India Newborn Action Plan (INAP)

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Introduction

Neonatal mortality accounts for nearly two-thirds of infant deaths in India.
Despite improvements in institutional deliveries and child survival programs, the neonatal mortality rate (NMR) in 2014 was ~29/1000 live births, contributing significantly to under-five mortality.
To align with the Every Newborn Action Plan (ENAP, WHO-UNICEF, 2014), India launched the India Newborn Action Plan (INAP) in September 2014 with the goal of achieving “Single Digit NMR by 2030” across all states.

Global Context
- ENAP called for an end to preventable newborn deaths and stillbirths.
- Targets: NMR ≤10 per 1000 live births and stillbirth rate ≤10 per 1000 births by 2035.
India’s Adaptation
- INAP tailored to Indian epidemiological diversity.
- Dual target:
  - Reduce NMR to ≤10 by 2030.
  - Reduce stillbirth rate to ≤10 by 2030.
Principles of INAP
- Equity, Universal coverage, Convergence of maternal-newborn-child health, Accountability, and Community participation.

INAP interventions are organized into six thematic packages, classified as:

Essential (E):
- Promotion of adolescent health, prevention of early marriage and pregnancy.
- Universal antenatal registration, minimum 4 ANC visits.
- Birth spacing
- Nutitioal related interventions like balanced diet
- Iron and folic acid supplementation, calcium supplementation.
- Screening for hypertension, gestational diabetes, anemia, infections (syphilis, HIV, hepatitis B).
- Tetanus-diphtheria immunization.
- Screening or anemia , PIH, DM , HTN etc
Situational (S):
- Screening for hemoglobinopathies (sickle cell, thalassemia) in endemic regions.
- Malaria prophylaxis in high-endemic states.
- Screening for Hepatits , HIV etc
Advanced (A):
- Use of advanced diagnostics (e.g., ultrasound for congenital anomalies, genetic counselling).
- Preconception counseling and fertility services.

Essential (E):
- Skilled Birth Attendance at all deliveries.
- Clean and safe delivery practices.
- Partograph use for labour monitoring.
- Active management of third stage of labour (AMTSL).
- Use of corticosteroids
- Immediate resuscitation of newborns (availability of resuscitation corners).
Situational (S):
- Use of antenatal corticosteroids for preterm labour where neonatal intensive care is available.
Advanced (A):
- Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) centers.
- Use of technology for intrapartum monitoring (fetal heart monitoring devices).

Essential (E):
- Delayed cord clamping.
- Prevention of hypothermia (drying, skin-to-skin contact, delayed bathing).
- Early initiation of breastfeeding within 1 hour of birth.
- Vitamin K1 injection to all newborns.
Situational (S):
- Chlorhexidine cord application in high neonatal sepsis prevalence areas.
Advanced (A):
- Use of point-of-care diagnostics for newborn infections.
- Universal newborn screening (hearing, metabolic disorders).

Essential (E):
- Exclusive breastfeeding up to 6 months.
- Kangaroo Mother Care (KMC) for low birthweight babies.
- Immunization as per National Immunization Schedule.
- Home-based Newborn Care (HBNC) visits by ASHAs.
Situational (S):
- Special counseling in high-prevalence areas for breastfeeding substitutes.
Advanced (A):
- Lactation management centers at district hospitals.
- E-health support for families through tele-counseling.

Essential (E):
- Establishment of Newborn Care Corners (NBCC) at all delivery points.
- Special Newborn Care Units (SNCU) at district hospitals.
- Stabilization Units at CHCs.
- Integrated Management by IMNCI
- Referral transport (102/108 services).
Situational (S):
- Surfactant therapy and CPAP in neonatal units in high preterm burden states.
- Use of antibiotics guided by regional antimicrobial resistance patterns.
Advanced (A):
- Neonatal Intensive Care Units (NICUs) with ventilators, advanced imaging.
- Use of advanced therapies (exchange transfusion, therapeutic hypothermia).

Essential (E):
- Early childhood development services.
- Screening for developmental delays and disabilities.
- Linkage with ICDS and Rashtriya Bal Swasthya Karyakram (RBSK).
Situational (S):
- State-led programs for high prevalence conditions (e.g., congenital hypothyroidism, hearing impairment).
Advanced (A):
- Pediatric rehabilitation centers, early intervention clinics.
- Research and use of digital tools for growth monitoring.

Framework: Based on RMNCH+A continuum of care.
Key Components:
- Input indicators: Availability of trained staff, equipment, essential drugs.
- Process indicators: % of mothers receiving 4 ANC visits, skilled birth attendance.
- Output indicators: % newborns breastfed within 1 hour, % sick newborns referred.
- Outcome indicators: Neonatal mortality rate, stillbirth rate.
Mechanisms:
- Facility-based Maternal and Perinatal Death Surveillance and Response (MPDSR).
- Periodic supportive supervision visits by state/district nodal officers.
- Use of Health Management Information System (HMIS) for real-time monitoring.
- Community-based monitoring through VHSNCs (Village Health Sanitation and Nutrition Committees).

States urged to prepare State Newborn Action Plans (SNAPs) aligned with INAP.
District health societies to contextualize interventions based on burden and system readiness.
Focus on equity: high priority districts, tribal areas, urban slums.

Decline in NMR from 29 (2014) to 19 (2022), but disparities remain between states.
Challenges:
- Shortage of neonatal specialists.
- Infrastructure gaps in SNCUs.
- High out-of-pocket expenditure.
- Persisting social determinants: malnutrition, early marriage, gender bias.

INAP is India’s commitment to ensure “Every Newborn Counts.”
By combining universal essential interventions, context-based situational strategies, and advanced care where feasible, India aims for equitable newborn survival.
Monitoring and accountability at every level remain the backbone for achieving single-digit NMR by 2030.