Critical Appraisal of New Born Care
Policies, Programs, Guidelines and
Implementation Strategies
1
Aslam Aman
MPH-3rd Batch
School of Health and Allied Sciences (SHAH)
Pokhara University (P.U>)
2
Contents:

Back Ground and Introduction

Progress and Trend of New Born Health Care

Provision of New Born Health Care Packages

Policy, Program and Strategies

Gaps in Neonatal health and Recommendations
Historical Over view of New Born Care and
Child Health Program in Nepal
Control of
Diarrhoeal Disease
(CDD)-1983
Community
Based Integrated
.
Management of Newborn Care &
Childhood Illness
(CB-IMNCI)- 2014
Community Based
Newborn Care Program
(CB-NCP)-2007
New
Born
Care &
Child
Health
Community Based integrated
Management of Childhood
Illness (CB-IMCI)- 1997
3
Control of ARI Program
(CAP) -1987
Community Based ARI
(CB-ARI) Control
Program -1995
Community Based ARI &
Diarrhoea Control (CBADC) Program-1996
4
New Born Care

A newborn infant, or neonate, is a child under 28 days of age.

During these first 28 days of life, the child is at highest risk of dying.

Essential newborn care is the basic care needed to help ensure the survival and well
being of the babies and includes warmth, normal breathing, feeding, infection
prevention and encompasses: immediate care at birth, care during the first day and
care up to 28 days.

It is thus essential that appropriate feeding and care are provided during this period,
both to improve the child‘s chances of survival and to lay the foundations for a
healthy life.

Neonatal health is an important component of the national reproductive health
strategy
5
New Born Period
6
New Born Death Period
7
New Born Care

The following essential care should be taken to prevent new born from infection and
complications:

The new born dried with a clean, soft and dry cloth

The newborn wrapped from head to with another dry cloth and kept warm along with the
mother (Kangaroo Care)

Breast feeding (colostrum) initiated within one hour of birth.

Cord kept dry and nothing applied to the cord (But recent strategies have to use cholorhexagin

Bathing of newborn avoid for the first 24 hours.

Health worker contacted for the first PNC visit within 3 days (Preferably within 24 hours).At the
same time new born should get BCG immunization
8
New Born Care

Following are the life threating danger signs in New born:

Unable to suck or Breast feed

Lethargic or Unconscious

Fever

Cold Hands and Feet

Fast breathing or difficulty in breathing or severe chest indrawing

Umbilical discharge with redness extending to the surrounding skin

One abscess or more than 10 skin postulates on the newborn baby‘s body

Weak cry or absent cry
9
Neonatal Mortality Factors
10
Plan and Policies of Nepal on New
Born Care
11
The National Safe Motherhood Program is a priority area for the government of Nepal to
improve maternal and neonatal health (MOH 2015b). As part of this program
the National Neonatal Health Strategy was endorsed in 2004 to provide guidelines on
improving neonatal health (MOHP 2004).
National Safe motherhood and Newborn Health long Term Plan (2006-2017)have goal to
Improved maternal and neonatal health and survival, especially of the poor and
excluded.
The key indicators for this NSMNH-LTP goal are:
1. A reduction in the maternal mortality ratio from 539 per 100,000 live births1 to
134 per 100,000 by 2017
2. A reduction in the neonatal mortality ratio from 39 per 1,0002 to 15 per 1,000
by 2017.
12
Plan and Policies

Likewise, a policy on skilled birth attendants (SBAs) endorsed in 2006 by the
MOH identified the importance of SBAs at every birth and embodied the
government of Nepal‘s commitment to training and deploying doctors, nurses,
and auxiliary nurse midwives with required skill across the country.

Furthermore, in 2008-2009, the birth preparedness package was rolled out in all
75 districts to improve timely access to delivery care services.

Similarly, a maternity incentive scheme was introduced in 2005 to encourage
women to use health facilities for maternity care and improve access to
maternity and New Born care services (MOH 2015b).
13
Plan and Policies



In 2016, the government of Nepal endorsed the country‘s Every
Newborn Action Plan, which sets a vision for the country ―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.‖
MoHP has made newborn health a priority and initiated integrated
newborn health care package called CB-IMCI and later on modified as
―Community Based Newborn Care Program (CB-NCP)‖ based on the
National Neonatal Health Strategy 2004 and Now it is called as CB-IMNCI
The major causes of neonatal deaths in Nepal are(IBPH) – Infection, Birth
Asphyxia, Preterm birth, Hypothermia
14
Community Based Integrated Management
of New Born Care (Neonatal care) and
Childhood Illness (CB-IMNCI)
15
Introduction :CBIMNCI

CB-IMNCI is an integration of CB-IMCI and CB-NCP Program that is being implemented
across the country after the decision of MoH on 2071/6/28 (October 14, 2015). This
integrated package of child‐survival intervention addresses the major problem of sick
newborn such as birth asphyxia, bacterial infection, jaundice, hypothermia, low birth
weight, counseling of breastfeeding. Among the age group of 2 months to 59 months
children, it addresses major childhood illnesses like Pneumonia, Diarrhea, Malaria,
Measles and Malnutrition in a holistic way.

In CB‐IMNCI program, FCHVs are expected to carry out health promotional activities
for maternal, newborn and child health and dispensing of essential commodities which
do not require assessment and diagnostic skills like distribution of iron, zinc, ORS,
chlorhexidine and immediate referral in case of any danger signs appear among sick
newborn and child.
16

And health workers will counsel, and provided the health service like management of
non‐breathing cases, skin to skin contact and management of neonatal sepsis and
common childhood illness. Also program has provisioned the post‐natal visits by trained
health workers through primary health care outreach clinic. For treatment of possible
severe bacterial infection (PSBI), treatment recommended is injection Gentamicin and
inj. Ampicillin or oral Amoxicillin.
17
Goal

Improve newborn and child survival and healthy growth and
development.
18
Objective

To reduce neonatal morbidity and mortality by promoting essential
newborn care services

To reduce neonatal morbidity and mortality by managing major causes
of illness

To reduce morbidity and mortality by managing major causes of illness
among under 5 years
19
Targets

Reduction of Under-five mortality rate (per 1,000 live births) to 28 by
2020

Reduction of Neonatal mortality rate (per 1,000 live births) to 17.5 by
2020
20
Strategies
Quality of care through system strengthening and referral services for
specialized care
 Ensure universal access to health care services for new born and young
infant
 Capacity building of frontline health workers and volunteers
 Increase service utilization through demand generation activities
 Promote decentralized and evidence-based planning and
programming

21
Major Interventions


Newborn Specific Interventions
Promotion of birth preparedness plan

Promotion of essential newborn care practices and postnatal care to
mothers and newborns

Identification and management of non-breathing babies at birth

Identification and management of preterm and low birth weight babies

Management of sepsis among young infants (0-59days) including
diarrhoea
22
Major Interventions

Child Specific Interventions

Case management of children aged between 2-59 months for 5 major childhood killer
diseases (Pneumonia, Diarrhoea, Malnutrition, Measles and Malaria)

Cross-cutting Interventions:

Behaviour change communications for healthy pregnancy, safe delivery and
promote personal hygiene and sanitation

Improved knowledge related to Immunization and Nutrition and care of sick children

Improved interpersonal communication skills of HWs and FCHVs
23
Monitoring Indicators of CB-IMNCI
% of Institutional delivery
 % of newborn who had applied Chlorhexidine gel immediately after
birth (within one hour)
 % of infants (0 % of under 5 children with pneumonia treated with
antibiotic
 % of under 5 children with diarrhoea treated with ORS and Zinc
 Stock out of the 5 key CB-IMNCI commodities at health facility (ORS,
Zinc, Gentamicin, Amoxicillin/Cotrim, CHX)

24
Vision 90 by 20

CB-IMNCI vision to provide targeted services to 90% of the estimated population by 2020 as
shown in the diagram
25
Impact of Program

Institutional delivery has increased

Newborn Sepsis identified and treated at community level

Universal treatment procedure over the district

Government providing incentives to HW, Mothers and FCHVs for new
born care

Community people are satisfied due to no cost for the treatment

Decreased neonatal and child morbidity and mortality

Improvement in other safe-motherhood and Child Health indicators

Recognization of FCHVs in the community/ social mobilization
26
Criticisms/Challenges
Sustaining the quality of CB-IMNCI
 No Separate focal Person for CB-IMCI in districts
 IMNCI protocol not used properly
 New Health worker without CB-IMNCI training
 Inadequate resources to sustain CB-IMNCI
 Inadequate and poor quality supply of drug and equipment for CBIMNCI


Slow Scale up (Interventions)
27
Recommendation

Implementation of revised CB-IMCI Package

Need to arrange the fund for continuity of the program

Separate post for focal person of CB-IMCI should be created

Close monitoring and supervision at all level

Provision of training for newly recruited staff on CB-IMNCI

Strengthen facility based new born care

Adequate budget allocation and timely procurement of drugs and equipment
and implementation
28
Trends of New Born Health Care





More than half of births (57%) are delivered in a health facility, primarily in
government sector facilities. However, 41% of births are delivered at home.
Women with SLC and above education (85%) and those in the wealthiest
households (90%) are more likely to deliver at a health facility. Only 8% of births in
1996 were delivered in a health facility, compared to 57% in 2016.
Overall, 58% of births are assisted by a skilled provider, the majority by doctors.
One in ten births are assisted by no one.
Skilled assistance during delivery has increased from 9% in 1996 to 58% in 2016.
More than half of women (57%) receive a postnatal check within two days of
delivery, while 42% did not have a postnatal check within 41 days of delivery.
57% of newborns receive a postnatal check within two days of birth, while 40%
did not have a postnatal check.
Of total pregnancies, 81% were live births, 9% were induced abortions, 9% were
miscarriages, and 1% were stillbirths.
29
Trends of New Born care

Source: NDHS 2016
30
Trends of New Born care
31
Trends of New Born care

Source: NDHS 2016
32
Trends of New Born Care
33
Trends of New Born Care
Main Strategies of Safe Motherhood
and New Born Care Program
34

Free New Born care Services: The Government of Nepal (GoN) has made provisions on
treating sick newborn free of cost through all tiers of its health care delivery outlets. The
aim of this program is to prevent any sorts of deprivation to health care services of the
newborn due to poverty. Based on the treatment services offered to the sick-newborn,
the services are classified into 3 packages: A, B and C. The new born corners in health
posts and PHCs offer Package ‗A‘, district hospitals with Special Newborn Care Unit
(SNCU) offer Package ‗B‘ and zonal hospitals and other tertiary hospitals offering
Neonatal Intensive Care Unit (NICU) provide services for Package ‗C‘.

The government has made provisions of required budget and issued directives to
implement the free newborn care packages in Nepal. The goal of the Free Newborn
Care Service Package is to achieve the sustainable development goal through
increasing access of the newborn care services to reduce newborn mortality. The
program makes the provision of disbursing Cost of Care to respective health institutions
required for providing free care to inpatient sick newborns.
Main Strategies of Safe Motherhood
and New Born Care Program





35
Promoting inter-sectoral coordination and collaboration at central, regional,
districts and community levels to ensure commitment and action for
promoting safe motherhood with a focus on poor and excluded groups.
Strengthening and expanding delivery by skilled birth attendants and
providing basic and comprehensive obstetric care services at all levels.
Interventions include:
developing the infrastructure for delivery and emergency obstetric care;
standardizing basic maternity care and emergency obstetric care at
appropriate levels of the health care system;
strengthening human resource management — diploma in gynaecology
(DGO), advanced skilled birth attendant (ASBA), SBA, anaesthesia assistant
training and deployment;
Main Strategies of Safe Motherhood
and New Born Care Program
36

Establishing a functional referral system with airlifting for emergency
referrals from remote areas, the provision of stretchers in VDC wards
and emergency referral funds in remote districts; and

strengthening community-based awareness on birth preparedness
and complication readiness through FCHVs and increasing access to
maternal health information and services.

Supporting activities that raise the status of women in society.

Promoting research on safe motherhood to contribute to improved
planning, higher quality services and more cost-effective interventions.
Safe Motherhood and New Born Care
Activities
37

Nyano Jhola Programme to protect newborns from hypothermia and infections and to increase the
use of peripheral health facilities (birthing centres). Two sets of clothes (bhoto, daura, napkin and
cap) for newborns and mothers, and one set of wrapper, mat for baby and gown for mother are
provided for women who give birth at birthing centres and district hospitals.

Birth Preparedness Package (BPP) OR Jeewan Suraksha Karyakram:

Focused on ANC , Safe delivery and PNC

Expand and maintain MNH activities at community level including the Birth Preparedness Package
(jeevan suraksha flipchart and card) and distributed the matri suraksha chakki (misoprostol) to
prevent postpartum haemorrhage (PPH) in home deliveries.

birth preparedness and complication readiness (preparedness of money, health facilities for the
delivery, transport and blood donors); antenatal care (ANC) and postnatal care (PNC) (iron,
tetanus toxoid, albendazole); self-care (food, rest, no smoking and alcohol) in pregnancy and
postpartum periods; essential newborn care; and the identification of and prompt care seeking for
danger signs in the pregnancy, delivery, postpartum and newborn periods.
Safe Motherhood and New Born Care
Activities
38

Community Based Maternal and Neonatal Care Program (CB-MNCP):

FCHV provide antenatal health education, promote seeking care by SBA, arrangement of
money, transportation and blood for birth preparedness, appropriate care seeking of danger
signs, postnatal home visits and assessment of new born and mothers

Distribution of Misoprostol tablets for prevention of PPH at home birth

Identification and Management of LBW babies
Safe delivery Incentive programs (SDIPS)

For newborns: A payment to health facilities for providing free sick newborn care. Facilities are
reimbursed for set packages of care: Packages 0, A, B and C costing nothing, NPR 1,000, NPR
2,000 and NPR 5,000 respectively. Health facilities can claim a maximum of NPR 8,000
(packages A+B+C), depending on medicines and diagnostic and treatment services
provided.
Safe Motherhood and New Born Care
Activities
39

Safe delivery Incentive programs (SDIPS) OR Ama and New Born Care Parogram

Incentives to health workers (to be arranged from health facility reimbursement
amounts): For deliveries, a payment of NPR 300 to health workers for attending all
types of deliveries. A payment of NPR 300 to health workers for providing all forms of
packaged services.

Transport incentive for institutional delivery: Cash payment to women immediately
after institutional delivery (NPR 1,500 in mountains, NPR 1,000 in hills and NPR 500 in
Tarai districts).

Incentive for 4 ANC visits: A cash payment of NPR 400 to women on completion of
four ANC visits at 4, 6, 8 and 9 months of pregnancy, institutional delivery and
postnatal care.
Safe Motherhood and New Born Care
Activities
40

Free institutional delivery services:

A payment to health facilities for providing free delivery care. For a normal delivery health
facilities with less than 25 beds receive NPR 1,000 and health facilities with 25 or more beds
receive NPR 1,500.

For complicated deliveries health facilities receive NPR 3,000 and for C-sections (surgery) NPR
7,000.
Safe Motherhood and New Born Care
Activities
41

Emergency Referral Fund

The main objective of this programme is to support emergency referral transport to
women from poor, Dalit, Janajati, geographically disadvantaged, and socially and
economically disadvantaged communities who need emergency caesarean sections or
complication management during pregnancy or child birth.

Safe Abortion Services

Pre and post counseling on safe abortion methods and post-abortion contraceptive
methods;

Termination of pregnancies as per the national protocol;

Diagnosis and treatment of existing reproductive tract infections; and

Provide contraceptive methods as per informed choice and follow-up for post-abortion
complication management
42
Gaps and Recommendations

Gaps in Training and HR Issues

Chronic and worsening shortage of health personnel at rural health facilities, frequent transfer of
staff, vacant posts, problem retaining staff

Not all pre-service and in-service training have updated neonatal health training component

Lack of standardization of training by numerous private medical and nursing colleges

Recommendations:

Include updated Neonatal Health Training Component in all pre-service and in-service Training.

The HR unit needs to be further supported in resolving the training and HR issues

Work to disseminate existing neonatal training courses to more training sites and institutions, both
public and private
43
.
Thank You
for
Your:
Suggestions
Attention