intervals. To
enable frank discussion by those normally not vocal, we
strongly suggest focus groups be both socially and gender
homogenous. Information obtained through these sepa-
rate sources, would better delineate the existing barriers
to local populations in seeking healthcare and utilizing
existing healthcare facilities. In addition, such discus-
sions are likely to identify solutions that would be more
acceptable among the communities, rooted in their active
participation in arriving at those decisions.
Based on the current trends of decline in the neonatal
and infant mortality in India, it is unlikely to meet its
MDG target for IMR set for 2015. There are known cost-
effective interventions targeting acute obstetrical and
neonatal care in developing countries that could reduce
NMR by over 50% [20]. However, understanding of the
contextual differences are important for success of those
packages of interventions when applied to another re-
source poor setting [19].
We have proposed a format of mixed-methods re-
search, conducted concurrently with national level sur-
veys, which will generate additional qualitative data on
the community needs which would serve the useful
function of providing clients’ perspective on bottlenecks
in the delivery of health services. There are several po-
tential advantages of undertaking this research action at
the national level. First, the inferences drawn from the
data collected would have greater validity due to appro-
priate sampling techniques used in its collection, and its
collection by an independent agency (DLHS staff) rather
than local healthcare employees who may have vested
interest in maintaining status quo. Second, quantitative
data from each community (or district) could be easily
collated with its qualitative data on an ongoing basis to
understand its unique barriers and its felt needs. Lastly,
the availability of these results would help program
managers make timely and more effective programmatic
changes at local level, as the changes made in the deliv-
ery of health services will be based on direct inputs from
those communities.
In summary, the organization and delivery of MCH
services at primary care level in India have been grossly
inadequate in meeting its population’s needs, resulting in
India’s repeated failures in achieving its set targets for
infant and neonatal mortality. We have suggested a
framework of mixed-methods research at the national
level, strongly grounded in active participation from
local communities, as a model for ongoing health ser-
vices research which would better delineate the prob-
M. Ku mar et al. / Open Journal of Preventive Medicine 1 (2011) 62-65
Copyright © 2011 SciRes. http://www.scirp.org/journal/OJPM/
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