Neonatal Health in Nepal; where does it stand? Key Findings and Trends

Introduction: Nepal continues to have a high rate of Neonatal Mortality (NNM), 33 per 1,000 live births, among Asian countries. This rate is more than double the Post Neonatal Deaths (15 per 1,000 live births) in Nepal, as per 2006 Demographic and Health (DHS) survey. One of the targets of the millennium development goals (MDG's) is to achieve two-thirds reduction in infant and child mortality by 2015; however, progress in reducing NNM rates has been slow. Similar to other places NNM has declined at a slower pace in Nepal than other rates of childhood mortality. Also, in Nepal, an overwhelming majority of deliveries in the five years preceding the survey were at home (81 percent) and less than one-fifth of the births took place with the assistance of a Skilled Birth Attendant (SBA). Of these 81 percent women who delivered at home 80, percent did not receive any health care services after the delivery. A country where half of all deliveries are conducted by relatives/others, it becomes crucial to examine this subset of population. Also, of all these deliveries that happen at home, it is largely unknown when any type of care is provided and whether it is geared towards the newborn, mother, or both. Hence, this paper examins the trends in NNM in Nepal in last 10 years, compares the proportion of women and children receiving care after delivery, then investigates the prevalence of various high risk newborn care practices in light of Neonatal mortality.

Methodology: Data for this investigation comes from 1996 Nepal Family Health Survey (NFHS), 2001 Nepal Demographic Health Survey (NDHS) and 2006 NDHS. The study looks at the neonatal mortality data collected since 1996 in Nepal. Neonatal mortality was calculated using the birth history method including for each live birth, the sex, month and year of birth, survival status, and age at the time of the DHS survey. The NNM data presented here is for the five years preceding the survey. In the recent round of 2006 Nepal DHS all the women who did not deliver in an institution were asked about the care provided to them and the babies separately. The new set of questions included in the survey enquired about the practice of taking care of newborn, including the use of safe delivery kits, cord cutting practices, drying and bathing practices, and health services for newborn children. Bivariate analysis was conducted to look at the NNM rates by various socio-demographic characteristics and the new available information around the newborn care practice. Tables were also run to investigate the gap in care provided to mother versus newborn immediately after birth. The study plans to prepare a multivariate model to look at the influence of newborn care practices on neonatal mortality controlling for various background characteristics.

Results: NNM Trends- In Nepal, in spite of a steady progress in the reduction of overall childhood mortality, currently, NNM comprises 54% of the total childhood mortality, compared to 42% ten years ago. The rate of decline in NNM since 1996 is 34 percent vs. the 48 percent decline in the Post Neonatal Mortality (PNN). When comparing NNM of Nepal with other countries of the region it is evident that Vietnam and Cambodia have been successful in reducing the NMR at a much faster pace compared to Nepal.

Comparison of Postnatal Care (PNC) for children and Postpartum Care (PPC) for mother- On comparing the care provided to newborns with their mothers, only 4 percent of newborns received any care compared to 20 percent women who received some type of care postpartum. Nepal DHS 2006 data suggest that there is less interest for Neonatal Care compared to postpartum care. When looked at the timing of how soon the services were provided to newborns and postpartum women who received any type of care 2.7 percent of newborns and 17 percent of women received it within 24 hours after delivery, although, there seems to be no pattern in terms of timing of the care provided.

Neonatal health determinants and mortality- The conduct of population based surveys where women of fertile age recall the circumstances around the birth of their last-born child presents a unique opportunity to explore some of the factors associated with neonatal mortality further. The study results show an inverse relationship of education with the Neonatal mortality rate in Nepal 2006 DHS. Women without any formal education have the highest probability of losing their newborn in the first month of life (39 per 1,000 live births compared to 16 per 1,000 live births for women with secondary or higher education). Also, women who deliver in a non-institutional setting like home or other places are at a great risk of losing their newborn. Women who are delivered by using the safe delivery kits have a lower risk of developing infections and hence, reduced risk of Neonatal mortality. Newborns that are not dried immediately after birth have higher NNM rate (24 per 1,000) compared to if they were (11 per 1,000) dried immediately. The detailed breakdown of NMR by different background characteristics and newborn characteristics are presented in a tabular format (could not be displayed in this abstract). Multivariate analysis to investigate the individual influence of child care determinants after controlling for various background characteristics is under study.

Discussion and recommendations: It is clear from the mortality data that post neonatal mortality rates have declined at much faster rate compared to the neonatal mortality. And, since the gravest mortality risks happen soon after birth, actual deliveries should be attended by a skilled person. If this is not possible, the skilled attendant should be present within the first two hours after delivery. It is well known that maternal mortality contributes to the neonatal morbidity and mortality, effort and commitment –either by training and providing skilled staff to reach out to all delivering women, or by ensuring that all women delivering at home have access to a nearby facility or skilled provider immediately after birth— need to be ensured.

Postnatal and postpartum care is scarcely provided in Nepal which is a topic of grave concern. Considering that 50 percent of deliveries are conducted by friends and others in Nepal, it is unreasonable to expect that women and their newborn will receive any kind of skilled care post delivery. Even if women who get lucky and receive any kind of care (quality of care is in question here and also the limitation of the study), less than 3 percent of the newborns are looked at within 24 hours after birth. The majority of women in Nepal received their first PPC at home, an indication of the need for community strategy to provide maternal and newborn care services at the grass root level. Data also indicate that eight of ten providers of this care among non-institutional births are Trained Birth Attendants (TBAs); hence, the focus has to be to train these TBA's for basic newborn care and the use of safe delivery kits. In spite of all the necessary training, programs have to make sure that the safe delivery kits are available to these TBA's when needed.

As with other health indicators, the occurrence of NNM is highly and consistently related to improved education and economic capacity. Programs like distribution and use of safe delivery kits have shown to reduce maternal mortality. Hence programs like this at primary care levels should be encouraged and strengthened by the support of program managers and policy makers.