This presentation is prepared as part of the Course assignment of “Demography, Reproductive Health ” for the Master's Degree of Public Health (MPH), Pokhara University and can be used as reference materials for critical review and appraisal of newborn programs of Nepal. The content and facts included in the presentation are as of information available till July 2022 and no conflict of interest is associated with the presentation. The presentation is prepared by Sagar and Sunita.

1. 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

2.  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
Content Outlines

3. • 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

4. Categorization of Neonatal
Period
 Perinatal Period
 Early-natal period
 Late Neonatal period
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Newborn Health & Newborn Health Care Services

5. 5
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

6. 6
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

7. 7
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
5. High Temperature (37.5 C or more)
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
Danger
Signs

8. • 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

9. 12/20/2022 9
Newborn Health; Global Status
WHO 2020

10. 12/20/2022 10
Newborn Health; Global Causes of Newborn Death
34.7
24.1
15.2
11.2
6.1
0.6
1.2
1.3 5.6
Global causes of Newborn Deaths, UNICEF 2018
Preterm birth complications
Intrapartum related events
Sepsis or Meningitis
Congenital
Pneumonia
Diarrhoea
Tetanus
Injury
Others

11. 53 50 39
33 33
23 21
16 12
99
78
64
48
46
33 32 25
142
118
91
61
54
38
39 28
25
0
20
40
60
80
100
120
140
160
NMR IMR U5MR
Under-five mortality rate  by 73%
Infant mortality rate  by 68%
Neonatal mortality rate  by 60%
11
Trend of Under-5 Mortality Rate in Nepal

12. 42
43
54
61 60 60
63
61
69
72
69 69
0
10
20
30
40
50
60
70
80
NFHS 1996 NDHS 2001 NDHS 2006 NDHS 2011 MICS 2014 NDHS2016
NMR as % of U5MR NMR as % of IMR
12
% of NMR among U5MR and IMR

13. Infection specific
to perinatal
period
16%
Congenital
malformations &
deformations
7%
Sudden neonatal
death
6%
Hypothermia
4% Other
7%
Respiratory &
cardiovascular
disorder of
perinatal period
31%
Complications
of pregnancy,
labor & delivery
31%
NDHS, 2016
13
Causes of Neonatal Deaths

14. 32 30
37
26
12
19
7
7
10
2
5
10 5
Female Male
Other
Hypothermia
Sudden neonatal death
Congenital malformations &
deformations
Infection specific to perinatal
period
Complications of pregnancy,
labor & delivery
Respiratory & cardiovascular
disorder of perinatal period
Percent distribution of neonatal deaths within 0-27 days of birth
14
Causes of Neonatal Deaths by Sex
NDHS, 2016

15. <1 hour
17%
1-23 hours
40%
24-167 hours
22%
7-27 days
21%
Percent distribution of neonatal deaths within 0-27 days of birth
15
Time period of Neonatal Deaths
NDHS, 2016

16. Complications of
pregnancy, labor &
delivery
41%
Unspecified
cause
54%
Congenital
malformations
&
deformations
1%
Disorders
related to
length of
gestation &
fetal growth
4%
Percent distribution of causes of stillbirths
16
NDHS, 2016
Causes of Stillbirths

17. • 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
Treatment of Newborn (0-28 days) cases in FY 077/78

18. 18
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

19. 12/20/2022 19
Factors affecting Neonatal Mortality
NDHS, 2016

20. 12/20/2022 20
Factors affecting Neonatal Mortality
Source: Determinants of Neonatal Mortality, Indonesia

21. 1979
• National Immunization Program (EPI)
1983
• Diarrhea Control Program
1987
• ARI Control Program
1998
• Community Based Integrated Management of Childhood Illness
Program- CBIMCI
2005
• Morang Innovative Neonatal Intervention pilot(MINI)
• Zinc + Low osmolar ORS for diarrhea treatment
21
Child Survival to Child Health Programs- Major Milestones

22. 2009
• Community Based Newborn Care Program (CB-NCP)
2011
• Use of Chlorhexidine for cord care
2014
• Community Based Integrated Management of Neonatal and Childhood
Illnesses- CBIMNCI
2015
• Facility based IMNCI and free newborn care
2016
• Nepal Every Newborn Action Plan
22
Child Survival to Child Health Programs- Major Milestones

23. 12/20/2022 23
Policies and programs Development

24. Child Health
Programs
Newborn Care
Services
Level I
(Newborn
corner)
HP/PHCC/
Hospital
Level II
(Special
Newborn Care
Unit)
Hospitals
Level III
(Newborn Intensive
Care Unit)
Zonal Hospital
and above
IMNCI
CB-
IMNCI
HP/PHCC/DH
FB-IMNCI
DH
Referral
24
Newborn and Child Health Services Structure

25. Level IMNCI Service Newborn Care Service
HP (without Birthing
Center)
Case management protocol
Health Post (with
birthing center)
+ Essential newborn care
+ Resuscitation
+ Case management
(Newborn corner, through SBA)
PHCC Case management
Focused treatment
Emergency Management
Level 1 care
(Newborn corner, ENC, PMTCT, thermal
care, feeding, transfer, growth and
nutrition monitoring)
Hospital Case management
Focused treatment
Emergency management
Level 2 care
(Level 1 care + Special Newborn Care
Unit (SNCU)+ KMC care)
Zonal Hospital and
Above
Case management
Focused treatment
Emergency management
Level 3 care
(NICU) (Level I + Level II + KMC care
unit + Ventilation)
25
Services and Level of Care

26. 26
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

27. • 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
27
Newborn Specific Program Interventions

28.  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
Newborn Specific Programs & Provisions

29. Package Type Treatment and Care services for Health Facility per case management Unit Cost
Package 0 - Resuscitation
- KMC
- Antibiotics as per IMNCI protocol
No Cost
Package 'A' Medicines- Antibiotics and other drugs as per National Neonatal Clinical
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
Rs. 1000
29
Free sick newborn care packages

30. Package Type Treatment & Care Services for Health Facility Unit Cost
Package ‘B’ Photo therapy
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)
Rs 2000
Package ‘C’ NICU Admission (Must)
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
Rs 5000
30
Free sick newborn care packages

31. 31
NICU and SNCU Service Sites

32. 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
Newborn & IMNCI Program Key Monitoring indicators

33. • 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

34. 34
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

35. 35
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

36. 36
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

37. 37
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.

38. • 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
Government Plans for Newborn Health

39. 39
Helping Babies Breathe and Helping Mother Survive

40. 40
Critical Appraisal; Issues and Challenges
Building Blocks of
Health System
Issues, Challenges and Constraints
Service
Delivery
Lack of designated SNCU & NICU at Health Facility-combined with other
services, No address of SNCU/NICU/KMCU at Health Facility Structure
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
Human
Resources
Lack of trained Human resources/Coach/Mentor for mentoring sessions at
national level, No refresher trainings on time, Frequent HSP transfer resulting
into service discontinuation,
Information
Less IEC materials and A/V contents on Newborn danger signs and
management, Newborn care services information
Lack of effective Social Behavior Change Communication(SBCC) Strategies

41. 41
Critical Appraisal; Issues and Challenges
Building Blocks of
Health System
Issues, Challenges and Constraints
Medicines &
Technologies
More Central procurement for Newborn and Child Health Programs
Commodities- lack of timely dispatch to local levels, discontinuation of
services due to lack of commodities
Healthcare
Financing
Less prioritized budget for newborn care programs
Provincial and local government giving less priority to MNH Programs during
Annual Work Plan Budgeting (AWPB) Preparation
Hospitals more dependent on government budget,
Leadership &
Governance
Lack of regular supportive supervision, monitoring and evaluation
Lack of effective referral pathway, mechanism and guidelines
Not so expected Public private partnership and stakeholder engagement

42. 42
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

43. 12/20/2022 43
• 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

44.  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
12/20/2022 44
Newborn Health & Investment in Newborn Health
Care Services: Necessity from Policy to Actions

45. 12/20/2022 45
Newborn Health & Investment in Newborn Health Care
Services: Necessity from Policy to Actions

46. • https://www.who.int/westernpacific/health-topics/newborn-health
• https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/newborn-
health/essential-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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References

47. 12/20/2022 47
Thank you!