Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality

Abstract

Background: Nepal has made substantial progress in reducing under-five mortality and is on track to achieve Millennium Development Goal 4, but advances in neonatal health are less encouraging. The objectives of this study were to assess relative and absolute inequalities in neonatal mortality over time, and to review experience with major programs to promote neonatal health.

Methods: Using four nationally representative surveys conducted in 1996, 2001, 2006 and 2011, we calculated neonatal mortality rates for Nepal and for population groups based on child sex, geographical and socio-economic variables using a true cohort log probability approach. Inequalities based on different variables and years were assessed using rate differences (rd) and rate ratios (rr); time trends in neonatal mortality were measured using the annual rate of reduction. Through literature searches and expert consultation, information on Nepalese policies and programs implemented since 1990 and directly or indirectly attempting to reduce neonatal mortality was compiled. Data on timeline, coverage and effectiveness were extracted for major programs.

Results: The annual rate of reduction for neonatal mortality between 1996 and 2011 (2.8 percent per annum) greatly lags behind the achievements in under-five and infant mortality, and varies across population groups. For the year 2011, stark absolute and relative inequalities in neonatal mortality exist in relation to wealth status (rd = 21.4, rr = 2.2); these are less pronounced for other measures of socio-economic status, child sex and urban-rural residence, ecological and development region. Among many efforts to promote child and maternal health, three established programs and two pilot programs emerged as particularly relevant to reducing neonatal mortality. While these were designed based on national and international evidence, information about coverage of different population groups and effectiveness is limited.

Conclusion: Neonatal mortality varies greatly by socio-demographic variables. This study clearly shows that much remains to be achieved in terms of reducing neonatal mortality across different socio-economic, ethnic and geographical population groups in Nepal. In moving forward it will be important to scale up programs of proven effectiveness, conduct in-depth evaluation of promising new approaches, target unreached and hard-to-reach populations, and maximize use of financial and personnel resources through integration across programs.

Figure 1

Trend in child, infant and neonatal mortality in Nepal for 1990 to 2011 in relation to the MDG baseline for 1990 and MDG targets for 2015. Note: Estimates of child, infant and neonatal mortality are based on the five-year period preceding the surveys. The MDG baseline is not survey-based but was estimated based on backward extrapolation of trends. Neonatal mortality does not form part of the MDG indicators, and the values for MDG baseline and MDG target are taken from the Nepali national health plan. U5MR: Under five mortality rate; IMR: Infant mortality rate; NMR: Neonatal mortality rate; MDG: Millenium Development Goal; NFHS: Nepal Family Health Survey; NDHS: Nepal Demographic and Health Survey.

Figure 2

Major maternal, neonatal and child health-related policies, programs and projects in Nepal (1990–2015). FCHV: Female Community Health Volunteer; EPI: Expanded Program on Immunization; NVAP: National Vitamin A Program; CBAC: Community based ARI Control of Diarrheal Diseases program; CB IMCI: Community based Integrated Management of Childhood Illness; BPP: Birth Preparedness Package; SDIP: Safe Delivery Incentive Program; CS/FP Project: Child Survival and Family Planning Project; NFHP: Nepal Family Health Program; USAID: United States Agency for International Development; NSMP: Nepal Safer Motherhood Project; SSMP: Support to Safe Motherhood Program; NHSSP: Nepal Health Sector Support Program; DFID: UK Department of International Development; DACAW: Decentralized Action for Children and Women; UNICEF: United Nations Children’s Fund; SNL: Saving Newborn Lives program; CB NCP: Community based Newborn Care Package; CHX Cord Care: Chlorhexidine for Umbilical Cord Care; CB MNH: Community based Maternal Newborn Health program; CSHGP: Child Survival Health and Grant Program; MIRA: Mother and Infant Research Activity; MINI: Morang Innovative Neonatal Intervention; NDHS: Nepal Demographic and Health Survey; NFHS: Nepal Family Health Survey.