Community Based Newborn Care Program Nepal CB-NCP Dr. Senendra Raj Upreti Director Child Health Division, Department of Health Services

Trends in Child Mortality in Nepal At 33 per 1000 live births, Nepal continues to have quite high neonatal mortality (Nepal Demographic Health Survey, 20 11). Although there has been a marked decline in infant and child mortality neo-natal mortality has remained at essentially the same level over the past decade; with neonatal mortality now accounting for most under-5 deaths, unless we have important progress on decreasing neonatal deaths we cannot sustain major reductions in child mortality. The MDG targets for Under five mortality is 54 per 1000 but observing the decrease in trend of child mortality in the previous years, NHSP II set new target which is 38 per 1000. There are no targets for neonatal mortality in MDGs. National targets: Under five :38 Infant :32 Neonatal Mortality: 16 Source: NDHS, NHSP

Causes of Neonatal mortality 3 causes account for 90% of all newborn deaths Main message: Three main killers of newborns – preterm birth complications, intrapartum-related and severe infections (pneumonia, sepsis and meningitis) – account for over 90% of all newborn deaths. This figure shows the causes of neonatal death in Nepal for the year 2010. Source: Pradhan YV et al. 2012. Newborn survival in Nepal: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii57–iii71. Data source: Nepal mortality estimates (Liu et al. 2012). Note: Severe infection includes sepsis, meningitis, pneumonia and tetanus. 3

Community Based Newborn Care Program (CB-NCP) As an approach to reduce newborn mortality in Nepal Main message: Not much attention was given to newborn survival prior to 2000. Since then however, Nepal has evidence of significant progress in incorporating newborn care into national MNCH policies and programmes.

Background and Context of CB NCP When was policy and programme change achieved? Pivotal milestone for newborn survival involving multiple champions, partners and wide ownership Main message: Not much attention was given to newborn survival prior to 2000. Since then however, Nepal has evidence of significant progress in i incorporating newborn care into national MNCH policies and program. A National Neonatal Health Strategy 2004-2010, was endorsed in 2004. The strategy focused on delivering a core package of neonatal interventions at community and facility levels, and outlined the systems supports that would be required to deliver interventions. In 2007, an assessment of progress in the area of newborn health by the Department of Health Services (DHS) found that limited progress had been made in implementation of the strategy. Since most deliveries (81%) still took place in the home, the assessment recommended the development of a community-based approach to improving ANC, ENC and PNC. The timing of PNC visits in the Neonatal strategy was on days 3, 7 and at 6 weeks – and it was recognized that this timing needed to be changed in response to increasing evidence that neonatal deaths occurred in the early postnatal period. A CB-NCP strategy paper was developed and endorsed by the MOH in 2007 The CB-NCP was finalized in 2008, as the primary government approach to improving maternal and newborn care at the community level. In the longer term, it aimed to integrate the package with existing safe motherhood and c-IMCI packages, already being implemented. Source: Pradhan YV et al. 2012. Newborn survival in Nepal: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii57–iii71.

Underlying key principles of CB-NCP Reaching mothers and newborns early is critical to reducing mortality. Mothers need to be identified when they become pregnant and followed up through delivery and post-natal period. Community volunteers can be trained to deliver an essential package of newborn interventions, including use of antimicrobials and the management of birth asphyxia . The health system at all levels needs to support community based efforts, to ensure newborn care practices improved. Reaching mothers and newborns early is critical to reducing mortality because even during the neonatal period there is variation in daily risk of death. Mortality is highest in the first 24 hours of death (25%-45%).Globally, three quarters of neonatal deaths happen in the first week after birth( The lancet Neonatal Series) Mothers need to be identified when they become pregnant and followed up through delivery and post-natal period. The FCHVs were responsible for identifying the pregnant mothers and referring them to Health facility( accompany them to the Health Facility) The national policy is that all deliveries should be conducted at a health facility equipped for deliveries, by a skilled birth attendant. SBAs include doctors, nurses, auxiliary nurse midwives and paramedics who have received appropriate SBA training. Community volunteers can be trained to deliver an essential package of newborn interventions, including use of antimicrobials : learning from MINI Initiativ

Policy and strategy adoption Formation of a technical working group and sub-committees under the leadership of the DoHS and MoHP to collect and review data, synthesize recommendations and develop methods .   Policy to allow FCHVs to classify and treat sick newborns with the first dose of co-trimoxazole. Policies on incentives for FCHVs, mothers and facility workers to support ANC, delivery and early PNC practices These policy adoption reflect a strong national commitment The formation of a technical working group, and sub-committees to collect and review data, synthesize recommendations and develop methods and materials was essential to widespread acceptance of the CB-NCP, which included an updated policy on early PNC contacts. As a result the package was used by all partners, and activities were coordinated by the MOH – implementation was subsequently planned systematically.   A policy to allow FCHVs to classify and treat sick newborns with the first dose of co-trimoxazole and then refer was successfully integrated into the national CB-NCP approach. Policies on incentives for FCHVs, mothers and facility workers to support ANC, delivery and early PNC practices have been developed. These reflect a strong national commitment to improving both demand and supply for MN care, particularly around the time of delivery and the early PN period.

Seven Interventions included in CB-NCP 1. Behavior Change and Communication (BCC) 2. Promotion of institutional delivery and clean delivery practices in case of home deliveries 3. Postnatal home visit for newborn 4. Case management of Possible Severe Bacterial Infection (PSBI) 5. Management and care of low birth weight newborns 6. Prevention and management of hypothermia 7. Recognition and management of birth asphyxia The Female Community Health Volunteer (FCHV) is identified as pivotal for implementation of CB-NCP. FCHVs are responsible for implementing the CB-NCP. It recommends 4 ANC visits, 1 visit at delivery (the guideline is that they should accompany the mother to a facility), and PNC visits at days 1, 3, 7 and 29. Mothers and newborns are screened at the same time. The training package includes the 7 core competencies recommended by WHO and others – in order to deliver key maternal and newborn interventions . In addition, the policy allows FCHVs to treat newborns with suspected pneumonia or possible severe bacterial infection with the first dose of co-trimoxazole and then refer. They are also responsible for following-up newborns who have been treated at facilities on day 3 after the initiation of treatment Core PNC competencies: Promotion of NB care (early/exclusive BF, warmth, hygiene); Promotion of optimal care for mother (nutrition & family planning); Promotion of care-seeking for mother & newborn; Identification of danger signs in mother + referral; Identification of danger signs in newborn + referral; Support for breastfeeding; Care of low birth weight infant (feeding, skin-to-skin contact)

Implementation Phases of CB-NCP Phase I (pilot): 10 districts Phase II (scale up)—34 districts “covered”, 5 districts- trainings ongoing Chlorhexidine included in the CB NCP package Assessment of CB NCP pilot districts : completed May 2012 CB NCP Implementation was begun in 10 pilot districts. The intention was to determine whether or not the CB-NCP was feasible and effective, and to learn lessons. Implementation was subsequently expanded – by 2013 – to 15 additional districts. Early implementation districts were supported by the Government of Nepal and by development partners.

Main message: all coverage indicators have increased, particularly antenatal care 1 visit, tetanus toxoid vaccine and skilled birth attendance, and many have high coverage (eg tetanus toxoid and exclusive breastfeeding). Some interventions and packages however reach less than half of the population (contraceptive prevalence rate, ANC 4 visits or more, facility births and postnatal care) Source: Pradhan YV et al. 2012. Newborn survival in Nepal: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii57–iii71. Data source: Nepal mortality estimates (Liu et al. 2012). Note: Severe infection includes sepsis, meningitis, pneumonia and tetanus.

Learning from CB NCP FCHV role in complication management much smaller than expected Enhanced co ordination across divisions (FHD, CHD, MD, LMD, NHTC, NHEICC) required for smoother implementation of peripheral level neonatal (and maternal) services Streamline MNCH within the Department of Health Services .

Steps forward: Revision of CB NCP Increase focus on quality of care and effective coverage for newborn and maternal complications at peripheral health facilities Increase the focus on FCHV counseling/ health education during pregnancy and post-natally. (In areas with difficult access to health facility care, ensure program support for an FCHV role in newborn sepsis management) Use a flexible, micro-planning approach to determine inputs and service-delivery Ensure seamless integration across the range of maternal-newborn services delivered at the primary health care/ community level .

Challenges Funding Gaps Wide disparities by socio-economic status in NMR Collaboration with private and other non health sector. Eg education, environment Capacity for rapid scale up of Newborn Programs across the country to meet the NHSP target Quality and infrastructure of referral centres Institutional delivery still low in some communities.

Changes in official development assistance for MNCH in Nepal Child health donor projects with no reference to newborn terms in the search fields MNCH donor projects with reference to newborn terms in the search fields Maternal health donor projects with no reference to newborn terms in the search fields Main message: Between 2003 and 2008, ODA for MNCH increased from $22 million to $54 million. ODA for maternal health received the majority of the disbursement to MNCH. Funding specific to newborn health was only $4.78 million of the total $54 million for MNCH in 2008. Source: analysis of the OECD database using search terms related to MNCH and specifically newborn. Only 8% of official development assistance for MNCH mentioned newborns in 2008 Source: Pradhan YV et al. 2012. Newborn survival in Nepal: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii57–iii71. Data source: (Pitt et al. 2010) with special analysis done by C. Pitt Note: All values are in constant 2008 USD. MNCH donor projects with reference to newborn health include MNCH donor disbursements that mention the word ‘newborn’ or relevant search terms in titles or project descriptions. The OECD database does not systematically capture funding from emerging donor states, foundations, non-governmental organizations or faith-based groups. 14

Opportunities Newborn program is the governments priority program Increasing interest of EDPs and partners, thus increased funding Implementation and scale up plan developed for Newborn interventions: IMCI/NCP 5 year costed Multi year plan HRH strategy endorsed by the government Experience and learning from our community based maternal, newborn and child health programs

Director Family health Division Innovation in Reducing Neonatal Death in Nepal: Chlorhexidine (CHX) a Simple Intervention Dr. Kiran Regmi Director Family health Division

Causes of neonatal death Innovation in Reducing Neonatal Death in Nepal: CHX a simple intervention > Overview Child mortality Causes of neonatal death Chlorhexidine a simple intervention in reducing neonatal death Milestones of Chlorhexidine in Nepal Evidence that Chlorhexidine is effective for cord care Chlorhexidine application Nepal policy Chlorhexidine implementation approach in Nepal Key to Program Success in Nepal Lesson learnt/ challenges

Marked decline in infant and child mortality Innovation in Reducing Neonatal Death in Nepal: CHX a simple intervention > Child mortality status Marked decline in infant and child mortality At 33 per 1000 live births, Nepal continues to have quite high neonatal mortality (Nepal Demographic Health Survey, 20 11). Although there has been a marked decline in infant and child mortality neo-natal mortality has remained at essentially the same level over the past decade; with neonatal mortality now accounting for most under-5 deaths, unless we have important progress on decreasing neonatal we cannot sustain major reductions in child mortality. Less improvement with neonatal mortality and no change from 2006-2011 Source: NDHS&NHSP*

Innovation in Reducing Neonatal Death in Nepal: CHX a simple intervention > Causes of neonatal death Each year 3.6 million newborns die globally, and infection causes more than a quarter of these deaths. In resource-poor, high mortality settings, infections account for up to half of the neonatal deaths. Unhygienic exposures around the time of birth and in the first week of life increase the risk of deadly but preventable infections. WHO recommends clean and dry umbilical cord care, and its 1998 guidelines indicate that generally antiseptics are not necessary. However, the guidelines indicate that topical antiseptics (including chlorhexidine specifically) can be appropriate for application to the cord stump in areas with high infection risk. Neonatal mortality shares 61% of the under five mortality which is much higher as compared to global i.e. 40%. Every hour 3-4 hours newborn die in Nepal. The leading cause is infection. It is well known that unhygienic cord-care practices are common in Nepal and in many other countries.

Innovation in Reducing Neonatal Death in Nepal > CHX a simple invention An important initiative in Nepal over the past 4-5 years has been the community-based neonatal care program. This program is now running in 39 districts and it is based on services provided in the home by female community health volunteers. During home visits during the post-natal period, counseling is provided. When FHCVs attend home births, they help to ensure appropriate essential newborn care. They also do assessments and initiate treatment for possible sepsis. About 50 thousand Female Community Health Volunteers who have also been providing maternal-newborn related services including antenatal counseling during home visits, dispensing of antenatal iron-folate, chlorhexidine gel tube and misoprostol for preventing PPH. Over the past 10 years, there have major efforts to promote institutional deliveries and to improve the quality of this care.

Innovation in Reducing Neonatal Death Nepal > CHX a simple intervention

Addressing a problem with high population health burden Efficacy Innovation in Reducing Neonatal Death in Nepal > CHX a simple intervention Addressing a problem with high population health burden Efficacy Low cost Simplicity Safety Acceptability Low regulatory requirements Health system compatibility Scalability Commercial viability Efficacy-to replace harmful traditional cord care practices Low cost -only 23 cent Simplicity - mother and family can apply themselves Safety- no side effect reported after use in …….babies Acceptability- very high acceptance Health system compatibility-especially distribution, procurement Scalability- integrating with ongoing program Commercial viability- Product locally available in Nepal

1st consultative meeting in Nepal Innovation in Reducing Neonatal Death in Nepal: CHX a simple intervention > Milestones 2007 1st consultative meeting in Nepal 2008-09 Non-inferiority trial of CHX gel compared to aqueous Gel versus aqueous community acceptability study 2009-11 Pilot program in four districts

Coverage and compliance study Innovation in Reducing Neonatal Death in Nepal: CHX a simple intervention > Milestones 2009-11 Coverage and compliance study CHX international meeting at Banke, Nepalgunj Approval from MoHP for national level scale up Government of Nepal with strong support of JSI and other partners working together to scale up at national level

Providing a learning platform to many international visitors Innovation in Reducing Neonatal Death in Nepal: CHX a simple intervention > Milestones 2012 Onwards Providing technical and product Supply to neighboring Asian and several African countries for doing formative work and preparing to pilot Providing a learning platform to many international visitors Providing technical support to other implementing partners

68% reduction in serious infection Source: Mullany (2011). Innovation in Reducing Neonatal Death in Nepal: CHX a simple intervention> Evidence > Literature An estimated 1 in 6 neonatal deaths could be averted with Chlorhexidine cord care. A simple technology with potential to prevent 500,000 global neonatal deaths annually. Soure : Hodgins et.al(2013) Application of Chlorhexidine in freshly cut umbilical cord stump can reduce neonatal mortality by 23% 68% reduction in serious infection Source: Mullany (2011). the clinical trials from Nepal, Pakistan, and Bangladesh showed a reduction of neonatal mortality from 20% to 38%, with a reduction of omphalitis from 24% to 75%. These trials also indicated that applying Chlorhexidine immediately after cord cutting was critical to reduce omphalitis and neonatal mortality.

Overall NMR (at time of study) 39/1000 36/1000 30/1000 Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Evidence > Research Community based RCT Study Characteristic Nepal Bangladesh Pakistan Overall NMR (at time of study) 39/1000 36/1000 30/1000 % of births at home (at time of study) 92% 88% 80% Total sample size 15,123 29,790 9,741 Primary outcomes Neonatal mortality Omphalitis Comparison group Dry cord care Frequency of application Days 1,2,3,4,6,8,10 First 24 hours Daily for 7 days Daily for 14 days Intervention provider Project staff TBA and care taker Product form used Water-based liquid To note: In Bangladesh, RCT examined the effect of chlorhexidine cleansing in the context of a basic package of maternal and newborn health interventions. It also compared the effect of two regimens: i.e., Single application on the day of birth vs 7-day application.

Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Evidence > Research Community based RCT > Result 24 hours post application 4.6% (15 of 327) of cultures were positive in the gel group 10.7% (35 of 326) in the aqueous group The absolute difference in rates (gel minus aqueous) was 6.1% (95% CI: 10.2%, 2.1%) The gel formulation was not inferior to aqueous and gel reduced bacterial colonization to a greater degree

Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Evidence > Research Community based RCT > Recommendations 7.1% Chlorhexidine digluconate is safe for neonatal umbilical cord care All RCTs showed sufficient evidence to recommend 7.1% Chlorhexidine digluconate for umbilical cord care to reduce neonatal mortality All studies recommended for the application of Chlorhexidine as early as possible, specifically within 24 hours of birth (NOTE: RCT detail slides are included in the Appendix) 7.1% chlorhexidine digluconate is safe to use for neonatal umbilical cord care. All RCTs showed sufficient evidence to recommend 7.1% chlorhexidine digluconate for umbilical cord care to reduce neonatal mortality. The studies all point to the importance of applying chlorhexidine as early as possible, within 24 hours of birth. The design of the trials to date has primarily tested multi-day application; that is what we have the most evidence for. Countries/programs may repeat application once daily through the first week of life or until the cord separates. Further benefits may be realized. The gel form is not inferior to liquid form in terms of reducing bacterial colonization.

CHX integrate with essential newborn care Scaling up Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Nepal policy Application of Chlorhexidine to each newborn irrespective of facility and home birth Single dose resume immediate after cord cutting as a part of essential newborn care followed by clean and dry cord care practices CHX integrate with essential newborn care Scaling up Ensuring sustainability Community targeted implementation approach

Chlorhexidine integration into ongoing programs Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Nepal policy > Integration Chlorhexidine integration into ongoing programs Community-based programs Health Facility Delivery Skilled Birth Attendant Training Misoprostol Program Chlorhexidine integration into ongoing programs Use for institutional deliveries Advance distribution: CHWs, ANC, (social marketing) District by district roll-out AND system-wide institutionalization/ main-streaming - e.g. SBA in-service and pre-service curricula, supply-chain management, HMIS… CHX is not stand alone and isolated program in Nepal. Applying chlorhexidine to the cord is being implementing and incorporated into maternal and newborn health programs with relative ease, as it can be delivered through existing channels, does not require highly trained health workers or sophisticated infrastructure and costs very little. Such as CBNCP, Mispprostrol, SBA and it will be made available through social marketing approach. Implementation modality Video…………

Completed and Active Districts: 41 Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Nepal policy > Scale up Completed and Active Districts: 41 Planned: Entire Country (75 districts)

Implementation approach FCHVs distributes CHX to pregnant mother at 8th month of pregnancy after counseling Orientation to service providers of all level Orientation to FCHVs Chlorhexidine orientation to stakeholders and staff of DPHO/DHO Service delivery at hospital and peripheral health facility Availability of service at home birth Monitoring and quality assurance For quality assurance of the program- District health office, supporting partner and CNC is doing TSV, follow up after training, midterm assessment and regular feedback on recording reporting.

Government leadership since inception of the program Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Key to success Government leadership since inception of the program Supply is ensured through the government logistics supply norms Local manufacturer (Lomus Pharmaceutical) producing a good-quality product - 3 gram of 7.1% Chlorhexidine digluconate gel tube - Nepali brand name Kawach Current price is Rs.18 ($0.23) for Government Pictorial instruction inside box Partners and professional organisation involvement since beginning to scaling up Nepal – member of global Chlorhexidine working group Ensuring sustainability Video Logistics………..

Chlorhexidine added in Essential Drug List of Nepal Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Key to success > Sustainability Chlorhexidine added in Essential Drug List of Nepal Chlorhexidine cord care is a part of an essential newborn care Government of Nepal included Chlorhexidine procurement in multi-year procurement plan Included in routine health information system for recording and reporting After this Video

Traditional harmful practices of cord care can be replaced Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Lesson learnt Rapid scale up is possible through the existing government health system in Nepal Traditional harmful practices of cord care can be replaced Video………….

41% of newborns had some material on stump. Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Challenges 63% deliveries at home Among non institutional birth- 82 % used clean delivery kit or new/boiled blade 41% of newborns had some material on stump. From the findings of the 2011 DHS we know that most deliveries in Nepal continue to happen at home. Although clean blades are now normally used for cutting the cord, application of diverse substances to the cord remains common. (oil, unknown ointment or powder, turmeric or ash) Increased risk of infection by other practices like, surface used for cord cutting, handling the baby without hand washing, unclean baby wrapper etc. Source : NDHS, 2011

WHO position (1998) understood to be against antiseptic use Innovation in Reducing Neonatal in Nepal: Chlorhexidine a simple intervention > Challenges WHO position (1998) understood to be against antiseptic use Program shifting for cord care may create confusion in service provider & recipient Integrating program at different level i.e. LMIS, HMIS and other essential newborn care related programs

References: Hodgins S, Pradhan YV, Khanal L, Upretti S, KC NP. Chlorhexidine for umbilical cord care: game-changer for newborn survival? Glob Health Sci Pract. 2013;1(1):5-10. http://dx.doi.org/10.9745/GHSP-D-12-00014 Mullany , L(2011) Chlorhexidine Cord Cleansing. Summary and Meta Analysis of South Asian Trials Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland.

Thank you