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Home-based newborn care (HBNC) under the national health mission in urban India – A cross country secondary analysis

Background: There is a paucity of evidence in the coverage of the home-based newborn care (HBNC) program delivered through the National Urban Health Mission (NUHM). Hence, an analysis was undertaken to identify gaps and progress in its implementation and inform policy and strategies to achieve universal access to newborn services. Objectives: The study aimed to evaluate and understand the status of the HBNC program in urban areas of India through a health systems approach. Methods: Cross-sectional intra-country study was undertaken based on facility records and supporting literature available in the public domain. After categorizing the states into four groups, the programme’s status in urban areas was analysed and presented in median and interquartile ranges. Statistical significance in the difference between the medians across the groups was checked using the Kruskal Wallis test. Results: Overall, the median full HBNC coverage was less than one-fifth (< 20%) of the total reported live births (P = 0.17). Excepting the union territories (UTs), the median coverage was found to be less than one-fifth (< 20%) of the reported institutional deliveries (P = 0.16) and more than half (> 50%) of the reported home deliveries (P = 0.83) in urban areas. The differences in the medians across the groups were not statistically significant. Conclusion: The differential coverage calls for strengthening referral linkages to specialized newborn care facilities, ensuring skilled personnel at varying levels of facilities, and improving the engagement of frontline workers in urban communities under the NUHM.


Introduction
The days and weeks following childbirth are crucial for the health and survival of both the mother and the newborn. Given that the health and well-being of women, newborns, and children are inherently linked, [1] the core principle underlying maternal, newborn, and child health programmes, is the 'continuum of care'. [2] Newborn health serves as a sensitive marker of a functional continuum of care and good linkages that serve to address delays in care for both the mother and the newborn during and after childbirth. [3] care in settings with high baseline neonatal mortality and weak health systems. Home-based newborn care (HBNC) package is one such package proven to be 'very cost-effective' [7] in terms of programmatic costs borne by the government; at low (54%) or high level (83%) of coverage; cost per death averted; out-of-pocket expenditure averted by the care package; inherent financial risk protection accorded by the package; and in reducing morbidity and mortality. [8][9][10][11][12][13][14] Effectiveness studies in Indian settings [9,15] have shown that HBNC facilitated a substantial reduction of neonatal mortality, improvement in coverage of newborn practices, uptake of routine immunization, early detection, timely referral, and appropriate management of sepsis or other infections. Recognizing its ability to overcome the demand-side barriers in accessing post-natal care at health facilities, HBNC was recommended as a primary strategy for combating neonatal mortality. [16] It was initially launched under the National Rural Health Mission (NRHM) in 2011, [16] and subsequently subsumed under the National Urban Health Mission (NUHM), a sub-mission of National Health Mission (NHM), in 2013.
Despite a reduction in maternal and child mortality rates over the past two decades, [17] neonatal mortality and stillbirths still require sustained attention. There exist rural-urban discrepancies in the country, [18] with a differential pace of decline in the indicators of interest between the regions. [19] Though rural disparities are higher than their urban counterparts, heterogeneous, complex, and intertwined challenges like improper housing (as in slums), poor access to water and sanitation facilities, larger presence of the private sector, large number of unregistered practitioners serving as the first point of contact, congested secondary and tertiary facilities or underutilized primary facilities, multiple health challenges, inadequate services and poor referrals, non-notified slums, weak demand, struggle for subsistence, and multidimensional vulnerability disproportionately affect the urban poor and people with multiple marginalizing identities in urban spaces. [19] Neonatal mortality is a sensitive indicator of healthcare access such as institutional delivery, vaccination, medical treatment of diseases, nutrition, and hygiene. [20] In India, neonatal mortality is higher among the urban poor when compared to the urban average. [21] Hence, to redress inequity among the urban poor and vulnerable, NUHM was launched to improve the efficiency of the public health system in the cities by strengthening, revamping, and rationalizing existing government primary urban health structure and designated referral facilities.
Most of the studies undertaken in India on HBNC were in rural/ tribal settings, with very few focusing on urban programmatic progress. Hence, a cross-country study was undertaken to evaluate and understand the status of the HBNC program in urban areas of India through a health systems approach. Specific objectives of the study were (i) to understand the resources in place to facilitate safe intrapartum and post-partum care in urban areas, (ii) to assess HBNC coverage in urban areas, and (iii) to review the outcomes achieved through the urban HBNC programme across the states and UTs.

Methodology
Secondary data available or updated as of the financial year 2019-20 were extracted from health management information system (HMIS) (2019-20), Rural Health Statistics 2019-20, accredited social health activist (ASHA) update (July 2019), and HMIS' quarterly progress report (QPR HMIS) report (2019-20). Indicators used for analysis were restricted to infrastructure (primary level facilities, sub-district level, and district level secondary facilities), human resources (frontline workers and facility-based provider status), intrapartum services (home delivery or institutional delivery), post-natal care services (HBNC service components), programmatic outputs (immunization status) and outcomes. Indicators' descriptions are shared in the Appendix. Proxy indicators for referral and sick-newborn care (i.e., newborn stabilization unit (NBSUs) and newborn care corner (NBCCs) status) were excluded due to a lack of baseline information for assessment. Among union territories, Lakshadweep was excluded from the assessment because it was not covered under the NUHM; information on Jammu and Kashmir was considered inclusive of Ladakh due to unified reporting for the fiscal year (FY) 2019-20 following their reorganization in October 2019, and information on Dadra and Nagar Haveli was combined with Daman and Diu owing to their merger in January 2020.
Analysis was undertaken on anonymised State/UT aggregate reports of urban areas or consolidated reports, wherever applicable. For data management, a preliminary analysis was performed using institutional STATA/MP Version 16.1 to identify the outliers, followed by data cleaning and description in terms of median (M) and interquartile range (IQR). Kruskal Wallis test with a level of significance of 0.05 was performed to determine if there were statistically significant differences between the medians of the groups. Data of indicators that did not apply to a certain group were presented as not applicable (N/Appl), and missing data were presented as not available (Na). The findings of the indicators of interest were presented in four groups-Group A: High Focus States -North-East (NE), Group B: High Focus States -Other than NE, Group C: Non-High Focus States-Large, and Group D: Non-High Focus States-Small and UTs [ Table 1].

Infrastructure
Analysis showed that the median density of urban primary level facilities 1 was relatively higher in group D (M = 1.96; IQR = 0.52) and less in group C (M = 0.66; IQR = 0.31). The median density of sub-district secondary level facilities 2 was relatively higher in group C (M = 2.04; IQR = 1.12), while that of district-level facilities 3 was relatively higher in group A (M = 14.74;  Table 3]. In general, the median percentage of full HBNC visits for institutional delivery was less than one-fifth (< 20%) of the reported institutional deliveries, excepting group D. Whereas for home deliveries, more than half (> 50%) of the reported home deliveries received full HBNC visits. The differences between the groups were not statistically significant [ Table 3].

Immunization
The median percentage of newborns receiving a birth dose of BCG was over 83 percent across all groups [ Table 4]. The median immunization coverage for infants with birth dose of Oral Polio Vaccine (OPV), Hepatitis B vaccine (Hep B) and Pentavalent 1-3 doses was less in group A when compared with the rest (M = 47.98%, IQR = 23.71%; M = 41.72%, IQR = 32.18%; M = 68.12%, IQR = 22.55%). The differences between the medians were not statistically significant [ Table 4].

Outcomes
Analysis of pregnancy outcomes [ Table 4] revealed that the median percentage of newborns who weighed less than 2.5 kg was comparatively high in group D (M = 13.27%; IQR = 2.06%). The median percentage of newborns breastfed within one hour of birth was least in group D (M = 72.97%; IQR = 12.48%). The median percentage of 'full HBNC visits' delivered to the newborns in urban areas of groups A, B, and C was less than one-fifth (< 20%) of the total reported live births. The median share of newborn deaths to infant deaths was comparatively high in groups B and C (> 72%), while the median total reported maternal deaths was comparatively high in group C (M = 86, IQR = 72.50). The differences between the medians were not statistically significant [ Table 4]. 7 Full HBNC visits for home deliveries -7 visit 8 Full HBNC visits for institutional deliveries -6 visits Despite that, the median density of special newborn care units (SNCUs) and nutrition rehabilitation center (NRCs) were least in group A when compared with the rest (M = 0.53; IQR = 0.2 and M = 0; IQR = 0; respectively). The differences in the median density of primary andsecondary level facilities, SNCUs, and NRC beds for the groups were not statistically significant [ Table 2].

Human resources
Evaluation of human resource for the HBNC program showed that group A had the highest proportion of ASHAs positioned (M = 100.0%; IQR = 5.33%) and trained in modules 6 and 7 (M = 97.34%; IQR = 15.67%) in urban areas. Though group A reported being well-equipped with HBNC kits (M = 92.18%; IQR = 100.00%) than other groups, wide intra-regional disparities existed within the group. The median density of frontline workers (FLWs) 4 was highest in group B (M = 14.41; IQR = 14.15). The median density of facility-based providers (FBPs) 5 at the primary level (per 50,000 population) was relatively high in group D (M = 3.49; IQR = 1.08) and at the secondary level (per 5,00,000 population)6 was relatively high in group C (M = 4.90; IQR = 5.76). The differences in the median availability of FLWs and FBPs in the groups were not statistically significant [ Table 2].

Intrapartum
Analysis of intrapartum records revealed that the median institutional deliveries in urban areas were over 98% across all groups. The median percentage of reported home deliveries was least in group C (M = 0.03%; IQR = 0.57%), and relatively high in group B (M = 1.31%; IQR = 2.36%). However, the median percentage of home deliveries attended by skilled birth attendants (SBA) was found to be low across all groups, especially group D (M = 0.71%; IQR = 8.11%). The differences in the medians were not statistically significant [ Table 3]. 4 FLWs-Urban ASHAs, Health workers (female/ANM) at urban primary healthcare facilities 5 Allopathic doctors and nursing staffs at UPHCs 6 General Medical Duty Officers (GDMOs), nursing staffs and specialists at urban CHCs Volume 11 : Issue 8 : August 2022

Discussion
The study's findings show that the HBNC visits undertaken in urban areas across the states are differential. Reflecting the NUHM framework, the service delivery and utilisation of the HBNC package in urban areas are concentrated majorly among the vulnerable and socially disadvantaged population. This may reflect as suboptimal service coverage if the entire urban cohort is considered. Future studies may explore HBNC service coverage and uptake among different groups in urban areas.
It is known that the HBNC program needs the integration of community care subsystems and healthcare facilities with well-equipped and skilled professionals. [1] The findings on the infrastructural density indicate the structures in place for the programme. However, it needs to be interpreted alongside factors like the level of urbanisation within the groups, geographical terrain, slum settlements/concentration, and the presence of private providers in the urban areas of each state and UT. Regardless, all groups have a considerably higher density of district-level secondary facilities which may be due to the high caseload from both rural and urban populations at the district level facilities. In the case of group A, a comparatively high density of district-level facilities may also be attributed to less population in the North-east (NE) region.
HBNC programme also depends on the presence of higher-level healthcare facilities for the management of sick newborns identified and referred by FLWs during home visits. The reported density of specialised newborn care facilities for the urban population is low, which may be due to, but not limited to, actual lack of infrastructure in the urban public health facilities or due to under-reporting of facilities not meeting the functionality criteria. The same is reflected in other studies, [22,23] thereby warranting more field-level exploration in urban areas and focused actions for deficiencies, if any. Given the programmatic needs, frontline workers at the community level, doctors at the primary healthcare level, and specialists at the secondary level of care are important components for effective programmatic implementation and coverage. Considering the evidence on the vital role of community health workers (CHWs) in improving maternal and newborn care, [9,24] expanding HBNC in areas without their coverage is likely to pose a challenge. Hence, the status of ASHAs/CHWs deployed, trained, and equipped with HBNC kits needs more attention. Similarly, the importance of having trained and well-equipped health care professionals during childbirth to avoid obstetric complications and maternal mortality is well documented. [25] Human resource requirements of FBPs at the primary and secondary level healthcare facilities ought to be met based on the requirements of their respective geographical and population needs.
While the overall percentage of reported home deliveries in urban areas is low, state-level records of 2019-20 revealed that a few states/UT (Meghalaya, Arunachal Pradesh, Bihar, Himachal Pradesh, Punjab, and Andaman and Nicobar Islands) reported high home deliveries in urban areas within their respective groups. [26] Even among them, very few had assistance from skilled birth attendants. Though the present study is limited in understanding the reasons for home delivery in urban areas, a cross-country analysis has highlighted that women delivering at home in urban areas were 3.5 times more likely to be from socioeconomically disadvantaged neighbourhoods. [27] Given the study's findings, components envisioned under the NUHM to redress inequity in access and utilisation need focused attention to reach the beneficiaries.
The study's finding of high institutional delivery (> 98%) across the groups indicates an increasing proportion of births attended by medically trained providers and is known to have a positive association with reducing maternal and neonatal mortality. [28] Yet, intra-country disparities in facility birth in urban areas can be deduced from a relatively low level of reported institutional deliveries from States like Arunachal Pradesh, Meghalaya, and Andaman and Nicobar islands (<40%). [26] A similar finding was reported in a study assessing the contribution of NHM to maternal health, which showed that though there was an increase of 40.2 percentage points of institutional delivery post-NRHM/ NHM era, inter and intra-state disparities remain. [29] The study showed that most of the women with home deliveries were given the 1 st PNC within 48 hours after birth. Yet, full HBNC visits for home and institutional deliveries in urban areas were suboptimal across the groups with intra-group variations. It may be implied that CHWs may have lesser engagement in states with less coverage, either because their baseline neonatal health outcomes are better, or alternative modes of neonatal care delivery are more effective, or due to unidentified socioeconomic challenges, just as elucidated in a modelling analysis. [13] It may be conjectured from the study that CHWs are more effective in mobilising the beneficiaries for intrapartum services over post-partum services in urban areas. Nonetheless, cost-effectiveness studies on HBNC packages for various levels of coverage [13,14] present a strong case for increasing the coverage of HBNC services in urban areas.
One of the programmatic outputs achievable through HBNC mobilisation include immunisation of newborns with a birth dose of Bacille Calmette-Guerin (BCG), Oral Polio vaccines, and Hep B/Penta 1. Given the lack of disaggregated information on the role of HBNC services in mobilising infants for immunisation, the potential association of HBNC visits on immunisation uptake in urban areas could not be explored. Nevertheless, the findings of birth dose immunisation coverage in urban areas present an opportunity to improve immunisation uptake through strengthened HBNC activities.
In the continuum of care, outcomes of low birth weight and uptake of newborn care practices like immediate breastfeeding are more closely associated with pre-partum services than with post-partum services. Even though the study is limited by the lack of disaggregates and reports on HBNC follow-up undertaken on low birth weight or sick newborns, evidence supports that HBNC visits, referral, and follow up of low birth weight infants mitigate the risk of mortality; while counselling of mothers on newborn care practices increases the chances of survival. Commensurately, the present study also showed a high percentage share of newborn deaths to total infant deaths in groups B and C where HBNC coverage was poor, especially for home-delivered newborns, thereby calling for focussed and time-bound visits to the urban population.

Limitations
Data integrity of reports in HMIS posed a limitation on the quality of extracted data. It was addressed by removing the outliers and by presenting the median values of the distribution. Despite that, it is recommended to interpret the findings under each group and indicator with caution as perceived poor performance may be due to good reporting by States/UTs and vice versa.

Conclusion and Recommendations
The study clearly shows that HBNC coverage in urban areas is highly differential within the states and across the country. The intricacies of the urban population nested in an environment characterised by multiple options, vulnerabilities, and social practices challenge assessing its coverage/uptake when measured with the yardstick meant for rural health systems. To overcome this, primary studies to understand HBNC service coverage among population subsets in urban areas and referral linkages are needed, followed by an evidence-informed increase in programmatic coverage in urban areas. This also calls for simultaneous strengthening of referral linkages to specialised newborn care facilities, ensuring skilled personnel at varying levels of facilities, and improving community engagement of frontline workers in urban areas under the NUHM.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest. Facility-based Providers per 5,00,000 population include General Medical Duty Officers (GDMOs), nursing staff and specialists (Surgeons, OB&GY, Physicians and Paediatricians) at urban CHC (sub-district level) in urban areas Percentage of home deliveries to total reported deliveries Home deliveries include reported deliveries in urban areas (attended and not attended by SBA) Total reported deliveries include total home deliveries and institutional deliveries reported in urban areas Percentage of home deliveries attended by SBA Estimated using reported home deliveries attended by SBA and total reported home deliveries in urban areas Percentage of Institutional deliveries to total reported deliveries Estimated using total reported institutional deliveries and total reported deliveries in urban areas Percentage of women receiving 1st post-partum check-up within 48 hours of home delivery out of the total reported home delivery Estimated using women receiving 1 st PNC within 48 hours of home delivery and total reported home delivery in urban areas Percentage of newborns reported to have received full HBNC visits for home deliveries Estimated using newborns reported to have received full HBNC visits for home delivery (7 visits) and total reported home deliveries in urban areas Percentage of newborns reported to have received full HBNC visits for institutional deliveries Estimated using newborns reported to have received full HBNC visits for institutional delivery (6 visits) and total reported institutional deliveries in urban areas Percentage of newborns reported to weigh less than 2.5kg against total reported live births Estimated using newborns reported to weigh less than 2.5 kg and total reported live births in urban areas Total reported live births include male & female live births in urban areas Percentage of newborns breastfed within 1 hour of birth against total reported live births Estimated using newborn breastfed within 1 hour of birth and total reported live births Percentage of newborns reported to have received full HBNC visits out of the total reported live births Estimated using newborns reported to have received full HBNC visits and total reported live births Share of newborn deaths to infant deaths (%) Estimated using the total number of newborn deaths (occurring within 24 hours and up to 4 weeks of birth) and the total number of infant deaths (birth to 12 months)