Models of Facility-Based Newborn Care in India: NBCC, NBSU & SNCU
A Comprehensive Guide for Nursing Students
“Every newborn, no matter where they are born, deserves the best possible start in life and access to quality healthcare services.”
Fig 1: India’s three-tier system of facility-based newborn care showing NBCC, NBSU, and SNCU levels
Table of Contents
- Introduction to Facility-Based Newborn Care in India
- The Three-Tier System of Facility-Based Newborn Care
- Newborn Care Corner (NBCC)
- Newborn Stabilization Unit (NBSU)
- Special Newborn Care Unit (SNCU)
- Impact on Neonatal Mortality
- Mnemonics for Facility-Based Newborn Care
- Challenges & Best Practices
- Success Stories & Case Studies
- Conclusion
- References
Introduction to Facility-Based Newborn Care in India
Facility-based newborn care in India has undergone significant transformation over the past two decades. With a population of over 1.4 billion and approximately 25 million births annually, India faces unique challenges in providing quality healthcare to all newborns. Historically, neonatal mortality has been a major public health concern in India, with neonatal deaths constituting nearly two-thirds of all infant deaths in the country.
Key Statistics:
- Neonatal mortality rate in India has declined from 44 per 1,000 live births in 2000 to approximately 20 per 1,000 live births in recent years.
- 45% of neonatal deaths occur within the first two days of life.
- Major causes include prematurity, birth asphyxia, infections, and congenital anomalies.
- As of recent reports, there are 887 Special Newborn Care Units (SNCU), 2,421 Newborn Stabilization Units (NBSU), and over 20,336 Newborn Care Corners (NBCC) across government hospitals in India.
To address these challenges, India adopted a systematic approach to facility-based newborn care through the National Health Mission, implementing a comprehensive three-tier system. This system was designed to ensure that appropriate care is available at different levels of the healthcare system, from primary to tertiary care facilities.
The Three-Tier System of Facility-Based Newborn Care
India’s facility-based newborn care system comprises three levels of care, each designed to cater to specific needs and complexities of newborn health:
Newborn Care Corner (NBCC)
Located within delivery rooms at all healthcare facilities where deliveries take place. Provides essential facility-based newborn care at birth.
Location: Primary Health Centers, Community Health Centers, and all delivery points
Newborn Stabilization Unit (NBSU)
Intermediate care facility for sick newborns. Provides stabilization and initial management before referral if needed.
Location: First Referral Units (FRUs), Community Health Centers (CHCs)
Special Newborn Care Unit (SNCU)
Advanced care facility for sick newborns requiring intensive care, except assisted ventilation and major surgeries.
Location: District Hospitals, Sub-district Hospitals, Medical Colleges
This hierarchical structure ensures that all newborns receive appropriate facility-based newborn care based on their medical needs, with clear referral pathways between different levels. The system is designed to bridge the gap between community-based and specialized hospital care, ensuring timely interventions for newborns in need.
| Parameter | NBCC | NBSU | SNCU |
|---|---|---|---|
| Primary Location | Delivery room in any healthcare facility | First Referral Units (FRUs), CHCs | District/Sub-district Hospitals, Medical Colleges |
| Space Requirement | 20-30 sq ft within labor room | Minimum 200 sq ft floor space | Minimum 1500 sq ft for 12-bed unit |
| Capacity | Single point of care | 4 beds (radiant warmers) | 12 or more beds |
| Staff Requirement | Staff available in labor room | 1 trained doctor, 4 staff nurses | 3-4 doctors, 10-12 staff nurses, 4 support staff |
| Level of Care | Essential newborn care, resuscitation | Basic stabilization, initial management | Advanced care (excluding ventilation, major surgery) |
Newborn Care Corner (NBCC)
The Newborn Care Corner (NBCC) serves as the first point of facility-based newborn care immediately after birth. It is a designated space within the delivery room or obstetric operation theater where essential care is provided to all newborns at birth.
Infrastructure & Setup
- Located within the labor room or obstetric operation theater in any healthcare facility where deliveries occur
- Dedicated space of 20-30 square feet in a draught-free area
- Adequate lighting and controlled temperature (24-26°C)
- Wall-mounted oxygen supply or oxygen cylinder with flow meter and tubing
- Easy access to electrical outlets
- Wall-mounted clock with seconds hand
Essential Equipment
- Radiant warmer with bassinet
- Resuscitation kit (bag and mask, suction devices)
- Oxygen supply with flow meter
- Stethoscope (neonatal)
- Digital thermometer
- Baby scale
- Wall clock with seconds display
- Clean linen, towels, and sheets
- Cord clamps/ties
- Gloves and other infection control supplies
- Emergency drugs (Vitamin K, Adrenaline)
- Mucus extractor/suction device
Services Provided
The “WARM START” Mnemonic for NBCC Services
Warmth – Thermal management through drying, skin-to-skin contact
Airway clearance and breathing assessment
Resuscitation when required
Monitoring of vital signs
Skin-to-skin care promotion
Timely breastfeeding initiation
Anthropometric measurements
Routine care (eye care, cord care, vitamin K)
Transfer decisions for sick newborns
The NBCC provides the following essential services:
- Prevention of infection through clean delivery practices
- Provision of warmth through drying, wrapping, and skin-to-skin contact
- Newborn resuscitation when required
- Weighing the newborn
- Early initiation of breastfeeding (within 1 hour)
- Administration of Vitamin K injection
- Eye care and cord care
- Immunization as per schedule (BCG, OPV, Hepatitis B)
- Identification of sick newborns requiring referral
Staffing Requirements
The NBCC is typically managed by the staff already available in the labor room:
- Medical officer/doctor trained in essential facility-based newborn care and resuscitation
- Staff nurse/ANM trained in essential facility-based newborn care and resuscitation
All healthcare providers involved in delivery care should be trained in Navjaat Shishu Suraksha Karyakram (NSSK) or other relevant facility-based newborn care training programs.
Important Note:
Every delivery point must have a functional NBCC as it serves as the first critical point of care for all newborns. The NBCC plays a vital role in reducing early neonatal mortality by providing timely interventions at birth.
Newborn Stabilization Unit (NBSU)
The Newborn Stabilization Unit (NBSU) serves as an intermediate facility for facility-based newborn care, positioned between NBCCs and SNCUs. They are established at First Referral Units (FRUs) and Community Health Centers (CHCs) to provide care to sick newborns who do not require intensive care but need more than basic care.
Infrastructure & Setup
- Minimum 200 square feet dedicated floor space
- Located in close proximity to labor room/maternity ward
- 24-hour water and power supply with backup
- Temperature-controlled environment (24-26°C)
- Adequate lighting and ventilation
- Hand washing stations and facilities for infection control
- Space for mothers to stay with their babies (rooming-in)
Essential Equipment
- 4 radiant warmers (plus 2 additional in postnatal ward)
- Phototherapy units
- Oxygen concentrators
- Pulse oximeters
- Suction machines
- Laryngoscopes and endotracheal tubes
- IV infusion pumps
- Digital thermometers
- Baby scales
- Glucometers
- Infantometers
- Essential medications and IV fluids
- Feeding supplies (cups, spoons, nasogastric tubes)
Services Provided
The “STABLE” Mnemonic for NBSU Care
Sugar and Safe Care – Glucose management and safety protocols
Temperature – Maintaining optimal temperature
Airway – Maintaining clear airways
Blood pressure – Monitoring and stabilizing
Lab work – Essential diagnostic tests
Emotional support – For mother and family
The NBSU provides the following services:
- Thermal management for hypothermic newborns
- Management of hypoglycemia
- Treatment of jaundice (phototherapy)
- Oxygen administration for respiratory distress
- Management of sepsis (with antibiotics)
- Feeding support for low birth weight babies
- Stabilization of sick newborns before referral to SNCU
- Follow-up care of babies discharged from SNCU
- Initial management of common neonatal problems
Staffing Requirements
- One trained doctor (medical officer) responsible for the unit
- At least one full-time staff nurse trained in facility-based newborn care per shift
- Minimum of 4 full-time staff nurses to cover all shifts
- Support staff for cleaning and maintenance
All medical and nursing staff at NBSU must be trained in Facility-based Integrated Management of Neonatal and Childhood Illnesses (F-IMNCI) or equivalent facility-based newborn care training programs.
Admission Criteria
The NBSU admits newborns with:
- Hypothermia (temperature < 36.5°C)
- Hypoglycemia (blood glucose < 45 mg/dl)
- Jaundice requiring phototherapy
- Minor respiratory distress
- Feeding problems
- Low birth weight babies (1800-2500g)
- Mild birth asphyxia (recovered with resuscitation)
- Stable preterm infants (>34 weeks)
Conditions requiring referral to SNCU:
- Severe birth asphyxia (Apgar < 4 at 1 minute)
- Very low birth weight babies (<1800g)
- Extreme preterm (<34 weeks)
- Severe respiratory distress
- Severe infection/sepsis
- Seizures or neurological problems
- Severe jaundice (requiring exchange transfusion)
- Major congenital malformations
Special Newborn Care Unit (SNCU)
The Special Newborn Care Unit (SNCU) represents the highest level of facility-based newborn care in India’s three-tier system. It provides specialized care for sick newborns and is established at district hospitals, sub-district hospitals, and medical colleges.
Infrastructure & Setup
- Minimum 1500 square feet for a 12-bed unit
- Located in close proximity to labor room/obstetric operation theater
- Separate inborn and outborn areas (to prevent cross-infection)
- Step-down area for recovering babies
- Designated areas for:
- Nurse station with clear visibility of all beds
- Doctor’s room
- Counseling room
- Breastfeeding/expression area
- Washing area/changing room
- Store room
- Entrance area with foot-operated washing facilities
- Temperature-controlled environment (24-26°C)
- 24-hour water and electricity supply with backup
- Central oxygen and suction supply
- Adequate lighting and infection control measures
Essential Equipment
- Radiant warmers (12 or more)
- Phototherapy units (at least 4)
- Transport incubators
- CPAP machines
- Multipara monitors
- Pulse oximeters
- Infusion pumps and syringe pumps
- Oxygen concentrators/cylinders
- Portable X-ray machine
- Laboratory equipment (for blood gas analysis, electrolytes)
- Electronic weighing scales
- Bilirubinometer
- Refrigerator for medication storage
- Advanced resuscitation equipment
- Double-volume exchange transfusion sets
Services Provided
The “INTENSIVE” Mnemonic for SNCU Services
Infection management – Comprehensive sepsis treatment
Nutrition support – Specialized feeding for vulnerable babies
Thermal regulation – Advanced warming techniques
Emergency care – For critical conditions
Neurological support – For seizures and brain injuries
Special procedures – Blood transfusions, CPAP
Imaging and diagnostics – X-rays, lab tests
Vital monitoring – Continuous assessment
Education and counseling – For parents and caregivers
The SNCU provides comprehensive care for sick newborns, including:
- Management of respiratory distress (including CPAP)
- Care of very low birth weight babies (1000-1800g)
- Advanced thermoregulation
- Management of severe infections and sepsis
- Advanced management of jaundice (including exchange transfusion)
- Management of seizures and neurological problems
- Management of shock and cardiovascular support
- Specialized feeding support for premature infants
- Neonatal transport services
- Follow-up services for high-risk infants
- Parental counseling and education
SNCU Limitations:
SNCUs do not provide advanced ventilation support (except CPAP) or major surgical interventions. Cases requiring these services are referred to Neonatal Intensive Care Units (NICUs) in tertiary care hospitals.
Staffing Requirements
The SNCU requires dedicated staff trained in facility-based newborn care:
- Medical Officers:
- 3-4 full-time doctors trained in facility-based newborn care
- At least 1 pediatrician (desirable)
- 24-hour medical coverage
- Nursing Staff:
- 10-12 staff nurses for a 12-bed SNCU (nurse-to-patient ratio of 1:4)
- At least 1 nursing sister for supervision
- Support Staff:
- 4 support staff for cleaning and maintenance
- Data entry operator for maintaining records
All medical and nursing staff must undergo specialized training in neonatal care, including:
- Facility-based IMNCI training
- SNCU training modules
- Regular refresher courses and skill updates
Impact on Neonatal Mortality
The implementation of the three-tier facility-based newborn care system in India has shown significant positive impacts on neonatal mortality rates and outcomes:
Key Achievements
- Reduction in neonatal mortality rate from 44 per 1,000 live births in 2000 to around 20 per 1,000 in recent years
- Establishment of over 887 SNCUs, 2,421 NBSUs, and 20,336 NBCCs across India
- Over 1 million sick newborns treated annually in SNCUs
- Decline in SNCU mortality rates from over 15% to below 10% in many states
- Improved geographical access to facility-based newborn care services
Evidence of Impact
- Studies show 7.8% reduction in neonatal deaths in districts with functional SNCUs
- Significant improvement in survival rates of low birth weight babies
- Reduction in both inborn and outborn death rates in SNCUs over time
- Better management of birth asphyxia leading to improved outcomes
- Increased institutional deliveries due to availability of facility-based newborn care facilities
Recent data from an SNCU study showed that the death rate of both inborn (from 14.90% in 2018 to 12.90% in 2023) and outborn (from 24.30% in 2018 to 11.70% in 2023) newborns admitted to SNCUs has shown significant improvement, demonstrating the effectiveness of these specialized units.
Mnemonics for Facility-Based Newborn Care
Mnemonics are valuable tools for nursing students to remember complex protocols and procedures in facility-based newborn care. Here are some useful mnemonics specific to India’s facility-based newborn care models:
APGAR
For assessing newborn condition at birth:
Appearance (color)
Pulse (heart rate)
Grimace (reflex irritability)
Activity (muscle tone)
Respiration
STABLE
For post-resuscitation/pre-transport care:
Sugar and Safe care
Temperature
Airway
Blood pressure
Lab work
Emotional support
TABC
For immediate facility-based newborn care:
Thermal protection
Airway clearance
Breathing support
Circulation assessment
SPINES
For danger signs in newborns:
Seizures
Poor feeding
Inactivity/lethargy
Not breathing properly
Excessive crying
Skin color changes (jaundice, cyanosis)
CARE LEVELS
For remembering India’s three-tier facility-based newborn care system:
Corner (NBCC) – For essential care at birth
Assessment and stabilization (NBSU) – For basic management of sick newborns
Referral and special care (SNCU) – For advanced neonatal care
Evaluation of all newborns at each level
Linkages between facilities are crucial
Essential equipment at each level
Vital training for all staff
Emergency services available
Location-specific design
Specific services at each tier
Challenges & Best Practices
Key Challenges
- Human resource shortages, especially trained nurses and specialists
- Maintenance of equipment and ensuring regular supplies
- Infection control in crowded facilities
- Gaps in referral systems between different levels of care
- Disparities in facility-based newborn care services between urban and rural areas
- Inconsistent quality of care across facilities
- Inadequate follow-up systems for high-risk infants
- Limited community awareness about available facility-based newborn care services
Best Practices
- Standard operating procedures (SOPs) for all procedures
- Regular skill-based training and mentoring for staff
- Implementation of quality improvement cycles
- Family-centered care approaches, including KMC (Kangaroo Mother Care)
- Digital data management systems for monitoring outcomes
- Telemedicine support for peripheral units
- Public-private partnerships to expand services
- Integration with community-based facility-based newborn care initiatives
Quality Improvement Approach:
Successful SNCUs and NBSUs implement continuous quality improvement methods, including:
- Regular clinical audits
- Death reviews to identify preventable factors
- Monitoring of key performance indicators
- Peer learning and sharing of best practices
- Implementation of standardized protocols
Success Stories & Case Studies
The Purulia Model: Pioneer in District-Level SNCU
The first district-level SNCU was established in Purulia, West Bengal, through a collaboration between the state government and a non-profit organization. This model demonstrated that specialized facility-based newborn care services could be provided at the district level with limited resources.
Key achievements of the Purulia model included:
- Significant reduction in neonatal mortality at the district hospital
- Development of locally adapted, cost-effective protocols
- Training model for district-level medical and nursing staff
- Successful implementation of infection control measures
The Government of India adopted the Purulia model as the national standard for establishing SNCUs across the country.
Kerala’s Integrated Approach
Kerala has successfully integrated all three levels of facility-based newborn care facilities with strong referral linkages and follow-up systems. The state’s approach focuses on:
- Universal coverage of essential facility-based newborn care through functional NBCCs at all delivery points
- Strategic placement of NBSUs to ensure geographic accessibility
- High-quality SNCUs with trained staff and advanced equipment
- Strong community linkages through ASHAs (Accredited Social Health Activists)
- Comprehensive tracking system for high-risk infants
This integrated approach has contributed to Kerala achieving one of the lowest neonatal mortality rates in India.
Madhya Pradesh’s Facility-Based Newborn Care Initiative
Madhya Pradesh, a state that previously had high neonatal mortality rates, has shown remarkable improvement through the systematic implementation of facility-based newborn care:
- Rapid scale-up of SNCUs in all district hospitals
- Implementation of the Sick Newborn Care (SNCU) Online software for real-time monitoring
- Development of mentoring teams to support quality improvement
- Integration with community-based interventions
- Focus on follow-up care after discharge from SNCU
This comprehensive approach led to a significant reduction in neonatal mortality in participating facilities, demonstrating the effectiveness of the three-tier system when implemented with quality and coverage.
Conclusion
India’s three-tier facility-based newborn care system—comprising Newborn Care Corners (NBCC), Newborn Stabilization Units (NBSU), and Special Newborn Care Units (SNCU)—represents a comprehensive approach to addressing neonatal mortality. This system ensures that appropriate care is available at different levels of the healthcare system, from primary to tertiary facilities.
The significant expansion of these facilities across the country has contributed to improved facility-based newborn care outcomes and reduced mortality rates. However, challenges remain in ensuring consistent quality of care, adequate staffing, and equitable access across all regions.
For nursing professionals, understanding this tiered approach is essential for providing appropriate care and facilitating effective referrals. The continued strengthening of this system, along with integration with community-based interventions, will be crucial for further reducing neonatal mortality and achieving India’s health targets.
Future Directions:
- Integration of digital health solutions for improved monitoring and decision support
- Enhanced focus on quality of care through standardized protocols and continuous quality improvement
- Strengthening follow-up systems for high-risk infants
- Development of specialized nursing cadres for facility-based newborn care
- Research on cost-effective interventions suitable for different levels of care
References
- National Health Mission. Facility Based Newborn Care (FBNC). https://nhm.gov.in/index4.php?lang=1&level=0&linkid=484&lid=754
- Special Newborn Care Units in India – National Health Mission. https://nhm.gov.in/images/pdf/programmes/child-health/annual-report/Two_Year_Progress_of_SNCUs-A_Brief_Report_(2011-12_&_2012-13).pdf
- Facility-Based-Newborn-Care-Operational-Guide-FBNC. https://www.aspirationaldistricts.in/wp-content/uploads/2019/02/Facility-Based-Newborn-Care-Operational-Guide-FBNC.pdf
- Special Newborn Care Unit (SNCU) – UP National Health Mission. https://upnrhm.gov.in/assets/site-files/gogl/SNCU-SNCU-002.pdf
- Newborn Stabilization Unit Training Participants’ Module. https://nhm.gov.in/images/pdf/programmes/child-health/guidelines/NBSU/NBSU-Participants-Module.pdf
- Assessment of Newborn Care Corners (NBCC) & Newborn Stabilization Units (NBSU) in Secondary level health care facilities in Kerala. https://prc.mohfw.gov.in/fileDownload?fileName=Assessment%20of%20Newborn%20Care%20Corners%20(NBCC)%20Newborn%20Stabilization%20Units%20(NBSU)%20in%20Secondary%20level%20health%20care%20facilities%20in%20Kerala.pdf
- Sen, A., Mahalanabis, D., Singh, A. K., Som, T. K., & Bandyopadhyay, S. (2005). Development and effects of a neonatal care unit in rural India. The Lancet, 366(9479), 27-28.
- Neogi, S. B., Malhotra, S., Zodpey, S., & Mohan, P. (2011). Assessment of special care newborn units in India. Journal of Health, Population, and Nutrition, 29(5), 500-509.
- Neonatal mortality outcome and trends: A 6-year retrospective analysis of Special Newborn Care Unit in district hospital in Eastern India. https://pmc.ncbi.nlm.nih.gov/articles/PMC11845011/
- UNICEF India. Newborn and child health. https://www.unicef.org/india/what-we-do/newborn-and-child-health