According to UNICEF, Nearly 46 per cent of all maternal deaths and 40 percent of neonatal deaths happen during labour or the first 24 hours after birth. Pre-maturity (35 per cent), neonatal infections (33 per cent), birth asphyxia (20 percent) and congenital malformations (9 per cent) are among the major causes of new-born deaths. Nearly 3.5 million babies in India are born too early, 1.7 million babies are born with birth defects, and one million new-borns are discharged each year from Special New-born Care Units (SNCUs). These new-borns remain at high risk of death, stunting, and developmental delay [1]. 

During attaining adulthood the life is divided into 3 critical age groups, viz the children under five years, the next five years and finally adolescence. The first 5 years of life are further subdivided into the neonatal period (the first 28 days of life), infancy (the first year of life), and pre-school years (from 1 to 5 years). The most important indicators of health status of under-5 children relate to their mortality, morbidity, nutrition, growth, and development. Poor health and survival are linked to social and economic development and child mortality is one of the most sensitive barometers of this relationship [2].

Children whose environments have limited resources need interventions to protect them against the major causes of mortality and morbidity. There are two main types of interventions. The first, promote health and prevent specific disease conditions. The second are case management interventions which help reduce severity of illness thereby improving health and survival. In this article we will be discussing the first aspect, that is, promoting health and preventing diseases among the under-5 children.

The declines in the neonatal mortality rate have been slower than those in the mortality rate for older children [3]. According to the data from the Sample Registration System, 2018, the Neonatal mortality rate (NMR) reduced from 24 to merely 23 per 1000 live births, while the Under-5 mortality rate reduced from 39 to 36 per 1000 live births from the year 2016 to 2018 [4]. Improving newborn health and survival requires a continuum of care from pregnancy, childbirth, and the newborn period, into childhood and adolescence. Newborn health interventions can be classified into those relevant for all mothers and newborns, and those relevant only for newborns with conditions that require additional care.

There are certain new-born conditions that need to be taken care of that might contribute to the reduction of under-5 mortality and morbidity. These include preterm birth, perinatal asphyxia, and neonatal sepsis. Appropriate antenatal care should be started right at the time of diagnosis of pregnancy. The World Health Organisation recommends at least four Antenatal visits in the hospital. The first visit is recommended as soon as the diagnosis of pregnancy up to the gestational age of 12 weeks. The second visit should be taken between 14 weeks and 26 weeks of pregnancy. The third visit should occur between 28 and 34 weeks of pregnancy, while the fourth visit should occur as soon as the pregnancy touches 36 weeks of gestation. The pregnant woman should be counseled appropriately and regular check-ups should be advised. The auxiliary nursing midwife (ANM) plays an important role in this as she is the first point of contact at the hospital who will be taking care of her medications including her immunization, investigations and complete follow-up under the supervision of a doctor. As soon as the mother visits the health centre, she should be registered and folic acid should be started. It is recommended that the first dose of adult Tetanus (Td) may be administered irrespective of the gestational age of the mother followed by a second dose after one month from the last date of vaccination [5]. In addition to this, she should be counseled for regular check-ups at the health care centre. In the second trimester, she should be started with iron tablets and should be continued throughout her pregnancy. It is an important point to note that there is very little acceptance of iron due to its gastrointestinal side effects. She may then be advised to take her Iron tablets along with her meals or with lemon water in order to enhance the absorption of iron in her body. At least one ultrasonography should be done in each trimester to look out for the foetal well-being, any congenital malformation (like neural tube defects), placental localisation and presentation of the foetus in later stages. This will help in early intervention to prevent neonatal mortality.

Secondly, there should be the availability of the Skilled Birth Attendants (SBA) during labour and birth. Every pregnant woman and her family desires to have a joyful birthing experience with a safe and healthy mother and new-born [6]. The services provided within the labour-room and maternity operation theatre are critical to meet this aspiration. The Ministry of Health & Family Welfare, Government of India launched 'LaQshya' initiative in 2017, which has intended to improve the Quality of Care in Labour Rooms & Maternity Operation Theatres in Government Medical College Hospitals, District Hospitals, Sub-district Hospitals and other high case-load health facilities. Under the LaQshya initiative, States have undertaken concerted efforts in a campaign mode to ensure that respectful and high quality maternal care is provided to each woman during delivery and immediate postpartum. It would essentially entail undertaking several actions simultaneously at different levels - National, States, Districts and Health Facilities.These "LaQshya" guidelines have been launched for improvement of care provided around the child birth and during immediate postpartum period by having targeted intervention. Such patient-centric care is expected to be based on the available scientific evidence. Improvement in Quality of interface between the beneficiaries and service providers in terms of language, behavior and attitude is also an important component under this intervention for ensuring 'Respectful Maternity Care' to pregnant women. This will help in dramatic improvement of maternal and newborn outcomes [7].

Third important aspect that needs to be considered is the Care at the time of birth. The delivery should be carried out  in a warm room. As soon as the baby is delivered, it should be dried thoroughly and the baby should be given to the mother as soon as possible to promote skin-to-skin contact which is known as the Kangaroo Mother Care (KMC) which has been seen to reduce neonatal mortality in the lower and middle income countries (LMIC). Health personnel must follow at all times the 5 "C's": clean hands, clean surfaces, clean blades, clean cord ties, and clean cord stump to further reduce the incidence of the neonatal infection [8]. In addition to this, care of the eyes in order to prevent Ophthalmia Neonatorum which is a type of conjunctivitis that is seen in the neonatal period. Its prevalence has been cited to be between 1% to 12% among the neonates [9]. It is transmitted during vaginal delivery, and is associated with severe complications such as corneal ulceration and perforation, that have a potential to result in permanent blindness. The World Health Organisation suggests early initiation of breastfeeding as soon as the mother and the baby are ready (usually within the first hour of birth) [10]. Infants who are devoid of breastfeeding or are breast fed for short periods carry a higher risk of contracting infection in comparison to those who are breastfed optimally.  In the Promotion of Breastfeeding Intervention Trial (PROBIT) in Belarus, the findings suggested that the newborns who are not optimally breast fed are more prone to develop gastrointestinal infections than their counterparts [11].

Management of newborn infections in a swift and appropriate manner can substantially reduce neonatal mortality. It is therefore important to have community- and health-facility-based activities which support families in identifying the danger signs and seeking timely and appropriate care. Newborns with severe infections should receive parenteral antibiotics, along with intravenous fluids or alternative feeding methods and other supportive therapy such as oxygen in a hospital. Research studies are currently underway to determine if a proportion of these children can be safely managed at home using intramuscular or oral antibiotics.

Poor health and survival are linked to social and economic dis- advantages. Child deaths are unequally distributed in the world. Within countries, child morbidity and mortality tend to be higher in the rural areas and within the poorer and least educated families. Poorly nourished, LBW, sick, and disabled children all are at particular risk of adverse outcomes and have special needs for care. Global progress in child health is attributable to a broad range of factors that include high coverage of good quality effective interventions, development programming, and strategic delivery of health services, along with improvements in education, child protection, respect for human rights, and economic gains in developing countries.

1. UNICEF. “C4D gender results report.” Available from: https://www.unicef.org/india/reports/c4d-gender-results-report [Last accessed on 28.05.2021].

2. Karlsson L., Lundevaller E.H., Schumann B. “Season of birth, stillbirths, and neonatal mortality in Sweden: the Sami and non-Sami population, 1800–1899.” International Journal of Circumpolar Health, vol. 78, no. 1, 2019, 1629784. doi:10.1080/22423982.2019.1629784.

3. National Health Mission. “Maternal health programme.” Available from: http://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=819&lid=219 [Last accessed on 28.05.2021].

4. Census of India. “Maternal mortality ratio bulletin 2016–18.” Available from: https://censusindia. gov.in/vital_statistics/SRS_Bulletins/MMR%20Bulletin%202016-18.pdf.

5. “Guidelines for vaccination in normal adults in India.” Indian Journal of Nephrology, vol. 26, Suppl. 1, 2016, pp. S7–S14.

6. Ministry of Health and Family Welfare. “SBA guidelines for skilled attendance at birth.” Available from: http://nhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/sba_guidelines_for_skilled_attendance_at_birth.pdf.

7. Ministry of Health and Family Welfare. “LaQshya guidelines.” Available from: http://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCH_MH_Guidelines/LaQshya-Guidelines.pdf.

8. Rani R. “Safe motherhood programme.” Nursing Journal of India, vol. 84, no. 10, 1993, pp. 231–233. PMID: 8139984.

9. Castro Ochoa K.J., Mendez M.D. “Ophthalmia neonatorum.” In: StatPearls, Treasure Island (FL): StatPearls Publishing, 2021. PMID: 31855399.

10. World Health Organization. “Early initiation of breastfeeding.” Available from: https://www.who.int/elena/titles/early_breastfeeding/en/ [Last accessed on 28.05.2021].

11. Kramer M.S. et al. “Promotion of breastfeeding intervention trial (PROBIT).” JAMA, vol. 285, no. 4, 2001, pp. 413–420.