Review and Critical Appraisal of Newborn

Health Policies and Programs of Nepal

Sagar Parajuli
Sunita Poudel
MPH 2022
School of Health & Allied Sciences
Pokhara University
 Content Outlines

 Introduction to Newborn and Newborn Health

 Essential Newborn care services
 Danger Signs in Newborn
 Global, SEARO and National Status- Newborn Health
 Policies & Programs (Brief about programs and guiding policies)
 Key Monitoring Indicators
 International Practices in Newborn Health
 Critical Appraisal; Issues, Challenges and Constraints
 Critical Appraisal- Recommendations
 Need of investment in Newborn Health
 References

2
Newborn Health & Newborn Health Care Services
• Newborn Infant or Neonates- Children below 28 days of Life (WHO Definition)
• Neonatal period- a very crucial period for child’s survival as there is always highest risk
of infections and deaths during first week and month of birth.
• Essential Newborn care services includes immediate care at birth and continuation of
care till neonatal period.

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Newborn Health & Newborn Health Care Services

Categorization of Neonatal
Period
 Perinatal Period
 Early-natal period
 Late Neonatal period

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Components of Essential Newborn Care
“High quality universal newborn health care is the right of every newborn everywhere”- WHO

• Includes immediate care at birth and essential care during newborn period
• Essential Newborn care includes
1. Immediate care at birth- 4 elements
2. Thermal Care
3. Resuscitation when needed
4. Support for breastmilk feeding
5. Nurturing Care
6. Infection Prevention
7. Assessment of Health Problems
8. Recognition & response to danger signs
9. Timely and safely referral when needed
5
Components of Essential Newborn Care
• Major Four Elements of Immediate care at birth , also known as time-bound
interventions
1. Immediate and thorough drying
2. Skin to Skin contact
3. Cord clamping (1-3 minutes)
4. Early initiation of breastfeeding

• Indicator for monitoring Newborn Health Services, WHO- “the proportion of

newborns who received all four elements”
• Five essential newborn care- CB-IMNCI Treatment Protocol, added Don't bath baby
within 24 hrs

6
 Danger Signs in Newborn
World Health Organization listed Danger signs:
1. Not being able to feed or stopped feeding well
2. Convulsion or fitted since birth
3. Fast breathing (Two counts of 60 breaths or
more in 1 minute)
4. Chest indrawing
Danger
5. High Temperature (37.5 C or more) Signs
6. Low Temperature (35.4 C or less)
7. Yellow soles
8. Movement only when stimulated, or no
movement on stimulation
9. Local infection signs: Umbilicus redness,
draining of pus, skin boils, ear draining pus
7
Newborn Health; Global Status
• Global number of newborns deaths declined
from 5 million in 1990 to 2.4 million in
2019, but there is always highest risk of
deaths during neonatal period.
• In 2019, 47% of all under-5 deaths occurred
in the newborn period with about one third
dying on the day of birth and close to three
quarters dying within the first week of life.
• Major causes of Newborn Deaths- preterm
birth, intrapartum complications, infections
and birth defects
Source: WHO, 2019
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Newborn Health; Global Status

WHO 2020
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Newborn Health; Global Causes of Newborn Death

Global causes of Newborn Deaths, UNICEF 2018

1.2 5.6 Preterm birth complications
1.3
0.6 Intrapartum related events
6.1 Sepsis or Meningitis
34.7 Congenital
11.2
Pneumonia
Diarrhoea
15.2 Tetanus
Injury
24.1 Others

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Trend of Under-5 Mortality Rate in Nepal
160
140 142 Under-five mortality rate  by 73%

120 Infant mortality rate  by 68%

118
100 Neonatal mortality rate  by 60%
91
80 99
60 78 61
64 54
48 38
40 53 50 46 39
39 28
33 32 25 25
20 33 33 16
21 12
23
0
90 96 01 06 11 14 16 1 9 et
g
e 19 S 19 S 20 S 20 S 20 S 20 S20 S 20 T ar
lin F H H H H IC D H IC 0
e N D D D M N M 03
as N N N N N 2
B G
SD

NMR IMR U5MR

11
% of NMR among U5MR and IMR
80

70 72
69 69 69
60 63
61 61 60 60
50 54
42
40
43
30

20

10

0
NFHS 1996 NDHS 2001 NDHS 2006 NDHS 2011 MICS 2014 NDHS2016
NMR as % of U5MR Column1 12
Causes of Neonatal Deaths

Hypothermia Other
Sudden 4% 7%
neonatal
death
6%
Congenital Respiratory &
malformations cardiovascular
& deforma-
tions disorder of
7% perinatal period
31%

Infection spe-
cific to perinatal
period Complications
16% of pregnancy,
labor & delivery
31%
NDHS, 2016

13
Causes of Neonatal Deaths by Sex
Percent distribution of neonatal deaths within 0-27 days of birth

10 5
5 Other
2
7 10
Hypothermia
12 7
Sudden neonatal death
19
Congenital malformations & de-
formations
37
26 Infection specific to perinatal
period
Complications of pregnancy,
labor & delivery
32 30 Respiratory & cardiovascular
disorder of perinatal period
Female Male NDHS, 2016

14
Time period of Neonatal Deaths
Percent distribution of neonatal deaths within 0-27 days of birth

<1 hour
7-27 days 17%
21%

24-167 hours
22%
1-23 hours
40%

NDHS, 2016

15
Causes of Stillbirths
Percent distribution of causes of stillbirths
Congenital malformations Disorders related to length
& deformations of gestation & fetal growth
1% 4%

Complica-
tions of
pregnancy,
labor & de-
livery
41%

Unspecified
cause
54%

NDHS, 2016

16
Treatment of Newborn (0-28 days) cases in FY 077/78
 
• Total cases- 21,813
• Among total cases
 10.63 % Possible Severe Bacterial Infection cases,
 39.91% Local Bacterial Infections (LBI),
 3.9% jaundice,
 5.9% of low weight or feeding problem
• 114 newborn deaths reported (HF+ORC)

17
 Studies on Newborn Care Program, Nepal
 
• Less than 1% receiving WHO four
essential elements of Newborn care
• 19.5% skin to skin contact, 68.2% delayed
cord clamping
• Risk of mortality declined with increase in
no of essential elements
1. 50% reduction in risk of mortality on
receiving one element also
2. 72% reduction in risk of mortality on
receiving four elements

18
Factors affecting Neonatal Mortality

NDHS, 2016

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Factors affecting Neonatal Mortality

Source: Determinants of Neonatal Mortality, Indonesia

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 Child Survival to Child Health Programs- Major Milestones
• National Immunization Program (EPI)
1979

• Diarrhea Control Program

1983

• ARI Control Program

1987

• Community Based Integrated Management of Childhood Illness

1998 Program- CBIMCI

• Morang Innovative Neonatal Intervention pilot(MINI)

2005 • Zinc + Low osmolar ORS for diarrhea treatment

21
Child Survival to Child Health Programs- Major Milestones
• Community Based Newborn Care Program (CB-NCP)
2009

• Use of Chlorhexidine for cord care

2011

• Community Based Integrated Management of Neonatal and Childhood

2014 Illnesses- CBIMNCI

• Facility based IMNCI and free newborn care

2015

• Nepal Every Newborn Action Plan

2016

22
Policies and programs Development

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Newborn and Child Health Services
Structure
Child Health
Programs

Newborn Care
IMNCI
Services

Level II
Level I Level III Referral
(Special CB-
(Newborn FB-IMNCI
Newborn Care (Newborn Intensive IMNCI
corner) Unit) Care Unit)

HP/PHCC/ Zonal Hospital

Hospitals HP/PHCC/DH DH
Hospital and above

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Services and Level of Care
Level IMNCI Service Newborn Care Service
HP (without Birthing Case management protocol
Center)
Health Post (with + Essential newborn care (Newborn corner, through SBA)
birthing center) + Resuscitation
+ Case management
PHCC Case management Level 1 care
Focused treatment (Newborn corner, ENC, PMTCT, thermal
Emergency Management care, feeding, transfer, growth and
nutrition monitoring)
Hospital Case management Level 2 care
Focused treatment (Level 1 care + Special Newborn Care
Emergency management Unit (SNCU)+ KMC care)
Zonal Hospital and Case management Level 3 care
Above Focused treatment (NICU) (Level I + Level II + KMC care
Emergency management unit + Ventilation)

25
Vision 90 by 2030
Goal: Improve newborn child survival and
ensure healthy growth and development.

Objectives:
1. To reduce neo natality mortality and
morbidity by promoting essential newborn
care services and managing major cause of
illnesses
2. To reduce childhood mortality and
morbidity by managing major cause of
illnesses

26
Newborn Specific Program Interventions
•Promotion
–Birth preparedness plan
–Essential newborn care practices
–Postnatal care to mother and newborn
•Identification and management
–Non-breathing babies
–Preterm and Low birth weight babies
–Sepsis among young infants (0-59 days) including diarrhea
•Management of sick newborn through
–New born corner at PHCC
–SNCU at district hospital
–NICU at zonal hospital and above
–Implementing Free Newborn Care Services
 
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Newborn Specific Programs & Provisions
 Free Sick Newborn care packages; Package A, B, and C, Incentives for sick
newborn case management, Incentive NRs 300 to health workers for providing
all forms of packaged services to be arranged from health facility reimbursement
amounts
 NICU, SNCU and KMCU Services
 Basic Emergency Obstetric & Newborn Care (BEONC) program- Management
of complicated pregnancies, resuscitation of newborn
 Safe Motherhood Program- From ANC to PNC, women encouraged for 8 ANCs
and at least 3 PNCs for monitoring pregnancy, delivery women’s health and
newborn health, promoting breastfeeding, immunization, hygiene,
 Immunization & Nutrition Program
 Equity and Access Program
 FCHV Program & PHC-ORC, HF level Interventions
28
 Free sick newborn care packages
Package Type Treatment and Care services for Health Facility per case management Unit Cost

Package 0 - Resuscitation No Cost

- KMC
- Antibiotics as per IMNCI protocol

Package 'A' Medicines- Antibiotics and other drugs as per National Neonatal Clinical Rs. 1000
Protocol, NS, RL, 5% dextrose, 10% dextrose, 1/5 NS with 5% or 10%
dextrose, Potassium chloride, Adrenaline, Buro set, IV Canula

Laboratory services- Blood TC, DC, Hb, Micro ESR, CRP, Blood Sugar,
blood grouping, Serum Bilirubin (total and direct).
Oxygen Supply by hood box /nasal prong
X-ray / USG

29
 Free sick newborn care packages
Package Type Treatment & Care Services for Health Facility Unit Cost

Package ‘B’ Photo therapy Rs 2000

Laboratory Services- Blood culture, RFT (Sodium, Potassium, Urea createnine), Serum
calcium
Lumber Puncture and CSF Analysis
Medicine- Dopamine, Dobutamine, Phenobarbitone, Phenytoin, Midazolam, calcium
Gluconate, Aminophylene
Bubble CPAP (Continuous Positive Airway Pressure)

Package ‘C’ NICU Admission (Must) Rs 5000

NICU bedside Ultrasonography (USG)
NICU bedside Portable X-Ray
Lab: ABG, Magnesium, Chloride, Serum Osmolarity, Urine Specific Gravity , Urine
Electrolyte
Double Volume Exchange Transfusion, Blood transfusion
Medicine: Caffine
Mechanical Ventilation

30
NICU and SNCU Service Sites

31
Newborn & IMNCI Program Key Monitoring indicators
1.% of institutional delivery
2.% of newborn applied with CHX immediately after birth
3.% of infants (0-2 months) with PSBI receiving complete dose of Inj. Gentamycin
4.% of U-5 children with pneumonia treated with antibiotics
5.% of U-5 children with diarrhoea treated with Zinc+ORS
6.Stock status of 5 key commodities: Zinc, ORS, Gentamycin, Amoxicillin, CHX
7.HMIS Recording- Total Newborn case (HF & ORC), PSBI cases, Local Bacterial
Infection (LBI) , jaundice, % with low weight or feeding problem, referred and
deaths, FCHV Program-Sick baby, Treated with amoxicillin, Referred
HMIS Recording & Reporting
HMIS 2.4 IMNCI Register, HMIS 8.4 SNCU NICU Register (Newly added)
HMIS 9.3 & 9.4 Reporting (IMNCI & Newborn Care Program)
32
 Guiding Documents
• Neonatal Health Strategy (2004)
• NENAP (2015-2035)
• National Neonatal Clinical Protocol (2016)
• Free Newborn Care Guideline (2015)
• Nepal Perinatal Quality Improvement Guideline
• CBIMNCI Training Package
• Comprehensive Newborn Care (Level II) Training Package
• Facility Based IMNCI Training Package
• Newborn care/ FBIMNCI Mentoring Guideline 2020
• Newborn care services mentoring Guideline

33
Guiding Documents- National Neonatal Health Strategy 2003

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.
Strategic Interventions: Policy, Behavior Change communication, Strengthening
Health Care Delivery, Strengthening Programme Management, Research

34
National Safe Motherhood and Newborn Health Long Term plan
Goal: Improved maternal and neonatal survival, especially of the poor and excluded.
Key Targets: Reduction of MMR from 539 to 134 per 100,000 by 2017
Reduction of NMR from 39 to 15 per 1000 by 2017
Outputs listed in NSMNH-LTP (2006-2017)
1. Equity and access
2. Services
3. Public Private partnership
4. Decentralization
5. Human Resource Development; SBA strategy
6. Information Management
7. Physical Assets and Procurement 8. Finance
35
 Nepal Every Newborn’s Action plan (NeNap) 2016
Vision: ‘A Nepal in which there are no preventable deaths
of newborns or stillbirths, where every pregnancy is
wanted, every birth celebrated, and women, babies and
children survive, thrive and reach their full potential’

Targets & Goal: Reduce NMR to less than 11 per 1000

live births and stillbirths to less than 13 per 1000 total
births by 2035, at national and provincial level.

Strategic Approaches: Equitable distribution of health

services, Quality for all, Multi-sectoral approach

Nine Strategic Objectives

36
 Nepal Safe Motherhood and Newborn Road Map 2030
• Nepal’s Safe Motherhood and Newborn Health (SMNH) Road Map 2030 aims to
ensure a healthy life for, and the well-being of, all mothers and newborns.
• The Road Map is aligned with the Sustainable Development Goals (SDGs) to reduce
Newborn Mortality Rate (NMR) from the current 21 to less than 12 deaths per 1,000
live births.
5 Outcomes listed
Outcome 1- The availability of high quality MNH Services increased, leaving no one
behind.
Outcome 2- The demand for and utilization of equitable MNH services increased.
Outcome 3- The governance of MNH services improved and accountability assured.
Outcome 4- M & E of MNH services improved.
Outcome 5- Emergency preparedness and response for MNH strengthened.

37
 Government Plans for Newborn Health
• Implementation of Free Newborn Care Program in all local, provincial and federal level
hospitals
• Development of Early childhood development guideline and its orientation
• Expansion of SNCUs in district hospitals (35 hospitals)
• Capacity building of SNCU/ NICU Staffs (Mos/ Nursing Staffs) through Level II training (10
batches)
• Research on Newborn and child health (Provincial level orientation done)
• Development of KMC Guidelines and KMC corners (Draft prepared)
• CBIMNCI/ FBIMNCI/ Newborn Care coach development and mobilization
• Routine Quality Data Assessment (RQDA)
• Point of Care Quality Improvement Program (7 provinces)
• Prioritization of Newborn and Child Health Programs in Nepal Health Sector Strategy(2022-30)
• Mother and Baby Friendly Hospital Initiatives
• Scaling up of KMC at institutional level and community level 38
Helping Babies Breathe and Helping Mother Survive

39
Critical Appraisal; Issues and Challenges
Building Blocks of Issues, Challenges and Constraints
Health System

Lack of designated SNCU & NICU at Health Facility-combined with other

Service services, No address of SNCU/NICU/KMCU at Health Facility Structure
Delivery Standards, Lack of assignment of focal person for Newborn services at HFs
resulting into lack of ownership and initiations, No CEONC sites in some
rural

Lack of trained Human resources/Coach/Mentor for mentoring sessions at

Human national level, No refresher trainings on time, Frequent HSP transfer resulting
Resources into service discontinuation,

Less IEC materials and A/V contents on Newborn danger signs and
Information management, Newborn care services information
Lack of effective Social Behavior Change Communication(SBCC) Strategies

40
Critical Appraisal; Issues and Challenges
Building Blocks of Issues, Challenges and Constraints
Health System
Medicines & More Central procurement for Newborn and Child Health Programs
Technologies Commodities- lack of timely dispatch to local levels, discontinuation of
services due to lack of commodities

Less prioritized budget for newborn care programs

Healthcare Provincial and local government giving less priority to MNH Programs
Financing during Annual Work Plan Budgeting (AWPB) Preparation
Hospitals more dependent on government budget,

Lack of regular supportive supervision, monitoring and evaluation

Leadership & Lack of effective referral pathway, mechanism and guidelines
Governance Not so expected Public private partnership and stakeholder engagement

41
 Critical Appraisal: Recommendations
 Need of Comprehensive Child Health Framework at national level
 Creating a pool/cadre of trained human resources and coaches through coach
development training for effective and frequent mentoring sessions
 Time and again orientation and refresher training to Health Service Providers on
updated guidelines, new protocols and policies
 Routine Quality Data Assessment is essential for identification of data clerks
 Public private partnership and multi-stakeholders engagement: Orienting private
clinics and pharmacies for referring cases, as they are first point of contact for most
of population, Engaging local stakeholders and policymakers
 Coordination & collaboration with EDPs, I/NGOs

42
 • Reduction of Still birth rates by 30%
from 17.6 to 12.4 per 1000 births,
leading MMR to 132 per 100,000,
NMR to 7 per 1000 live births
• 13 Interventions
• Neonatal Resuscitation, acute management of
third stage labor, Antenatal corticosteroids for
preterm labor, antibiotics for preterm
premature rupture of membrane, Tetanus
Toxoid during pregnancy, Early detection &
treatment of HIV in pregnant women
• Syphilis detection and treatment,
Hypertensive disease case management,
diabetes case management, MgSO4
management of pre-eclampsia, Fetal growth
restriction identification and management,
labor and delivery management, Inducing of
labor for pregnancies beyond 41 weeks
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 Newborn Health & Investment in Newborn Health
Care Services: Necessity from Policy to Actions

 Estimated USD 2-17 ROI for every dollar invested on Newborn despite
pessimistic growth projections
 For Nepal, estimated economic returns (USD) per dollar invested is 6,
while for Bhutwan-17 and India-11
 For meeting SDG target of 12 per 1000 live births Nepal needs an annual
rate of reduction (ARR) of NMR of 4.8%- Current ARR 4%

Source: Investment Case in Newborn Survival in South Asia, UNICEF

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 Newborn Health & Investment in Newborn Health Care
Services: Necessity from Policy to Actions

08/09/2022 45
 References
• https://www.who.int/westernpacific/health-topics/newborn-health
• https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/newborn-health/ess
ential-newborn-care
• https://nhssp.org.np/Resources/SD/SMNH%20Roadmap%202030%20-%20%20January%202020.pdf
• https://laerdalglobalhealth.com/Resources/news/hbb-hms-nepal/
• https://dhsprogram.com/pubs/pdf/FR336/FR336.pdf
• https://www.frontiersin.org/articles/10.3389/fpubh.2016.00015/full
• Investing in Newborn Health South Asia, UNICEF
• UNICEF Data portal
• World Health Organization Fact sheet 2022
• Nepal Every Newborn’s Action Plan 2006
• Nepal Safe motherhood and Newborn Road Map 2030
• Coverage of WHO’s four essential elements of newborn care and their association in newborn survival
• Triple Return on Investment: the cost and impact of 13 interventions that could prevent stillbirths and
save lives of mother and babies of South Africa

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08/09/2022
Thank you! 47