Background
Between 1990 and 2015, low- and middle-income countries (LMICs) achieved a 53% reduction in mortality among children less than 5 years of age. Although a significant achievement, this improvement fell short of the Millennium Development Goal target of 67% [
1]. The relative lack of improvement in neonatal survival, defined as survival through the first 28 days of life, explains, in part, why this goal was not reached. Neonatal deaths accounted for approximately 43% of deaths among children under age five globally in 2016 [
2]. In response, the Sustainable Development Goals (SDG) have placed renewed emphasis on neonatal survival and set a target neonatal mortality rate (NMR) of 12 per 1000 live births in all countries by 2030 [
3].
In India, substantial improvement in neonatal care will be required to meet this goal, as the countrywide NMR in 2016 was 21.8 [
2]. Success will likely be contingent on understanding and addressing the variations in neonatal mortality across the 29 Indian states, as more than half of neonatal deaths occur in only four states- Bihar, Uttar Pradesh, Madhya Pradesh, and Rajasthan [
4]. Additionally, the NMR in rural India is more than double that of urban India, and the NMR in the poorest 20% of the population is more than double that in the richest 20% [
4]. One-third of neonatal deaths in India occur within 24 h after birth, and the leading causes of neonatal death are preterm birth (< 37 completed weeks of gestation), birth asphyxia, and infection [
4]. Therefore, interventions aimed at improving the immediate care of neonates born to families living in rural Bihar, Uttar Pradesh, Madhya Pradesh, and Rajasthan may have the greatest impact on reducing the NMR in India.
In 2014, the World Health Organization developed the “Every Newborn Action Plan” to guide such interventions. This plan calls for research that explores barriers to evidence-based practices (EBP) in essential newborn care and neonatal resuscitation (NR) [
5,
6]. Multi-country analyses of barriers have identified numerous bottlenecks to care in LMICs related to leadership/governance, financing, workforce availability and skill, essential commodities, delivery of care, health information systems, and community partnerships [
7‐
11]. A similar analysis in India cited leadership/governance, human resources, and health information systems as the most significant national barriers [
4]. However, given the previously described variations in NMR across Indian states, a more focused evaluation of areas with the highest burden of neonatal mortality is needed to guide targeted interventions in these regions.
The state of Bihar, located in northeastern India, was found to be the poorest region in all of South Asia (including Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, and Pakistan) in 2016 [
12]. Based on the most recent census, Bihar had the highest crude birth rate in all of India at 27.7 and a NMR of 28 [
13], with significant under-reporting likely. The majority of the basic obstetric and neonatal care in Bihar is provided through primary health centers (PHCs), each of which serve a population of approximately 190,000 (number based on monitoring and evaluation data from CARE India [
14]) and are often poorly equipped for neonatal care [
15]. Obstetric and newborn care at PHCs are largely provided by nurses with an Auxiliary Nurse Midwife (ANM) qualification and occasionally by nurses with a General Nursing and Midwifery (GNM) qualification, which entail two and three and a half years of training respectively after completion of secondary school [
16]. These nurses frequently lack adequate training and skills in basic NR [
15]. Nevertheless, pediatricians are few in number and only available at higher levels of care [
17].
Despite the many potential barriers exposed by demographic and health system data, to the best of our knowledge, a focused analysis of barriers to EBP in immediate neonatal care and NR in Bihar has not been conducted. This information is needed to inform and improve the effectiveness of ongoing and future interventions in Bihar. One such intervention is
Apatkaleen Matritva evam Navjat Tatparta (AMANAT), a maternal and child health quality improvement program with a mentorship model of clinical instruction, implemented by CARE India and the Government of Bihar [
14,
18,
19]. AMANAT mentors are nurses with a 4-year bachelor’s degree recruited from across India and mentees were ANMs or GNMs working in PHCs throughout Bihar. Within the AMANAT intervention, PRONTO International trained mentors to teach emergency obstetric and neonatal management to ANM/GNM mentees using simulation [
20]. Ongoing evaluations of PRONTO training in Bihar have demonstrated that nurse mentees’ skills in NR lag behind their skill acquisition in obstetric emergencies [
21]. In response, this manuscript aims to characterize the logistical, cultural, and structural barriers to the use of EBPs in immediate neonatal care, defined as care required during the immediate transition to post-natal life, and NR.
Discussion
The provision of evidence-based immediate neonatal care and NR at PHCs in Bihar is hindered by numerous interwoven logistical, cultural, and structural barriers. Together, these barriers affect every aspect of immediate newborn care. Cultural norms including early administration of oxytocin and delayed presentation of laboring mothers to PHCs, precipitate and delay identification of fetal distress respectively. Distance between labor rooms and resuscitation areas prohibits timely initiation of NR. Supply issues, traditional clinical practices, and hierarchy prevent performance of key EBPs in NR such as bag mask ventilation. Finally, poverty and ineffective referral systems contribute to inadequate clinical care and unsafe transfers for the sickest neonates.
Key themes in this manuscript, including facility infrastructure and resources, referral processes, cultural norms, traditional practices, hierarchy, interpersonal relations, and poverty have been previously described as common barriers to neonatal care in LMICs in multi-country analyses [
7‐
9,
11] and in qualitative evaluations of the Helping Babies Breathe program [
27,
28]. However, to our knowledge, this is the first in-depth characterization of these barriers in Bihar. We believe this more nuanced understanding of the specific issues that sum into these larger thematic barriers will be key to addressing them. While we recognize solutions are not simple, we propose the following key action items.
Logistical barriers and action items
Logistical barriers identified by mentors included poor facility infrastructure, inadequate supplies, human resource shortages, and failures in the referral process. Regarding facility infrastructure, the majority of mentors explained that long distances between labor rooms and resuscitation areas prevented timely initiation of resuscitations. This issue of proximity of NBCCs has been previously cited as a barrier to care in Bihar [
15], and is distinct from lacking a resuscitation space all together-- a barrier identified in Tanzania in conjunction with the Helping Babies Breathe program’s emphasis on ‘the golden minute’ [
27]. Priority should be placed on moving dedicated resuscitation areas into labor rooms to enable mentees to establish effective ventilation within the first minute of life.
Like many LMICs, the availability of resuscitation supplies has also been identified as a barrier to care in Bihar [
15]. However, mentors in this study additionally identified functionality and accessibility of already available supplies as equally important issues. While ensuring the consistent availability of supplies such as mucus extractors, preterm-size masks, and clean towels is essential, training providers on delivery preparedness and handover techniques may improve the accessibility and timely utilization of already available equipment [
28]. Moreover, ensuring a more reliable power supply at PHCs would facilitate use of available radiant warmers and oxygen concentrators when indicated. However, training should continue to emphasize the importance of ventilation with room air using self-inflating bags and kangaroo care so that power supply does not become an unnecessary or false barrier to care.
Provider shortages been previously indentified as a problem in Bihar based on demographic data [
17]. Mentors unanimously felt the number of ANMs/GNMs was insufficient for the volume at PHCs and left nurses with difficult decisions about who to care for should maternal and neonatal emergencies co-exist. Although not explicitly mentioned by mentors in interviews, a recent systematic review identified workload as a strong contributor to provider burn out and emotional fatigue in LMICs [
29], which undoubtedly effects quality of care. While, training more ANMs and GNMs should remain a long-term goal [
30], a more immediate solution may be thoughtful task shifting within PHCs to less skilled providers including community health workers known as Ashas [
31]. Approximately 10% of neonates require only the initial steps of NR (drying, warming, and stimulating) whereas 3–6% require further intervention including bag-mask ventilation [
32]. Ashas could be trained to provide the initial steps of NR with clear guidance to immediately alert an ANM/GNM if a neonate does not transition with initial resuscitation measures. In turn, ANMs/GNMs could shift their focus to more complicated deliveries or other PHC duties, which may be particularly valuable in high-volume facilities.
Finally regarding referrals, future clinical training should teach indications for referral and measures to stabilize neonates who require more than basic resuscitation prior to transfer. However, given the reality of resource and personnel limitations at PHCs, improving the referral process will be key to improving neonatal outcomes. With the increase in hospital-based births in India, previous research has called attention to the importance of a well-linked referral system for neonates [
33]. Mentors identified the following key action items: eliminating the financial barrier for families to referral by providing free government transport and providing basic NR training to transport personnel so that resuscitation efforts can continue if necessary. In Madhya Pradesh, there is ongoing work to bolster the referral system that may serve as an example [
34].
Cultural barriers and action items
Cultural barriers indentified by mentors included norms, traditional clinical practices, hierarchy, and interpersonal relations. Regarding cultural norms, demographic data from Bihar has demonstrated decreased survival among female infants relative to male infants [
22], supporting what mentors cited as male infant preference. Addressing this and the perceived value of an infant’s life compared to that of the mother, particularly when obstetric and neonatal complications occur simultaneously, requires further research to better understand local values. Nonetheless, inappropriate administration of oxytocin, which has been proven to increase the risk of perinatal death in rural Bangladesh [
35], and late maternal presentation to PHCs, which prevents fetal monitoring that has been identified as a key determinant of resuscitations in Tanzania [
28], may be more easily addressed with birth planning during antenatal time.
The acceptance of EBPs in place of traditional clinical practices may be facilitated by ongoing exposure of all levels of providers, from Ashas to doctors, to demonstrate the effectiveness of EBPs in real deliveries. The inclusion of doctors in future trainings at PHCs should also be a priority to ensure that providers across all levels of care are aware and knowledgeable about current clinical guidelines to limit hierarchical conflicts. This may also improve the degree to which mentees feel supported in their clinical practice, another factor identified as being protective against burn out and emotional fatigue [
29].
In PHCs in Bihar, the relationship between nurses and patients’ relatives has a large impact on quality of care, as mentees routinely fear physical and/or verbal harm from delivering woman and their relatives. Implementing standard labor room limits on the number of family members permitted to enter at one time, may promote a more secure work environment and, in turn, improve neonatal care. Emphasizing communication and team training in any clinical skills training, which has been proven to be effective in PRONTO training in Mexico [
36], may also empower ANMs/GNMs to better navigate both relations with difficult families and tense interpersonal relations amongst themselves.
Structural barriers and action items
Poverty was described as an overarching structural barrier to immediate neonatal care and NR. While there is no clear solution to this systemic problem, improved equality of care may be achieved by eliminating out-of-pocket expenditures by families in public facilities for essential resuscitation equipment and for transportation to referral facilities. These financial burdens continue to exist despite the Janani Shishu Sukaksha Karyakaram program launched by the Government of India in 2011 to eliminate out-of-pocket costs for maternal and neonatal care at public facilities [
37]. Additionally, any clinical skills training should be respectful of cultural values yet create a standard of care and emphasize its relevance to all infants regardless of their family’s economic status.
Limitations
This study has several limitations. First, it does not provide an exhaustive characterization of all barriers to the provision of evidence-based immediate newborn care and NR in Bihar. It intentionally excludes barriers related to individual providers, such as clinical knowledge and skills, which are discussed in another manuscript [
26]. Additionally, although the mentors interviewed in this study had experience mentoring in PHCs, which included a combination of direct clinical care and supervision of clinical care, they were all from other states in India. This may have introduced information bias if interviewees had preconceptions about Bihar or local healthcare providers. To reduce the likelihood of this bias, mentors were only eligible for interview if they had at least 16 months of experience working in eight different PHCs. Additionally, interviews were conducted by a member of the United States based research team which, could have introduced interpretation bias. To mitigate this risk, interviews were conducted with fluent English speaking mentors and the same individual who conducted all interviews transcribed and analyzed all data. Double coding of two transcripts by another member of the research team demonstrated consistency across all themes, thus the overall magnitude of the aforementioned biases was likely minimal.
Next steps and conclusion
Further study of barriers to immediate neonatal care and resuscitation in Bihar including interviews with ANMs and GNMs, doctors, and community members would be useful for data triangulation and validation. It would additionally provide a more holistic view of barriers to care to guide future interventions. Nevertheless, in an effort to maximize the benefit of ongoing training, the next iteration of the PRONTO curriculum in Bihar has already been adapted to address some of the action items discussed above. Examples include incorporating training on delivery preparedness and provider handover techniques to improve effective utilization of supplies, as well as strengthened inter-professional and team training to address hierarchical issues between doctors and mentees and dynamics between mentees themselves.
This study has also identified barriers such as human resource shortages, ineffective referral systems, and challenging relationship dynamics between nurses, delivering mothers, and their families, which cannot be addressed by clinical training programs alone. Rather, addressing these barriers likely requires commitment from local government, strong local partnerships, and community outreach. Nevertheless, an understanding of such barriers is an essential beginning and important for adapting skills-based trainings developed in Western contexts to settings such as Bihar with the aim of reducing neonatal mortality in India to the SDG target by 2030 [
3,
5,
6].
Acknowledgements
The authors would like to express sincere gratitude to Rebecka Thanaki, Renu Sharma, and Praicey Thomas for their help in arranging and facilitating interviews. We would also like to thank all mentors who participated in interviews for their time and their dedication to teaching mentees throughout Bihar. We also thank Dr. Hemant Shah, Indrajit Chaudhuri, Dr. Sridhar Srikantiah, Kingshuk Bagchi, and the CARE India management team for their support of this research. Lastly, we would like to thank Hilary Spindler and Mona Sterling for their support of this research and their tireless efforts in improving the PRONTO program in Bihar.