Child Health in Nepal: Root Cause Analysis

Presenters:
Kusumsheela Bhatta (403)
Madhurjee Dhakal (404)
Shrijana Shrestha (410)
MPH, PAHS
Group 2
2nd Sep 2022
Child Health in Nepal: Root Cause
Analysis
Photo Courtesy: NENAP 2016

Outline of the presentation
• Introduction to RCA
• RCA Methodology
• Conceptual Framework
• Immediate Cause
• Underlying Cause
• Root Cause
• Conclusion
• References
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Group 2: Root Cause Analysis

Photo Courtesy: edgeofseven
Introduction to RCA
01
Photo Courtsey: Jacob Kassel/USAID Health for All Project

What is root cause analysis?
• RCA is a structured investigation that aims to identify the true cause of a
problem and the actions necessary to eliminate it with a permanent fix rather
than continuing to deal with the symptoms on an ongoing basis
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What
happened
?
Why
it
happened
?
How to
eliminate?

General Steps of RCA
9/02/2022 5
A group of problem
solving approaches to
identify the true causes of
problems or events

Root Cause Analysis Diagram
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Figure: Root Cause Analysis Diagram

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RCA
Methodology
02

How we did RCA!
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Situation Analysis/
Identification of Problem
Literature Review and
Identification of causal
factors
Brain storming and
Development of
conceptual framework
Determination of root
causes
01 02
03 04

How we did RCA!
9/02/2022 9
01
Situation Analysis/
Identification of
Problem
Source: NDHS 2016
SDG targets related to neonatal
and under-5 mortality in Nepal
are 12 and 20 deaths per 1,000
live births, respectively, by
2030

How we did RCA!
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02
Identification of
Causal Factors
Source: DHS Report no.120

How we did RCA!
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02
Identification of
Causal Factors
Lamichhane R, Zhao Y, Paudel S, Adewuyi EO. Factors associated with infant mortality in Nepal: a comparative analysis of
Nepal demographic and health surveys (NDHS) 2006 and 2011. BMC public health. 2017 Dec;17(1):1-8.

How we did RCA!
9/02/2022 12
02
Identification of
Causal Factors
Al Kibria GM, Khanam R, Mitra DK, Mahmud A, Begum N, Moin SM, Saha SK, Baqui A, Projahnmo Study Group in Bangladesh.
Rates and determinants of neonatal mortality in two rural sub-districts of Sylhet, Bangladesh. PloS one. 2018 Nov

How we did RCA!
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02
Identification of
Causal Factors
Source: UNICEF

Iceberg of child illness and mortality
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 Disease/Infection
 Mortality
 Complication during pregnancy/delivery
Poor hygiene practices
Maternal education
Maternal age at
marriage
Decision making capacity
Place of delivery
Health seeking behavior
Birth interval
Access to health
services
Cultural factors
Weight of child
Political factors
Place of
residence Inadequate
food access
Sedentary
lifestyle
Ignorance

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03 Conceptual
Framework
Brainstorming

Immediate Causes
02
Photo Courtesy: CBHS health

Disease/Infections/Birth Complications
9/02/2022 17
Source: WHO Fact Sheet
Immediate
cause
Infectious diseases, including
• Pneumonia
• Diarrhoea
• Malaria, along with
• Pre-term birth complications
• Birth asphyxia
• Trauma
• Congenital anomalies.
Globally Leading causes of death for children under
5 years

9/02/2022 18
Source: Lancet Child Adolescent Health 2022
Immediate
cause

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Source: Lancet Child Adolescent Health 2022
Immediate
cause
Global Causes of under-5 deaths in 2019

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Source: NDHS 2016
Immediate
cause

Malnutrition
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• Nearly half of all deaths in children under 5 are attributable to undernutrition
• Undernutrition puts children at greater risk of dying from common infections,
increases the frequency and severity of such infections, and delays recovery.
Source: UNICEF
The results from 53 developing countries with nationally representative data on child weight-for-age indicate
• 56% of child deaths were attributable to malnutrition's potentiating effects
• 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition
Immediate
cause
Pelletier DL, Frongillo EA Jr, Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries.
Bull World Health Organ. 1995;73(4):443-8

Malnutrition
9/02/2022 22
Undernutrition contributes to
25,000child deaths in Nepal per
year, accounting for 52 per cent of child
deaths, higher than any other cause.
52%
Immediate
cause
Source: UNICEF, 2019

9/02/2022 23
03 Conceptual
Framework
Brainstorming

Underlying Causes
05

• Maternal age at childbirth
Maternal factor
Report/Article Findings
NDHS 2016 Mortality rates are lower for children whose mothers were age 20-29 when they
were born than for children born to women below age 20 or age 30-39.
For instance, the neonatal mortality rate is 21 deaths per 1,000 live births for
children whose mothers were age 20-29 when they were born, as compared
with 39 and 31 deaths per 1,000 live births, respectively, for children whose
mothers were less than age 20 and age 30-39.
Maternal and newborn health
disparities, UNICEF
The NMR for younger mothers is 1.4 times higher than for mothers aged 20-34.
Underlying
cause

• Maternal age at childbirth
Maternal factor Continued.
Childhood Illness and Mortality
in Nepal: Trends and
Determinants, DHS further
Analysis Report 2019
Women age 15-24 (aOR: 1.5, 95% CI: 1.0-2.2, p < 0.05) were more likely to seek
treatment or advice from health facilities or providers compared to women age 25-
34
Association between maternal
age at childbirth and child and
adult outcomes in the offspring:
a prospective study in five low-
income and middle-income
countries (COHORTS
collaboration)
Younger maternal age remained for low birthweight (odds ratio [OR] 1·18 (95% CI
1·02–1·36)], preterm birth (1·26 [1·03–1·53]), 2-year stunting (1·46 [1·25–1·70]),
and failure to complete secondary schooling (1·38 [1·18–1·62]) compared with
mothers aged 20–24 years.
Older maternal age remained associated with increased risk of preterm birth (OR
1·33 [95% CI 1·05–1·67])
Underlying
cause

• Maternal age at marriage
Article Methodology Findings
Associations of maternal age at
marriage and pregnancy with infant
undernutrition: Evidence from first-
time mothers in rural lowland Nepal
Analyzed data on first-time
mothers (n = 3002) from a
cluster-randomized trial
(2012–2015)
Risk of stunting was higher in those
marrying at 15 years (adjusted OR 1.63,
95% CI 0.94, 2.85), 14 years (adjusted OR
1.61, 95% CI 0.91, 2.85) and 10–13 years
(adjusted OR 1.74, 95% CI 0.84, 3.60).
Girl-Child Marriage and Its
Association with Morbidity and
Mortality of Children under 5 Years of
Age in a Nationally-Representative
Sample of Pakistan
Nationally-representative
cross-sectional observational
survey data from Pakistan
Demographic and Health
Survey, 2006-2007
Marriage before age 18 years increased the
likelihood of recent diarrhea among children
born to young mothers (adjusted OR = 1.59;
95% CI: 1.18-2.14).
Underlying
cause

• Maternal age at marriage
Report/Article Method Findings
Early marriage, poor
reproductive health status of
mother and child well-being in
India
Data from the third wave
of National Family Health
Survey (NFHS, 2005–2006)
was used
Early age at marriage had detrimental effects on the
reproductive health status of women.
Children born to mothers with poor reproductive
health had lower chances of survival and a higher
likelihood of anthropometric failure (i.e. stunting,
wasting and underweight).
Underlying
cause

• Maternal BMI
The association between
maternal body mass index and
child obesity: A systematic
review and meta-analysis
Searches in MEDLINE,
Child Development &
Adolescent Studies,
CINAHL, Embase, and
PsycInfo were carried
out in August 2017 and
updated in March 2019.
There were significantly increased odds of child obesity
with maternal obesity (odds ratio [OR] 3.64, 95% CI
2.68–4.95) and maternal overweight (OR 1.89, 95% CI
1.62–2.19).
Underlying
cause

• Maternal BMI
The Impact of Maternal Obesity
on Maternal and Fetal Health
National data on obesity and
overweight in the United
States , National Health and
Nutrition Examination
Survey (NHANES)
Obesity data of Pregnancy
Risk Assessment Monitoring
System (PRAMS)
The fetus is at risk for stillbirth and congenital
anomalies. Children have a risk of future obesity and
heart disease. Women and their offspring are at
increased risk for diabetes.
Underlying
cause

• Decision making capacity
Maternal factor
Childhood Illness and Mortality in
Nepal: Trends and Determinants,
DHS further Analysis Report 2019
Under-5 children of women with weak decision-making capacity were
more likely to die before completing their fifth birthday (aOR: 1.9, 95%
CI: 1.1-3.5, p < 0.05) compared to children of women with strong
decision-making capacity.
Underlying
cause

• Exposure to public media program
Maternal factor
Report Findings
Maternal and Newborn Health Disparities, UNICEF Neonatal mortality is lower among births to those
exposed to public health media (27 deaths per 1,000
live births in 2011 and 29 in 2006) than among those
not exposed to public health media (37 deaths per
1,000 live births in 2011 and 35 in 2006).
Underlying
cause

• Multiple pregnancies
Maternal factor
Article Method Findings
General obstetrics: Preterm birth
and multiple pregnancy in
European countries participating
in the PERISTAT project
Analyses of data from vital
statistics, birth registers or
national samples of births.
The proportion of multiple births before
37 weeks varied from 68.4% in Austria to
42.2% in the Republic of Ireland. In half of
the countries, over 20% of all preterm
births were attributable to multiple
births.
Trends in preterm birth:
singleton and multiple
pregnancies in the Netherlands,
2000–2007
Nationwide prospective
cohort study. studied
1451246 pregnant women
from 2000 to 2007.
In multiple pregnancies, the preterm birth
risk increased significantly (47.3–47.7%,
P =0.047), mainly as a result of medically
indicated preterm birth, which increased
from 15.0% to 17.9% (P<0.0001).
Underlying
cause

• Inadequate dietary intake
Maternal factor
The differential effect of maternal
dietary patterns on quantiles of
Birthweight
Data for the study were obtained
from a Mother and Child in the
Environment birth cohort study in
Durban South Africa.
Quantile regression was used to
investigate the effect of maternal
dietary patterns on quantiles of
birthweight.
Both maternal undernutrition and
overnutrition of protein rich foods,
junk foods, snack and energy foods
and vegetable rich foods have shown
a substantial varying effects on those
infants with birthweights in the
lower and upper birthweight
quantiles.
Underlying
cause

• Inadequate dietary intake
Maternal factor
Associations between Maternal
Dietary Patterns and Infant
Birth Weight in the NISAMI Cohort:
A Structural Equation
Modeling Analysis
Prospective cohort study was
performed with pregnant women
registered with the prenatal service
(Bahia, Brazil)
Adherence to the “Meat, Eggs, Fried
Snacks and Processed foods” dietary
pattern (pattern 1) and the “Sugars
and Sweets” dietary pattern (pattern
4) in the third trimester directly
reduced birth weight, by 98.42 g
(Confidence interval (CI) 95%: 24.26,
172.59) and 92.03 g (CI 95%: 39.88,
165.30), respectively.
Insufficient dietary consumption in
the third trimester increases maternal
complications during pregnancy,
indirectly reducing birth weight by
145 g (CI 95%: −21.39, −211.45)
Underlying
cause

• Antenatal care visit
Maternal factor
Document Findings
Trends and determinants of Neonatal Mortality
NDHS further Analysis
In the 2011 survey, among most recent births the NMR
was:
13 deaths per 1,000 live births among those whose
mothers had made at least 4 ANC visits
24 deaths per 1,000 live births among those whose
mothers had fewer than 4 ANC visits
Underlying
cause

Maternal factor
Antenatal care services and
its implications for vital and
health outcomes of children:
evidence from 193 surveys in
69 low-income and middle-
income countries
used nationally
representative health and
welfare data from 193
Demographic and Health
Surveys conducted between
1990 and 2013 from 69 low-
income and middle-income
countries
At least one ANC visit was associated with a 1.04%
points reduced probability of neonatal mortality and
a 1.07% points lower probability of infant mortality.
Having at least four ANC visits and having at least
once seen a skilled provider reduced the probability
by an additional 0.56% and 0.42% points,
respectively.
At least one ANC visit is associated with a 3.82%
points reduced probability of giving birth to a low
birth weight baby and a 4.11 and 3.26% points
reduced stunting and underweight probability.
Underlying
cause

Maternal factor
Impact of Antenatal Care on
Maternal and Perinatal
utcome:
A Study at Nepal Medical
College Teaching Hospital
Prospective descriptive study
of women delivered at Nepal
Medical College Teaching
Hospital (NMCTH)
The proportion of low birth weight and preterm
babies was higher in women with inadequate or no
ANC.
Perinatal mortality rate in no ANC and inadequate
ANC groups was 16 times higher than that in the
group with more than 4 visits
Underlying
cause

Delivery factor
• Delivery assistance
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Article/ Report Findings
WHO. Trends in maternal mortality: 2000 to
2017: estimates by WHO, UNICEF, UNFPA,
World Bank Group and the United Nations
population division..
66% of maternal deaths and 43% of neonatal
deaths can be prevented in births that occur with
assistance of SBA
Underlying
cause

Delivery factor
• Place of delivery
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Article/ Report Method Findings
Infant death rates and animal-
shed delivery in remote rural
areas of Nepal
Retrospective study in Jumla Children born in an animal shed
were at significantly higher risk of
dying than were those born in the
home even after adjusting for socio-
economic status and biological
variables.
The association was stronger in the
neonatal period (OR=2.8, 95% CI
1.9–4.1) than during the post-
neonatal period (OR=1.3, 95% CI
1.02–1.6).
Underlying
cause

Delivery factor
• Place of delivery
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Is newborn survival influenced by
place of delivery? A comparison of
home, public sector and private sector
deliveries in India
Data of NFHS-4(national-level
household survey) , 2015–16
It was found that the adjusted odds of
death in the early neonatal period
were lower for deliveries in public
health facilities than for home
deliveries (OR 0.833 p<0.01)
Underlying
cause

Delivery factor
• Mode of delivery
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Neonatal morbidity and mortality by
mode of delivery in very preterm
neonates
Retrospective cohort study
of all singleton pregnancies,
delivered from 22 to 29
weeks' gestation between
2010 and 2015
Cesarean delivery performed for
standard obstetrical indications in
cases of very preterm neonates is
associated with a decreased risk for
death in the delivery room or
within 24 hours of delivery but is
not associated with an
improvement in the overall
morbidity or mortality.
Underlying
cause

Delivery factor
• Mode of delivery
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Neonatal respiratory morbidity and
mode of delivery at term: influence of
timing of elective caesarean section
Rosie Maternity Hospital,
Cambridge
All cases of respiratory
distress syndrome or
transient tachypnoea at
term requiring admission
to the neonatal intensive
care unit were recorded
prospectively for nine
years.
The incidence of respiratory
morbidity was significantly higher
for the group delivered by
caesarean section before the onset
of labour (35.5/1000) compared
with caesarean section during
labour (12.2/1000) (odds ratio,
2.9; 95% CI 1.9–4.4; P < 0.001), and
compared with vaginal delivery
(5.3/1000) (odds ratio, 6.; 95% CI
5.-8.9; P < 0.001).
Underlying
cause

Child related factor
• Age of child
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Article/ Report Findings
Childhood Illness and Mortality in Nepal: Trends
and Determinants, DHS further Analysis Report
2019
Children above age 2 were less likely to have diarrhea,
ARI and fever compared to a child age 2 and below.
Underlying
cause

• Sex of child
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Article/ Report Finding
Childhood Illness and Mortality in
Nepal: Trends and Determinants, DHS
further Analysis Report 2019
Female children (aOR: 0.7, 95% CI: 0.6-0.8, p < 0.01) were less likely
to have fever compared to the male children
Underlying
cause

• Birth order
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Article/Report Method Findings
Childhood Illness and
Mortality in Nepal: Trends
and Determinants, DHS
further Analysis Report
2019
Used data from NDHS 2006 and NDHS
2016
The prevalence of diarrhea was higher
among children with higher birth order.
Association between order
of birth and chronic
malnutrition of children: a
study of nationally
representative Bangladeshi
sample
Used data from the Bangladesh
Demographic Health Survey, 2011
(BDHS)
Order of birth is one of the significant
predictors of child being stunted. Third
order, fourth order, and fifth or higher
order children are 24%, 30%, and 72%,
respectively, more likely to be stunted
after adjusting for all other variables.
Underlying
cause

• Birth Interval
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Mortality rates are higher among children
born less than 2 years after a previous
birth than among children born 2 or more
years after a previous birth
Source: NDHS 2016
Underlying
cause

• Baby’s weight at birth
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• Neonates weighing less than normal
weight (2,500 gram to 3,499 gram) at
birth were more likely to die in the
neonatal period compared to neonates
with normal birth weight.
Underlying
cause

• Dietary intake
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Effects of dietary and health
factors on nutritional status of
children in pastoral settings in
Borana, southern Ethiopia,
August–October 2015
Community based cross-sectional
study, using multistage cluster
sampling
Children who consumed more
diverse foods were at a lower risk of
being underweight (PR = 0.72, 95 %
CL: 0.59–0.88), stunted (PR = 0.80,
95 % CL: 0.68–0.93) and wasted
(PR = 0.42, 95 % CL: 0.27–0.66).
Intake of increased milk frequency
was also associated with lower risk
of underweight (PR = 0.86, 95 %CL:
0.76–0.97), stunting (PR = 0.83, 95
%CL: 0.75–0.91) and wasting
(PR = 0.73, 95 %CL: 0.56–0.96).
Underlying
cause

• Dietary intake
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The relationship between dietary
intake and stunting among pre-
school children in Upper Egypt
Community-based cross-sectional
study
Included 497 pre-school children
aged 2-5 years in rural Upper Egypt.
Children who were stunted
significantly consumed poultry, eggs
and fruits less often than non-
stunted children
Dietary diversity, dietary patterns
and dietary intake are associated
with stunted children in
Jeneponto District, Indonesia
Follow up study, namely nutrition
intervention in pregnant and
lactating women using the RCT-DB
design.
The results showed that a lack
of energy intake associated with
children stunted was 132 (44.9%)
(p = 0.050), and lacked fat
intake was 125 (45.6%) (p < 0.050).
For the dietary diversity there is a
relationship with stunted at a mean
value of 7.51 ± 0.87 (p < 0.050).
Underlying
cause

• Breastfeeding
• Infants aged 0–5 months who are not breastfed have;
• seven-fold times increased risks of death from diarrhoea compared
with infants who are exclusively breastfed
• five-fold times increased risks of death from pneumonia compared
with infants who are exclusively breastfed
• At the same age, non-exclusive rather than exclusive breastfeeding
results in more than two-fold increased risks of dying from diarrhoea or
pneumonia
• 6 to 11 month old infants who are not breastfed also have an increased
risk of such deaths.
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Source: Where and why are 10 million children dying every year? | Child Survival I | The Lancet
Underlying
cause

• Immunization
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Immunization Coverage and
Infant Mortality Rate in
Developing Countries
For immunization coverage, that
of DPT (diphtheria, tetanus,
pertussis) and that of poliomyelitis
were used since they were most
often available.
Immunization coverage is one of the
main predictors of the infant
mortality rate.
Underlying
cause

• Sedentary lifestyle
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Food habits, physical activities
and sedentary lifestyles of
eutrophic and obese school
children: a case–control study
Of 1,441 children (6–12 years old)
screened in elementary schools, 202
obese (BMI ≥95th pc) and 200
normal-weight children (BMI 25th-
75th pc), as defined by the 2000
CDC criteria, were included in a
case–control study.
The children who performed ≥1
h/wk of exercise at school
demonstrated an inverse association
for the risk of obesity compared
with those who performed <1 h/wk
(OR: 0.33; 95% CI: 0.15:0.72)
Underlying
cause

• Postnatal check-up
Post-delivery factors
Article/Report Evidence
Neonatal mortality among babies born to a mother
who had a postnatal visit within three days of birth
was 17 deaths per 1,000 live births, compared with a
rate of 19 among those who had not had a postnatal
visit.
Underlying
cause

• Immediate newborn care
Post-delivery factors
Reports/Article Evidences
Childhood Illness and Mortality in Nepal: Trends
and Determinants, DHS further Analysis Report
2019
Those who did not receive immediate newborn care
were nearly twice as likely to die before reaching
their fifth birthday.
In the 2011 survey, NMR was:
• 12 deaths per 1,000 live births among babies who
received good immediate newborn care
• 18 deaths per 1,000 live births among babies who
did not receive good immediate care.
• Cord care practices also affect neonatal mortality
rates.
Underlying
cause

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03 Conceptual
Framework
Brainstorming

Root Causes
05

Biomass use
• The exposure of children to air pollution in low resource setting is believed to
be high because of the common use of biomass fuels for cooking.
• Globally solid fuel use is estimated to cause 3.5 million premature deaths per
year around 1 million of which are attributed to acute respiratory infections
in young children.1
• The burning of biomass in Nepal has been shown to exacerbate respiratory
disease in children.
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1. Devakumar D, Semple S, Osrin D, Yadav SK, Kurmi OP, Saville NM, Shrestha B, Manandhar DS, Costello A, Ayres JG. Biomass fuel use and the exposure of
children to particulate air pollution in southern Nepal. Environment international. 2014 May 1;66:79-87.
Root cause

Biomass use
• In Nepal about 2/3rd of households rely on biofuels mainly wood, in their
daily cooking practice.2
• About 40% of children under age 5 are stunted, 11% are wasted and 29% are
underweight.2
• In a study which analyzed the secondary data from 2011 NDHS showed
positive association between the biofuel smoke(high pollution fuel exposure)
and stunting among children under 5.2
• The estimated stunting prevalence among children with exposure to biofuel
smoke was about twice as high as the children without exposure.
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2. Dadras O, Chapman RS. Biomass fuel smoke and stunting in early childhood: finding from a national survey Nepal. Journal of Health Research. 2017 Nov
28;31(Suppl. 1):s7-15
Root cause

• Poor hygiene practices contributes to the burden of disease from diarrhea.
• High rates of diarrheal disease in childhood predispose to malnutrition
among young children.
• Diarrhea risk increases during the infant weaning period in low income
settings and child growth often falters after the initiation of weaning.
• Poor hygiene practices include long gaps between meal preparation and
feeding, use of unclean utensils, washing of utensils in contaminated water,
allowing flies to access foods, not washing hands before food handling and
feeding and use of dirty clothes for wiping hands/utensils.3
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3. Gautam OP, Schmidt WP, Cairncross S, Cavill S, Curtis V. Trial of a Novel Intervention to Improve Multiple Food Hygiene Behaviors in Nepal. The American
journal of tropical medicine and hygiene. 2017 Jun 7;96(6):1415-26.
Root cause

• Children in low-income countries face a range of interrelated problems such as
inadequate water, sanitation and hygiene(WASH), consequent infections and
growth and development impairments.4
• In a study in eastern region of Nepal it showed that 31.5% of children were found
to be infected with intestinal parasites and parasitic infections were significantly
associated with not using soap after defecation, the habit of thumb sucking, and
not wearing sandals. 5
• Access to a safe , reliable and continuous supply of water, cultural practices of
painting mud floors in home with animal dung etc are some reasons which is
responsible for poor hygiene practices.
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4. Shrestha A, Six J, Dahal D, Marks S, Meierhofer R. Association of nutrition, water, sanitation and hygiene practices with children’s nutritional status,
intestinal parasitic infections and diarrhoea in rural Nepal: a cross-sectional study. BMC public health. 2020 Dec;20(1):1-21.
5. Sah RB, Bhattarai S, Yadav S, Baral R, Jha N, Pokharel PK. A study of prevalence of intestinal parasites and associated risk factors among the school
children of Itahari, Eastern Region of Nepal. Tropical parasitology. 2013 Jul;3(2):140.
Root cause

Unsafe drinking water and food
• Intestinal parasitic infections are most common in school going children and
they tend to occur in high intensity in 3-12 year age group.
• Protozoa and Helminthes spread faeco-orally through contaminated sources.
• High prevalence of intestinal parasitic infection often occurs in low socio-
economic condition, characterized by inadequate water supply and poor
sanitary disposal of faeces.6
• In a study done in saktikhor , Chitwan showed parasitic infection rate in well
water higher(16/55) than that of tap water(53/253).7
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6. Al-Agha R, Teodorescu I. Intestinal parasites infestation and anemia in primary school children in Gaza Governorates--Palestine. Roumanian archives of
microbiology and immunology. 2000 Jan 1;59(1-2):131-43.
7. Bhattachan B, Panta YB, Tiwari S, Sherchand JB, Rai SK. Intestinal parasitic infection among school children in Chitwan District Of Nepal. Journal of Institute
of Medicine. 2015 Nov 6;38(2).
Root cause

Unsafe drinking water and food
• In one of the community-based survey of kaski district which included 524
mother of 3-5 years old children who are no longer breastfed showed that
34% did not choose healthy food from stores and 12 % lacked food.
• Study suggested that important factors of knowledge, attitudes and beliefs
about healthy diet are poverty, education, strong cultural beliefs, family size,
household income and growing preference for fast food.
• It also showed that almost 19% mothers of the community believed that
feeding of green leafy vegetables and fruits during the illness period caused
harm to child and 10% mothers have no knowledge about it.
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8. Acharya J, van Teijlingen E, Murphy J, Hind M. Study on nutritional problems in preschool aged children of Kaski district of Nepal. Journal of Multidisciplinary
Research in Healthcare. 2015 Apr 23;1(2):97-118.
Root cause

Socioeconomic characteristics
• The rate of full vaccination coverage shows a clear increment with increasing
maternal education in all NDHS years, being 57% in infants of mothers with no
education to 90.9% among those with higher education in 2001 and from 67.8%
to 91.2% in 2016.9
• Infants born to mothers with primary or higher education had higher chances of
being fully immunized compared to infants born to mothers with no education.
• Similarly, infants born in households with higher wealth quintiles had higher
chances of being fully immunized compared to infants born in the poorest wealth
quintile.
9/02/2022 64
9. Acharya K, Paudel YR, Dharel D. The trend of full vaccination coverage in infants and inequalities by wealth quintile and maternal education: analysis from four
recent demographic and health surveys in Nepal. BMC public health. 2019 Dec;19(1):1-1
Root cause

• In one of the study which has analyzed DHS data from 42
developing countries shown the association between
socioeconomic characteristic and child health.10
• Household wealth offers leverage for improving child health
within countries in much the same way that economic
development level can improve child health nationally.
• It provides an opportunity to improve the material circumstances
of the family and to purchase goods and services that are health
enhancing
9/02/2022 65
10. Boyle MH, Racine Y, Georgiades K, Snelling D, Hong S, Omariba W, Hurley P, Rao-Melacini P. The influence of economic development level, household wealth
and maternal education on child health in the developing world. Social science & medicine. 2006 Oct 1;63(8):2242-54.
Root cause

• Women's education offers leverage for improving child health through the
provision of more effective parental care in the home and enhanced use of
treatment and prevention services from the health care system.
• Maternal education may also contribute to delayed child bearing, longer birth
intervals and fewer children as well as improved opportunities to pursue
work outside the home and to generate additional household wealth.
• Studies show repeatedly that women's education is associated with longer life
expectancies, lower death rates and improved child health and nutrition.
9/02/2022 66
10. Boyle MH, Racine Y, Georgiades K, Snelling D, Hong S, Omariba W, Hurley P, Rao-Melacini P. The influence of economic development level, household wealth
and maternal education on child health in the developing world. Social science & medicine. 2006 Oct 1;63(8):2242-54.
Root cause

• A child’s socioeconomic status can be reflected by parent or family-based
characteristics(parental education, occupation and family affluence).
• Socioeconomic status is related to physical and psychosocial health of children
and adolescents.
• Effects of socioeconomic status on child health are mediated by structural,
behavioral and psychosocial factors.
• Low SES shows adverse short-time and long-time effects on physical and
psychosocial health of child.
9/02/2022 67
11. Poulain T, Vogel M, Kiess W. Review on the role of socioeconomic status in child health and development. Current Opinion in pediatrics. 2020 Apr
1;32(2):308-14
Root cause

Cultural practices
• Nepal being a culturally rich country, has diverse customs, caste groups and
deep-rooted religious beliefs and practices.
• One of the disheartening cultural practices women are subject to is
“chhaupadi Pratha”(seclusion of women during menstruation and after
childbirth).12
• Women during childbirth and after delivery are separated from the family
members for 10-12 days. During isolation women are not allowed to consume
milk and milk products such as ghee nor are they allowed other nourishing
food items.12
9/02/2022 68
12. Lama D, Kamaraj R. Maternal and Child Health Care in Chhaupadi Pratha, Social seclusion of mother and child after delivery in Achham, Nepal. Public Health
Research Series. 2015;4:22-33
Root cause

Cultural practices
• Traditionally in care of newborns the child is given a bath immediately after
birth and daily until the mother is purified.
• Health problems like cough, cold, fever, diarrhea and pneumonia are the most
common problem reported due to such cultural practices.
• Many women go through difficulties and with no doubt the care given to the
newborns are also compromised due to such cultural practices which results
in child’s poor health outcome.
9/02/2022 69
12. Lama D, Kamaraj R. Maternal and Child Health Care in Chhaupadi Pratha, Social seclusion of mother and child after delivery in Achham, Nepal. Public Health
Research Series. 2015;4:22-33

Cultural practices
• The practice of shaving off newborn’s head after delivery was found in some
clusters in Jhapa Rajbanshi.
• A case of neonatal tetanus after shaving head recorded in Jhapa.
• Health worker reported that child died from neonatal tetanus resulted after
3-4 days of shaving off the head.
• Son preference culture and practices has guided to have more childbirth until
a son birth.
• Caring mother and child are good when boy is born due to which gender
discrimination creates an environment for maternal and child mortality.
9/02/2022 70
13. Subba NR. Traditional practices on mother and child health care in Rajbanshi Community of Nepal. American Journal of Health Research. 2015;3(5):310-7.

Health system characteristics
• Distance to health facility is related to utilization of health services which
affects the child health.
• Compared to communities that are 2-3 hours away from a health post, use of
both antenatal and child immunization services is higher when the health
post is located within the community.
• Immunization coverage is 3-4 times higher among families whose nearest
health post is a high quality one than among those who have a poor-quality
post.
9/02/2022 71
14. Acharya LB, Cleland J. Maternal and child health services in rural Nepal: does access or quality matter more?. Health policy and planning. 2000 Jun
1;15(2):223-9

• Skilled birth attendants provide important interventions that improve
maternal and neonatal health and reduce maternal and neonatal mortality.
• Utilization remains poor in rural and remote areas of Nepal.
• In a study among 2481 women of mid and far western Nepal who delivered a
baby within. Past 12 months showed that 48% of the women delivered their
babies with aid of SBAs.
• Distance from health facilities and inadequate transportation pose major
barriers to the utilization of SBAs.
9/02/2022 72
15. Choulagai B, Onta S, Subedi N, Mehata S, Bhandari GP, Poudyal A, Shrestha B, Mathai M, Petzold M, Krettek A. Barriers to using skilled birth attendants’ services in
mid-and far-western Nepal: a cross-sectional study. BMC international health and human rights. 2013 Dec;13(1):1-9.
Root cause

• Despite efforts by the GoN, data from last three DHS show contribution of
neonatal deaths to infant and child mortality.
• There are several community-based programs like safe motherhood, birth
preparedness package, community-based newborn care package and IMCI.
• Challenges like inadequate policy environment, funding gaps, inadequate
procurement and insufficient supplies of commodities, as well as human
resource management has been found to be impeding service delivery.
9/02/2022 73
16. Khatri RB, Mishra SR, Khanal V, Gelal K, Neupane S. Newborn health interventions and challenges for implementation in Nepal. Frontiers in Public Health.
2016 Feb 11;4:15.
Root cause

- Poor adherences to essential newborn care standards
- Low programmatic priority of birth preparedness package
- Inadequate family and community awareness on preterm labor
- Poor supply of logistics to perform KMC
- Poor competency of SBAs to manage the birth asphyxia
- Lack of postnatal care guideline for newborn at home
- Delay procurement and poor supply chain management
- Lack of neonatal nurse and other skilled health human resources
9/02/2022 74
16. Khatri RB, Mishra SR, Khanal V, Gelal K, Neupane S. Newborn health interventions and challenges for implementation in Nepal. Frontiers in Public Health.
2016 Feb 11;4:15.
Root cause

9/02/2022 75
03 Conceptual
Framework
Brainstorming

Political and economic structure
- The politics of health sector decision-making and resources allocation can be
more complicated in the context of decentralization.
- Weaknesses in access to and use of data and information, human resource
capacity and sub-national democratization limit effective political advocacy
for the health sector.
- Political economy analysis is an important for determining the reasons for
decisions made and resource allocations in the health sector.
9/02/2022 76
17. Hipgrave DB, Anderson I, Sato M. A rapid assessment of the political economy of health at district level, with a focus on maternal, newborn and child health, in
Bangladesh, Indonesia, Nepal and the Philippines. Health Policy and Planning. 2019 Dec 1;34(10):762-72.

Political and economic structure
Barnish, M.S., Tan, S.Y., Taeihagh, A. et al. Linking political exposures to child and maternal health outcomes: a
realist review. BMC Public Health 21, 127 (2021)

Conclusion
06

• Thus child health is determined by the state of child morbidity and mortality.
• Child morbidity and mortality has its cause deep rooted which needs to be
looked for.
• Root cause analysis is required to address the problems of child health and to
design the intervention to address it
• For every immediate cause there is underlying and that underlying cause
remains or prevails due to root cause.
• Child mortality or morbidity may be due to disease or conditions like injuries.
Underlying causes like outdoor air pollution, child care practices, indoor air
pollution combined contributes to prevalence of such disease/conditions .
• And as we further analyse- factors like poverty, illiteracy, low SES etc are the
root causes.
Conclusion

References
07

References
1. Devakumar D, Semple S, Osrin D, Yadav SK, Kurmi OP, Saville NM, Shrestha B, Manandhar DS, Costello
A, Ayres JG. Biomass fuel use and the exposure of children to particulate air pollution in southern
Nepal. Environment international. 2014 May 1;66:79-87.
2. Dadras O, Chapman RS. Biomass fuel smoke and stunting in early childhood: finding from a national
survey Nepal. Journal of Health Research. 2017 Nov 28;31(Suppl. 1):s7-15.
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Multiple Food Hygiene Behaviors in Nepal. The American journal of tropical medicine and hygiene.
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9. Acharya K, Paudel YR, Dharel D. The trend of full vaccination coverage in infants and inequalities by
wealth quintile and maternal education: analysis from four recent demographic and health surveys in
Nepal. BMC public health. 2019 Dec;19(1):1-1.
10. Boyle MH, Racine Y, Georgiades K, Snelling D, Hong S, Omariba W, Hurley P, Rao-Melacini P. The
influence of economic development level, household wealth and maternal education on child health in the
developing world. Social science & medicine. 2006 Oct 1;63(8):2242-54.
9/02/2022 83

References
11. Poulain T, Vogel M, Kiess W. Review on the role of socioeconomic status in child health and
development. Current Opinion in pediatrics. 2020 Apr 1;32(2):308-14.
12. Lama D, Kamaraj R. Maternal and Child Health Care in Chhaupadi Pratha, Social seclusion of mother
and child after delivery in Achham, Nepal. Public Health Research Series. 2015;4:22-33.
13. Subba NR. Traditional practices on mother and child health care in Rajbanshi Community of Nepal.
American Journal of Health Research. 2015;3(5):310-7.
14. Acharya LB, Cleland J. Maternal and child health services in rural Nepal: does access or quality matter
more?. Health policy and planning. 2000 Jun 1;15(2):223-9.
15. Choulagai B, Onta S, Subedi N, Mehata S, Bhandari GP, Poudyal A, Shrestha B, Mathai M, Petzold M,
Krettek A. Barriers to using skilled birth attendants’ services in mid-and far-western Nepal: a cross-
sectional study. BMC international health and human rights. 2013 Dec;13(1):1-9.
16. Khatri RB, Mishra SR, Khanal V, Gelal K, Neupane S. Newborn health interventions and challenges for
implementation in Nepal. Frontiers in Public Health. 2016 Feb 11;4:15.
9/02/2022 84

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17. Hipgrave DB, Anderson I, Sato M. A rapid assessment of the political economy of health at
district level, with a focus on maternal, newborn and child health, in Bangladesh, Indonesia, Nepal
and the Philippines. Health Policy and Planning. 2019 Dec 1;34(10):762-72
18. Perin J, Mulick A, Yeung D, Villavicencio F, Lopez G, Strong KL, Prieto-Merino D, Cousens S,
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Child Health in Nepal: Root Cause Analysis

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