Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality

Insufficient progress in reducing neonatal mortality

While infant and under-five mortality rates in developing countries have declined significantly in the past decades, newborn mortality rates have decreased much more slowly [1]. An estimated 18% to 37% of neonatal deaths, defined as deaths occurring during the first 28 days of life, could be averted through expanded coverage of cost-effective interventions, if delivered through family or community approaches [2].

Nepal is one of the few developing countries considered “on track” to achieve Millennium Development Goal (MDG) 4 to reduce child mortality by two-thirds between 1990 and 2015, [3] with reductions in under-five mortality from 118 to 54 per 1,000 live births (54% reduction) and infant mortality from 79 to 46 per 1,000 live births (41% reduction) between 1996 and 2011 [4–7]. Over the same time period, the neonatal mortality rate decreased by only 34%, from 50 to 33 per 1,000 live births. Socio-economic disparities in neonatal mortality in Nepal have been well documented, for example, neonatal mortality is evidently higher among poor groups and socially disadvantaged castes [8–10]. These are likely to be among the reasons for insufficient progress made to date, as interventions rarely reach all population groups in equitable ways.

Direct and underlying causes of neonatal deaths

Globally, the main direct causes of neonatal death are preterm birth (28%), severe infections (26%), asphyxia (23%), and neonatal tetanus (7%) [11]. Information about the causes of neonatal deaths is limited in Nepal. Verbal autopsy findings of newborn deaths in the 2006 Nepal Demographic and Health Survey showed that major causes of death are infections (39%), birth asphyxia/birth injury (33%), congenital anomalies (8%) and pre-maturity or low birth weight (6%) [5]. Other Nepalese community- and hospital-based data also suggest infections, birth asphyxia, preterm birth and hypothermia as the most important causes, [12–14] largely in agreement with the general picture of the developing world.

In addition to lack of basic prenatal, natal and postnatal healthcare, a range of socio-economic and cultural factors, such as inability to pay for transportation and services, poor knowledge and attitudes in relation to healthcare, and various forms of gender bias negatively affect newborn survival in developing countries [15]. For example, in most of the cultures in rural Nepal, mothers are considered ritually “polluted” until nwaran (the name-giving ceremony on the ninth or eleventh day) and are restricted to stay at home, preventing access to care during this critical period. Also, newborn bathing immediately after birth and applying oil and turmeric powder to the cord stump are commonly practiced traditions and are known to increase the risk of neonatal infections [16].

Community-level efforts to improve prevention and care

Critical interventions to reduce neonatal mortality include behavior change communication; community mobilization and engagement for improved antenatal, intrapartum, and postnatal care practices; and community-based case management of illness [2]. A major challenge in relation to these is promoting demand for healthcare and meeting this demand through interventions delivered at family and community levels. Indeed, studies from South Asia demonstrate that simple community- and home-based prevention and treatment interventions during pregnancy, birth and the post-natal period can effectively save the lives of newborns [17–19].

Drawing on international, regional and national evidence, the Government of Nepal initiated a series of policies and programs to address neonatal mortality in Nepal with efforts delivered through the governmental health system and its hospitals and peripheral health facilities (i.e. primary health care centres, health posts and sub-health posts) as well as through the strong workforce of 48,000 female community health volunteers. To date, no comprehensive review and analysis of these policies and programs has been undertaken with respect to their implementation and impact on newborn health.

The objectives of this study are to assess relative and absolute socio-economic inequalities in neonatal mortality over time, and to review current experience with programs to promote neonatal health in relation to progress towards achieving MDG 4.

Time trends and socio-economic inequalities in neonatal mortality

The most recent estimates for neonatal, infant and under-five mortality in Nepal are 33, 46 and 54 per 1,000 live births respectively, for the period 2006-2011 [6]. The overall rate of reduction in childhood mortality between 1990 and 2011 is impressive; however, there are stark differences in the annual rate of reduction for under-five, infant and neonatal mortality (5.2, 3.6 and 2.8 percent per annum respectively for the five-year period preceding the survey). As shown in Figure 1, the country had already achieved the MDG 4 target for under-five mortality by 2011, but reductions in infant and neonatal mortality are a must if childhood survival is to improve further.

Major policies and programs to improve neonatal health

Since 1990, Nepal has developed, piloted and gradually scaled-up a broad range of facility- and community-based programs to address maternal, neonatal and child health; many of these have since been integrated with regular public health programs. Figure 2 provides a graphical overview of these programs, distinguishing between national programs (presented in bold) and sub-national programs or pilots (presented in italics) and showing support from external donors. They cover the continuum of maternal and child health and comprise integrated approaches to addressing multiple health concerns among target populations (e.g. community-based Integrated Management of Childhood Illness), highly vertical programs to address specific health conditions (e.g. National Vitamin A program) and interventions to strengthen the health system (e.g. female community health volunteers program). While neonatal health is not an explicit focus in all of these programs, they illustrate the considerable background activity prior to the introduction of focused newborn interventions, with specific components of all programs directly impacting newborn health.

Newborn survival was made a development priority for the country through a major strategic document endorsed by the Ministry of Health and Population, the Nepal Neonatal Health Strategy 2004 [28]. In an effort to develop recommendations towards the implementation of this strategy, a rapid assessment of neonatal health programs in Nepal was conducted in 2007 to analyze the status of ongoing programs and the roles of different partners, and to identify gaps and constraints in the implementation of evidence-based interventions [29]. All recent policy documents, such as the periodic health plans (9^th plan, 10^th plan and interim plan) and the Nepal Health Sector Plans I (2004–2009) and II (2010–2015) recognized neonatal health as a priority and listed it as a component of essential health care services [30–36]. Some of these policy documents also emphasize improved access for poor and vulnerable groups [33]. Taken together, these policies and strategies provide both a conducive environment and a framework for developing, piloting and implementing newborn programs in the country [37].

The community-based Integrated Management of Childhood Illness (CB IMCI) represents an established approach and is globally considered one of the best models for integrated delivery of care at family and community level for the most common illnesses (i.e. pneumonia, diarrhoea, malaria, malnutrition) during the first five years of life. The birth preparedness package (BPP) targets pregnant women, helping them and their families to be prepared for a safe delivery and for the arrival of the baby, and to recognize danger signs and seek care from a health provider when needed. It emphasizes the need to be ready for emergencies, such as blood transfusion or caesarean section, and to reduce delays in seeking care for maternal or neonatal illness (in particular newborn asphyxia, postpartum haemorrhage and severe bacterial infections). The main objective of the Safe Delivery Incentives Program (SDIP) is to increase deliveries at health institutions (i.e. hospital, primary health care center or health post and sub-health post with birthing center) and thus to provide better care for mothers and newborns during and immediately after birth. Institutional deliveries or safe home deliveries are expected to contribute to reducing all causes of neonatal mortality, in particular they can prevent newborns from dying due to birth asphyxia and severe bacterial infections. More recent programs include the community-based newborn care package (CB NCP) and the umbilical cord care for newborns (CHX cord care) program; both are in early phases of implementation and roll-out. Based on the experience of implementing these programs and results to date, these programs are being revised to integrate approaches by harmonizing efforts and messages. These changes are expected to create synergies in the delivery of better neonatal health outcomes.

As shown in Table 3 evidence of effectiveness of these programs in Nepal with respect to neonatal health outcomes, as obtained from the scientific publications and documents reviewed, is scarce. Notably, we were unable to quantify coverage of the five programs beyond a general statement about the geographical spread of implementation (i.e. national or various districts); likewise, we were unable to document equity or inequity in program implementation. To date, studies of program impact on neonatal mortality are rare. We were only able to identify two such studies, where a cluster-randomized controlled trial of a pilot showed large and statistically significant declines in cord infections as a result of applying chlorhexidine [44] and an interrupted time series study in one district failed to demonstrate any impact on neonatal mortality for the implementation of the SDIP program [45]. Current gains in reducing under-five mortality in Nepal can be plausibly linked to CB IMCI [46] but, as of yet, no evidence is available for a measurable impact on neonatal mortality. Instead or in addition to looking at neonatal mortality, several programs measured impact in term of changes in intermediate outcomes, such as birth preparedness (BPP, [43]), institutional or safe home delivery (SDIP, [45]) and case reporting and case severity (CB IMCI, [41, 42]).

Critical considerations across programs

Based on the data available, Nepal has made very good progress in terms of reducing child and infant mortality [3]. In order to be able to achieve further gains in child survival, the main challenge for the country will be to reduce neonatal mortality. Neonatal mortality varies greatly by wealth status and, to a lesser extent, by maternal education, caste and ethnicity and geographical location. Absolute and relative inequalities in neonatal mortality are relatively stable and interventions to date do not appear to have acted to greatly decrease or increase inequalities. As the annual rate of reduction in neonatal mortality has stagnated in recent years and as inequalities in neonatal mortality persist, labelling a country as “on track” to achieve the MDGs may divert focus and slow the momentum of ongoing efforts. Despite persistent high levels of neonatal mortality, in the last decade Nepal has witnessed a higher rate of decline in neonatal mortality (3.6 percent per annum) compared to the global average (2.1 percent per annum) and compared to progress made in neighbouring countries [47, 48]. This achievement can be plausibly linked to the country’s progress with respect to family planning, antenatal and delivery care practices as well as significant improvements in infrastructure over the same period.

The Government of Nepal, together with major international donors, has implemented a broad range of programs to address maternal, neonatal and child health problems over the past twenty years. It is difficult to attribute the progress made to date to individual programs, in part because of the broad range of ongoing activities and in part because of insufficient impact data for individual programs. In particular, information on coverage and uptake of the five programs most directly concerned with reducing neonatal mortality and evidence of impact on neonatal mortality rather than intermediate outcomes is limited. Moreover, the available information is rarely disaggregated for different socio-economic groups, although descriptive data suggest that programs do not equitably reach those in greatest need [6]. Given the substantial financial and personnel resources dedicated to these programs, it will be important to carefully evaluate their future performance in terms of coverage and effectiveness.

Other programs covered by Figure 2 but not further considered in Table 3 are also likely to contribute to improved newborn health. Specific interventions, such as tetanus toxoid injections and the safe motherhood program improve coverage and quality of care of obstetric and newborn care services. Other programs are mobilizing communities and their change agents to educate mothers and their families, promoting healthy behaviors for better maternal and newborn health in different parts of the country. With respect to strengthened primary health care, female community health volunteers (FCHV) are a unique and strong cadre for all community-based programs in Nepal and play a crucial role in delivering newborn interventions under the CB NCP and CHX for cord care [49]. Beyond these front-line health workers, Nepal’s public health system is suffering from a shortage of health personnel and services, especially in rural areas. For example, many birthing facilities do not offer a 24-hour service seven days a week and, as a result, expectant mothers are often reluctant to deliver at a health facility. Therefore, greater capacity of providers at all levels and broader health system strengthening will also be necessary to improve maternal and newborn health care services further [50].

A further hidden reason behind the limited impact of neonatal health programs to date is the fact that some practices, such as immediate care for newborns and recently delivered women, are greatly affected by existing cultural norms and behaviors. In Nepal and many south-Asian cultures, birth and the postnatal period are considered ritually polluted, and the new mothers often face seclusion which undermines their ability to seek health care when needed for themselves or their babies [51, 52]. Their care-seeking behavior is further limited by decision-making authorities in the household, where the ultimate decision to seek care and pay for travel, care or medication usually resides either with the male head of household or older women such as mothers-in-law [53]. As a result, new mothers might not be able to follow recommended newborn care practices due to existing family and social pressures and their inability to negotiate on these matters. Furthermore, issues related to health worker behavior, gender-friendliness in service delivery and perceived quality of care affect service utilization and compliance. In south-Asian cultures, many women do not visit health facilities as most of the providers are male, or because they have not been treated respectfully during previous visits. The design of programs and their delivery will therefore need to pay attention to implementing interventions in socio-culturally appropriate ways, in particular among socio-economically disadvantaged and hard-to-reach population groups.

The strong support from high-level policy makers, as evident in the recognition of neonatal health in the long-term health sector plan and the neonatal health strategy, has been and will be a critical ingredient of making progress. Likewise, effective partnerships between the government and a range of donors have enabled the country to develop and implement neonatal health programs and to scale these up over a relatively short period of time [37, 38]. There are, however, some missed opportunities to integrate and harmonize across efforts. Some programs are implemented in a vertical fashion with distinct implementation modalities and information systems, and limited attempts are being made to harmonize messages for behavior change across programs. For example, CHX for cord care is delivered as a stand-alone program even though it clearly fits into the CB NCP and CB IMCI program framework. Similarly, the SDIP could be extended from just focusing on the number of institutional deliveries to expanding quality care for mothers and newborns. This is likely to be particularly relevant for newborn survival as the institutional delivery rate is rapidly increasing and as this early contact between health workers and mothers is an opportunity for timely diagnosis and treatment of newborn illnesses and for the promotion of essential newborn care practices. Most of these programs focus on increasing health workers’ knowledge and skills to deliver services to prevent, diagnose and manage newborn illnesses on the one hand, and on improving community behaviors and generating demand for care and services on the other hand. At the same time, efforts should be targeted more towards strengthening health systems to improve the delivery of basic supplies and equipment, such as chlorhexidine for cord care, gentamicine for newborn infections and resuscitation-kits to manage asphyxia, all of which are critically needed to prevent and manage newborn illness.

Nepal has witnessed considerable political unrest and even armed conflict during 1996 – 2006. Nevertheless the country continued to improve most of its health indicators despite some disruption to health services [54]. During the last two decades, Nepal has also undergone significant socio-economic changes, in particular improved transportation and communication infrastructure and girls’ education. International labour migration has been a recent phenomenon leading to young males not being at home to support and care for recently delivered women and their newborns but also generating greater household income due to remittance. The effect of these major societal changes on neonatal and broader health indicators among different population groups has not been yet systematically assessed.

Strengths and limitations

We provided time trends in neonatal mortality and conducted an assessment of absolute and relative differences in neonatal mortality, based on best-available data (Table 2). There are, however, several problems with these data. Due to limited sample size, neonatal mortality was calculated for the last ten years preceding the survey, resulting in sample overlaps between estimates for different points in time. Also, the MDG baseline for 1990 and the MDG targets for 2015 in Figure 1 are estimates provided by the Ministry of Health and are thus not truly comparable to survey data for the years 1996, 2001, 2006 and 2011. Most importantly, NFHS and NDHS data are designed to be representative at the national level but may not necessarily be representative for each of our subgroup analyses, e.g. selected caste and ethnic groups; therefore, the comparison of rate differences and rate ratios and their changes across time must be made with caution.

A major limitation in relation to our review of efforts to reduce neonatal mortality is that information on relevant programs and policies and evidence of their coverage and effectiveness is based on non-systematic literature searches. Through conducting searches of the grey literature as well as the scientific literature and, in particular, through consultation with relevant stakeholders in Nepal, we are confident to have captured all important programs of direct relevance to neonatal health. We are less confident to have unearthed all available evidence on the effectiveness of different programs, especially as much unpublished additional evidence may reside with implementing organizations. Also, we did not conduct any formal quality appraisal for studies of effectiveness and have therefore not examined the evidence in terms of methodological flaws and potential bias due to non-independent evaluations.

Nevertheless, we believe that this study provides an important and much needed overview of key developments in neonatal health in Nepal over the past 20 years, capturing time trends in neonatal mortality in a disaggregated way, examining absolute and relative inequalities and providing an analysis of current experience with policies and programs.