2. Introduction
• Neonate : first 28 day of life
• Infant : from birth through first year of life
• Fetal death : death of fetus after 22 WOG
• IMR : death of infants per 1000 live birth
3. The ‘Two Third Rule’ on global
infant mortality
• Almost 2/3rd of infant deaths occur in the first
month of life
• Among those who die in the first month of
life, about 2/3rd die in the first week of life
• Among those who die within the first week,
2/3rd die in the first 24 hours of life
4. Where do newborn babies die?
• High income countries - 4/1000
• Low and middle income countries – 44/1000
• WHO region:
• Africa - 44/1000
• America - 12/1000
• East Mediterranean- 40/1000
• Europe- 11/1000
• South East Asia- 38/1000
• Western pacific- 19/1000
• Overall- 30/1000
6. Trend of Nutritional Status of under 5 Children
57
49
41
43
39
29
11
13
11
60
50
40
30
20
10
0
2001 NDHS 2006 NDHS 2011 NDHS
Stunting (Ht/Age) Underweight (Wt/Age) Wasting (Wt/Ht)
7. Causes of under five mortality in Nepal
Combined
infection, 60%
ARI and
diarrhea ,
7.50%
Injury, 10.70%
Diarrhea,
13.20%
Others, 8.60%
DHS-2006
8. Leading causes death of children in
developing world
• Perinatal Condition 23.1%
• Lower reparatory condition 18.1%
• Diarroheal diseases 15.2%
• Malaria 10.7%
• Measles 5.4%
• Congenital abnormalities 3.8%
• HIV/AIDS 3.6%
• Pertusis 2.9%
• Tetanus 1.8%
• PEM 1.3%
• Others 14%
Source; World health report 2003
9. Millenium Development Goal
• GOAL 4 : Reduce Child Mortality
• Targtets
– 4 A : Reduce U5MR by 2/3rd between 1990-2015
• Indicators
– 4.1 : U5MR
– 4.2 : IMR
10. Progress
• Child Survival
– Global U5 deaths dropped from 12 million in 1990
to <9 million in 2008
• Micronutrient Supplementation
– 2 doses of Vit A increased from 16% to 62%
• Routine Immunization
– 3 doses of DPT increased from 75% in 1990 to
81% in 2007
11. • Vaccines
– Decreased global measles death by 74% since
2000
• Malaria prevention
– Use of insecticide treated nets risen sharply
• Improved drinking water
– More than 1.6 billion have gained access between
1990 & 2006
• Primary school enrollment
– No. of chlidren out of school decreased from 115
million in 2000 to 101 million in 2007
12. IMCI Implementation
CDD program started 1982
ARI program started 1986/87
ARI strengthening program at community focused on pneumonia
1995
treatment as a pilot in 4 districts
Evaluation of ARI pilot program 1997
Scale up Pneumonia treatment program at community with CBAC 1998/1999
IMCI piloted in Mahottari 1997
Merged Community component and program management
component in IMCI in and named as CB-IMCI.
1999/2000
Initially expanded in CB-IMCI in three districts 1999/2000
Revised the package and incorporated zinc 2006
Scaled up through out the country in 2010 2010
13. Causes of deaths of under five
children
DISEASE PREVALANCE
PNEUMONIA 19%
DIARRHOEA 17%
MALARIA 8%
MEASLES 4%
HIV/AIDS 3%
INJURIES 3%
OTHERS 10%
CHERG estimates as presented in WHO,World Helath Report 2005
14. Neonatal(36%)
Pre term birth(10%)
Severe infection(mainly pneumonia and
sepsis)(10%)
Birth asphyxia(8%)
Congenital anomalies(3%)
Tetanus(2%)
Neonatal diarrheal diseases(1%)
Others (2%)
15. Pneumonia
• kills 2 million children each year
• 1 in 5 deaths under 5 years of age.
• Around 6 lakhs children’s life could be saved
• Number of saved life could be doubled to 1.3
million by both prevention and treatment
Diarrhea
• Causes dehydration and kills 1.9 mi children
under 5
• 88% or 1.5 mi deaths each year are due to unsafe
drinking water ,inadequate availability of water
for hygiene and lack of assess to sanitation
• Related illness indirectly kill many more
16. Malaria
• Kill over 1 mi and sickens 350 to 5oo mi people
each year
• 8/10 deaths in sub-Saharan Africa. Malaria kill a
child in every 40 seconds
• Particularly damaging to pregnant women and
their newborn
• Maternal anemia and low birth weight
Measles
• A highly contagious disease
• Although vaccination since 1960,454000 under 5
deaths in 2004
• Survivor are left with lifelong disabilities-blindness
and brain damage.
17. HIV/AIDS
• Directly affecting mi of children adolescents and young
people.
• In 2005,2.3 million children under 15 were living with
AIDS.
Under-nutrition
• Underlying cause of 53%of child's death each year
• Leave children mentally and physically impaired
• Illness, insufficient breastfeeding and shortfalls of food
and micronutrient
• Universal iodination of salt Vit A supplementation-spectacular
results
• Powerful tool-promoting exclusive breastfeeding in 1st
6 months of life
• Policies-better nutrition knowledge in family and
community, disease control, safe water and basic
sanitation.
18. Cause of under five deaths in Nepal
Cause of death Male Female Total
Possible ARI and possible
26.4 29.4 27.9
Diarrhea
Birth injury 10.7 8.6 9.7
ARI 22 24.1 23.1
Birth asphyxia 6.3 9.2 7.8
Congenital abnormality 4 4.4 4.2
Preterm/LBW 3.8 2.3 3.1
Tetanus 2.3 0.1 1.2
Diarrhea 5.6 4.0 4.8
ARI and Diarrhea 2.6 2.2 2.4
Malnutrition 3.2 3.1 3.2
Injury 5.5 0.8 3.1
measles 0.2 0.0 0.1
Measles followed by ARI 0.4 0.0 0.2
Cause not identified 6.8 11.5 9.1
total 100 100 100
19. Global strategy for women’s and children
health
22 September 2010:Ban ki-moon launched Global
strategy for women’s and children health
Key elements of the global strategy:
• Country led health plans
• A comprehensive, integrated package of essential
interventions and services
• Integrated care
• Health system strengthening
• Health workforce capacity building
• Coordinated research and innovation
20. Neonatal health
• Critical stage of life
• The first 4 week of life-the neonatal period
caries highest risks of life
• Neonates-major focus for mortality and
morbidity reduction
• There was widespread mistaken assumption
that problems of newborns being addressed by
safe motherhood and child survival programs
• MDG stimulated the importance of newborn
survival globally and has aimed to reduce under
5 mortality by 2/3 rd.
21. Increasing attention on newborn health
• An estimated 3.1 million deaths before 1
month,98% in poor countries at home in absence
of any skilled health care
• MDG 4 and MDG 5
• Most neonatal deaths are preventable
via,immunization,medications,care during and
after delivery,keeping baby warm,cutting umbilical
cord clean,breast feeding & famliy planning
practices.
• Neonatal deaths- 2/3rd all deaths in first year of life
& 40% of deaths before age of five
22. • “Two third rule” on global IMR
Deaths in 1st months of life
Among those deaths in 1st months of life, about
2/3rd die in 1st week of life
Among those who die in 1st week of life die in
first 24 hours of life
• Marked variation of neonatal deaths between
high income and low income countries.
• Healthy newborns are likely to enjoy better
health in childhood and in late life; growing
evidence for and interest in the influence of in-utero
health on future cognitive development
23. • Related evidence that when a newborn
dies,many mothers are inclined to enter
more quickly into another pregnancy to
provide replacement baby.
For above reasons, recently government
international NGOs,donors and health
institutions are putting a lot of efforts and
resources in improving neonatal health.
25. • It is difficult to find out the causes of neonatal
deaths in developing countries. Because most
of the deaths occur at home there is lack of
well registration system. Families are reluctant
to seek outside help for sick child.
26. Following are main causes of neonatal
deaths
a) Severe infections (tetanus, sepsis,
pneumonia, diarrhea)
b) Asphyxia
c) Preterm birth
d) Congenital anomalies
e) Indirect causes
27. Severe infections
• It accounts for 36% of all new born deaths
• Four most common infections are tetanus, sepsis,
pneumonia and diarrhea
• Other infections include infection of skin,
umbilical cord, lungs, GI tract etc.
• Severe infection can occur any point during 1st
month of life
• Providing TT for mother clean delivery practice
maintaining clean cord and exclusive breast
feeding reduce most of infection.
28. Asphyxia
• Difficulty in breathing after birth due to
inadequate supply of oxygen immediately
before during or just after birth
• It accounts 23% of new born deaths
• Can be prevented by improved care during
labor and delivery, conduction of delivery by
trained health worker who is able to detect
the sign and resuscitate the new born.
29. Pre term birth
• A baby born before 37 completed weeks of gestation
calculating from the first day of the last menstrual
period.
• It causes 28% of new born deaths
• Most of preterm baby weigh 2.5 kg or less
• It is difficult to feed maintain body temperature and
prevent from infection
• Commonly seen complications are asphyxia,
hypothermia, pulmonary syndrome like pulmonary
edema, intra alveolar hemorrhage, Idiopathic
respiratory distress syndrome, cerebral hemorrhage
etc.
30. Congenital anomalies
• It includes neural tube defects, cretinism and
congenital rubella syndrome
• It causes 8% of new born deaths
• To prevent neural tube defects mothers can be
given folic acid during 1st trimester of
pregnancy, to prevent cretenism mothers can
be provided with adequate iodine and
congenital rubella syndrome can be prevented
by immunizing mothers against rubella
31. Indirect causes
• Low birth weight
• Gender bias
• Poverty
• Poor maternal health status
• Poor coverage of health service
32. Causes of neonatal deaths in Nepal
Cause of death % of neonatal deaths
Other serious infections 20.6
Birth injury 18.5
ARI 18.1
Birth asphyxia 14.9
Congenital abnormality 8.1
Pre term birth/low birth weight 5.9
Tetanus 2.3
Diarrhea 0.8
ARI and diarrhea 0.5
Cause not identified 10.1
33. Continuum care for maternal neonatal
and child health
• World health report defines
• “the core principle underline the strategies to
develop MNCH programs is the continuum of
care. This expressions has two meanings first it
means care has to be provided as a continuum
throughout the life cycle including adolescence,
pregnancy, childbirth and childhood. Second it
indicates that care has to be provided in a
seamless continuum that spans the home
community health centre and hospital.”
34. Principles of continuum of care
• Actions to improve the health of women, new
borns and children are most effective and
sustainable when they are integrated and
delivered in convenient, cost effective
packages to communities and families
• Health systems are most useful when they
integrate dynamically the different modes of
care – facility based, outreach and out patient
services and community and family care
35. • Strengthening health system to improve health
outcomes for mothers and children requires
combining and integrating the strength of vertical
and horizontal approaches to health services
delivery, rather than choosing either approach in
isolation
• A result oriented approach to health system
development, centered on effective and evidence
based interventions is useful in setting agendas
and policies and in monitoring and evaluating
progress
36. • Results are best achieved through
collaborative action between programs,
policies and partnerships working towards
improving maternal, newborn and childcare
37. Ways to improve neonatal and child
health
• Status of neonatal and child health depends
on many factors, health system, culture,
education, economic, political commitment,
support from donor international partners
38. Basic practices for community based
health care intervention
Exclusive breast feeding -: up to 6 month
Complementary feeding -: starting about at 6
months, feeding children with energy and
nutrient rich foods while continuing to breast
feed for at least 2 years
Micronutrient supplement -: improving the
intake of vitamin A in communities where it is
deficient
Hygiene
39. Immunization -: full course immunization
(BCG, Diphtheria, Pertusis, TT, Polio and
measles) before 1st birth day
Malaria prevention -: in the malaria endemic
areas
Psychosocial care and development-: it is
done by talking playing and providing
stimulating environment to the child
40. Feeding and fluids for sick children
Home treatment
Care seeking -: recognize when sick children need
treatment outside home and seek care from
appropriate providers
Appropriate practices -: follow the health workers
advice about treatment, follow-up and referral
Antenatal care -: at least 4 antenatal visits with
appropriate health care provider and receiving
recommended doses of TT along with support
from family and community
41. Essential care for new born health
Care of future mothers
Improve health and status of women
Discourage early marriage and early child
bearing
Promotes safer sexual practice
Provide female education
42. Care during pregnancy
Improve nutrition of pregnant woman
Immunize against tetanus
Screen and treat infection specially syphilis
and malaria
Improve communication and counseling
43. Special attention
Monitor and treat pregnancy complications
such as anemia preeclampsia and bleeding
Promote voluntarily counseling and testing for
HIV
Reduce the risk of mother to child
transmission of HIV
44. Care at time of birth
Ensure skilled care at delivery
Provide for clean delivery -: clean hands, clean
delivery surfaces, clean cutting, tying and stump
care and clean clothes
Keep the new born warm
Initiate the immediate, exclusive breast feeding at
least with in one hour
Give prophylactic eye care
45. Special attention
Recognize danger sings in both mother and
baby and avoid delay in seeking care and
referral
Recognize and resuscitate asphyxiated baby
immediately
Pay special attention to warmth feeding and
hygiene practices for pre term and LBW babies
46. Care after birth
Ensure early postnatal contact
Promote continued exclusive breast feeding
Maintain hygiene to prevent infections, ensure
clean cord care and counsel mother on
general hygiene
Provide immunization such as BCG, OPV and
HepB
47. Special attention
Recognize danger sign in both mother and
new born particularly of infection and avoid
delay in seeking care and referral
Support HIV positive mother to make
appropriate, sustainable choices about
feeding
Continue to pay special attention to warmth,
feeding and hygienic practices for LBW babies
