About NRP

Newborn Resuscitaion Program: First Golden Minute Project

The proposed project will help in accelerating bringing down of Infant and under-5 Child Mortality Rates and reaching the goal of National Population Policy (NPP) 2000 of reduction infant mortality rate to below 30 per 1000 live births. This project aims to train about 300,000 health professionals in Basic Newborn Care and Resuscitation with ultimate aim to have one person at every delivery trained in neonatal resuscitation.

Background and Rationale

In 2006, for the first time, the number of children in the world dying before their fifth birthday fell below 10 million, to 9.7 million annually. However, South Asia’s contribution to this figure remained a staggering 3.1 million while 2.1 million under five deaths occurred in India. This means that India bears around 21 per cent of the global burden of deaths of children under five years of age (State of World’s Children 2008).

Improving Child Health and Survival has been an important goal of the Family Welfare Programs in India. National Population Policy (NPP) 2000 while addressing the unmet needs for contraception, health care infrastructure, and health personnel, also aimed to provide integrated service delivery for basic reproductive and child health care. The policy sets various National Socio-Demographic Goals to be achieved and included reduction infant mortality rate to below 30 per 1000 live births. However, rate of decline of IMR over a period of time has been slowed down. During the period 1980 to 1990 IMR declined by 34 points (114 to 80), whereas during the period 1990 to 2000 annual decline rate was just 12 points (80 to 68). Further the decline in IMR has not been uniform across all States over the years.

The IMR and under 5 child mortality in some States such as Madhya Pradesh, Orissa, UP, Rajasthan, Bihar, Jharkhand, Chhattisgarh, Assam, Arunachal Pradesh and Andhra Pradesh continue to be unacceptably high(Table 1). If India is to reach the NPP goal of IMR below 30/1000 live births and MDG (Millennium Development Goal) of 38 by 2015, the average annual rate of reduction over the coming years must be far higher, or around 7.6 per cent (Source: SOWC 2008 & PFC 2007). There is no doubt that if some urgent measures are not initiated, IMR goals set by NPP and MDG would not be achievable in foreseeable future.

Why IMR continues to be high in India?

The major reason for this situation has been a very slow decline in the neonatal mortality rate. Worldwide 37 per cent of under-five deaths are attributed to neonatal causes (within the first 4 weeks of life). National Family Health Survey-3 reports that neonatal mortality accounts for 50% of under 5 deaths, which means that the proportion of U5 deaths by neonatal causes is disproportionately high in this country. (Source: PFC 2007 & SRS). Efforts have to be made to tackle this situation in a much focused manner. Each year, globally around 4 million children die in the neonatal period. . In India, this number is estimated to be around one million. (Source: PFC 2007 & SRS). At 1.1 million deaths under 4 weeks of age each year, India contributes 30% of the global burden of neonatal deaths; highest for any country. Current neonatal mortality rate in India is 36 /1000 live births accounting for almost two thirds of the infant deaths(SRS 2008). NMR shows a wide variation in different states being the lowest in Kerala with highest rates are seen in Chattishgarh, Jharkhand, UP and Madhya Pradesh . Within the neonatal period, the first week is crucial. Early neonatal deaths accounted for 80% of all neonatal deaths. Early neonatal death has, in fact, increased from 26/1000 to 29/1000 live births (SRS 2004 & 2007). Primary cause of neonatal deaths are perinatal asphyxia (23%), severe infections (36%) preterm births (25%), neonatal tetanus 4%) and congenital malformations (4%). (World Health Statistics 2007; http://www.who.int/child_adolescent_health/data/media/cah_chp_india.pdf)

The World Health Organization (WHO) reports that between 4 and 9 million newborns have birth asphyxia, of whom an estimated 1.2 million die from birth asphyxia. The stillbirth rate varies from 5 per 1000 births in developed countries to 32 per 1000 births in south Asia and sub-Saharan Africa. In India, estimated number of stillbirths is 1 million. More than one-third of stillbirths are intrapartum and largely preventable by newborn resuscitation program. In rural Gadchiroli India interventions by the trained VHW in basic newborn resuscitation reduced case fatality in severe asphyxia by nearly 50% and asphyxia specific mortality rate by 65% in comparison to management by TBA alone (Bang et al. J Perinatology 2005; Suppl 1: S82-91). It is also, noteworthy that, about 1 million children who survive birth asphyxia each year go on to develop cerebral palsy and other disabilities.

United Nations Millennium Development Goal 4 (MDG 4) targets the reduction of under-5 child deaths by two-thirds by 2015. Given that 75% of neonatal deaths occur in the first 7 days of life, and that almost half of newborns die at home, neonatal resuscitation is a crucial component of strategies to reduce the burden of newborn deaths. It is estimated that 6-42% of neonatal mortality or morbidity in the developing countries could be decreased by neonatal resuscitation(Lancet Neonatal Survival series March 2005). In addition, WHO estimates that the number of disability-adjusted life years (DALYS) for birth asphyxia exceeds childhood conditions preventable by immunization.

Birth asphyxia results from events in the antepartum (50%), intrapartum (40%), and postpartum (10%) periods. Given that preventive strategies can be severely hampered by a lack of specificity of determining risk factors and by the lack of qualified and skilled birth attendants, , it will be necessary to provide resuscitation in the community , and to those born in facility settings with limited resources both of equipments and trained personnel. Neonatal resuscitation has the potential of altering the outcome of intrapartum and postpartum events.

Neonatal resuscitation is an important starting-point in the scaled-up neonatal programs that are required to ensure that the world’s youngest citizens get the best possible start in life.Given the distribution of the burden of asphyxia, and the limitations of access, we must be prepared to target preventive and management strategies in various settings including Community health centers, First Referral Units ( FRUs), Primary Health Centres, District-level referral facilities, Urban referral/tertiary care centers, Nursing homes in private setup.

Neonatal Resuscitation Program ( NRP)

Asphyxiated neonates require prompt, skilled resuscitation to survive the neonatal period. Neonatal resuscitation is simple, inexpensive, available and cost-effective but often not initiated or the methods used are inadequate or wrong. Neonatal Resuscitation training has been widely used in the developed world but has had limited dissemination in developing countries (WHO Technical Working Group). The American Academy of Pediatrics (AAP) and American Heart Association (AHA) developed Neonatal Resuscitation Program (IAP NRP) in 1987 to provide resuscitation training to all delivery attendants.

WHO Essential Newborn Care (ENC) sets minimum standards for training in neonatal care, including thermoregulation, resuscitation, breastfeeding, etc. Essential newborn care (ENC) became a part of the Child Survival strategy in the Child Survival and Safe Motherhood programme and continued into the RCH I programme. While neonatal resuscitation is a part of ENC training, AAP’s IAP NRP is fully skill-based program and focuses exclusively on neonatal resuscitation and believed to result in better competency of persons trained.

The American Heart Association/American Academy of Pediatrics Neonatal Resuscitation Program (IAP NRP) was evaluated in Ireland, where 85% of participants had improved skills and confidence after the program. Midwives who received intensive training scored higher in the practical demonstration than those who did not receive the intensive training. A program with critical thinking skills that promotes life-long learning and knowledge is retained for a longer period of time. There is also emerging evidence from resuscitation training programs in health system settings that multi-tiered levels of staff training and provision of equipment can make a substantial difference to overall outcomes with reduction in rates of asphyxia and perinatal mortality (Z. Bhutta, unpublished observations).

NRP in India

First International Course on NRP in India was conducted in 1989. National Neonatology Forum (NNF) created a national faculty of 150 pediatricians and nurses for NRP, who trained 12,000 healthcare professionals in various parts of India over the following 2 years in advanced course of NRP. But there was no follow-up or monitoring and no system of certification or retraining was in place which is an essential component of good NRP Program. Since then, the NRP has been taught sporadically in India. However for a country of the size of India with 27 million deliveries per year the program need to be upscaled substantially. To have a skilled birth attendants trained for every delivery, more than 0.25 million health professionals needed to be trained in NRP including physicians, pediatricians, obstetricians, anesthetists, nurses, midwives and other categories. It is also essential that such skilled professionals are available in a short period of time to meet the requirement of MDG4 goal and NPP. This would require massive organizational support. Isolated training efforts have had little impact on influencing a national training effort, largely due to the size of the country.

Role of Indian Academy of Pediatrics in propagating NRP

Indian Academy of Pediatrics (IAP) has an efficient network of more than 51,600 members with 5 zones, 30 state branches, 357 local/city/district branches, 2 UTI, 2 foreign Braches 25 sub-specialty chapters and 5 sub-specialty groups. IAP also influences thousands of other pediatricians and medical practitioners who are not its members, but who follow IAP policies. Along with Federation of Obstetrics and Gynecological Society of India (FOGSI) IAP has also established an alliance with other health care professional organizations including Indian Society of Perinatology and Reproductive Biology (ISOPARB), Indian Medical Association (IMA) and Society of Midwives of India (SOMI).

Type of course needed

Only Basic IAP NRP course which includes Initial steps and Bag and mask ventilation is required to be disseminated at large scale. Till now, IAP NRP courses offered were Advanced IAP NRP including endotracheal Intubation and medication which is required only in 1% babies requiring resuscitation. American Academy of Pediatrics (AAP) has pledged full support to IAP. A team from AAP will visit India every year during Pedicon to support IAP on technical issues including training of trainers.

In addition to basic IAP NRP courses, self-sponsored advanced IAP NRP courses would also be conducted in addition to instructor courses, so as to increase pool of instructors for both basic as well as advanced IAP NRP Courses.

Goals and Objectives

The ultimate objective of this Project will be to have one person at every delivery point, trained in neonatal resuscitation. With India’s birth cohort of 27 million per year and with most of the deliveries being conducted in peripheral areas, this goal will require large number of trainers in each of the around 800 districts of India. This project aims to train about 16,300 (approx) health personnel in neonatal resuscitation by creating enough trainer pool as well as providers. Methodology of the project shall be conduct of Nationwide training workshops with the following objectives:

• Maintenance of Online Platform created in 2021 for use by IAP NRP educational purposes
• Creation of Training Videos and educational material
• Hybrid courses

Project Implementation Plan

Under the IAP NRP FGM project of from September 2026 to March,2029, the Basic IAP NRP courses include Basic IAP NRP Provider Course and Basic IAP NRP Instructor Course. In addition to training, the IAP NRP has also been involved in developing and disseminating guidelines for neonatal resuscitation. These guidelines are based on the latest evidence and are designed to ensure that all healthcare providers have access to the most up-to-date information and practices. IAP also conducts the Advanced NRP program but will the provider courses will not be funded by KENVUE.

Basic IAP NRP

The Basic IAP NRP Provider Course is designed for MBBS, AYUSH doctors, nurses, paramedical, and supporting staff posted at birthing centers, 24x7 PHCs or maternity hospitals. The course is conducted using a hybrid model of training, consisting of online and offline modules. The online course is an essential precursor to the physical course. It also allows participants to revise the videos of resuscitation anytime later.

The Basic IAP NRP Instructor Course is conducted at the district level and is intended to create trainers of Basic IAP NRP that in turn train the healthcare workers posted at birthing centers, 24x7 PHCs or maternity hospitals. The course is an essential precursor to the physical course, and successful participants are expected to conduct at least two Basic IAP NRP courses over the next year to help with capacity building.

Implementation of the Project: -

• To implement & supervise the IAP NRP-FGM project, IAP has formed the National Task Force- the Core Committee, along with coordinators at the Zonal level and State level.
• Course Coordinator is the person wholly responsible for all the logistics and arrangements for conducting the IAP NRP training course.
• The IAP NRP training course is registered on newly created web portal by the course coordinator in consultation with the State Academic Coordinator. Once the course is registered, State & Zonal Coordinators along with the IAP NRP committee approve the same depending on the feasibility of the program. State committee members also coordinate with appropriate government bodies for successful course execution. A course is finally approved by the National Coordinator.
• IAP NRP office team ensures the course conduction as per laid guidelines in all contexts and coordinates with the respective course coordinator for getting essential documents related to the courses in the prescribed formats and for transfer of advance payment through the respective IAP branch only.
• For Basic IAP NRP courses, the course coordinator ensures every participant to mandatorily undergoes online test module. The state coordinator is responsible for availing the training material (manikins)
• Once the course gets conducted successfully, a set of post-course details including the declaration form, photographs of the workshop & expense documents is uploaded on the portal. Original copies of all post course documents including bills and related vouchers to be submitted in hard copies at the IAP NRP office. After receipt of original hard copies of all post course documents, IAP NRP office team verifies it. In case of any deficiencies in this process, it must be completed by coordinating with course coordinator of the said course. If everything is found correct, then approval is sought from the authorities concerned to pay the full & final amount. After the approval is received, IAP NRP office ensures to pay the remaining amount of the actual expenses to the concerned local IAP branch bank account. The course is declared closed after settlement of full & final payment.

The Online Course Module:

• Available in Hindi and English Language
• Consists of 8 resuscitation videos, pre, post and in between video test to evaluate knowledge
• Total time taken is around 2-3 hours

The Offline Course Module:

• One day workshop. Duration 6 hours
• Workshop is conducted on workstations consisting of 8 participants and one Instructor
• Skill is evaluated with use of PCL and PET
• IAP has around 600 training kits available to conduct IAP NRP Courses all over India.

Monitoring & Evaluation Plan

A international level steering committee will be set up to monitor and evaluate Program on ongoing basis.

Process level evaluation will be carried out by assessing:

• Pre and Post test evaluation of participants
• % of health professionals trained
• % of institutions covered by NRP
• % of delivery attended by NRP trained persons
• % of positive feedback from trainees
• Publications
• Paper presentation in Scientific Conferences

Outcome:

(Immediate outcome indicator)

• Completion of successful training of 16,300 (approx) HCPs approx.

(Long term outcome indicator)

• Reduction in IMR
• Reduction in MMR
• Reduction in NMR

Sustainability

Through this project we propose to develop an efficient, cost effective and sustainable system for on-going training and monitoring of Neonatal Resuscitation Program in India. With 27 million births every year it is important to have a good neonatal resuscitation program which can fulfill needs of large scale training and periodic re-training and continuous evaluation with emphasis on quality control.

IAP is already working with Ministry of Health and Family Welfare for Navajaat Shishu Suraksha Karykram (Basic Newborn Care and Resuscitation Program) and created a pool of about 2000 District level trainers in Public sector and provider courses have been initiated in many states. By working with other partners of NRP collaboration we will develop, refine and implement a system that takes care of these needs. These systems, along with the information we will collect on their relative efficiency, will be a key resource for improving neonatal resuscitation practices in India. This program through network of dedicated Regional trainers and District Instructors plan to put a sustainable Neonatal Resuscitation Program in place.