A community based approach to reducing neonatal mortality in Nepal
Each year, nearly 35,000 Nepali children die before their fifth birthday, with almost two-thirds of these deaths occurring in the first month of life.1 Experts claim that over two thirds of these deaths could be prevented with relatively low costs and low-tech interventions.2 The Community Based Newborn Care Package addresses these issues within the national health system settings of Nepal.
While Nepal managed to reduce child and maternal mortality rate by 7.7% respectively 7.5%, slow progress has been made in terms of neonatal mortality rate (3.6%). Around the year 2000, the government has put newborn survival on its political agenda and enforced community-based and public health interventions. Nepal then was the first low-income country in South Asia to have a national newborn health strategy. The so called Community-Based Newborn Care Package (CBNCP) was developed in 2007 and piloted between January 2010 and June 2011 in 10 of 75 Nepali districts under the guidance of the Ministry of Health and Population (MOHP). It is delivered through the Female Community Health Volunteers (FCHV) and Community Based Health Workers (CHW), laywomen who receive targeted training. It comprises 7 health system components aiming at improving both health provider and population behaviour:
- behaviour change communication for birth preparedness and newborn care
- institutional delivery or clean home delivery through skilled birth attendants
- postnatal care
- care for low birthweight newborns
- management of newborn infections
- prevention of hypothermia
- recognition of asphyxia, initial stimulation and resuscitation
First evaluations after the 18-month implementation phase have shown a promising development: despite high levels of poverty, poor infrastructure, difficult terrain and cultural conflicts Nepal was on track for meeting the Millennium Developmental Goals for maternal and child health. One could observe that women benefiting from the package had decreased illnesses and complications during pregnancy and birth associated with decreased stillbirths, as well as perinatal and neonatal deaths. In a before and after survey, researchers analysed data from one district to measure the coverage of interventions. The survey demonstrated that coverage for both maternal and neonatal services had significantly increased as well as counselling to pregnant women by the FCHV, practice to prepare for birth, and antenatal check-ups from a skilled provider. Delivery assisted by a skilled birth attendant had increased by two-fold. FCHV attendance at birth for newborn care significantly increased by three-fold. Prevention from hypothermia and ensuring proper nutrition has considerably improved, too. Additionally, weighing of newborns delivered at home within 24 hours had increased by four-fold. Postnatal check-ups for mothers and newborns by FCHV, CHW and health facility workers have risen by more than 90%.
A new quasi-experimental follow-up study from 2017 evaluating the impact of the CBNCP has now concluded that in order to maintain and eventually accelerate the positive effects of the intervention certain steps need to be taken. For example, supervision, frequent training and monitoring of the FCHVs as well as including private providers in the package are regarded as inevitable. Adjusting the components of the package to the real-life situation of mothers and infants in the different districts is another important point highlighted by the study especially since Nepal has a very heterogeneous society with pregnant women living in all sorts of social, economic and geographic conditions.
Covering now 39 districts, the CBNCP has, together with a general decline in the birth rate and improvements in female education, contributed to reducing newborn and maternal mortality in Nepal.3
1 Pradhan, Y.V. et al., 2012.
2 Paudel, D. et al., 2017.
3 www.nepal.savethechildren.net (21.03.2018).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640009/ (Study from 2017)
https://www.ncbi.nlm.nih.gov/pubmed/22692416 (Study from 2012)
http://jnhrc.com.np/index.php/jnhrc/article/view/276/274 (Study from 2011)
https://nepal.savethechildren.net/about-us/health-and-nutrition (Website Save the Children, Nepal)