If little Manisha Kalindi did not have the good fortune to receive the attention of a local anganwadi worker, hers would have been one more name in the long list of newborn deaths of Pathergora village in Jharkhand's East Singhbhum district.
East Singhbhum is predominantly tribal with high levels of poverty. Manisha, weighing just two-and-a-half kilogrammes, was already underweight at birth. Instead of gaining weight as most babies do, her weight dropped to one kilogramme a couple of months later. With her undernourished mother unable to breastfeed her or take her to a hospital, she hovered dangerously close to death. It was at that point that a village anganwadi worker took charge and gave her a new lease of life.
Considering that close to 50 per cent of newborn deaths in India occur during the first seven days of birth, Manisha is lucky to be alive. Although the two-year-old continues to be underweight and is susceptible to periodic illnesses like diarrhoea and malaria, her chances of growing up normally are bright thanks to a new approach of infant care adopted by her carer: The integrated management of neonatal and childhood illness (IMNCI) approach.
The IMNCI was adopted by the Jharkhand government as the central strategy under the Reproductive and Child Health Programme, a five-year programme of the National Rural Health Mission. It offered a package of preventive, promotive, and curative interventions. The Jharkhand government is being aided by UNICEF in this programme which is currently being implemented in 28 states and 145 districts across the country.
The Government of India assesses that India will fall far short of its Millennium Development Goal target of achieving an Infant Mortality Rate of 26.7 deaths per 1000 live births by 2015, and the idea behind programmes like the IMNCI is to achieve a faster pace of change.
As part of this effort, frontline health workers like auxiliary nurse midwives and anganwadi workers are trained to focus on the prevention, treatment and management of malnutrition and minor childhood diseases like measles, malaria, pneumonia, and diarrhoea, in a holistic manner. A key component of IMNCI is a home visit to promote best practices for infant care, with mothers and families being counselled on the importance of breastfeeding. Low-birth weight babies are monitored at the village level, with serious cases being referred to local health centres.
Jharkhand has a neonatal mortality rate of 49 per 1000 live births - higher than the national average - and the IMNCI approach is making all the difference between life and death. In East Singhbhum, for instance, where many severely undernourished newborns like Manisha die because mothers are extremely malnourished and do not have sufficient knowledge of the importance of practices like breastfeeding, 1,455 anganwadi workers and 312 auxiliary nurse midwives have been trained so far. These frontline workers have been able to reach over 26,592 newborns within 24 hours of birth in the span of four years (2006-09).
The challenges of course were many. Making women aware of the importance of breastfeeding and the correct way of doing it was initially difficult in Pathergora. Santhi Hanoda, an anganwadi worker of Pathergora, recalls, "Breastfeeding was not considered crucial for a newborn. Women would wait until religious ceremonies were conducted before breastfeeding their babies. They didn't realise this could have fatal consequences. Information about the benefits of breastfeeding soon after birth has now brought about some change in feeding practices."
Hanoda realised that getting women to listen would be easier when they all congregate with their children during the Village Health and Nutrition Day, an event held every second Wednesday of each month. During this event, a broad range of services are provided, including delivering rations for pregnant and lactating women, immunising babies and administering Vitamin A and iron supplements.
While Hanoda has been an anganwadi worker for the last 11 years, it was only in 2008 that she received IMNCI training. She could not help but notice the difference the programme made. "It helped me understand better the correct way of breastfeeding and also recognise the danger signs of imminent illness that mothers often overlook. When I counsel them about health, pregnancy care and nutrition, I ensure that they understand the importance of breastfeeding. They don't feel shy because I come from the same community of Santhals as they do," says Hanoda.
Currently, 47,707 children under five years of age in East Singhbhum have been assessed for feeding problems, undernourishment, diarrhoea and serious infections.
Geeta Kumari Mahato, an auxiliary nurse and midwife, has been coming to the village since 2002. She believes that attitudes of women have changed ever since they became more aware about newborn care. "They see the difference in their children's health by following the right nutrition and immunisation practices. Which mother doesn't want a healthy child?" she remarks.
In the nearby Lovekeshra village, the IMNCI colour coded booklet classifies symptoms and severity of illness in three colours: Red, yellow and green. It has helped an anganwadi worker like Yamini Made take the right decisions. She knows that symptoms related to improper breastfeeding are marked in green - green, in fact, indicates mild health conditions that require simple home care. So when Mukti Saber's three-month-old underweight daughter kept falling ill, Made showed her the right way to breastfeed. When children display symptoms similar to those mentioned under the red code, she knows their illnesses are serious enough to warrant a visit to a health facility.
Additionally, another home care solution that Made learnt about was to keep the infant warm through the 'kangaroo care' method, named after the marsupial, which carries its young close to itself. It was initially developed to look after premature infants in areas where incubators were unavailable. Explains Made, "Since people here don't understand what a kangaroo is, I substitute it with a monkey. For instance, I told Mukti to hold her baby close to her chest, like a monkey does and she knew immediately that she needs to clasp her baby to provide it with warmth. She followed the suggestion and now her daughter no longer falls ill," explains Made. Saber beams in agreement. She is simply delighted that her daughter's weight has increased to four kilogrammes.
According to Arun Kumar, UNICEF IMNCI supervisor, every month a review meeting is held to see whether protocols are followed. "If kangaroo care has been given to anyone I visit the mother to verify details. We also check to see whether they (anganwadi workers) have been able to diagnose the problem correctly and can tell whether the illness needs home-based remedies or requires treatment in an institution. This way, they always have their thinking caps on," claims Kumar.
The encouraging results have ushered in other innovations. The Jharkhand government plans to rope in M.S. Dhoni, the Indian cricket team captain, and former Indian women's hockey captain, Sumrai Tete, to join in its awareness campaign. Celebrity endorsement is expected to give health awareness campaigns a higher profile.
Hopefully, this combined effort will help Jharkhand's babies to win the match of life! They desperately need to win: The Millennium Development Goals (MDGs) Report 2010 notes with concern that while child deaths are falling, especially after the year 2000, they are not falling quickly enough.
As India prepares for the September review of the world's progress on the MDGs and plans its blueprint for meeting its targets by the year 2015 - the deadline year for MDGs - it will do well to keep in mind the lessons learnt from the story of little Manisha. She is alive today because of timely, focused and planned care.
By arrangement with WFS