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Shedding light on infant survival in West Bengal

India is a country where one out of every 22 infants does not survive their first month of life. One of the leading causes of death is hypothermia.

Complications of hypothermia – low body temperature – are responsible for the majority of neonatal deaths (occuring within 28 days of birth) in India, and the condition goes largely unnoticed.

Infants at risk include low birthweight babies – under 2.5 kilograms – those not dried properly immediately after birth, infants not adequately fed and those kept in cold rooms.

Fortunately, there is an astoundingly simple, low-tech solution to manage hypothermia: the humble lightbulb.

In village-level hospitals in six districts in the state of West Bengal a 200 watt bulb – now an essential item in labour room kit – hangs over babies' cots. In Tamluk District Hospital, nurses use discarded cardboard medicine boxes to line cots to further protect infants from draughts.

Even in remote villages without electricity, a practical, low-tech intervention is at hand. Says Janaki Sahis, a trained midwife in Purulia district, "I make a coal and dung-cake fire in a malsa [an earthen plate] to make the room hot."

Since 1999 midwives like Sahis, as well as nurses and doctors at primary and secondary level hospitals in West Bengal, have been instructed in a package called Essential Newborn Care (ENC).

Abiding closely to World Health Organization guidelines – and distilled from practical experiences of Indian health workers – ENC promotes low-tech solutions to common causes of infant death and illnesses.

The guidelines are simple: Put low-weight, premature babies in warmers or under a light bulb. Don't bathe newborns. Instead, wipe them dry, put to the mother's breast and breastfeed immediately and exclusively. These low-cost, no-cost practices have saved thousands of babies who might have been among the 140 newborns dying every hour in India.

Chhabi Pal is one of the lucky mothers. Her daughter, born in January 2002 at Krishnanagar District Hospital, was underweight at 2.3 kg. Three years earlier, Pal would have been forced to take her infant to a district hospital on a cool winter night.

Instead, Pal's well-wrapped baby slept in a cot under a 200-watt bulb while nurse Rekha De put a finger against the soles of her feet, checking for hypothermia. "The baby will be okay if her soles are warm," says De.

Such practical interventions for detecting hypothermia will reduce neonatal deaths by half, says Dr Vinod Paul of the All India Institute of Medical Sciences (AIIMS) in Delhi and a member of a WHO research project on newborn care.

Although infant deaths due to vaccine-preventable diseases have declined in the past 30 years, the neonatal death rate has risen to constitute two-thirds of infant mortality. One out of every 22 infants dies before they complete the first month of life – a statistic that the federal government has declared unacceptable.

To demonstrate political will, Prime Minister Atal Bihari Vajpayee inaugurated the Newborn Week in 2001 and extended ENC programmes to 60 districts covering 14 states. In February the government pledged to lower the infant mortality rate from 68 to 45 per 1,000 live births in the next five years.

However, if entering this world is a risky proposition for Indian babies, it is equally dangerous for the women who bear them – and experts argue that child survival cannot be tackled without addressing long-standing gender inequities.

Of the almost 600,000 women worldwide who die every year from pregnancy related causes, over one-sixth are in India, where one woman dies every five minutes. Studies show that maternal mortality has not declined as significantly as general mortality or infant mortality. One reason, according to Federal Health and Family Welfare Minister Sushma Swaraj, is the second class status of women.

To increase child survival, Paul points out, the top priority should be stopping too early marriage and childbirth, a primary cause of underweight babies and infant mortality. In West Bengal nearly 68 out of every 1,000 women between the ages of 15 and 19 have given birth, higher than the national average of 54 per 1,000. The link between child survival and female literacy is now well established, yet 40 per cent of women in the state are illiterate.

Worringly, management of hypothermia is still a patchy affair, and it is not routinely taught in the country's medical colleges. In labour rooms of teaching hospitals in Kolkata, babies are routinely bathed after delivery, not breastfed immediately after birth or wrapped warmly enough for the long trek from labour room to nursery.

Says National Neonatology Forum president Dr A. Dutta, "Few doctors know that hypothermia kills babies even in the height of summer."

There is good news from West Bengal, however, and the work of the state's 1,200 ENC-trained midwives has not gone unnoticed. "The efforts on newborn care in West Bengal in the last two years have been exemplary…and need to guide the rest of the country," says Dr K Suresh of the UN Children's Fund in Delhi.

Dr Alok Lahiri, a neonatologist with the SSKM post-graduate teaching hospital in Kolkata, has trained many midwives in the new ways of birthing – and his methods are innovative and revolutionary.

He communicates easily with the midwives, teaching them messages of newborn care and maternal nutrition in two-line rhymes such as "maye-chaye gaye-gaye" (mother and baby skin-to-skin), which have become popular among midwives. Lahiri also insists on training midwives, nurses and doctors together rather than separately – which is the norm.

Such training alongside doctors and nurses has given midwives new self-esteem. The midwives of Anandapur village say that their profession has always been regarded as "dirty" (of low caste).

"Many families don't want marital relations with us," complains Lakshmi, a midwife in Anandapur village.

Yet midwives radiate a sense of dignity few other professions can match. Says village midwife Janaki: "The rich go to the fields to gather their harvest. We go to people's homes. They may lose their land or their harvest, but our harvest shall live on."

Swati Bhattacharjee is a journalist working with the Kolkata-based newspaper, Ananda Bazar Patrika.

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