This presentation by JSI's Leela Khanal, "Better Cord Care Saves Babies' Lives" was part of a dynamic panel moderated by JSI's Dr. Penny Dawson on February 13, 2015 at the 14th World Congress on Public Health in Kolkata, India. Four speakers summarized evidence for interventions proven to reduce newborn mortality (e.g., chlorhexidine) and shared important policy and programmatic experiences in prevention and treatment of neonatal infections. JSI's Leela Khanal and Dr. Nosa Orobaton spoke about experiences from Nepal and Nigeria in scaling up chlorhexidine use in those countries. Another speaker shared results from the COMBINE trial in Ethiopia, implemented primarily by JSI with support from SAVE/SNL, which evaluated the impact on neonatal mortality of health extension worker-led management of bacterial infections.

1. BETTER CORD
CARE SAVES
BABIES LIVES
Leela Khanal, Project Director, JSI
Chlorhexidine Navi (Cord) Care Program
February 13, 2015

2. Nepalese Context ofDeliveryandCord Care
45% deliveriesoccurred at home (Source:MICS 2014)
Among the home deliveries,82 % used a
clean delivery kit or new/boiledblade
(Source:NDHS2011)
Child birth consideredan impure and dirty
process
Among the home deliveries,41% of
newborns had material on stump (Source:NDHS
2011)

3. Around 40 newborns die per
day in Nepal
Source: MICS 2014
Source: Verbal autopsy to ascertain causes of neonatal
deaths inNepal, 2014
Sepsis istheleading causeofneonataldeaths inNepal

4. Source: * NDHS, ** MICS
118
91
61
54
38
79
64
48 46
33
50
39
33 33
23
0
20
40
60
80
100
120
140
1996* 2001* 2006* 2011* 2014**
Per1000livebirths
Trend of Under-5 Mortality Rates in Nepal
U5MR IMR NMR

5. InNepal,agroundbreakingprogram hasprevented
atleast3,900newborndeaths
Winner 2013
​USAID
PioneersPrize
in Scienceand
Technology
Project name: Chlorhexidine Navi (Cord) Care Program
Program Period: 2011-2017
Principal Donors: USAID, the Government of Norway, Bill & Melinda
Gates Foundation, Grand Challenges Canada and Department for
International Development
Partners: Ministry of Health and Population, PLAN, SAVE, UNICEF,
CARE, OHW, Lomus Pharmaceuticals

6.  Addressing a problem with high
population health burden
 Efficacy & low cost
 Simplicity,acceptability & safety
 Low regulatory requirements
 Health system compatibility &
scalability
Why Nepal acceptedChlorhexidine (CHX) cordcare
First evidence was from Nepal (Source: JHU/NNIPSRCT,2006)

7. CHX in Nepal: A timeline
2002-5
Initial
efficacy
research in
Sarlahi
2008-9
Lomus begins
CHX
Production
2006
Sarlahi trials
show 34%
reduction in
neonatal
mortality
2014
Scale up to 49
districts,included
CHX in ANM
curriculum,HMIS
and CBIMNCI
2017
Goal: Scale
up at
national
level
2011
Government
approved and
included CHX
in essential
drug list
2005-7
Technical
Advisory
group on
CHX
2008-9
JSI conducted
efficacy and
community
acceptability
study on liquid
vs. gel
2011
Regional
conference held
in Nepal, JSI lead
piloting in three
districts
2013
JSI/CNCP
won The
USAID
Pioneers
Prize

8. CHX ImplementationModalities in Nepal
​ CHX is now available to prevent newborn sepsis at both
facility and home deliveries integrating with on-going
government programs.

9. 9

10. CentralRegion
Eastern Region
Mid-Western Region
Far-WesternRegion
WesternRegion
Humla
Darchula
Baitadi
Dadeldhura
Kanchanpur
Kailali
Doti
Bajhang
Achham
Mugu
Mustang
Manang
Rasuwa
Kalikot
Dailekh
Surkhet
Jumla
Jajarkot
Banke
Rukum
Salyan
Rolpa
Pyuthan
Myagdi
Baglung
Gulmi
Kapilvastu
Arghakhanc
hi
Kaski
Syangha
Rupandehi
Palpa
Lamjung
Tanahu
Gorkha
Chitwan
Dhading
Nuwakot
Makwanpur
Nawalparasi
Parsa
Bara
Rautahat*
Taplejung
Solukhumbu
Sankhuwasava
Sindhupalchowk
Sarlahi
Dhanusha
Siraha
Saptari
Sindhuli
Kavre
Dolakha
Ramechhap
Okhaldhunga
Udayapur
Morang Jhapa
Ilam
Khotang
Bhojpur
Dhankuta
K
L
B
N
Mahottari
Dang
45 scaled up districts
4 pilot districts
Implementationstatus
CHX program:
49/75districts

11. 11

12. 12
Enabling Factors
1. The involvementof government and implementing
partners from initial phase
2. The utilizationof existing public health delivery
systems to implement
3. The integrationwith on-going health programs at
the health facility and community level

13. 13
Enabling Factors continued
4. The integrationof CHX in pre-service and in-
service curricula
5. The logistics supply mechanism through the
existing government system
6. Ensuring the sustainability through the
government ownership of the program (included in
the multi-year Procurement plan, HMIS, essential
drug list, etc.)

14. 14
Challenges
• Maintaining high coverage at scale
• Assuring the quality of the CHX product by
different pharmaceuticalcompanies
• Assuring the quality of routine information
systems
• Ensuring timely supply of CHX
• WHO cord care guidelines need updating

15. Next Steps
1. Expansion at the national level
2. Continue efforts to ensure the quality of the program
3. Integrate CHX in national health policy documents
4. Include CHX in logisticsinformation system, free drug
list, in-service and pre-service curricula
5. Strengthen routine health information systems
6. Support for uninterruptedsupply of CHX

16. Based on the
experienceofthe
Nepal CHX
program,
werecommend:
• Ensuring governmentleadership
from the start
• Planning integration from the
start
• Joining existing networks
• Adding CHX to the essential
medicines list
• Leveraging resources from other
countries and programs
• Ensuring funding commitments
for sustainability

17. Conclusions
• CHX application saves newborn lives
• CHX is safe, acceptable and low-cost
• Harmful cord care practices can be replaced
• Mother or family members can easily apply
• Easy to distribute to pregnant women through community-
based volunteers and antenatal clinics included in the public
health service delivery system
• Other countries with similar conditions should consider CHX to
save newborn lives