1. Neonatal Health in Nepal
Saroj Rimal (BPH,MPH)
2023.05.27

2. Outline
02
03
Situation/Trend
01
Introduction
04
Supporting Organizations
2
Policy, plan,strategies & Programs
05 Conclusion and Recommendations
04
01
02
06 Bibliography

3. Definitions
● Neonatal period: 0-27 days after birth (first month after birth)
● Early neonatal period: 0-6 days after birth (first week after birth)
● Late neonatal period: 7-28 days after birth (2nd week to 4th week after birth)
3

4. 4
Source: https://www.healthdata.org/nepal [IHME]
Status of Neonatal Health in Nepal

5. Status of Neonatal Health in Nepal
5
Source: https://www.healthdata.org/nepal [IHME]

6. Trends in Early
Childhood
Mortality Rates
(NDHS, 2022)
6

7. Neonatal Mortality in Nepal
7
By Sex
Male: 24 per thousand
Female: 17 per thousand
By residence
Urban: 16 per thousand
Rural: 26 per thousand
Source: NDHS 2016
By ecological zone
Mountain: 35 per thousand
Hill: 23 per thousand
Terai: 28 per thousand

8. Neonatal Mortality by Age at Death
8
Source: NDHS 2016

9. Causes of Neonatal Mortality
9
Source: NDHS 2016

10. Major factors affecting neonatal mortality
10
Mother’s age at birth
<20 : 39 per thousand
20-29 : 21 per thousand
30-39: 31 per thousand
Birth order
1 : 30 per thousand
2-3 : 19 per thousand
4-6: 29 per thousand
Mother’s education
No education : 36 per thousand
Primary : 25 per thousand
Some secondary: 20 per thousand
SLC and above: 12 per thousand
Source: NDHS 2016

11. During COVID-19
● There was a reduction of 52.4% births during lockdown.
● Institutional neonatal mortality increased from 13 per 1000 live births to 40 per
1000 live births.
● The institutional stillbirth rate increased from 14 per 1000 total births before
lockdown to 21 per 1000 total births during lockdown.
● However, some behaviors improved like hand hygiene and keeping the baby
skin-to-skin with their mother.
11
Source: Ashish KC, Gurung R, Kinney MV, Sunny AK, Moinuddin M, Basnet O, Paudel P, Bhattarai P, Subedi K, Shrestha MP, Lawn JE.
Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective
observational study. The lancet Global health. 2020 Oct 1;8(10):e1273-81.

12. Critical Actions for Increasing Child Survival
1. Skilled care during pregnancy and birth
- Safe and clean delivery at birth
- Care of newborn at birth
2. Appropriate feeding during sickness and in health
- Exclusive breastfeeding for first 6 months of life
- Appropriate complementary feeding along with breastfeeding, starting at 6 years
of age upto 2 years and beyond
- Micronutrient supplementation- Vit A, Iron, Folic acid
12
Source: Bhandari G. An Introduction to Family Health, 2012
*Actions that directly improve neonatal health are in green fonts

13. Critical Actions for Increasing Child Survival..
3. Prevention of Illness
- Vaccination
- Insecticide treated materials
- WASH
4. PMTCT of HIV/AIDS
- Antiretroviral therapy
- Safer infant practices
5. Treatment of Illness
- ORT to prevent and treat dehydration resulting from diarrhea
- Zinc to reduce the duration and severity of diarrhoea
- Antibiotics for sepsis, pneumonia and dysentry
13
Source: Bhandari G. An Introduction to Family Health, 2012
*Actions that directly improve neonatal health are in green fonts

14. SDG targets
Child health targets include:
● Newborn: From 23 to 12 per thousand
● Under 5: From 38 to 20 per thousand
● Reduction of preventable deaths of newborn and children to less than 1%
14
Indicators 2016 (NDHS) 2022 (NDHS) 2025 2030
Neonatal Mortality 21 21 (16) 14 12
Under 5 Mortality 39 33 (27) 24 20
* Digits in parentheses indicate targets set
Source: National Planning Commission, SDG Status and Roadmap: 2016-2030

15. Landmarks for Neonatal Health in Nepal
15
1979
National Immunization
Program
Control of Diarrhoeal
Diseases (CDD program)
1983
ARI Control Program
1987
CB-ARI Program Piloting
1995/96
Source: DoHS Annual Report, 2077/78

16. Landmarks for Neonatal Health in Nepal..
Source: DoHS Annual Report, 2077/78
16
1997/98
CBAC Program
CB-ARI program combined
with CDD
IMCI Program
Initiated from Mahottari
1997
CBAC + IMCI = CB-IMCI
1999
Nutrition and
Immunization were also
incorporated in CBAC
program
1999
Source: DoHS Annual Report, 2077/78

17. Landmarks for Neonatal Health in Nepal..
17
2004
National Neonatal
Health Strategy
First South Asian Country
to do so
Low Osmolar ORS +
Zinc for diarrhoea
treatment
Morang Innovative
Neonatal Intervention
Pilot (MINI)
2005
Community Based
Newborn Care
Program (CB-NCP)
was designed
2007
CB-NCP Piloted in10
districts and CB-IMCI
covered nationwide
2009
Source: DoHS Annual Report, 2077/78

18. Landmarks for Neonatal Health in Nepal..
18
2011
Chlorhexidine (CHX)
use initiated for cord
care
CB-IMCI revised
incorporating new
interventions
and
CB-NCP scaled up
nationwide
2012
CB-IMNCI (Community
Based- Integrated
Management of
Neonatal and Childhood
Illness
2014
Source: DoHS Annual Report, 2077/78

19. Landmarks for Neonatal Health in Nepal..
19
2016
● Nepal Every
Newborn Action
Plan (NENAP)
● Establishment and
expansion of
SNCU and NICU
● Free Newborn
Care Program
● Facility based
IMNCI Program
Comprehensive
Newborn Care
Training (Level II)
Package
2017
Kangaroo Mother Care
Program
2021
Source: DoHS Annual Report, 2077/78

20. 20
Major Plans and Policies

21. Constitution of Nepal- 2072 BS
Article 35: Right relating to health
(1) Every citizen shall have the right to free basic
health services from the State, and no one shall be
deprived of emergency health services.
Article 39: Right of child
(1)Each child shall have the right to his/her identity
with the family name and birth registration.
21

22. National Health Policy - 2048 BS
# First National Health Policy of Nepal
By the year 2000 AD
❏ The mortality rate of children below 5 years will be
reduced to 70 per thousand from the present 197 per
thousand.
22

23. NHP 2048….
● Preventive Health Services
These services Family Planning and Maternal and Child Health, Expanded
Immunization will be provided in an integrated way.
● Curative Health Services
At least one hospital in each district with maternity and child health
services, immunization services.
● Basic Primary Health Services
❏ At least one Health Institutions (SHP/HP/PHC) will be in each VDC.
❏ Immunization, child health will also be extended by these Sub-Health
Posts, up to the ward level
23

24. GOAL : “To improve the health and survival of
newborn babies in Nepal”
Strategic Objectives
● To achieve a sustainable increase in the adoption
of healthy newborn care practices and reduce
prevailing harmful practices.
● To strengthen the quality of promotive, preventive
and curative neonatal health services at all levels.
24

25. Strategic Interventions
● Policy
● Behavior Change Communication
● Strengthening health service delivery
● Strengthening program management
● Research
25
Source: Division F. NATIONAL NEONATAL HEALTH STRATEGY [Internet]. Available from:
https://km.mohp.gov.np/sites/default/files/2018-07/National_Neonatal_Health_Strategy.pdf

26. 1.Policy
● Institute Family Health Division as the focal point for neonatal health activities
● Facilitate the institutionalization of neonatal care as a sub-specialty with
appropriate training courses (both in-service and pre service) for different
cadres of health workers at the tertiary and secondary level of care.
● Ensure the activation of the National Breastfeeding Promotion and Protection
Committee (to monitor health facility Baby friendly status and adherence to
Nepal’s Code for Marketing of Breast milk Substitutes).
● Support and coordinate for the strengthening of the system of universal
registration of all births and deaths.
26
Source: Division F. NATIONAL NEONATAL HEALTH STRATEGY [Internet]. Available from:
https://km.mohp.gov.np/sites/default/files/2018-07/National_Neonatal_Health_Strategy.pdf

27. 2. BCC(Behaviour change communication)
● BCC emphasize improved immediate and exclusive breast feeding
● Newborn care practices such as clean cord cutting, drying,
wrapping, delayed bathing, applying nothing on cord stump etc.
● Promote BCC activities through TBAs, FCHVs , mothers’ groups and
other community groups with the involvement of husbands and
families.
● Reinforcement of BCC messages targeting danger signs during
pregnancy, delivery and the postnatal period.
27
Source: Division F. NATIONAL NEONATAL HEALTH STRATEGY [Internet]. Available from:
https://km.mohp.gov.np/sites/default/files/2018-07/National_Neonatal_Health_Strategy.pdf

28. 3. Strengthening Health Service Delivery
● The improved coverage of skilled attendance at delivery.
● Linking up with the Integrated Management of Childhood Illnesses to
include the total neonatal period as well.
● The introduction, promotion and evaluation of “kangaroo mother
care” or other culturally appropriate practices for LBW babies at
various levels of care.
● Postnatal visits (within 24 to 48 hours, again within 6 days and a third
at 6 weeks) by skilled / trained attendants at home or at health
facilities.
28
Source: Division F. NATIONAL NEONATAL HEALTH STRATEGY [Internet]. Available from:
https://km.mohp.gov.np/sites/default/files/2018-07/National_Neonatal_Health_Strategy.pdf

29. 4. STRENGTHENING PROGRAM MANAGEMENT
❏ The review of neonatal content of existing curricula (pre- and in-
service) and protocols, in particular the ones developed for Safe
Motherhood, IMCI, for all levels of care providers.
❏ Continuing Medical Education for updating to be arranged at
regular intervals for medical and paramedical personnel.
❏ Promote newborn care health practices in governmental, non-
governmental and private through coordination and collaboration at
different level.
29
Source: Division F. NATIONAL NEONATAL HEALTH STRATEGY [Internet]. Available from:
https://km.mohp.gov.np/sites/default/files/2018-07/National_Neonatal_Health_Strategy.pdf

30. 5. RESEARCH
● Community based operations research to improve neonatal care
● The evaluation of the quality of maternal and neonatal care offered by
all levels of health workers along with reassessment and strengthening
of their role as skilled attenders in the light of the results
● The promotion of verbal autopsy of perinatal deaths in the community
and perinatal death audit or review in peripheral hospitals
30
Source: Division F. NATIONAL NEONATAL HEALTH STRATEGY [Internet]. Available from:
https://km.mohp.gov.np/sites/default/files/2018-07/National_Neonatal_Health_Strategy.pdf

31. National Policy on Children, 2069
31

32. 32

33. National Health Policy-2071
1.15 Periodical health related programs will be
made and implemented making the action plan on the
basis of the indices based on maternal death rate,
Neonatal & U5 death rate and Increase the Life
expectancy.
1.22 Unified child-disease management program to
promote the child health will be strengthened, made
current and acted upon.
33

34. Provision for Immunization service
● Free immunization services to targeted group
● Provision to make compulsory use of vaccines
● Duty of guardians to get children vaccinated
● Those who come for vaccination should be provided complete information
about the vaccine
● Responsibility of doctors and Health workers to get involved in vaccination
according to this act.
● There cannot be any obstacle for conducting vaccination programs.
34
Source: Nepal_2016.01.26_Act_Nepal-Vaccination-Act-2072_NEP.pdf

35. Chapter-2:
Every citizen shall have the right to obtain free basic health services under
the following headings, as prescribed:
(a) Vaccination service,
(b) Motherhood, infant and pediatric health service such as integrated
infant and pediatric disease management, nutrition service, pregnancy, labor
and child birth service, family planning, abortion and reproductive health.
35
Source: Public health service act 2018

36. National Health Policy 2076
1. Free basic health services shall be ensured from health
institutions of all levels as specified.
20. In accordance with the concept of health across the
lifecycle, health services around safe motherhood, child
health, adolescence and reproductive health, adult and
senior citizen shall be developed and expanded.
20.2. Health services targeted to vulnerable age groups such
as maternal-infant health, child health, adolescent health,
adult health and geriatric health shall be strengthened.
36

37. Public Health Service Regulations, 2020
37
Source: Public health service regulation 2020

38. 38
Source: Public health service regulation 2020

39. Second long term Health plan(1997-2017)
Objective:
● To improve the health status of the population of the most vulnerable groups, particularly
those whose health needs often are not met-women and children, the rural population, the
poor, the underprivileged, and the marginalized population.
Target:
● To reduce the infant mortality rate to 34.4 per thousand live births;
● To reduce the under-five mortality rate to 62.5 per thousand;
● To increase the percentage of deliveries attended by trained personnel to 95%;
● To increase the percentage of pregnant women attending a minimum of four antenatal
visits to 80%;
● To decrease the percentage of newborns weighing less than 2500 grams to 12%
39
Source: .Government of Nepal MINISTRY OF HEALTH AND POPULATION SECOND LONG TERM HEALTH PLAN
Perspective Plan for Health Sector Development Health Sector Reform Unit Kathmandu, Nepal Reprinted [Internet].
1997. Available from: ttps://nepalindata.com/media/resources/items/20/bSecond_Long_Term_Health_Plan-2.pdf

40. 40

41. ● Nepal was one of 10 fast track countries that were on-track to achieve MDG 4.
● Nepal notably had a lower IMR and U5MR than India and Bhutan among
five South Asian countries.
41

42. 42

43. What makes MDG 4 Successful???
❏ Semi-annual vitamin A supplementation and de-worming programme;
❏ Community-based Integrated Management of Childhood Illness (CB-IMCI),
❏ Community Based-Integrated Management of Neo-natal and Childhood Illness
(CB-IMNCI),
❏ SBA policy
❏ Community Based Newborn Care Package (CB-NCP),
❏ High rates of full child immunization
❏ Coverage of the exclusive breastfeeding of children under-six months.
❏ National Immunization Programme (NIP)
❏ Nepal has also seen the rapid expansion of private health care, which has
improved access to health care
43

44. Goal: Improved maternal and neonatal health and
survival, especially of the poor and excluded.
The key indicators for this NSMNH-LTP goal are:
1. A reduction in the maternal mortality ratio from 539 per
100,000 live births to 134 per 100,000 by 2017.
2. A reduction in the neonatal mortality ratio from 39 per
1,000 to 15 per 1,000 by 2017.
44
National SMNH Long term Plan (2006-2017)

45. Purpose:
Increased healthy practices, and utilisation of quality maternal and neonatal
health services, especially by the poor and excluded, delivered by a well-
managed health sector.
Key indicators for this include:
1. Increase in the percentage of deliveries assisted by an SBA to 60% by 2017
2. The percentage of deliveries taking place in a health facility increased to
40% by 2017
3. Increase in met need for emergency obstetric care of 3% per year
4. Increase in met need for caesarean section of 4% per year
45

46. 46

47. 47

48. 48

49. 49

50. Nepal Health Sector Strategy 2015-2020 AD
Articulates nation’s commitment towards
achieving Universal Health Coverage (UHC) and
provides the basis for gathering required resources
and investments
Strategic Principles
◆Equitable access to health services
◆Quality Health Services
◆Health System Reform
◆Multi Sectoral Approach
50

51. Vision
All Nepali citizens have productive and quality lives with highest level of
physical, mental, social and emotional health
Mission
Ensure citizens’ fundamental rights to stay healthy by utilizing available
resources optimally and through strategic cooperation between service
providers, service users and other stakeholders
Goal
Improved health status of all people through accountable and equitable health
service delivery system
51
Target
◆MMR- 125 (per 100,000 live births)
◆U5MR- 28 (per 1000 live births)
◆NMR - 17.5 (per 1000 live births)

52. 52

53. SDG Target
53

54. Supporting program for SDG
- NENAP( Nepal Every Newborn Action Plan) 2016-2035
- NHSS(2015-2020)
- HF-IMNCI (2016)
- Free Newborn Care program(2016)
- Comprehensive newborn care training package level -II (2017)
- Vit-K1 to Newborn babies (2018/19)
- SMNH Road map (2019-2030)
- Full fledged KMC Program(2021)
54

55. Contd…
- Public Health service Act 2075
- National Health policy 2019
- National HRH Strategy (2077/78-2086/87)
- National Guideline on ANC/PNC care 2076
- Strategy for Skilled Health Personnel and SBA (2020-2025)
- National Strategy on Nurses and Midwifery 2022
55

56. Vision: ‘There is no preventable deaths of New-
born or stillbirths, where every pregnancy is
wanted, every birth celebrated and women,
babies and children survive, thrive and reach
their full potential'.
Strategic directions:
● Equitable utilization of health services,
● Quality for all,
● Multi-sectoral approach and
● Reform, particularly for poor and vulnerable
populations.
56

57. Goal 1: Reduce preventable newborn deaths in every province to less than 11
newborn deaths per 1000 live births by 2035.
Goal 2: Reduce preventable stillbirths in every province to less than 13 stillbirths
per 1000 total births by 2035.
57

58. Strategic Objectives of NENAP
1. Rebuild and strengthen Health system ( infrastructure, HR & supply chain)
2. Improve the quality of care at the point of the delivery
3. Ensure the utilization of health care services
4. Strengthen decentralized budgeting and planning
5. Improve sector management and governance
6. Improve sustainability of health sector financing
7. Improve healthy lifestyle and Environment
8. Strengthen management of public health emergencies
9. Improve availability & use of evidence based decision making process at
all level
58

59. Strategic objectives of NENAP
59

60. NENAP Target
60

61. NSMNH Road Map 2019- 2030
Vision: All Nepali citizens have the physical, mental,
social and spiritual health to lead productive and high-
quality lives
Goal: Ensuring healthy lives and promoting wellbeing
for all mothers and newborns.
61

62. The Road Map adapts the conceptual framework proposed by the 2018 Lancet
Commission on Quality of Care.
62

63. Outcomes
Outcome 1: The availability of high-quality MNH services increased,
leaving no one behind
Outcome 2: The demand for and utilisation of equitable MNH services
increased.
Outcome 3: The governance of MNH services improved, and
accountability ensured.
Outcome 4: M&E of MNH improved.
Outcome 5: Emergency-preparedness and response for MNH strengthened
63

64. Neonatal Health in Five Year Plan
Plan Period Focus
Fourth 1970-1975 Life expectancy to 42.3 & IMR to 157/1000 live birth
Thirteenth 2013-2015 MDG
Fifteenth 2018-2023 Balanced development and expansion of health service at
federal, provincial and local level,
64
Source: Periodic Plans || National Planning Commission [Internet]. Npc.gov.np. 2015 [cited 2023 May 12]

65. Neonatal Health in Current 5 Year Plan
Strategy 3:
To address the health necessity of citizens of all age groups as per the Life
Course Approach and to make additional improvements and expansion of
overall development of mother and child, children and adolescents, and family
management services.
Working Policy 1:
The overall development of mother and child, children and adolescents, and
family management services will be reformed further and expanded as per the
concept of the life cycle.
65
Source: The Fifteenth Plan National Planning Commission Singhadurbar, Kathmandu [Internet]. Available from:
https://www.npc.gov.np/images/category/15th_plan_English_Version.pdf

66. Expected Result
Neonatal mortality rate will have decreased to 14 per 1000 live births
The percentage of pregnant women having their antenatal check-ups according
to the protocol will have reached 81 %
The percentage of children born in the presence of skilled healthcare workers
will have reached 79 %
The percentage of children with total vaccination will have reached 95 %
66
Source: The Fifteenth Plan National Planning Commission Singhadurbar, Kathmandu [Internet]. Available from:
https://www.npc.gov.np/images/category/15th_plan_English_Version.pdf

67. Neonatal Health Related Programs in Nepal
67

68. National Immunization program
● The National Immunization initiative (NIP) of Nepal, also known
as the Expanded Program on Immunization, was started in 2034
BC and is a priority 1 initiative.
● The Immunization Act, 2072 of Nepal has recognized
immunization as a right of all children.
68
Source: Annual Report Department of Health Services 2077/78 (2020/21)

69. Contd…
Vision
● Nepal: a country free of vaccine-preventable diseases.
Mission
● To provide every child and mother high-quality, safe and affordable vaccines
and immunization services from the National Immunization Program in an
equitable manner.
Goal
● Reduction of morbidity, mortality and disability associated with vaccine
preventable diseases.
69
Source: Annual Report Department of Health Services 2077/78 (2020/21)

70. Strategic Objectives
● Objective 1. Reach every child for full immunization
● Objective 2. Accelerate, achieve and sustain vaccine preventable diseases
control, elimination and eradication
● Objective 3. Strengthen immunization supply chain and vaccine
management system for quality immunization services
● Objective 4. Ensure financial sustainability for immunization program
● Objective 5. Promote innovation, research and social mobilization activities
to enhance best practices
70
Source: Annual Report Department of Health Services 2077/78 (2020/21)

71. 71
91%
Source: Annual Report Department of Health Services 2077/78 (2020/21)

72. Tetanus Toxoid for Pregnant Women
● Comprehensive Multi-year Plan for Immunization ( cMYPI
2017- 21 )
● The National immunization schedule was intended to
protect child at birth by providing 2 doses of TT (now TD)
containing vaccine to pregnant mothers and completing TT
towards 5 doses throughout her reproductive age.
Objective 4: Maintain maternal and neonatal tetanus
elimination status
Nepal achieved MNT elimination status in 2005.
72
Source: Comprehensive Multi-year Plan for Immunization ( cMYPI 2017- 21 )

73. ● 1983- Control of Diarrhoeal Disease (CDD)
program
● 1987 - Acute Respiratory Infection (ARI)
Control Program
● 1997/98 - ARI intervention combined with
CDD and named as CB-AC program
● 1999/2000- Nutrition and immunization were
also incorporated in the CBAC program
● IMCI program was piloted in Mahottari
district and was extended to the community
level as well 73
Source: Annual Report Department of Health Services 2077/78 (2020/21)
Community Based-Integrated Management of Childhood Illness and
Newborn Care Program

74. Contd…
● 1999 - Merge the CBAC into IMCI and named it as Community-Based Integrated
Management of Childhood Illness (CB-IMCI) as both of the program targeted
same population with involvement of similar Health Service Providers
● The CB-IMCI and CB-NCP programs are combined into the CB-IMNCI program in
Nepal.
● This integrated package of child-health intervention addresses the major problems
of sick newborn such as birth asphyxia, bacterial infection, jaundice,
hypothermia, and low birth weight.
● Aims: To address major childhood illnesses like Pneumonia, Diarrhoea, Malaria,
Measles and Malnutrition among under 5 year’s children
74
Source: Annual Report Department of Health Services 2077/78 (2020/21)

75. Goal:
● Improve Newborn child survival and ensure healthy growth and development.
Targets:
● Target for reduction of NMR, U-5MR & Stillbirths by NHSS, NENAP, SDGs
Objectives
● To reduce neonatal morbidity and mortality by promoting essential Newborn
care services & managing major causes of illness
● To reduce childhood morbidity and mortality by managing major causes of
illness among under 5 years of age children
75
Source: Annual Report Department of Health Services 2077/78 (2020/21)
Contd…

76. Strategies
● Quality of care through system strengthening and referral services for
specialized care
● Ensure universal access to health care services for Newborn and under 5
years of age children
● Capacity building of health service providers and FCHVs
● Increase service utilization through demand generation activities
● Promote decentralized and evidence-based planning and programming
76
Source: Annual Report Department of Health Services 2077/78 (2020/21)
Contd…
Contd…

77. Major interventions
Newborn Specific Interventions
● Promotion of birth preparedness plan
● Promotion of essential Newborn care practices and postnatal care to mothers
and Newborn
● Identification and management of non-breathing babies at birth
● Identification and management of preterm and low birth weight babies
● Management of sepsis among young infants (0-59days) including diarrhoea
77
Source: Annual Report Department of Health Services 2077/78 (2020/21)
Contd…

78. CB-IMNCI Vision
78
Source: Annual Report Department of Health Services 2077/78 (2020/21)

79. Community-Based NewBorn Care Program (CB-NCP)
● National Neonatal Health Strategy was formulated by the government of Nepal
in 2004 to improve neonatal survival and health.
● CB-NCP was designed in 2007, piloted in 2009 in 10 district, and incorporated
seven strategic interventions to target new-borns at the community level.
➢Behaviour change communication
➢Care of low-birth-weight New-born,
➢Promotion of institutional delivery
➢Prevention and management of hypothermia
➢Postnatal care,
➢Recognition and resuscitation of birth asphyxia
➢Management of neonatal sepsis
79
Source: Annual Report Department of Health Services 2077/78 (2020/21)

80. Facility-Based Integrated Management of Childhood and Neonatal Illnesses
● Started in 2016 to bridge the gap in the management of neonatal and
childhood cases referred from peripheral level health institutions to higher
institutions.
● Aim: To capacitate team of health service providers at district hospital
with required knowledge and skills to manage complicated under-five and
neonatal cases to ensure timely and effective management of referral cases
● Linked with the CB-IMNCI
● Addresses the major causes of common childhood illnesses towards
diagnosis and treatment especially new-born care, cough, diarrhoea, fever,
malnutrition and anemia.
80
Source: Annual Report Department of Health Services 2077/78 (2020/21)

81. Comprehensive NewBorn Care program
● Purpose: Reducing Neonatal mortality and timely management of sick
Newborn
● To provide training to paediatricians, senior medical officers and medical
officers working in the hospitals providing level II newborn care services
81
Source: Annual Report Department of Health Services 2077/78 (2020/21)

82. Contd…
This package covers
● Counselling
● Infection prevention
& control practices
● Care of newborn
● Feeding
● Neonatal resuscitation
82
● Thermal protection
● Fluid management
● Identification, and management of
small &/or sick neonates
● Management for low birth weight and
● Neonatal sepsis
Source: Annual Report Department of Health Services 2077/78 (2020/21)

83. Kangaroo Mother Care Program
● Cost-effective intervention to care for stable preterm/LBW babies
● Skin to skin contact has been part of different programs/ training packages
such as CB-IMNCI, FB-IMNCI, SBA Training, Comprehensive level-II
new-born care etc. a full-fledged KMC program from 2021
Goal:
● To end preventable newborn deaths due to prematurity & low birth weight
through skin-to-skin contact, breastfeeding and early discharge from health
center.
83
Source: Annual Report Department of Health Services 2077/78 (2020/21)

84. Infant and young child feeding (IYCF)
● Include early initiation of breastfeeding within an hour of
childbirth, exclusive breastfeeding for six months and providing
nutritionally adequate and appropriate complementary feeding
starting from six months with continued breastfeeding up to two
years of age or beyond
● IYCF programme has been ongoing in all 77 districts from the FY
2072/73.
● Nationally, the 5 year data trend shows an increase in exclusive
breastfeeding among children aged 0-6 months from 25.1% in FY
2073/74 to 36.9% in this FY 2077/78
84
Source: Annual Report Department of Health Services 2077/78 (2020/21)

85. Integrated management of acute malnutrition (IMAM)
● Integrated Management of Acute Malnutrition (IMAM) Program (previously
known as Community based Management of Acute Malnutrition [CMAM]
program) provides treatment for children aged 0-59 months with Severe
Acute Malnutrition (SAM) through inpatient and outpatient treatment
services at health facility and community levels.
● Aim: To integrate across health, early childhood development, WASH, and
social protection sectors for the continued rehabilitation of SAM cases and to
widen the reach of malnutrition prevention programs and services.
● Program was piloted in 2009/10 in five districts; Achham, Kanchanpur,
Mugu, Bardiya and Jajarkot
85
Source: Annual Report Department of Health Services 2077/78 (2020/21)

86. Contd…
● Pilot evaluation in 2011/12,and after evaluation program sifted from CMAM
to IMAM program and gradually scaled up throughout the country covering
many more district
● 22 nutritional rehabilitation homes (NRHs) in different federal and provincial
level hospitals for inpatient treatment of severe acute malnutrition
86
Source: Annual Report Department of Health Services 2077/78 (2020/21)

87. Nutrition in emergencies (NiE)
● Family Welfare Division provides essential and high-quality nutrition
services during emergencies.
● Nutrition in emergencies interventions focuses on pregnant and lactating
women (PLWs) and children under-five years of age as they are nutritionally
the most vulnerable during any type of emergency
87
Source: Annual Report Department of Health Services 2077/78 (2020/21)

88. Pillars of NiE:
● Promotion, protection and support to breast feeding of infants and young
children aged 0-23 months.
● Promotion of proper complementary feeding for infants and young children
aged 6-23 months.
● Management of moderate acute malnutrition (MAM) among the children
aged 6-59 months and among PLWs through targeted supplementary feeding
program (TSFP).
● Management of severe acute malnutrition among the children aged 6-59
months through therapeutic feeding
● Intensification of Micro-nutrient supplementation for children and women
including MNP and Vitamin A for children aged 6-59 months, IFA for
pregnant and postnatal women.
88
Source: Annual Report Department of Health Services 2077/78 (2020/21)
Contd…

89. Vitamin K1 to newborn babies
● FY 2077/78, after the decision of Ministry of Health and Population
to introduce Vit K1 injection to newborn babies for preventing from
Vitamin K Deficiency Bleeding (VKDB) Family Welfare Division
allocated budget to purchase injection Vitamin K1 for distributing in
all BC/BEONC and CEONC sites
● Injection Vitamin K1 need to be given to newborn IM after breast
feeding within 1 hour of delivery.
89
Source: Annual Report Department of Health Services 2077/78 (2020/21)

90. Free Newborn Programme
Aim: To prevent any sort of deprivation to health care services of the newborn due
to poverty
Goal: to achieve the sustainable development goal to reduce newborn mortality
through increased access of the newborn care services
Based on the treatment services offered to the sick-newborn, the services are
classified into 3 packages: A, B and C.
● Package A: newborn corners in health posts and PHCCs
● Package B: district hospitals with Special Newborn Care Unit (SNCU)
● Package C: provincial and other tertiary hospitals offer Neonatal Intensive Care
Unit (NICU) services
90
Source: Annual Report Department of Health Services 2077/78 (2020/21)

91. Nyano Jhola Programme
● The Nyano Jhola Programme was launched in 2069/70 to protect newborns
from hypothermia and infections and to increase the use of peripheral
health facilities (birthing centres).
● Two sets of clothes (bhoto, daura, napkin and cap) for newborns and
mothers, and one set of wrapper, mat for baby and gown for mother are
provided for women who give birth at birthing centres and district
hospitals.
● The programme was implemented in all 75 districts in 2072/73.
91
Source: Annual Report Department of Health Services 2077/78 (2020/21)

92. Nepal Chlorhexidine (Navi Cord Care) Program
● About 70 percent of under-five deaths in Nepal occur within the first
month of life, and approximately 50 percent are attributed to infection.
● Chlorhexidine is proven to be a safe, efficacious antiseptic to prevent infection and
sepsis among newborns if applied to the umbilical stump immediately after cutting
the cord.
● In Nepal, use of this simple antiseptic has decreased newborn deaths by 24 percent
and newborn infections by 68 percent.
● The Chlorhexidine “Navi” Care Program is a six-year (2011-2017)
92
Source: Nepal fact sheet chlorhexidine “Navi” (cord) care program.

93. Objectives
● Scaling up chlorhexidine in all 75 districts as an essential component of
Maternal Newborn and Child Health
● Establishing a strong monitoring and supervision system for chlorhexidine
● Including chlorhexidine in all policies and strategies related to newborn care
● Increasing demand for chlorhexidine at the community and facility levels
● Sharing Nepal’s experience and learning on chlorhexidine at national and
international fora
● Providing technical support to enhance the capacity of local pharmaceutical
companies to manufacture quality chlorhexidine gel
93
Source: Nepal fact sheet chlorhexidine “Navi” (cord) care program.

94. Program Activities
● Advocacy, training, and orientation on the use of chlorhexidine gel
● Support to the MoHP’s Child Health Division to roll out the revised
Community-Based Integrated Management of Newborn and
Childhood Illness protocol in new districts
● Support MoHP to sustain the chlorhexidine program as a part of its
newborn and maternal and child health programs
● Monitoring and supervision of chlorhexidine programming
94
Source: Nepal fact sheet chlorhexidine “Navi” (cord) care program.

95. ● Coordination and networking among chlorhexidine partners
● Advocacy to include chlorhexidine in pre-service training of nurses
and other medical professional curricula
● Work with Family Health Division and National Health Training
Center to include chlorhexidine in the in-service curriculum of skilled
birth attendants
95
Source: Nepal fact sheet chlorhexidine “Navi” (cord) care program.
Contd…

96. ● A comparative observational study carried out in the Neonatal unit, Paediatrics
Department of Kathmandu Medical College Teaching Hospital shows no
significant difference between the cord separation times in dry and chlorhexidine
cord care regimens. Both dry cord care and chlorhexidine cord care regimens
were found to be safe and effective.(1)
● The WHO recommends clean, dry cord care for all newborns and daily CHX
application to the umbilical stump for the first week of life for home births in high
neonatal mortality settings (> 30 deaths/1000 live births) Use of chlorhexidine in
these situations may be considered only to replace application of a harmful traditional
substance, such as cow dung, to the cord stump.(2)
96
Source: 1. Basnet R, Manandhar SR, Bhatta A, Shah RK, Basnet R. Effect of dry cord care versus chlorhexidine cord care on cord separation time in
healthy newborns: A comparative study. Journal of Kathmandu Medical College. 2020 Jun 30;9(2):70-3.
2.World Health Organization: Recommendations on Postnatal care of the mother and newborn. 2014 WHO library cataloguing- Oct 2013
Significance of Use of Chlorhexidine Gel for cord care

97. Maternal and Perinatal Death Surveillance and Response (MPDSR)
● Continuous process of identification, notification, quantification and
determination of causes and factors to avoid all maternal and perinatal
deaths, as well as the use of this information to respond with actions that will
prevent future deaths
● Aim: To measure and track all maternal deaths in real time with the objective to
understand the underlying factors contributing to mortality and to provide
guidance on how to respond and prevent future deaths.
● FWD conducted policy dialogues and orientation on MPDSR to sensitize and
orient policy maker from Health Directorates, Health Offices and Provinces and
service providers from hospitals as well as districts.
97
Source: Annual Report Department of Health Services 2077/78 (2020/21)

98. Contd…
Community-based MPDSR: At present, community based MPDSR program is
being implemented in 15 districts. In the community-based MPDSR program,
only maternal deaths are reviewed and responses are planned.
Hospital-based MPDSR: 95 hospitals are implementing MPDSR program. In
the hospitals, the maternal death review (MDR) form is filled for every
maternal death, which is then reviewed. Whereas, in case of perinatal death, the
perinatal death review (PDR) form is filled for every perinatal death, but
only the summary perinatal death review form is reviewed once a month and
responses are planned.
98
Source: Annual Report Department of Health Services 2077/78 (2020/21)

99. Partner Organizations for
Neonatal Health
99

100. 1. The United Nations
Children’s Fund
(UNICEF)
Source: UNICEF Nepal
100

101. Maternal and perinatal death surveillance and
response (MPDSR) approach for maternal and
neonatal mortality.
Establishing intensive care units for newborns and
relevant referral systems for mothers and
newborn babies.
Promotion of postnatal and essential newborn
care and early screening, detection, referral and
the rehabilitation of children with disabilities
Practices that harms the care of mothers and
newborns will be addressed by promoting positive
care seeking behaviour.
Source: UNICEF Nepal- Country Program Action Plan 2018-22 101

102. 2. World Health
Organization (WHO)
Source: WHO Nepal
102

103. Source: WHO Nepal-CCS 2018-22
103

104. Source: WHO Nepal-CCS 2018-22
104

105. 3. Save the Children • Save the Children, with its life cycle approach design, ensures
that every child survives and grows in an environment that
prevents them from dying from preventable causes.
• Save the Children works to complement and in partnership
with the Government focusing on improving their capacities
and strengthen systems for service delivery and with local
NGOs and communities by focusing on health care practices
and nutrition for newborns, children and mothers.
• Save the Children supports the Ministry of Health and
Population and its department, divisions and provincial
offices to design, revise, pilot, scale-up, monitor and review
of newborn, child, adolescent and maternal health-focused
activities at local, provincial and national levels
Source: Save the Children Nepal
105

106. 4. USAID Nepal
Source: USAID Nepal
106

107. • USAID is providing coaching and mentoring to health
care providers and other staff on clinical care, data
management, and supply chain management. This
enables health facilities to offer a full range of high
quality, client-centered maternal newborn, child health,
and family planning services.
• USAID is expanding the reach and quality of critical
public health services especially maternal, newborn,
child health and family planning. To achieve this, the
activity provides private health care providers access to
standard treatment protocols and guidelines.
Source: USAID Nepal- SSBH https://www.usaid.gov/nepal/fact-sheets/ho-ssbh 107

108. 108

109. Conclusion
● Maternal infections, prematurity, and multiple births are important
risk factors for birth asphyxia mortality in the low-resource,
community-based setting.
● Hospital based data suggest that the major direct causes of neonatal
death in Nepal are:
➢ Infection
➢ Birth asphyxia/trauma
➢ Prematurity
➢ Hypothermia
109
Source:1. Lee AC, Mullany LC, Tielsch JM, Katz J, Khatry SK, LeClerq SC, Adhikari RK, Shrestha SR, Darmstadt GL. Risk factors for
neonatal mortality due to birth asphyxia in southern Nepal: a prospective, community-based cohort study. Pediatrics. 2008
May;121(5):e1381-90.
2. Paudel D, Shrestha IB, Siebeck M, Rehfuess EA. Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of

110. Conclusion
Underlying these direct causes is a constellation of underlying causes,
including:
➢ Poor pre-pregnancy health
➢ Inadequate care during pregnancy
➢ Inadequate care during delivery
➢ Low birth weight
➢ Inadequate newborn and postpartum
Source: Chalise SP, Mishra SK, Kasakar P, Anjum MF. Causes of Mortality in Low Birth Weight Babies at a Tertiary Care Hospital. Journal of
Nepal Paediatric Society. 2021;41(3):150-6.
110

111. Conclusion
● Low socioeconomic status is highly associated with neonatal mortality.
● Neonatal mortality varies greatly by socio-demographic variables.
● Much remains to be achieved in terms of reducing neonatal mortality across
different socio-economic, ethnic and geographical population groups in
Nepal.
● Low coverage & quality of care of program.
● Boys had higher mortality in the first week followed by no sex difference in
weeks 2 and 3 and a reversal in risk in week 4, with girls dying at more than
twice the rate of boys.
111
Source: 1. Lee AC, Mullany LC, Tielsch JM, Katz J, Khatry SK, LeClerq SC, Adhikari RK, Shrestha SR, Darmstadt GL. Risk factors for neonatal mortality due to birth
asphyxia in southern Nepal: a prospective, community-based cohort study. Pediatrics. 2008 May;121(5):e1381-90
2. Erchick DJ, Lackner JB, Mullany LC, Bhandari NN, Shedain PR, Khanal S, Dhakwa JR, Katz J. Causes and age of neonatal death and associations with maternal and
newborn care characteristics in Nepal: a verbal autopsy study. Archives of Public Health. 2022 Dec;80(1):1-0.
3.Subedi S, Katz J, Erchick DJ, Verhulst A, Khatry SK, Mullany LC, Tielsch JM, LeClerq SC, Christian P, West KP, Guillot M. Does
higher early neonatal mortality in boys reverse over the neonatal period? A pooled analysis from three trials of Nepal. BMJ open. 2022

112. Conclusion
● The main reason for the stagnation in reducing neonatal deaths in
Nepal is the continuing challenge in delivering quality neonatal health
services, characterised by inadequate and unskilled human resources,
poor infrastructure and equipment, and inaccessible health facilities,
especially in hills and mountain districts.
● Though delivery services are free, neonatal care cost high, due to
which most parents are found reluctant to provide treatment for ill
newborns.
112
Source:Neupane S, Doku DT. Neonatal mortality in Nepal: a multilevel analysis of a nationally representative. Journal of
epidemiology and global health. 2014 Sep

113. Recommendations
● Programs:
○ Scale up programs of proven effectiveness, conduct in-depth evaluation of
promising new approaches, target unreached and hard-to-reach populations,
○ Maximize use of financial and personnel resources through integration
across programs.
○ Strengthen quality improvement Onsite coaching program.
○ Need for interventions at the individual level with regard to access and
utilization of healthcare in order to reduce the neonatal mortality in Nepal.
○ Focus on tertiary care.
○ Strengthen measurement, programme-tracking and accountability to count
every newborn and stillbirth.
113
Source:1. Lee AC, Mullany LC, Tielsch JM, Katz J, Khatry SK, LeClerq SC, Adhikari RK, Shrestha SR, Darmstadt GL. Risk factors for neonatal mortality due to birth asphyxia in
southern Nepal: a prospective, community-based cohort study. Pediatrics. 2008 May;121(5):e1381-90.
2. https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality

114. Recommendations
● Midwifery:
○ Provide high quality of antenatal care, skilled care at birth, postnatal care
for mother and baby, and care of preterm baby and sick newborns.
○ A large proportion of neonatal deaths occur during the first 48 hours
after delivery. So, prompt postnatal care for the child is important to
treat any complications arising from the delivery.
○ Improve the quality of maternal and newborn care from pregnancy to the
entire postnatal period, including strengthening midwifery.
Source: 1. Paudel D, Shrestha IB, Siebeck M, Rehfuess EA. Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality. BMC Public Health.
2013 Dec;13(1):1-3.
2. https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality
114

115. Recommendations
● Focus on determinants:
○ Promote engagement of and empower mothers, families and
communities to participate in and demand quality newborn care.
○ Reduce inequities in accordance with the principles of universal
health coverage, including addressing the needs of newborns in
humanitarian and fragile settings.
115
Source:1. Paudel D, Shrestha IB, Siebeck M, Rehfuess EA. Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce
neonatal mortality. BMC Public Health. 2013 Dec
2. https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality

116. Bibliography
1. The Fifteenth Plan National Planning Commission Singhadurbar, Kathmandu [Internet].
Available from:
https://www.npc.gov.np/images/category/15th_plan_English_Version.pdf
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3. Annual Report Department of Health Services 2077/78 (2020/21) Government of Nepal
Ministry of Health and Population Department of Health Services Kathmandu
4. Nepal fact sheet chlorhexidine “Navi” (cord) care program
5. Lee AC, Mullany LC, Tielsch JM, Katz J, Khatry SK, LeClerq SC, Adhikari RK, Shrestha
SR, Darmstadt GL. Risk factors for neonatal mortality due to birth asphyxia in southern
Nepal: a prospective, community-based cohort study. Pediatrics. 2008
May;121(5):e1381-90.
6. Paudel D, Shrestha IB, Siebeck M, Rehfuess EA. Neonatal health in Nepal: analysis of
absolute and relative inequalities and impact of current efforts to reduce neonatal
mortality. BMC Public Health. 2013
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Bhattarai P, Subedi K, Shrestha MP, Lawn JE. Effect of the COVID-19 pandemic response
on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective
observational study. The lancet Global health. 2020 Oct 1;8(10):e1273-81.
8. Neupane S, Doku DT. Neonatal mortality in Nepal: a multilevel analysis of a nationally
representative. Journal of epidemiology and global health. 2014 Sep
9. Bhandari G. An Introduction to Family Health, 2012
10. UNICEF Nepal- Country Program Action Plan 2018-22
11. WHO Nepal-Country Cooperation Strategy 2018-22
12. Save the Children, Nepal
13. Constitution of nepal 2072
117

118. 14. National Health policy 2048
15. National Health Policy 2071
16. National Health Policy 2076
17. Public health service act 2075
18. Public health service regulation 2077
19. NENAP 2016-2035
20. National policy on Children 2069
21. Basnet R, Manandhar SR, Bhatta A, Shah RK, Basnet R. Effect of dry cord care versus
chlorhexidine cord care on cord separation time in healthy newborns: A comparative study.
Journal of Kathmandu Medical College. 2020 Jun 30;9(2):70-3.
22. World Health Organization: Recommendations on Postnatal care of the mother and newborn.
2014 WHO library cataloguing- Oct 2013
23. Comprehensive Multi-year Plan for Immunization ( cMYPI 2017- 21 )
24. Subedi S, Katz J, Erchick DJ, Verhulst A, Khatry SK, Mullany LC, Tielsch JM, LeClerq SC,
Christian P, West KP, Guillot M. Does higher early neonatal mortality in boys reverse over the
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119. 119